Condom Distribution as a Structural Level Intervention
Scientific Support for Condom Distribution
Individual-level and group-level risk reduction interventions are effective in increasing condom use and reducing unprotected sex. These types of interventions, however, focus on an individual’s personal risk and do not address barriers beyond the individual, such as not having access to condoms. Structural-level interventions are particularly attractive in HIV prevention efforts because they are designed to address external factors that impact personal risk for HIV. A recent meta-analysis, reviewing the scientific literature on structural-level interventions aiming to increase the availability, accessibility, and acceptability of condoms, found that:
- Structural-level condom distribution interventions or programs (CD programs) are efficacious in increasing condom use, increasing condom acquisition or condom carrying, promoting delayed sexual initiation or abstinence among youth, and reducing incident STIs.
- Interventions that combined CD programs with additional individual-, group- or community-level activities showed the greatest efficacy. One possible reason for this is that these different modalities address different behavioral determinants as well as other prevention needs of individuals in affected communities.
- CD programs were efficacious in increasing condom use among a wide range of populations, including youth, commercial sex workers, adult males, STD clinic patients, and populations in high risk areas.
CD programs have been shown to be cost-effective and cost saving. It was estimated that one state-wide CD program led to saving millions of dollars in future medical care costs by preventing HIV infections.
Programmatic Considerations for Condom Distribution
Programs should consider implementing CD programs in their communities. As resources and capacity warrant, programs should also consider integrating a CD program with other HIV prevention strategies and health care services as part of a comprehensive HIV prevention approach.
Those interested in designing and implementing a CD program should consider including these elements:
- Provide condoms free of charge.
- Conduct wide-scale distribution.
- Implement a social marketing campaign to promote condom use (by increasing awareness of condom benefits and normalizing condom use within communities).
- Conduct both promotion and distribution activities at the individual, organizational, and environmental levels.
- Target: 1) individuals at high risk, 2) venues frequented by high-risk individuals, 3) communities at greatest risk for HIV infection, especially those marginalized by social, economic, or other structural conditions, or 4) the general population within jurisdictions with high HIV incidence.
- Supplement the CD program with more intense risk reduction interventions or other prevention or health services for individuals at highest risk. Integrate CD program activities within other community-level intervention approaches to promote condom use and other risk reduction behaviors.
- Establish organizational support for condom distribution and promotion activities in traditional and non-traditional venues.
- Conduct community-wide mobilization efforts to support and encourage condom use.
Important issues to consider while planning and designing a CD program are:
- Develop a process for identifying and engaging appropriate community partners.
- Identify who plans, implements, manages, and provides resources to support a CD program.
- Identify obstacles to reaching members of vulnerable or hard-to-reach populations and strategies to overcome them.
- Calculate the costs and determine the scale of a CD program.
- Identify the laws, policies, or practices that may support or hinder a CD program.
- Define programmatic objectives, key indicators for measuring performance, and how these data will be collected. Key indicators to consider are:
- Number of condoms distributed
- Number of agencies, venues, or settings where free condoms are distributed
- Estimated number of audience impressions from campaign messages
Snapshots of Existing CD Programs
New York City Department of Health & Mental Hygiene (NYC DOHMH)
- The NYC DOHMH distributes free condoms and water-based lubricants to partnering organizations through their web site.
- Partners include traditional public health agencies (e.g. clinics, hospitals, CBOs, shelters), schools, and businesses (e.g. health clubs, bars, barbershops, clothing stores, hotels).
- Distribution grew from 5.8 million free condoms in 2004 to 17.3 million in 2006 to 41.5 million in 2009.
- Since 2007, DOHMH has branded, packaged, and distributed its own “NYC Condom” to appeal to the local community.
- Social marketing campaigns are conducted annually and include TV and subway ads, web banners, and posters. Ad designs are tailored to particular communities within NYC.
- Social media are being used to promote condom use.
- The web site also provides information on free condoms by zipcode and borough, correct condom usage, and other HIV/STD resources in the city.
District of Columbia (DC) Department of Health: HIV/AIDS, Hepatitis, STD, & TB Administration (HAHSTA)
- HAHSTA distributes free condoms and lubricants to partnering organizations and to any DC resident through their web site.
- More than 300 traditional partners and hundreds of other local businesses (e.g. clubs, laundromats, convenience stores, beauty shops, nail salons, barber shops, liquor stores) provide free condoms to the community.
- Distribution grew from 500,000 free condoms in 2007 to 3.5 million in 2009.
- The social marketing campaign includes customized condom packages, dispensers, information cards, stickers, t-shirts, and posters/decals to promote condom use and emphasize condom availability at participating locations.
- The web site provides information on where to obtain free condoms and correct condom usage.
- Youth-specific condom promotion and education campaigns have been developed to work with youth-serving CBOs and schools.
- Social media are being used to promote condom use and to identify locations that provide free condoms by zip code.
CDC has identified additional examples of condom distribution programs implemented in various settings that may be useful to agencies interested in initiating or augmenting their condom distribution programs.