The New York State Female Condom Promotion Program

In an innovative collaboration, researchers at the HIV Center are working with the AIDS Institute of the New York State Department of Health to conduct a structural intervention promoting the use of the female condom in agencies throughout the state.

"The collaboration started about eight years ago when we began discussions about our concern that the female condom is a highly underutilized prevention method," said the study's Principal Investigator Theresa Exner, Ph.D. "Our discussion deepened as it became clear that microbicides are some years down the horizon, and that when they do arrive on the scene -- in maybe 5 or 10 years – the first generation is going to be substantially less effective than  condoms. In fact, they will probably be recommended for use with a condom."

Since barrier methods will clearly continue to be important tools for the prevention of HIV, STIs, and unintended pregnancy for the foreseeable future, HIV Center researchers and AIDS Institute policymakers began to consider how to best promote the female condom -- a method that has been proven highly effective and is widely available yet rarely used.

"The female condom gives us an opportunity to frame a new kind of prevention effort, because it has some major advantages over other methods," said Exner. "It is a non-hormonal form of contraception, and there are many health reasons that women may have for not wanting to put hormones into their bodies. Also, many men are used to having women set the agenda in terms of contraceptive methods, and may be open to using the female condom if it is presented in that context." Thus, the female condom may present an important new frontier in the promotion of "dual protection" against both unintended pregnancy and HIV and STI infection.

"Our previous research shows that there are fundamental biases against the female condom, often caused by lack of information, negative press, and negative word of mouth," noted Exner. She ascribed the resulting  underutilization not to deficiencies in the method but rather in its promotion. "There still has not been a concerted effort to engage either agency directors or front-line counselors, all of whom directly deal with issues of sexual risk reduction and who are in a position to either promote or marginalize the method. We felt that it was time to put the female condom on the agenda and to do so by bringing in the key players who hadn't been part of the picture."

The New York State Female Condom Promotion Program utilizes the organizational infrastructure, training, and capacity-building mechanisms already in place at the AIDS Institute. To date, 30 agencies funded by the AIDS Institute have been recruited as participants in the intervention, representing a broad spectrum, including CBOs primarily engaged in outreach; medical facilities that provide HIV primary care; HIV case management; contraceptive or STI services; harm reduction programs, including needle exchanges; and drug treatment programs. The study is now about at the halfway point, with approximately 30 more agencies still to be recruited. The agencies reflect a geographic spread that roughly mimics the distribution of the HIV epidemic in New York State, with about two-thirds in the greater New York City area and one-third throughout the rest of the state.

Intervening at the Structural Level

As a structural intervention, the New York State Female Condom Promotion Program goes beyond the usual emphasis on individuals, couples, or families to address broader policy development and practical implementation. The study design compares a basic intervention to an enhanced intervention (given the clear need for intervention and the efficacy of the female condom, it was  

decided not to include a no-treatment control condition). In both conditions, agencies are provided with subsidized access to female condoms for one year. In addition, agency directors are invited to a meeting where the researchers lay out the empirical evidence on the efficacy of the female condom as well as on utilization patterns in NYS. At this meeting, there is also an attempt to develop consensus about the importance of the project and to gain the commitment of the directors to promote the female condom within their agencies. At the end of the meeting, directors are asked to develop an action plan for female condom promotion for their specific agency.

In the enhanced intervention, the program additionally provides a one-day training for sexual risk reduction counselors at the agency. Further, the researchers provide consultation and support through monthly phone calls, both to directors and counselors, to assist them in their action plans for female condom promotion. For example, if a counselor is having trouble with helping clients negotiate female condom use, the researchers would make sure that the counselor had materials, they might conduct role playing about specific issues and problem solving, and they might help counselors to team up with one another or might arrange for more frequent supervision to be provided.

In another agency, the action plan might include the decision to make sure that the female condom is reaching into the community beyond their specific agency. For instance, some counselors have worked with local pharmacies and the program has provided them with a cover letter explaining the study and offering information for the pharmacist about the female condom. The program has also assisted agencies with preparing a presentation about the female condom to their community advisory board.

Research-Government Collaboration

This partnership has brought together a group of HIV and sexuality researchers with policy leaders in public health from through New York State. Working with Exner at the HIV Center are Co-Principal Investigators Susie Hoffman, Dr.P.H., and Joanne Mantell, Ph.D. and Co-Investigators Joyce Hunter, D.S.W. and Jessica Adams-Skinner, Ed.D.

At the AIDS Institute, which coordinates all HIV public health initiatives in New York State, the Co-Principal Investigator is James Tesoriero, Ph.D., who directs the Office of Program Evaluation and Research. AIDS Institute Co-Investigators include Susan Klein, M.S., Deputy Director for Program Planning, Development, and Evaluation; Alma Candelas, M.P.H., Associate Director of the Division of HIV Prevention; and the Director and Assistant Director of HIV Education and Training Programs, Richard Cotroneo, M.A., and Dara Shapiro, M.P.H..

"We are such full partners – it has been a privilege to work with them every step of the way," said Exner. "The involvement of the AIDS Institute has been critical to understanding what agencies are out there and what their missions are, and to facilitating a sense of collaboration with the agencies who are our study participants throughout New York State." Because of the close collaboration on many levels, the intervention, if successful, can be quickly integrated into existing HIV educational programs throughout the state, reaping early returns on the research investment.

If successful, the program will demonstrate that training health care providers is a more effective way to widely promote the female condom than just offering agencies access to free female condoms without providing training.  The study may show that one-on-one instruction can be key to women's successful uptake of the female condom.  The collaboration with the NYS Department of Health in this effort means that if successful, the program has a high likelihood of being permanently adopted across the State and by public health agencies in other high prevalence regions as well.

For more information, visit the New York State Department of Health webpage on the female condom. For a bibliography of published research on the female condom conducted at the HIV Center, click here.