Female condoms a hard sale in Malawi

In the corridors of public health discussions and initiatives in Malawi, specifically in the prevention of new HIV and AIDS cases and other Sexually Transmitted Infections, the topic of female condoms remains both relevant and concerning.

Introduced with optimism as a means to offer women and girls enhanced protection and autonomy, female condoms have struggled to gain traction in a society entrenched in cultural norms and gender dynamics.

Mary (not her real name), a sex worker by profession, epitomizes the challenges surrounding the uptake of female condoms in the country. As she navigates the complexities of her profession, she has always remained firm in her resolve to protect herself and her clients. Yet, despite her diligence in carrying and promoting condom use, there is a glaring gap in her arsenal; the absence of female condoms.

“I have never used a female condom because I have limited information about these condoms, which makes me sceptical about using them and opting for male condoms that are not complicated to use,” Mary shared, echoing the sentiments of many women in similar circumstances.

Mary’s story echoes the prevailing trend across Malawi, where the uptake of female condoms remains disproportionately low years after they were launched in the country to empower women with greater control over their sexual health choices.

Her sentiments are echoed by Mercy Khonje, who, despite having enough information on female condoms, refrains from broaching the topic with her partner due to fear and perceived usability issues.

“I have been in a relationship with my partner for some time and each time we have sex, we use male condoms. I am afraid to introduce the topic of trying female condoms because of the perceived stigma against condoms especially coming from a female person. I also hear that they are not user-friendly,” Mercy explained.

Female condoms were adopted in Malawi with high hopes of empowering women and girls to take control of their sexual health and were expected to revolutionize HIV and AIDS prevention. However, their utilization remains low.

This is despite having the 2015-2020 National Condom Strategy, which was a guiding strategy to improve the availability of and access to quality male and female condoms by all sexually active persons.

Data collected from some health facilities in the northern region paints a stark picture of the situation. Despite efforts to promote female condoms, consumption rates remain disproportionately low compared to their male counterparts.

For example, in 2023, the Mzimba South District Health Office distributed around 2,241, 244 male condoms against 5, 402 female condoms. At Mapale Health Centre in Mzuzu, male condoms consumption in the last quarter of 2023 was 144, 713 while for female condoms it was 655, while for Mzimba North District Health Office there was an average consumption of 655 female condoms with male condoms at 174, 014 during the same period.

Studies conducted before have revealed various reasons contributing to the low uptake of female condoms among the broader population. One of these studies is a 2013 situation analysis commissioned by the Family Planning Association of Malawi (FPAM) with funding from the United Nations.

Among others, the study revealed that most women and girls shun female condoms claiming that they are not user-friendly, stigma associated with condoms specifically in married situations, entrenched gender imbalances that give men more power in sex discussions, and less involvement of men in promoting the use of female condoms.

Indeed, the reluctance to embrace female condoms extends beyond individual choices to societal perceptions, with men often harboring negative attitudes toward them. Julius Msimuko of Mzimba, for instance, views women carrying condoms as a sign of promiscuity. Such views contribute to discouraging women from using female condoms so they are not labelled prostitutes.

“A woman or a girl carrying any kind of a condom is a sign that she sleeps around with a lot of men. Let us leave that to sex workers because they meet several men who they have sexual intercourse with,” Msimuko said.

While Malawi has made significant progress over the last decade in fighting the HIV epidemic through various initiatives, resulting in the reduction of new HIV infections, the low uptake of female condoms as a preventive measure is concerning as it has the potential to derail the gains achieved.

More concerning is the fact that despite the gains made, women and girls continue to be more affected compared to men. For example, according to the Malawi HIV Fact Sheet, a product of the National AIDS Commission, of the 1, 006, 633 people living with HIV as of 2022, 58 percent were women and girls. Additionally, of the 15, 630 people who were newly infected by HIV in the year, women and girls accounted for 61 percent.

This calls for swift implementation of interventions aimed at increasing the uptake of female condoms to give more women and girls the power to protect themselves.

The Ministry of Health acknowledges the challenges associated with female condom uptake, citing poor demand creation and a lack of training for health personnel as key gaps in promoting female condoms.

“Indeed, Malawi as a country has been struggling in trying to promote the usage of female condoms. This is an issue not only affecting Malawi but it is in most countries in Africa especially Southern and Eastern Africa,” Martin Kapito, HIV Prevention Officer in the Ministry of Health said.

He added; “After we discovered this problem, we had to do our background work and it came out that we did not create enough demand for the female condoms such that most of the clients do not know how to use female condoms. The second issue is that our health personnel were not trained to demonstrate how to use a female condom.”

Acknowledging these challenges, Kapito said the Ministry of Health has outlined strategies to increase awareness and usage of female condoms.

“Using Global Fund resources, we have procured 10, 000 Demonstration Vaginas, which will support health workers to demonstrate how to use a female condom. On top of that we have also allocated some resources to train health workers all over the country so that they can be able to teach clients how to use female condoms,” Kapito said.

The National AIDS Commission (NAC) a government entity responsible for coordinating HIV and AIDS-related activities is also coming in to help increase the uptake of female condoms.

“We are aware that more users prefer male condoms than female condoms because of limited information regarding the use and benefits of female condoms,” NAC Chief Executive Officer Beatrice Lydia Matanje said.

“In this regard, NAC has developed a communication plan for condoms and lubricants, which contains specific demand creation approaches and messages for both female and male condoms to address this knowledge gap. This plan will be rolled out in due course within this fiscal year,” she added.

However, deeper cultural norms and gender imbalances continue to pose formidable barriers to widespread adoption.

Health rights activist George Jobe advocates for assessments to understand the root causes of low uptake and devise tailored interventions that address the unique challenges faced by women.

“We think the starting point should be an assessment, a study as to why there has been low uptake of female condoms. When we do that study, we will understand the reasons behind it, and then we should have interventions that should respond appropriately,” Jobe said.

He added; “For example, we know there have been talks about gender imbalances where females do not have much negotiating power when it comes to issues of sexual activities and there might be other talks. And we have been hearing from the females themselves, those who have not been using, what are the reasons. I think that is what we can advise at the moment.”

As Malawi grapples with the complex challenges surrounding female condom uptake, the journey towards empowering women in sexual health decision-making remains an ongoing endeavour.

In the quest for gender equality and reproductive autonomy, bridging the gap in condom access and awareness stands as a crucial step towards a healthier and more equitable future for all Malawians.