Currently, condoms are the only product on the market that provide individuals with dual protection against pregnancy and sexually transmitted infections (STIs), including HIV. The United Nations (UN) Department of Economic and Social Affairs recently reported a worldwide increase in condom use from 1994 to 2015. During this time, the percentage share of male condoms of all contraceptives used globally among married or in-union women aged 15 to 49 increased from 8% to 12%. In addition to condom prevalence, contraceptive use overall has increased rapidly since the creation of various modern methods (such as the pill and IUD) in the 1960s and 1970s. More women are using contraceptives now than ever before.

Nonetheless, the UN also reported, “in at least one of out every four countries or areas with data, a single method accounts for 50 per cent or more of all contraceptive use among married or in-union women.” The most commonly used methods included the pill, injectables or IUDs—none of which protect against STIs. Based on available data, it is evident that millions of women worldwide lack a range of options to protect themselves from unplanned pregnancy and STIs.

The advent of a variety of dual-protection methods, beyond the male condom, is long overdue. In the United States, the only other dual-protection method available is the female condom, the FC2. Yet, despite receiving FDA approval in 1993, the FC2 has not become widely used and is mainly produced for international export for the US Agency for International Development (USAID) and the UN. A range of barriers including cost, associations of partner mistrust, perceptions of promiscuity, a lack of spontaneity, decrease in sensation, discomfort, cultural stigma and more prevent many women from utilizing this product. It is also slightly misnamed as both males and females can use it for anal or vaginal sex.

As one author for The Atlantic stated, “The persistent myths around female condoms highlight the danger of searching for panaceas in global development. One object alone isn’t sufficient to solve an issue with complex social and cultural meanings, particularly if the recurring costs of these objects aren’t factored in.” Thus, the movement to develop a broad range of “multipurpose prevention technologies” (MPTs) has gained international attention and increased funding in recent years. In 2015, investments in MPTs rose by 50%, reaching up to $48 million USD, mainly from USAID and the National Institutes of Health (NIH). The US public sector provided 86% of global MPT funding in 2015 and 99% of public funds toward MPT research and development. Initiatives such as the Initiative for Multipurpose Prevention Technologies and the International Partnership for Microbicides have been created to encourage collaboration across disciplines and countries on MPT development.

Thus far, at least five other versions of internal condoms (a more accurate description of the “female” condom) have been approved for sale in different parts of the world, using diverse designs that aim to make this method more comfortable and acceptable for women. New products, such as the Cupid Female Condom, Reddy Female Condom, and Natural Sensations Panty Condom are available in limited international markets and utilize innovative designs, including tampon-like applicators, sponges placed internally, and even a disposable panty attachment to hold the condom in place. A diverse array of over 30 other MPT products, including intravaginal rings, dissolvable vaginal tablets, biodegradable films and microbicides are currently at various stages of development. These products, all designed to be initiated by women, aim to simultaneously prevent unplanned pregnancy and HIV (and some other STI) transmission through a variety of hormonal and non-hormonal active ingredients.

In addition to meeting the diverse needs of sexually active women, female-initiated prevention technologies hold an enormous amount of potential in reducing STI/HIV and unplanned pregnancy prevalence while contributing more broadly to female empowerment. Yet, as mentioned by The Atlantic, we must avoid falling complacent once these products reach international markets. Although women may find MPTs both acceptable and desirable, many will likely face insurmountable barriers to reliable MPT usage. In many low and middle-income countries (LMICs), women generally lack the agency to negotiate condom use with male partners; introduction of MPTs alone is not likely to change this. If governments, NGOs, and public-private partnerships cannot adequately maintain supply chains, high costs and lack of local availability will likely impede universal access to MPTs.

Developing products that are safe, effective, acceptable and can serve the needs of diverse women is only the first step in providing dual STI and pregnancy prevention. But, through successful education and implementation strategies, MPTs have the potential to make male-dominated STI prevention a relic of the past.

Emily Nagler, Duke University 2019

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