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In today’s climate of budget cuts, reproductive health facility administrators may be tempted to eye free distribution of condoms as a potential source for belt-tightening. However, a recently published study indicates that when condom distribution programs switch from a no-charge to even a minimal-charge status, use of such protection drops.1
Any budget savings is not worth the risk of potential HIV infection, contends Thomas Farley, MD, MPH, medical director of the HIV/STD prevention program in the Louisiana Office of Public Health’s Department of Health and Hospitals in New Orleans. "The calculation we use here is that if you assume that an HIV infection in one person indebts you to $100,000 in future medical costs, then if you distribute 2 million condoms and prevent only one HIV infection, then it is cost-effective," notes Farley, a co-author of the study.
As a response to the epidemic of HIV and the high rates of other sexually transmitted diseases (STDs), the Louisiana Department of Health and Hospitals developed Operation Protect in 1993.
A statewide social marketing campaign, Operation Protect was designed to increase accessibility of condoms by providing them in a targeted fashion at 93 public health clinics, 39 community mental health centers, 29 substance abuse treatment sites, and more than 1,000 small businesses in neighborhoods with high rates of STD and HIV, says Deborah Cohen, MD, MPH, associate professor in the department of public health and preventive medicine at Louisiana State University Medical Center in New Orleans. Cohen served as lead author for the two evaluations addressing the Operation Protect program.
From 1994 to 1996, more than 33 million condoms were distributed for free in the state.2 Self-reported condom use increased, especially among African-American men and African-American women with two or more sex partners, research shows. The demand for free condoms eventually outstripped the purchasing budget, Cohen says.
"The problem we had was that we were victims of our own success. The condoms were so popular that we ran into budget problems," Farley says.
State acted as condom broker
To address the budget situation, the state then experimented with developing a private-label brand of condoms, says Farley. The state acted as a broker by obtaining a guaranteed price from Ansell Personal Products of Eatontown, NJ, the condom manufacturing company, then directing participating retail outlets to communicate directly with the manufacturer on orders. Retail outlets then were able to purchase condoms at the negotiated 8 cents per condom bulk rate and sell them at a discounted rate of up to 25 cents each. A number of retail sites switched from free distribution to for-sale distribution.
The state evaluated the impact of the transition on reported condom use among persons with two or more sex partners with pretest and post-test surveys. At pretest, 57% of respondents had obtained free condoms, and 77% had used a condom during their most recent sexual encounter. When the price was raised to 25 cents, the respective percentages decreased to 30% and 64%.
"We saw the number of condoms distributed go down dramatically, and condom use went down as well," observes Farley.
Based on the surveys’ results, the state terminated the low-cost condom program and returned to the free distribution method, Farley reports.
"We are trying to re-establish the free condom distribution in small businesses in neighborhoods with a high incidence of STD/HIV," says Cohen. "We are continuing to encourage free distribution in public sites as well."
The commitment to the statewide condom program is not lightly taken, Farley observes. "Using state funds, [the condom budget] runs $600,000 a year," he says. "In very rough terms, it costs us 5 cents per condom, and we distribute 12 million condoms a year."
State public health officials say the cost is worth the commitment, given the fact that Louisiana is one of the top 10 states in the nation in syphilis, gonorrhea, and other STD rates and is experiencing rapid increases in heterosexually transmitted HIV. Given the spread of HIV and the acknowledgement of the protective role condoms play in averting disease transmission, more emphasis should be put on a national condom distribution program, Farley and Cohen contend. The two served as co-authors of a paper calling for such a policy.3
"People frequently list purchase of condoms as sort of the last item on their budget, when I think it perhaps ought to be the first," says Farley. "At the bare minimum, we ought to have an adequate supply of condoms for everyone out there, and to the extent that we can afford it, we also should have people who can provide counseling and other services."
1. Cohen D, Scribner R, Bedimo R, et al. Cost as a barrier to condom use: The evidence for condom subsidies in the United States. Am J Public Health 1999; 89:567-568.
2. Cohen DA, Farley TA, Bedimo-Etame JR, et al. Implementation of condom social marketing in Louisiana, 1993 to 1996. Am J Public Health 1999; 89:204-208.
3. Cohen DA, Farley TA, Bugg S. Why the U.S. needs a national policy on condoms. AIDS & Public Policy J 1997; 12:128-135.