Zimbabwe has experienced a rapid rise in HIV seroprevalence in the past ten years. In 1985 the National Blood Transfusion Service began testing volunteer blood donors and in 1986 found over two per cent to be HIV positive.(1) Current estimates of infection rates among adults are between 15-25 per cent.(2-4) There are two main directions that national HIV/STD prevention strategies have taken: first, to promote fidelity within marriage, and second, to encourage condom use, especially in extra-marital sex. Condoms were not previously widely promoted for contraception in Zimbabwe.(5) In a study among factory workers in Harare, 24 per cent of married men reported using condoms with their wives, compared with 44 per cent who used them with sex workers and 36 per cent who used them in other extra-marital affairs.(4) Even though there have been encouraging signs of better acceptance of male condoms in many areas,(6,7) many women still feel unable to negotiate for protection from sexually transmitted infections. There has therefore been increasing demand from women for safer sex methods that they can initiate, as an alternative to a method that requires male consent and initiative. As the special vulnerabilities of women to infection with HIV were identified, women's health activists began to hold HIV prevention discussions with groups of women to encourage them to protect themselves. Members of the Women and AIDS Support Network kept coming up against the same barrier -- that women found it impossible to bring up the issue of safer sex in their marriages and relationships, in particular to ask their partners to use condoms. Even though the contradictions and double standards were recognised, it was considered to be going against tradition for wives to openly address their husbands' infidelity. It was too confrontational or accusatory and implied lack of trust. Women often asked why doctors could not design a female condom, one that women could use. During these discussions it was apparent that the women were asking for something comparable to injectable contraception, something invisible that they could use without their partners knowing, which would protect them from infection. Then a female condom was developed in Europe, but it was far from invisible and needed the cooperation of both players. The female condom is a 17cm long polyurethane tube with an outer and inner ring. The inner ring anchors the condom at the top of the vaginal canal around the cervix, while the outer ring covers the vulva and prevents the condom from slipping up the vagina. The condoms are supplied with their own lubrication, which plays an essential role in the mechanical functioning of the device during intercourse. Laboratory tests show that female condoms are an effective barrier against HIV and other STDs,(8,9) and are less likely to leak than latex condoms for men.(10) There is no evidence of trauma to the lower genital tract in women having frequent sexual intercourse who use them.(11) Their contraceptive efficacy and continuation of use is similar to that of other barrier methods for women.(12) There have been mixed reactions to the method in European studies, (13,14) but this is among women who, in the main, have wider choices with more power and expectations, in their relationships. Studies from Thailand(15,16) and Cameroon(17) describe more promising reactions, but these have mainly been carried out among sex workers. Low income African-American women in the Usafer sex practice without challenging the power of their male partners.(18) We believed the female condom might offer an alternative that women in Zimbabwe could use. An appropriate first step seemed to be an acceptability study among different groups of women, to see whether it was liked or not and whether women could negotiate its use. This was done through the Zimbabwe AIDS Prevention Project and the Department of Community Medicine at the University of Zimbabwe Medical School. Background and setting Zimbabwe is a small landlocked country in Southern Africa with a population of 10.4 million. The main route of transmission of HIV in Zimbabwe is heterosexual. There have been 38,552 cases of AIDS reported through the Ministry of Health,(19) but the real figure is estimated to be 90,000, with a million people infected with HIV. The ratio of male to female cases is 1.3 to 1 but there is considerable under-reporting of AIDS in women, especially in the rural areas. In many other countries in the region, there are more women infected than men.(20,21) Sentinel surveys in urban and rural areas of Zimbabwe in 1993 showed HIV seropositive rates of 14-40 per cent in women attending antenatal clinics and 50-60 per cent of patients attending for STD treatment (both male and female).(2) The study The study was conducted among volunteers from three different groups of women: sex workers, urban women and rural women. The sex workers were women involved in a peer education programme in Masvingo, a provincial town in southern Zimbabwe, which recruits sex workers to promote condom use and to give HIV/AIDS information in bars and beerhalls. The women meet together every week to share information and report on their activities. A second group of sex workers were recruited at a later date. Approximately 30 of the women in the second group were also in the first group. The fact that so many of them took part in both the first and second recruitment was an indication of their desire to continue having access to the method. The urban women were attending the family planning unit attached to Harare Central Hospital. The third group of women were mainly peasants in a rural area of western Zimbabwe (Gokwe) who were participating in an HIV/AIDS needs assessment research project. These women were all either married or in stable, long-term relationships.(22) The condom was shown and explained to each group by a research nurse. It was explained that the device was not being tested as a contraceptive device and women wanting to avoid pregnancy needed to use some other method which would not interfere with the study (eg. oral contraception, sterilisation, or an IUD). The women were then invited to volunteer for the study. Women were eligible if they were sexually active, over 18 years of age and able to give informed consent. They were excluded if they had any anatomical abnormality or pelvic problem which might have interfered with proper use of the female condom (eg. uterine prolapse or severe genital warts). Those who volunteered were not paid for participation. Incentives to participate in the study included free clinical examinations and treatment of symptomatic sexually transmitted diseases, reimbursement of travel costs, and refreshments at the follow-up sessions. Volunteers were counselled, given a pelvic examination and shown how to fit the condom, on an individual basis. If they wanted to proceed with the trial, they gave written consent and were interviewed using an enrolment baseline questionnaire. The questionnaire had closed responses and asked for socio-demographic data, and about knowledge of HIV transmission and perceived personal risk (see Table 1). They were then given a supply of male and female condoms. Participants from all three groups were followed up on two subsequent occasions. Both times, we used the same questionnaire and gave the women a further supply of condoms. The first group of sex workers were followed up after one week and then after a further week. The questionnaires used elicited specific information on commercial sex work, including client behaviour and attitudes to the female condoms. The second group of sex workers were followed up similarly after one month. A longer period of follow up was allowed with the second recruitment to get a better idea of sustainability. The urban women were followed up for two consecutive weeks at the family planning unit and then involved in focus group discussions. Those who did not attend the unit for follow up were visited at their home addresses. They were considered lost to follow up if they could not be found after the third attempt. With the rural group there was a longer interval for follow up because many of them did not have much opportunity to use the condoms, as their husbands were away working in urban centres. Hence, we saw them twice but only used the questionnaire once. There were far fewer women in both the sex workers group and the urban group (48 per cent and 25 per cent respectively of those originally recruited) at second follow up because many had travelled to the rural areas or were away for family reasons. A few of the sex workers were sick at the time of follow up. At the end of the follow up for each group, focus group discussions were held with 8-10 participants at a time, to get more in-depth information on topics covered by the questionnaire. Because the focus group discussions were done at the end of the second follow up, there may have been a bias towards a more favourable response. In the main, however, the focus group discussions reinforced the impressions from the questionnaire interviews at the first follow up. Current contraceptive use Participants were advised to use other contraception and not to rely on the female condom as a family planning method during the study. However, 53 per cent of the sex workers, 14 per cent of the urban group and 22 per cent of the rural group were not using any other form of contraception. A few of the women in the urban group actively wanted to get pregnant and the family planning unit at the hospital was helping them with fertility problems. At the same time, they wanted to protect themselves against infection. We taught them to identify the fertile period of their cycle and, by using the condoms outside the fertile period, to maximise their chances of achieving both objectives. History of male condom use The majority of sex workers (95 per cent) reported having used male condoms before (ever-use), probably as part of the peer education programme, in which they actively promote condom use and provide free supplies. Of the urban women, 76 per cent had used condoms before. This may also reflect their contact with the family planning service, which often provides condoms along with other contraceptive methods. Those who did not use male condoms gave us reasons that their partners refused (45 per cent) or that they themselves did not like condoms (10 per cent). Of the rural group, 57 per cent had used condoms before. Of those who did not use them, 22 per cent said that their partners refused to use them, while 13 per cent did not like condoms themselves. Male condoms were not available to 8 per cent of the rural and urban women. When asked about condom use in the past year, 39 per cent of sex workers, 7 per cent of urban women and 17 per cent of rural women said they always used condoms; 36 per cent of sex workers, 14 per cent of urban women and 4 per cent of rural women had used them for more than half the time; 20 per cent of sex workers, 54 per cent of the urban group and 35 per cent of the rural group had used them for less than half the time. Responses to the female condom Most of the women in all three groups liked the female condom fairly well or very much, and most preferred it to the male condom. `They finished quicker' or `They took longer to finish' were both mentioned as benefits! They commented that use became easier with practice. Their responses to the questionnaire at first follow up are shown in Table 2. Trust and power in relationships All three groups of women were able to initiate use of female condoms with their partners by explaining that they were taking part in research or trying out a new family planning method. This was not perceived as threatening or confrontational. With a few exceptions, after discussing it their partners were usually also interested in trying out the method. The majority of women were very appreciative of the condom and at follow up they reported that the vast majority of their partners liked the method and were encouraging them to get more. Only a few partners of urban women objected to the women using the method because they thought it would encourage them to become casual about sex, or because the women would be more in control and no longer have to worry about becoming pregnant or getting an infection. The women's main reason for wanting to use this method was as protection against infection, because their partners often refused to use male condoms and they could not force them to do so. An overriding problem expressed during discussions with all three groups of women was a deep distrust of their partners. `Men sometimes take their condoms off during intercourse. You can't rely on them.' A curious anxiety they expressed was that their partners sometimes made pinholes or tears in male condoms, even through the packets. They said this was because their partners wanted to cheat them, that they did not consider the women really to belong to them unless they `left something behind'. This gave the women the feeling that their partners were protecting themselves, but not worrying about protecting the women. The female condom was more appealing in this context because the women kept them, opened the packets and inserted the condom themselves. Very few of the women felt they could rely their men to protect them, or to act in their best interests, or to be as careful as they themselves would be. With the female condom, they felt more confident because they inserted the condom themselves and they did not have to rely on their partners to do it. `We never see our men putting the condoms on, they turn away and hide themselves from us, and usually it is in the dark anyway. All we know is that these male condoms break very often and we are suspicious they have been tampered with.' The women felt more protected with female condoms because they looked strong and were unlikely to break. Many of the women were used to inserting water, cloths, and herbs into their vaginas in preparation for sexual intercourse and were familiar with how their vagina and cervix felt. Using female condoms became easier with practice and the majority felt that the method did not interfere with their sexual pleasure. Some of the women complained that the male condom was sometimes too small, leading to it breaking or being too tight for the man. None of them had these complaints about the female condom, which was perceived to `fit all sizes'. An added advantages mentioned by many women was that they liked to use the condoms when they were menstruating. Main problems experienced Because practically all the women came for the first follow up, the range and incidence of te problems they described and the solutions they tried were more representative than at the second follow up.(23) The urban group had more problems with the method overall, but they also used fewer condoms on average than the other groups. The main complaints from all three groups were initial difficulty of insertion (which became easier with practice), that the inner ring was uncomfortable, that there was too much lubrication and that they were afraid during sex that the outer ring might get pushed up during intercourse (see Table 2). Inner ring Among the most common complaints was that the inner ring felt uncomfortable during intercourse. This was more likely if the condom was not positioned so that the inner ring was anchored around the cervix (as with a diaphragm). We corrected this by again demonstrating how to insert the condom or by advising the woman to remove the inner ring after insertion. A few women solved this problem themselves by removing the inner ring and using their partners' penis as an insertor. Outer ring Many women expressed anxiety that the outer ring would get pushed up into the vagina during penetration, and some reported that they held on to the ring because of this. The information sheet that comes with the device addresses this issue. It recommends that more lubrication should be added inside the condom or directly onto the penis, in order to reduce friction between the condom material and the penis, and to assist the mechanics of penetration. We made the analogy to a car piston which needs plenty of oil to move smoothly in the cylinder! This was tried by some women with good results. Lubrication and dry sex Most women felt that there was adequate lubrication, which made the condom easy to insert and made sex enjoyable. Others felt there was too much lubrication, which potentially creates a problem about comfort during use. The whole issue of `dry sex' practices is a complex one. These are widespread in East and Southern Africa and have only recently been described openly. Women usually say they use vaginal drying agents because their men want them to, but these practices may themselves contribute to transmission of STDs and HIV.(26,27) Nothing has been published to date on what men actually feel about dry sex and why it is important for them. Another study in Harare, which is following up a cohort of factory workers, has done a small pilot survey with a group of 15 men to find out their views on these practices.(24) Most of the 15 men said they found women's vaginal fluids distasteful and a sign of `uncleanliness' rather than a sign of arousal: `I don't like it because those fluids give you diseases, like STDs.' Many of the men said they had asked their partners to sort themselves out, often sending them to female relatives to learn the techniques. Substances used vary from cold water and towels, to toothpaste, antiseptic and balm, as well as many traditional herbs. This was especially the case after childbirth. The men also felt it was easier to discuss this with their girlfriends than their wives, but they also expected their wives to perform these practices. Certain sex workers have developed good reputations as women who use a certain type of stone, which makes them `as tight as a virgin even though you know she isn't!' We found that it was not only tightness that was desirable, but also that the vaginal fluids would be removed. Several men mentioned that if they found a woman to be wet during sex, it made them suspicious of who had been there before them. This was the case not only with sex workers, but also with their wives. `If you find a woman too easy to penetrate, it shows she has been used a lot...' `Those fluids make a woman too big, like a river, then you think she is like a prostitute...' The men admitted that using a condom meant that they did not have to come into contact with these fluids, but at the same time, they said they missed that `skin to skin' contact. Table 1. Baseline data on women enrolled in the female condom acceptability study Characteristic Sex workers -- Urban Rural two groups women women N=89 N=84 N=23 Mean age (years) 29.7 29.3 28.0 Range (years) 19-59 18-45 15-44 Number married 10% 82% 83% Number divorced 67% 5% 0 Number with dependent children 72% 89% 96% Mean years in commercial sex 3-9 -- -- Number clients per week 0-4 57% -- -- 5-9 27% -- -- Ever-use of male condom 88% 76% 57% Refusal by partners to use male condom 62% 45% 22% Self-reported history of STD in past year 46% 13% 4% Knows person with AIDS 37% 58% 61% Feels she could get HIV/AIDS 72% 69% 70% Considers her risk high 19% 8% 4% Has had HIV test 15% 23% 4% Reason for joining trial -- wants protection from STD/HIV 84% 70% 78% First impression of female condom -- OK 42% 34% 56% First impression -- too big 28% 23% 17% Table 2. Response to female condom at first follow up Sex workers Sex workers Group 1 Group 2 Initial number enrolled 59 54 Number followed up (%) 59 (100%) 54 (100%) Time interval to follow up 1 week 1 month Mean number of female condoms used 7 20 General reaction -- Liked very much 88% 93% -- Liked fairly well 12% 4% -- Steady partners liked it 92% (N=26) 91% (N=33) -- Clients liked it 82% (N=39) 68% (N=22) Liked it better than male condom 81% 91% Material -- Liked it very much 76% 98% -- Liked it fairly well 24% -- Fits (right size) 78% 93% Method of insertion -- Using inner ring 92% 93% -- Condom on penis 8% 6% Ease of insertion -- Very easy 66% 94% -- Fairly easy 24% 0 -- Difficult 10% 4% Lubrication -- Not enough 7% 0 -- Just right 76% 82% -- Too much 17% 17% Condom stayed in place 76% 76% Use became easier with practice 89% 98% Easy to remove 85% 98% Specific problems -- Inner ring problematic 2% 1% -- Outer ring problematic 2% 0 -- Breakage 0 0 -- Penis went between vaginal wall and condom 1% 9% -- Outer ring was pushed up 3% 6% -- Interfered with sex 0 0 Urban Rural Initial number enrolled 84 24 Number followed up (%) 62 (74%) 18 (75%) Time interval to follow up 1-2 weeks 3 months Mean number of female condoms used 5 10 General reaction -- Liked very much 56% 100% -- Liked fairly well 39% 0 -- Steady partners liked it 74% 100% -- Clients liked it -- -- Liked it better than male condom 66% 100% Material -- Liked it very much 53% 100% -- Liked it fairly well 35% -- Fits (right size) 74% 100% Method of insertion -- Using inner ring 97% 100% -- Condom on penis 2% 0 Ease of insertion -- Very easy 61% 100% -- Fairly easy 26% 0 -- Difficult 11% 0 Lubrication -- Not enough 5% 0 -- Just right 61% 94% -- Too much 31% 6% Condom stayed in place 74% 89% Use became easier with practice 92% 100% Easy to remove 79% -- Specific problems -- Inner ring problematic 3% 0 -- Outer ring problematic 2% 0 -- Breakage 0 0 -- Penis went between vaginal wall and condom 1% 0 -- Outer ring was pushed up 10% 0 -- Interfered with sex 11% 0 Bassett, Mary|Machekano, Roderick|Manangazira, Portia|Maposhere, Caro, Acceptablilty of the Female Condom in Zimbabwe: Positive but Male- Centred Responses [Part 1 of 2]. , Reproductive Health Matters, 05-01-1995, pp 68-74.