Global War Against AIDS Runs Short of Vital Weapon: Donated Condoms

Published: October 09, 2002

Donations of condoms from rich nations to poor ones, already deeply inadequate, have declined over the past decade, just as a few countries have successfully used them to fight the ever-worsening AIDS epidemic.

The world's poorest countries need between 8 billion and 10 billion condoms a year to help stem the spread of the AIDS virus, which newly infects 14,000 people each day, public health officials say. But they receive less than 1 billion, and donations have slipped to 950 million from 970 million in the last decade, according to the United Nations Population Fund.

''We need a lot more condoms,'' said Dr. Nkandu Luo, a former health minister of Zambia. ''We don't have enough.''

The biggest decline in donations was from the United States, which gave the third world 800 million condoms in 1990 and only 360 million in 2000. The United Nations and European aid agencies, notably Britain's, stepped in to try to make up the difference.

Efforts to get affordable AIDS drugs to Africa have recently had more news coverage than condoms, but officials of Population Action International, a family planning group, emphasized that condoms can save more lives for pennies.

Many factors create the condom shortfall: little public discussion of the situation, shifting foreign aid priorities, laws that drive up prices, distribution problems in poor countries and religious opposition.

Mark Rilling, chief of the population commodities division of the United States Agency for International Development, America's foreign aid provider, said no one knows exactly how many condoms the third world needs, ''but we know it's a lot more than is being provided at the moment -- as a worldwide donor community, we're not close.''

American donations dropped for several reasons, he said. In the 1990's, some major condom recipients, including Pakistan, Bangladesh, Nigeria and Zaire, now Congo, became ineligible for foreign aid because of coups, wars, or shifts to other donors.

Also, ''buy American'' laws meant that the Federal government had to pay about 6 cents per condom, while the price from factories in India, China, Thailand and Malaysia, even with quality testing, is about 3 cents.

However, Mr. Rilling said, the newest contracts negotiated by the agency for international development push the price down close to 4 cents, and the agency has set aside $25 million for countries with the worst AIDS epidemics. If that were all spent on condoms, it would purchase 625 million.

Even with other nations stepping in, the need is growing. The United Nations Population Fund estimates that poor countries now need 10 billion condoms a year and will need nearly double that many by 2015. Donor countries used to buy about 41 percent of what was needed; now they buy only about 27 percent.

For every $1 million not spent on condoms, the United Nations estimates, there are 360,000 unwanted pregnancies, 150,000 abortions, 800 maternal deaths and 25,000 deaths of children under age 5.

While lobbying by the religious right has cut Federal budgets for related programs, Mr. Rilling contends that political pressure was ''not a factor'' in the decline of his agency's condom exports or new efforts to increase them.

Along with billions more condoms, Population Action said, poor countries need another $1.2 billion to help distribute them and teach their use. Illiteracy and unfamiliarity are major barriers to condom use, and even now, two decades into the epidemic, it is difficult in many societies to talk about condoms.

''In my country, it's taboo for a person like me to discuss sex with someone younger,'' Dr. Luo said.

A recent United Nations study of fears about condoms include widely accepted rumors that most condoms have holes, that the virus is inside them, or that the wrong size can cause the penis to break off.

The chief barrier to open discussion of condom use ''is not just its association with sex, but with 'dirty sex,' '' said Michael Fox, an AIDS prevention worker for international health agencies. He said he had heard of women in India, Africa and South America charged with prostitution for simply possessing a condom.

The few poor countries that have succeeded in getting new infection rates to level off or even drop -- including Brazil, Uganda, Senegal and Thailand -- ''all broke the condom barrier,'' he said.

Often, that includes a public effort to make condoms sound sexy or funny instead of merely clinical. In Thailand, an advocacy group opened a restaurant called Cabbages and Condoms in which all the table flowers and wall decor were made of condoms.

''In Brazil, the sexiest male and female soap stars came on TV holding condoms,'' Mr. Fox said. ''They'd look at the camera and say 'Yes, you probably would like to go to bed with me. But you don't have a chance if you don't use this.' ''

In Senegal and Uganda, health workers persuaded both imams and ministers to endorse condoms from their pulpits.

''Social marketers'' have had some success by repackaging free condoms to sell at low prices. Surveys find that men often value items they pay for more than those they get for free. They are also more likely to seek out condoms if they have names like King or Safari and are in envelopes featuring entwined lovers rather than plain white packs with public health messages. Famous soccer players have been recruited for endorsements.

But such advertising campaigns can inflame other passions. Religious leaders in Indonesia and Russia recently shut down two ''social marketing'' efforts, Mr. Fox said.

Public health officials favor condoms because they are cheap, generally reliable and prevent both AIDS and pregnancies as well as the venereal diseases that create sores that open the path for the AIDS virus. A study by the University of California at Berkeley estimated that counseling prostitutes in poor countries and giving them condoms costs about $3.50 per life saved. Even the cheapest generic antiretroviral regimens in Africa cost 100 times as much.

Estimating how many condoms an ideal world would have is an inexact science based on a mix of census figures and surveys of people's bedroom activities. The United Nations' estimate of 10 billion and Population Action's 8 billion are both based on a 2000 study by The Johns Hopkins University's School of Public Health, which used population figures for men ages 15 to 59 and ''coital frequency surveys'' from many sources, including anthropologists, aid agencies and a condom company.

The goal is to have condoms as widely distributed as other goods found in the smallest village shop in Africa or Asia, like Coca-Cola, soap and matches. Because condoms deteriorate in hot storerooms and expire after long storage, there are distribution problems, but they hardly rival those for other perishables like beer and sugar.

''Cigarettes can get to the most remote corners of the world,'' said Terri Bartlett, Population Action International's vice president. ''So should condoms.''