Female condom proves cost-effective in preventing HIV in Africa

By Jeff Sheehy on July 10, 2000

A new study headed by a University of California, San Francisco AIDS researcher
has determined that providing the female condom to women who are commercial sex
workers in rural South Africa is a highly cost-effective means of preventing
HIV transmission and would even save health care funds.

Study findings show that the results hold true even when the analysis is
extended to women who are not sex workers and who average only one casual
sexual contact a year. The analysis found that 5.9 cases of HIV, 38 cases of
syphilis, and 33 cases of gonorrhea would be averted per year in 1,000 female
condom recipients. 

Research results were reported today (Monday, July 10) at the XIII
International AIDS Conference in Durban, South Africa.

The research team sought to determine whether providing female condoms, which
can cost 20 times as much as male condoms, to 1,000 commercial sex workers
(CSWs) in Mpumalanga Province, South Africa would be an effective and economic
prevention intervention for HIV. 

The researchers conducted their analysis based on a statistical model.  Costs
were calculated from the perspective of a public-sector health payer.  One of
their key assumptions was that cheaper male condoms had been actively promoted
before the female condom was introduced.

According to the study’s lead author, Elliot Marseille, DrPH, MPP, a researcher
at the UCSF AIDS Research Institute and the director of Health Strategies
International, the reliability of the results are enhanced by the conservative
nature of the assumptions.

“We looked only at benefits to the female condom user and her immediate male
partner.  We did not estimate the benefits of additional prevented
transmissions to subsequent partners, and we did not examine the benefits of
the female condom as a contraceptive.  Also, we only looked at two other
sexually transmitted diseases—gonorrhea and syphilis—and ignored potential
benefits in preventing other STDs,”  he said.

He added,  “Given the severity of the HIV/AIDS epidemic in developing
countries, all effective and economic means of prevention should be deployed. 
Our findings show that the provision of the female condom can make economic
sense where male condoms have already been vigorously promoted.” 

The study’s second author, James G. Kahn, MD, MPH, of the UCSF AIDS Research
Institute and UCSF Institute for Health Policy Studies, noted, “Much of the
transmission of HIV that we are seeing in developing countries takes place in
cultural settings where men tend to dominate the decision-making process
regarding sex. The female condom can provide additional protection because its
use can be controlled by women.”

Study findings showed saved HIV/AIDS medical costs are estimated to be $12,090
($2,038 per case), and the saved costs of treating the syphilis and gonorrhea
cases are estimated to be $1,074.  Subtracting the $4,002 cost of providing
6,000 female condoms to the CSWs, the net savings to a public sector health
care provider is $9,163.

The analysis found that providing female condoms remains cost-effective even
when key factors are altered.  For instance, there are net savings even when
the prevalence of HIV is only 10 percent, the HIV transmission rate is only 0.1
percent per episode of intercourse, or the cost of treating HIV/AIDS is only
$625 per person.

Key parameters factored into the study model include an estimate of female
condom use in 12 percent of the occurrences of vaginal intercourse and that in
25 percent of these occurrences the female condom provides no additional
benefit because they only substitute for male condoms.  HIV prevalence was
projected at 50.3 percent among CSWs and 33 percent among their clients, with
CSWs having as few as 25 clients per year.  The risk of HIV transmission to
CSWs was estimated to be 0.4 percent per episode of unprotected sex and to
their clients was estimated to be 0.2 percent.  The female condom, like the
male condom was projected to be 95 percent effective at preventing transmission
per episode of use.

In addition, the model examined the provision of female condoms for 1,000
non-commercial sex worker women who have only one casual sex partner a year.
The women’s prevalence of HIV was estimated at 25 percent and their partners’
prevalence of HIV projected at 16 percent.  Assuming the remaining parameters
are unaltered, a public sector health payer achieves net cost savings of $202
under this scenario, according to study results.

In addition to Marseille and Kahn, study co-authors are Kelvin Billinghurst of
the Mpumalanga Department of Health and Joseph Saba, MD, of Axios
International.