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FC-Empowerment and protection

Sept 16 marks the second Global Female Condom Day, when the US National Female Condom Coalition and the Universal Access to Female Condoms Joint Programme encourage advocacy and education around these little-used products that can “empower and protect”. Why do female condoms need their own global day and are things set to change?
Female condoms are listed by the UN Commission on Life-Saving Commodities for Women and Children as one of the “essential but underutilised” commodities necessary to accelerate improvements in reproductive, maternal, child, and newborn health. The Commission describes the female condom as “the only barrier contraception that gives women and adolescent girls greater control over protecting themselves from HIV, other STIs and unintended pregnancy”. Yet several obstacles prevent the product from reaching the level of use enjoyed by the male condom. First, the average procurement cost is a relatively expensive US$0·57 compared with $0·03 for male condoms, and the cost of service provision is also more expensive because providers need training in demonstrating how to use the product. Second, few studies have been done to test the eff ectiveness of the female condom at preventing sexually transmitted infections (STIs). Third, awareness is low from the perspective of the user and of national governments. Fourth, there is little variety in the design of a product which can be diffi cult to use at fi

rst.
This fi nal obstacle is addressed in an Article in this month’s issue by Mags Beksinska and colleagues. When the study began, only one design of female condom, catchily named the FC2, was licensed by both WHO and the US Food and Drug Administration (FDA) and was approved for bulk procurement by UN agencies. Since FDA licensing and UN Population Fund (UNFPA) prequalifi cation require studies to demonstrate the functional performance of new designs, Beksinska and colleagues did a randomised, non-inferiority trial in China and South Africa to compare the performance of three new designs of female condom against the FC2 device. The functional performance (defi ned as the frequency of user-reported breakage or misplacement) of the three new products, which all diff er fairly signifi cantly in terms of shape, materials, and lubrication, was no worse than for the FC2 condom.
As a result, one of the new products, the Cupid female condom (manufactured in India), secured UNFPA prequalifi cation in July last year.
Will the public-sector procurement of new designs of female condom improve uptake? Maria Gallo and colleagues discuss this likelihood in their Comment. They suggest that having a wider choice of contraceptive products that diff er enough in terms of cost, duration of eff ect, and side-eff ects can drive up demand. Yet more needs to be done, they suggest. Hard data on the eff ectiveness of female condoms at preventing STIs might better convince policy makers to support the products, and implementation research is needed to explore what drives enthusiasm for female condoms among their small band of devoted users worldwide.
In other research in this issue, Rhoda Wanyenze and colleagues report the results of another randomised trial of the eff ects of abbreviated HIV counselling and testing on sexual risk behaviour in Uganda. An abbreviated strategy of provider-initiated HIV counselling and testing (ie, that off ered to patients who attend health centres for any diagnosis) has been adopted in Uganda since 2006. The strategy, which frees up precious health-worker time, largely skips personalised risk-assessment and pretest counselling, yet the eff ects of eliminating these elements have not been tested. Wanyenze and colleagues show that the abbreviated strategy is non-inferior to traditional counselling and testing protocols in terms of reported levels of unprotected sex in the year after testing. The study also assessed an enhanced linkage to care intervention for those found HIV-positive. The enhanced care package decreased time to the start of treatment in men and entry into HIV care in women, suggesting that resources might be better directed at care linkage and retention of those found HIV-positive than at extensive counselling before testing.
Finally, we join The Lancet in announcing its annual Highlights photography competition. Both journals seek arresting health-related images from daily life and practice in any part of the world. Winning entries will be published in The Lancet and could also feature as a cover image in The Lancet Global Health.
Zoë Mullan
Editor, The Lancet Global Health