The condom conundrum: how to persuade Africa's prostitutes to practice safe sex

In the second part of his 3,000 mile odyssey through the heart of Africa’s Aids epidemic, Jeremy Laurance discovers the elaborate strategies adopted to persuade sex workers to practise safe sex

Day Two Nairobi, Kenya

Gloria Gakki should be in line to win $100,000 (£62,000). Her idea for improving the appeal of condoms meets the “grand challenge” launched by Bill Gates who earlier this year offered the prize to anyone who could devise a means of increasing their popularity. She is training sex workers to put condoms on with their mouths.

Read more:

A journey to the heart of Africa’s Aids epidemic

The Ministry of Defence in Zambia could be a winner, too. It has designed a packet in camouflage colours and labelled it “Full Combat”.

The problem with the condom has never been its effectiveness but its acceptability. Despite 30 years of research and the expenditure of billions of dollars, no one has come up with a better form of protection against HIV. But worldwide only 5 per cent of men use them.

It’s like sucking a sweet with the paper on, its detractors say. You don’t eat a banana without peeling it.

On the wall of Ms Gakki’s office more than 100 different varieties are displayed – flavoured, ribbed, coloured – in their glittering packages. As prevention manager for the Sex Workers Outreach Project in Nairobi she hands out 1.5 million each year, more than any other organisation in Kenya. “If we didn’t have condoms, Nairobi would be on fire,” she said.

Condom use among sex workers in Nairobi has risen from near zero in the 1980s to approaching 100 per cent today. It has been achieved, she said, by “moving the focus from the professionals to the community that uses them”.

But condoms have a fatal flaw – it is called trust. While their use in casual sex has hugely improved over the past 20 years, once couples are established they discard them. To continue implies mistrust.

In Livingstone, on Zambia’s border with Zimbabwe and Botswana close to Victoria Falls, one in five of the population are infected with HIV. A border town with a mobile population, truck stops and cross-border traders smuggling fuel, alcohol and soft drinks it is a magnet for sex workers. Squatting in the dust with a group of a dozen sex workers, Abigail, 27, says she has three boyfriends. “They give you things. I don’t use condoms with them. It is not possible.”

In Johannesburg, a 2010 study found more than 90 per cent of sex workers said they used condoms with clients. But half said they dropped them with boyfriends and partners.

“They trust their boyfriends. That is what makes them vulnerable,” said Maria Sibanyoni, the sex worker programme manager at the University of Witwatersrand.

In Kampala, Molly Businge, the chief nurse at the Kawaala Health Centre, crowded with hundreds of patients on a Monday morning, wiped the sweat from her forehead and flung her handkerchief onto her desk.

“If a man uses a condom, the women will ask him ‘Are you sick?’ If a woman uses one, he will ask her ‘Are you having other men?’ Most people have negative attitudes to condoms. There is very little use by couples,” she said.

Even for those who want them, supplies are erratic. James Mamboleo, 36, a plumber, was lucky. He asked for a box while waiting for an HIV test at the Sokoni Centre in Nairobi and got it – contents: 144.

“How long will they last?” I asked, noting the alcohol on his breath. “Two weeks,” interjected his friend, laughing.

“He is an African man,” said Jane Thiomi, project leader at LVCT, a Kenyan HIV agency, smiling.

You do not see such largesse in Uganda, which has been plagued by shortages. Jennifer, a sex worker for 12 years in the Kisenyi slum in Kampala recalled the “condom crisis” a few years ago. “I used plastic bags. They were held in place with a rubber band,” she said.

Last year, just 58 million condoms were delivered for free distribution in Uganda, barely a quarter of what was ordered. This year supplies have improved – but more than half of the 280 million ordered are still awaited.

Those most vulnerable – schoolgirls – are denied them. It is against the law to distribute condoms to under-18s. Vastha Kibirige, Uganda’s condom czar, described passing a secondary school where a group of girls saw what she was carrying.

“‘Can you give us some?’ they shouted. I said ‘No, I will be in jail.’ They said: ‘What do you want us to do – die?’” she said.

Even where condoms are acceptable they have a major drawback. They are controlled by men. Negotiating condom use is difficult for women – and often impossible.

The female condom was supposed to hand control to women. But it must be inserted 10 to 15 minutes before sex to “warm up” or it is noisy – a key weakness for sex workers. Some have left a single one in place while having sex with different clients – transforming a protective device into a potentially lethal one.

Many in government and charity organisations I spoke to complained they had wasted thousands of dollars on female condoms which they could not give away. Its defenders, on the other hand, claimed the problem lay not with the product but with the marketing. It hasn’t had any. Male condoms are promoted on billboards, in bars and offices throughout Africa.

Regular users say the female condom improves pleasure for both partners, because the man moves inside it and the woman is stimulated by the external ring. In the Kenyan district of Makwene, 200km from Nairobi, men have begun asking for it after it was popularised by the District Aids Officer. “The message was sold right,” said Jane Thiomi.

To overcome these problems researchers have sought alternatives. Tests with microbicidal gels inserted in the vagina to kill HIV have yielded mixed results. While one study found a 39 per cent reduction in HIV infection another, in which women were required to insert the gel daily, showed no effect. Women claimed to be using it in order to get the regular medical check-ups but instead threw it away.

Deborah Baron, the manager of the latest and biggest study at the University of Wiwatersrand called Facts, involving almost 3,000 women at nine sites across South Africa, said: “We know these products work biologically. We have got to find a way to help women use them. I know sunscreen works – but when I go on holiday I get burnt.”

Researchers expected the women to use the gel secretly. In practice eight out of 10 told their partners. Some complained about the quantity they had to insert – 4mls – and said it leaked into their pants.

Dorcas, 28, a shop assistant from Daveyton in Johannesburg, with painted nails, a pink blouse, and gold earrings, who participated in an earlier study, said: “It was so uncomfortable. With lubricant you use a little but with this you had to put the whole thing. I was using it in the morning so when I had sex it had dried out. I was living with my boyfriend – it would have been impossible to keep secret.”

Catherine, 28, a saleswoman, and Khesani, 26, mother of a 20-month-old boy, said they would prefer a daily pill to the gel, which would be easier to use secretly, even though it would mean taking a higher dose of the drug. “You can hide them in the house, take them to work and swallow them,” said Catherine.

The greatest hopes now rest on the vaginal ring, a device made of soft silicone that slow-releases microbicide into the vagina and can be left in place for a month. It is being tested in 5,000 women in five countries across southern Africa (in two separate trials) and the results are due in 2015.

“You put it in and forget about it. Most women say they love it,” said Krina Reddy, one of the trial co-ordinators. “The staff are excited. We do have faith this will work.”

Dr Thesla Panalee, the international co-chair of the Microbicides Trials Network, said: “We have our fingers crossed. It has been a long time coming. We do need women-controlled methods against HIV.”

Western jazz: Madam C’s battle

In the battle against HIV, understanding the detail is critical.

In Uganda, Vastha Kibirige has held the position of condom czar for more than a decade. Madam C, as she is known, enjoys her job.

As she settled herself on the sofa at the Karibu Hotel in Entebbe she explained the difficulty the female condom poses for aficionados of “western jazz”.

“It is the name we use for foreplay – when the man uses the tip of his penis to play with the woman’s labia. But the labia is covered by the female condom – so it wasn’t popular.”

Only by attending to such human peccadilloes are lives saved – or lost.

The male condom remains the bedrock of the defence against the virus. But supply has been erratic.

“The moment we run out, people go back to BBC – body to body contact,” Ms Kibirige said. “Once they get used to BBC they stick to that. If you want people to use condoms you have to keep the flow going.”

Tomorrow: Children – a new approach to protecting the next generation - if the fathers agree.

Start your day with The Independent, sign up for daily news emails
News
newsAnother week, another dress controversy on the internet
Life and Style
Scientist have developed a test which predicts whether you'll live for another ten years
health
Life and Style
Marie had fake ID, in the name of Johanna Koch, after she evaded capture by the Nazis in wartime Berlin
historyOne woman's secret life as a Jew in wartime Berlin
News
news... and what your reaction to the creatures above says about you
Have you tried new the Independent Digital Edition apps?
ebooks
ebooksA special investigation by Andy McSmith
Latest stories from i100
Have you tried new the Independent Digital Edition apps?
Independent Dating
and  

By clicking 'Search' you
are agreeing to our
Terms of Use.

iJobs Job Widget
iJobs General

Recruitment Genius: Telesales & Customer Service Executive - Call Centre Jobs

£7 - £9 per hour: Recruitment Genius: Are you outgoing? Do you want to work in...

Ashdown Group: Finance Manager - Covent Garden, central London - £45k - £55k

£45000 - £55000 per annum + 30 days holiday: Ashdown Group: Finance Manager - ...

Ashdown Group: Systems Administrator - Lancashire - £30,000

£28000 - £30000 per annum: Ashdown Group: 3rd Line Support Engineer / Network ...

Recruitment Genius: Graduate Web Developer

£26000 - £33000 per annum: Recruitment Genius: A Web Developer is required to ...

Day In a Page

The difference between America and Israel? There isn’t one

The difference between America and Israel? There isn’t one

Netanyahu knows he can get away with anything in America, says Robert Fisk
Families clubbing together to build their own affordable accommodation

Do It Yourself approach to securing a new house

Community land trusts marking a new trend for taking the initiative away from developers
Head of WWF UK: We didn’t send Cameron to the Arctic to see green ideas freeze

David Nussbaum: We didn’t send Cameron to the Arctic to see green ideas freeze

The head of WWF UK remains sanguine despite the Government’s failure to live up to its pledges on the environment
Author Kazuo Ishiguro on being inspired by shoot-outs and samurai

Author Kazuo Ishiguro on being inspired by shoot-outs and samurai

Set in a mythologised 5th-century Britain, ‘The Buried Giant’ is a strange beast
With money, corruption and drugs, this monk fears Buddhism in Thailand is a ‘poisoned fruit’

Money, corruption and drugs

The monk who fears Buddhism in Thailand is a ‘poisoned fruit’
America's first slavery museum established at Django Unchained plantation - 150 years after slavery outlawed

150 years after it was outlawed...

... America's first slavery museum is established in Louisiana
Kelly Clarkson: How I snubbed Simon Cowell and become a Grammy-winning superstar

Kelly Clarkson: How I snubbed Simon Cowell and become a Grammy-winning superstar

The first 'American Idol' winner on how she manages to remain her own woman – Jane Austen fascination and all
Tony Oursler on exploring our uneasy relationship with technology with his new show

You won't believe your eyes

Tony Oursler's new show explores our uneasy relationship with technology. He's one of a growing number of artists with that preoccupation
Ian Herbert: Peter Moores must go. He should never have been brought back to fail again

Moores must go. He should never have been brought back to fail again

The England coach leaves players to find solutions - which makes you wonder where he adds value, says Ian Herbert
War with Isis: Fears that the looming battle for Mosul will unleash 'a million refugees'

The battle for Mosul will unleash 'a million refugees'

Aid agencies prepare for vast exodus following planned Iraqi offensive against the Isis-held city, reports Patrick Cockburn
Yvette Cooper: We can't lose the election. There's too much on the line

Yvette Cooper: We can't lose the election. There's too much on the line

The shadow Home Secretary on fighting radical Islam, protecting children, and why anyone in Labour who's thinking beyond May must 'sort themselves out'
A bad week for the Greens: Leader Natalie Bennett's 'car crash' radio interview is followed by Brighton council's failure to set a budget due to infighting

It's not easy being Green

After a bad week in which its leader had a public meltdown and its only city council couldn't agree on a budget vote, what next for the alternative party? It's over to Caroline Lucas to find out
Gorillas nearly missed: BBC producers didn't want to broadcast Sir David Attenborough's famed Rwandan encounter

Gorillas nearly missed

BBC producers didn't want to broadcast Sir David Attenborough's famed Rwandan encounter
Downton Abbey effect sees impoverished Italian nobles inspired to open their doors to paying guests for up to €650 a night

The Downton Abbey effect

Impoverished Italian nobles are opening their doors to paying guests, inspired by the TV drama
China's wild panda numbers have increased by 17% since 2003, new census reveals

China's wild panda numbers on the up

New census reveals 17% since 2003