Study of condom access and factors that influence uptake and utilization of male and female condoms in Zanzibar

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Condoms reduce the risk of transmitting Human Immunodeficiency Virus (HIV) and Sexually Transmitted Infections (STIs). Zanzibar AIDS Commission (ZAC) noted through the condom assessment of 2016 that although condoms acceptance and use increased in the past 10 years, availability was still limited. The strategy Zanzibar condom strategy of 2016 noted that condoms availability and distribution in Zanzibar was influenced by cultural and religious beliefs and laxity in the procurement and supply management system. ZAC therefore undertook a condom study within all the 11 districts October 2018. The overall goal of this study was to determine factors that influence the uptake and usage of male and female condoms in Zanzibar. The study sought information from community members, condom suppliers, connectors1 and influential persons with focus to determine the: extent to which male and female condoms are accessible; barriers to obtaining male or female condoms; reasons that make people use or not use condoms; community attitudes and perceptions towards condoms; and how condom accessibility might be improved. The study found that condoms are moderately accessible for community members in Zanzibar. 59% of the community members reported that condoms are easily accessible and available, while 50% reported having used a condom. Condoms were reported as more available in urban areas and easily accessed at health facilities and community outreach projects. The interviewees stated that they found it easier to use male condoms, yet many had never seen the female condoms and only 3% of the respondents reported using them. Condom brands that were reported most available in the communities were Salama, Government supplied condoms and Dume as mentioned by 37%, 35% and 10% of the community members interviewed. The Government condoms are distributed free of charge, Salama is sold at Tanzania Shillings (TZS) 500 and Dume at TZS 1,000. Barriers found to be limiting access to male and female condoms in Zanzibar included: (a) stigma faced at condom distribution outlets, whereby less than a half (47%) found the outlets very convenient; (b) unfriendliness of some service providers who violated privacy, were judgmental, refused to give out condoms, or did not understand the clients’ needs, whereby only 47% found the providers to be very friendly; (c) selling price and cost of obtaining condoms which ranged from free to TZS 6,000 for some people; (d) far distance from condom distribution outlets which led some to spend an average of TZS 500 to TZS 1,600 on transport; (e) ignorance on where to get and how to use condoms as noted by 20% of the interviewees; (f) lack of privacy where condoms are sourced; (g) and restrictive socio-cultural and religious norms as quoted by 49% of the interviewees. The study found a moderate use of condoms at the most recent sexual intercourse whereby 41% reported having used a condom on this occasion. Male and female condoms were used by 92% and 3% of the respondents respectively. The following proportion of those who used condoms at last sex reported various reasons for their usage: 56% to prevent STI; 38% to prevent unplanned pregnancies; 19% to prevent HIV re-infection; 10% to protect partner from infections; 10% to prevent HIV infection; and 6% to protect self from a partner who was not trusted. Likewise, the following proportion of those who did not use condoms at last sex reported the following reasons for non-usage: 46% due to trusting their sex partners; 24% because they or their partners did not like condom; 6% due to not having condoms; 5% for fearing perceived side effects2 of using condoms; 5% for not having tested for disease; and 3% in order to comply with religious restrictions for not using condoms. Other reasons reported by community members for non-use of condoms included: wanting to conceive children; fearing rejection or Gender Based Violence (GBV) from a sex partner who dislikes condoms; not having money for obtaining condoms; and fear of damaging their image or reputation due to the stigma associated with using condoms. 79% felt that it is challenging to use the female condom as compared male condoms. The study found a mix of both positive and supportive attitudes, as well as negative attitudes towards condoms among community members and other stakeholders interviewed. Most of the influential persons within the Government Ministries, Departments and Agencies (MDAs) and Development Partners held the notion that condoms play a critical function to prevent infection with diseases and unplanned pregnancies, therefore condom use should be promoted. The same position was held by health workers, pharmacists and connectors. Community members who also mirrored this notion specified the critical role of condoms to: prevent unplanned pregnancies, STIs, HIV, and HIV re-infection. Some also mentioned maintaining hygiene during sex and enhancing the freedom to enjoy sex without worrying about infections. Some of the religious leaders and a few community members did not embrace the use of condoms. The faith leaders mostly took the position of: promoting abstinence and faithfulness; forbidding condom use; allowing condom use only for HIV discordant couples; accepting condoms for Family Planning (FP) among married couples; and/or leaving condom use as a personal decision for individuals. The community members who did not support the promotion of condom use in Zanzibar stated that condoms: reduce the enjoyment and satisfaction of sex; have various negative side-effects; tend to burst during sex and thereby cause unplanned pregnancies and the spread of disease; promote promiscuity; and deny people the right to have children. Stakeholders who were interviewed made the following recommendations for improving access to and utilization of condoms: establish more condom distribution outlets, especially in the under-served remote and/or rural areas; distribute condoms in more diversified outlets like recreation places, hotels, learning institutions and other places; enhance client privacy and confidentiality at places where condoms are being distributed; undertake Information Education and Communication (IEC) for community members on benefits of, how to use and where to obtain condoms; implement Social and Behavior Change (SBCC) to increase uptake and utilization of condoms by community members; identify and deploy more connectors to distribute condoms and provide information among various community groups; engage all stakeholders in providing information and making decisions related to condom programming; increase friendliness of service providers; provide guidelines for condom programming; reduce price and cost of obtaining condoms; undertake quality assurance to make sure condoms don’t burst or have negative effects; compel written and drawn instructions for usage and disposal on the condom packaging; and control ages of persons whom condoms can be sold to.