The search for answers behind falling condom use
Baboki Kayawe | Friday July 28, 2017 15:51
Everyone remembers the ABCs of the HIV prevention: Abstain, Be Faithful and Condomise. When the pandemic struck in the mid-1980s, those were the little weapons local public health authorities had to use in the fight against a seemingly unstoppable disease that threatened to wipe out the entire nation.
All campaigns were centred on the condom, the frontline and physical barrier in the fight against HIV. Batswana, together with the rest of the world, grew accustomed to condoms and began to use them, even as government and other partners fought to roll them out countrywide.
Decades later, the rubber warrior is losing his shine. This week Ministry of Health and Wellness (MoHW) chief health officer, Elizabeth Koko shared data showing that over the years, condom usage has dropped remarkably countrywide, despite the wider availability of various free and commercial varieties on the market. According to studies, in 2008 condom usage amongst those aged between 15-24 years stood at a respectable 78.4%, a figure which dropped to 65.2% five years later in 2013. More worryingly, the fall in consistent condom use within this age group is associated with those having sex with non-regular partners, a trend providing fertile ground for Sexually Transmitted Infections (STIs).
Despite the fact that the Botswana government provides free condoms - which are an effective contraceptive commodity and HIV/AIDS prevention means, studies show that overall condom use in the general public dropped from 90.2% in 2008 to 81.9% in 2013. Again, the most unprotected sexual intercourse is happening with multiple-concurrent partners.
Analysts believe one of the major drivers of low condom use is the safety net provided by interventions such as the antiretroviral drug therapy (ARV) and Prevention of Mother to Child Transmission (PMTCT), both of which are provided free of charge.
Although condom usage is dropping, HIV deaths are not rising due to these interventions, removing the penalty of death that was previously associated with infection by the virus and lulling some into a false sense of security. What is rising however, are STIs, which are not covered by PMTCT or ARVs. According to MoHW statistics, urethral discharge syndrome, vaginal discharge and other STIs were on the increase between 2010 and 2015. In 2010 for instance, there were 13,218 cases of urethral discharge syndrome with the figure shooting up to 27,585 in 2015. Vaginal discharge cases increased from 31,500 in 2010 to over 55,000 in 2015.
Koko has her own thoughts on why condoms are losing their popularity among Batswana.
“We still have cultural and religious belief systems that prohibit condom use,” she says. “The other reason we have noted as health authorities is that the fertility value of the semen is seen to go to waste when a condom is used.”
Analysts have also blamed periodic shortages in the provision of free condoms by government. For the first time, in the history of health care management, the Central Medical Stores is experiencing a huge backlog of condoms, which authorities attribute to system inefficiencies within the distribution value chain.
Batswana have their own ideas on the falling condom use. Mmegi undertook an impromptu online survey, which revealed a wide range of factors associated with the trend.
Malebo Mokoka is of the view that condom marketing has fallen over the years and thus there has been no demand creation for condom use, as was the case before free antiretroviral drugs.
She advises health promotion officials to go back to the basics and launch vigorous condom use awareness campaigns throughout all the various media platforms.
“Condoms are no longer advertised on television. Advertising should be frequently aired to remind people to use them. This is a serious issue and it needs to be tackled because we all know that once condom use declines, HIV/AIDS simulteneously spreads,” she says.
Anthony Molosi blames the trend on distribution accessibility challenges. He says free condoms are placed in non-conducive environments where picking them up has an associated social embarrassment. For some reason, sexual norms have turned condom use into form of a taboo.
“People are shy (to collect free condoms in public spaces),” says Molosi. “You could see people passing by with interest, but the fear of what others could be thinking held them back from taking the condoms,” he says. Readers also believe there is a stigma attached to buying condoms as well.
According to Masego Moesi, buying condoms from a shop can even be more socially awkward than collecting the free varieties.
“At times even the shop assistant looks at you as if they are saying ‘there she goes sinning again’. Neither buying condoms nor picking them in a public space is a comfortable experience.”
Misconstrued safe male circumcision messages have also been fingered as contributing to lowered consistent condom usage. Thabo Makwala says most men think the fact that circumcision reduces heterosexually acquired HIV/AIDS, means total elimination of risk.
“I think circumcision contributes to this negligence. Circumcision must not replace condom use,” he says.
Makwala also mentions alcohol abuse as yet another driver of low condom usage, saying people tend to totally forget about protection after imbibing alcoholic beverages.
In the past, the poor variety of free condoms has also been blamed for the declining usage.
Users have laid a litany of complaints against free condoms from them “smelling bad”, “being too thick” and “not nice”. Government has, to an extent, listened to the complaints and even withdrawn the Lorato condoms. A health ministry official says new flavoured and branded condoms are due before the end of the year.
“We have listened to the public outcry about Lorato and hence we will bring improved and flavoured products manufactured by Alpha Access. This is the same company that does South Africa’s Choice as well as Namibia’s Smile public condoms,” he said. Despite the views about condoms and the drivers of low usage, health experts say the latex warriors are still critical in the fight against HIV infection.
United Nations Population Fund (UNFPA) assistant representative, Mareledi Segotso says in a high HIV prevalence country like Botswana where 18% of the general population, and 11% of young women aged 15-24 live with HIV, condom use is crucial to prevention.
“Condoms are highly effective as triple protection against unwanted pregnancies, HIV and other STIs,” Segotso says.
She says young people particularly face a number of barriers to accessing condoms amongst others limited youth-friendly health services to offer condoms and other contraceptives, inadequate promotion of condoms especially the female condoms, supply side issues such as intermittent stock outs of condoms as well as limited provision of Comprehensive Sexuality Education for in and out-of-school youth.