Challenging Dogma - Fall 2011

Friday, December 23, 2011

Inadequacies of Male Condom Promotion as a Means of HIV/AIDS Prevention Among Commercial Sex Workers in Madagascar – Alison Mickiewicz


Madagascar, an island nation located off the south east coast of Africa, is a country faced with numerous health issues, one of the direst being rising rates of sexually transmitted infections (STIs) and HIV/AIDS. With a population of approximately 21.3 million, the number of persons 15-49 years of age living with HIV/AIDS is estimated at 0.1%, a number that has risen steadily over the past 20 years (1).


Figure 1. Source: Epidemiological Fact Sheet on HIV and AIDS, UNAIDS, 2008.

Although this is a relatively low figure compared to many countries in sub-Saharan Africa, the rates of STIs including syphilis, gonorrhea, and trichomoniasis remain high (2). According to the U.S. Agency for International Development (USAID), rates of STIs in Madagascar are among the highest in the world (1). The presence of an STI has been linked to heightened susceptibility to HIV infection (3). In addition to the prevalence of STIs in Madagascar, low literacy, limited access to healthcare services, pervasive poverty, and the acceptance of multiple sexual partners, has created the potential for epidemic-level HIV infections among the general population (4).

Three groups have been identified by USAID as most at risk of HIV infection: commercial sex workers (CSWs), men who have sex with men (MSM) and injecting drug users (1). This paper will focus on the effectiveness of condom promotion interventions as a method of HIV/AIDS prevention among CSWs. In Madagascar, CSWs have their own set of challenges for HIV prevention in addition to those of the general population. Fifty percent of the Malagasy population lives at or below the poverty line (5), when combined with low literacy rates and poor infrastructure, sex work is a quick and easy option for women to support their families (6). The work of a CSW is not without risk, in 2001, a study found the prevalence of chlamydia, gonorrhea, syphilis, and trichomoniasis among CSWs to be: 16.35%, 23.2%, 29.5%, and 53.05% respectively (7). In 2005, , the rate of HIV/AIDS among CSWs ranged from 0.6% for ‘major urban areas to 1.3% for ‘outside major urban areas’ (8), rates higher than the general population.

Focusing specialized interventions on CSWs is imperative, as this population has been described as the ‘nucleus of HIV transmission” (9). Condom promotion as a means of prevention against HIV transmission and other STIs is important to the general population, and critical to high risk groups such as CSWs. Current condom promotion interventions are centered around social marketing techniques which are based on the Theory of Reasoned Action (TRA). By employing mass media campaigns, the majority of the population is exposed to radio ads, billboards, and store signs promoting the use of condoms, an effective way to reach large numbers of people. However, my argument lies in the lack of support and education aimed directly at CSWs, given that they are such a high risk group with potential to act as a catalyst to the transmission of HIV and other STIs.

Developed in 1975 by Martin Fishbein and Icek Ajzen, The Theory of Reasoned Action lies on the premise that an individual’s actions are determined by said individual’s intentions (10). According to Fishbein, “at the simplest level, a reasoned action approach to the explanation and prediction of social behavior assumes that people’s behavior follows reasonably from their beliefs about performing that behavior” (11). Employing behavioral intentions as a basis for a health intervention appears reasonable, however, emotions and innate human irrationality is not taken into account. It is fair to say that what an individual intends to do is quite often not what that individual actually does; this is even more evident with behaviors related to health.


Figure 2. Theory of reasoned action. Adapted from Glanz, Rimer, & Lewis, 2002.

Sheppard, et al. point out that the original intention of TRA is to manage behaviors, not consequences that result from behaviors; more specifically, the behaviors outlined in the model are completely under the control of the individual (12). These limitations make TRA an unsuitable model for interventions that aim to modify behaviors with any strong outside influence, such as that from family, friends, media, and in the case of a CSW, a client.

Condom promotion in Madagascar is based heavily in brand recognition using mass media outlets. In 1998, Population Services International assumed management responsibility for the marketing of Protector brand condoms (13). In addition to administrative infrastructure changes and a product line expansion, PSI began an aggressive social marketing campaign to encourage use of Protector condoms as a means of HIV and STI prevention. PSI has succeeded in increasing sales, and presumably the use of, Protector brand condoms for the general population (see Figure 3). However, many studies conducted in recent years have demonstrated that condom use among CSWs is extremely low (14-16). Data suggests that such high risk groups present a need for dedicated condom promotion efforts that exceed current social marketing strategies through the TRA model. Current strategies do not address a number of limitations that CSWs are faced with in regard to condom use.


Figure 3. Source: Madagascar: Revitalizing a Social Marketing Program. PSI/Madagascar, 2003.

CSWs Have Limited Control Over a Male Partner’s Use of Condoms

Although male condoms do not eliminate the risk of infection, they are one of the most effective and economical options for prevention of HIV and other STIs (17,18). The drawback of male condom use is female reliance on her male partner to agree with use, therefore reducing female control over HIV and other STI prevention. In a study investigating perceived control over condom use among CSWs, it was found that almost 44% of the women interviewed answered “sometimes” when asked how frequently they used condoms with a client, approximately 41% answered “almost always,” and less that 7% answered “always” (16). Additionally, 40% of participants responded that they had “none/little” perceived control over male condom use with their client (16). CSWs face resistance to male condom use from their clients for a variety of reasons, some attributed to lack of knowledge, while other reasons stem from perceived loss of pleasure. Thomsen et. al. identified 50 reasons for not using a condom, gathered from interviews with male clients of CSWs in Mombasa, Kenya, an area that is similar to Madagascar in terms of CSW activity, as well as similar condom promotion techniques (19).

Clearly, current strategies are effective in condom promotion to the general population, but CSWs are faced with a set of challenges unique to their situation. When engaging in intercourse in exchange for money, CSWs are in a position in which they are often unable to negotiate the use of a male condom. Refusing to have sex with a client who will not use a male condom would mean loss of income for a CSW. More often than not, the decision is made to engage in unprotected sex; declining money is not an option for these women, many of whom support a family (6).Whether the CSW understands the dangers of unprotected sex and has knowledge of her risk for HIV/AIDS is inconsequential when her livelihood is dependent on satisfying her clients to obtain payment.

Variations in Definition of Relationship

Many CSWs polled in a study by Stoebenau, et. al. had a nonpaying “main partner” whom they identified as a boyfriend, husband, regular partner, or intimate partner (20). The majority of condom promotion mass media campaigns in Madagascar depict either a man and a woman together or a woman alone (21). The downside to this approach is that it does not clearly define what a partner is. Brochures and efforts targeting CSWs focus on condom use with a client, thus oversimplifying the range of relationships that a CSW may have. Often, the distinction between a nonpaying partner and a client can become unclear, as is the case when a tourist may began a relationship with a CSW as a paying client, but over the course of a two week vacation may enter into a relationship with the CSW. In this case, the tourist may pay for meals, clothes, and other gifts rather than exchange money for sexual intercourse exclusively; the definition of a “paying client” becomes uncertain.

Pettifor et al. found that of the CSWs participating in the study, approximately 42% had a nonpaying main partner; of those with a main partner, “the vast majority (70.8%) of women reported that their main partner probably or definitely had sex with other women in the past month” (16). Over 40% of CSWs surveyed reported never using a condom with their main partner; only 0.5% of CSWs in this same group reported that they never use a male condom with a client. Given that condom use with main partners is low, and sexual relationships with multiple partners is a common practice, relationships between CSWs and nonpaying or main partners are at a tremendous risk for HIV/AIDS and other STIs.

Social Marketing Campaigns Do Not Utilize CSW Support Systems

Although CSWs are stigmatized in Malagasy society, associations do exist to act as a support system. With the help of associations such as Fikambanana Miaro ny Zon’ny Rehetra (FIMIZORE), CSWs are able to seek out support in a safe environment. According to the International HIV/AIDS Alliance in Madagascar (the Alliance), a group that has provided financial and technical support to FIMIZORE, the group “promotes respect for [C]SWs through advocacy, information dissemination and training for relevant stakeholders, and contributes to the fight against infection” (9). Due to the shame many CSWs feel in response to societal marginalization, many are hesitant to join an association such as FIMIZORE. The association points out that CSWs are more inclined to prioritize their health when they are not forced to do so and when they have a strong support system (9).

Current condom promotion campaigns in Madagascar largely ignore the tremendous potential of groups like FIZIMORE as a resource. Creating a supporting environment for CSWs has been touted as an HIV/AIDS prevention best practice from the United Nations Programme on HIV/AIDS (22). A support system comprised of other CSWs promotes a sense of solidarity; by incorporating such groups into condom promotion interventions, the efficacy of such interventions will increase. Providing recognition to groups like FIZIMORE empowers CSWs and encourages positive health behavior change.

Proposed Intervention

Current efforts to increase awareness of and reduce rates of HIV/AIDS in Madagascar are commendable, given that such efforts have increased tremendously from virtually nothing in 15 years. Utilizing condom promotion as a primary means of HIV/AIDS prevention has proven an effective and financially prudent method. I would like to suggest that a proposed intervention would not replace current social marketing techniques, but rather build upon and expand the scope of the intervention.

Creating a plan that involves a multi-faceted approach to HIV/AIDS prevention aimed at CSWs will draw upon existing resources such as CSW associations and health clinics. The current situation in Madagascar is akin to a ticking time bomb, if preventative action is not taken immediately, rates of HIV/AIDS cases will skyrocket to rates currently occurring in other sub-Saharan countries.

Changing perception of CSWs is difficult and will require time, but it is possible to change efforts now to provide CSWs with HIV/AIDS education that goes beyond male condom social marketing promotion. It is imperative that Malagasy CSWs are equipped with the correct tools to protect themselves against HIV transmission, as they are in a position to potentially transmit HIV and other STIs to a large percentage of the population in a short amount of time.

Health clinics are located throughout the country and provide a framework upon which increased interventions can be built. As part of the Malagasy national health care system, Centre de Santé de Base (CSB) are local health clinics located throughout the country, providing healthcare access (albeit often rudimentary) to the Malagasy people. The CSB provides a location for expanded HIV/AIDS prevention efforts to reach a larger audience of CSWs while remaining accessible. As the CSB is a primary source of healthcare for the vast majority of Malagasy citizens, it services a wide range of healthcare issues and will not stigmatize CSWs as a healthcare center branded for CSWs only would. To address the three flaws identified with current HIV/AIDS prevention methods, I recommend three solutions that can be achieved with the proposed multi-faceted intervention.

Increase Awareness and Accessibility of Female Condoms

The most difficult barrier to overcome in regard to condom use cited among CSWs is convincing a client to use a male condom. Often, a higher rate can be negotiated to engage in sexual intercourse without a condom or a client may become violent at the suggestion of condom use (16). In the instance that a CSWs client refuses to use a male condom, a female condom can be used often without the client’s knowledge. Hoke et. al. states “a woman’s capacity to propose use of an alternative prevention method has reportedly heightened her bargaining power to insist on male condom use, furthering contributing to increases in protection” (15).

With respect to the proposed intervention, ensuring that female condoms are as readily available in shops as male condoms are will provide CSWs with a method to prevent the transmission of HIV that has proven as effective as the male condom (23). Many CSWs are aware of the benefits of condoms, but often are in a position in which they have limited influence over the decision to use or not use a condom when negotiating with a client. Promotion of the female condom puts the control in the hands of the CSW. Current social marketing campaigns promoting male condoms can easily be adapted in the context of female condoms, thereby building upon existing techniques, while also utilizing new interventions by involving the CSB.

Defining Sexual Relationships

In Malagasy culture, having multiple sexual partners is a practice which is quietly accepted. Based on the evidence, it is quite clear that many CSWs that have reported having a boyfriend or intimate partner are less likely to use a condom with that main partner than they are with a client. It is feasible that the main partner maintains a sexual relationship with one or more women in addition to the CSW; the interconnected nature of this situation allows for potential transmission of HIV or other STIs to an enormous number of people.

It is also important to recognize the various “levels” of sex work, low, middle, and high. Low sex work takes place during the day, often taking place in shacks or locations rented out in half hour increments for the purpose of sex. Middle work typically takes place at night on the street and is often prefaced by a verbal agreement between the CSW and client regarding financial compensation. Taking place in bars and nightclub, the high level of sex work is often the most undefined. Financial compensation is rarely discussed before the sexual exchange takes place, as many CSWs hope to find a potential husband. Regardless of the level of sex work, CSWs are at risk at every level, whether the sexual encounter took place in 30 minutes or over the course of a one year relationship.

The proposed intervention would rework current condom promotion strategies to explain the health implications of multiple partners and clearly emphasize the importance of condom use with all sexual partners. Providing a visual aid to show the connections that can potentially exist between multiple sexual partners will educate everyone to their possible risk of HIV/AIDS. It is important to highlight that a nonpaying partner is still at risk by not using a condom.

Collaborating With Existing CSW Support Systems

Faced with a great many hardships, CSWs often have limited or no access to healthcare. Social and environmental factors are highly influential to the behaviors of CSWs (33). Specifically, Peer-influence and social network norms have been found to increase condom use among CSWs (24). A strong social support system has been shown to help in reducing rates of HIV/AIDS among CSWs by promoting the use of condoms in a trustworthy environment. A recent study of CSWs in China found that a well-structured CSW social network prompted condom use in several ways: promoting wholesale purchasing of condoms, mediating condom use with clients, and providing options for clients who refuse to use a male condom (24).

Existing CSW groups in Madagascar, such as FIZIMORE, could benefit from collaboration with the local CBS to increase influence over decisions such as condom distribution and the availability of HIV testing opportunities. By establishing a presence in the community and making condom use and HIV/AIDS prevention a topic of conversation, CSB doctors and nurses can provide backing to the work of the CSW groups. Additionally, demographic information and health statistics can be gathered at the CSB, allowing for quantitative analyses to aid in the overarching campaign goals.


Poverty, stigma, violence, and lack of education are just a few adversities facing CSWs in Madagascar. The threat of HIV/AIDS may not appear as a threat to many CSWs, as symptoms are not immediately visible. Given the reach CSWs have among sexual relationships with clients and nonpaying partners, adoption of an effective HIV prevention method such as condom use is critical to preventing new cases. Existing condom promotion campaigns have laid the foundation for expanded techniques, and have brought to light the importance of HIV/AIDS prevention among CSWs as factor in HIV/AIDS prevention for the entire population.


  1. USAID. HIV/AIDS Health Profile. Antananarivo, Madagascar: USAID/Madagascar, 2010.
  2. World Bank. Results-Oriented Monitoring: A Successful Transition in Madagascar. World Bank Global HIV/AIDS Program, 2008.
  3. World Health Organization Media Center. Treatment for Sexually Transmitted Infections Has a Role in HIV Prevention. Geneva, Switzerland: World Health Organization, 2006.
  4. UNAIDS Regional Support Team for Eastern and Southern Africa. Madagascar Country Profile. Antananarivo: UNAIDS Country Office.
  5. The World Factbook. Madagascar Country Profile. Washington, DC: U.S. Centeal Intelligence Agency, 2011.
  6. Academic Presentation, Rachel Pryzby. Helping Women Help Themselves: Sex Work, Health, and Development in Mahajanga, Madagascar. Madagascar: Culture and Society, Fall 2007.
  7. UNAIDS. Epidemiological Fact Sheets on HIV/AIDS and Sexually Transmitted Infections. Antananarivo: USAIDS Country Office, 2004.
  8. UNAIDS. Epidemiological Fact Sheet on HIV and AIDS: Core Data on Epidemiology and Response. Geneva, Switzerland: UNAIDS/WHO Working Group on Global HIV/AIDS and STI Surveillance, 2008.
  9. International HIV/AIDS Alliance in Madagascar. Giving a Voice to Sex Workers in Madagascar: The Alliance’s Work with FIZIMORE. Madagascar.
  10. Fishbein, M and Ajzen, I. Belief, Attitude, Intention and Behavior: An Introduction to Theory and Research. Reading, MA: Addison-Wesley, 1975.
  11. Fishbein, M. A Reasoned Action Approach to Health Promotion. Medical Decision Making 2008; 28:834-844.
  12. Sheppard, B.; Hartwick, J.; Warshaw, P. The Theory of Reasoned Action: A Meta-Analysis of Past Research with Recommendations for Modifications and Future Research. The Journal of Consumer Research 1988; 15:325-343.
  13. Profile: Social Marketing and Communications for Health. Madagascar: Revitalizing a Social Marketing Program. Antananarivo, Madagascar: PSI/Madagascar, 2003.
  14. Feldblum, PJ; Hatzell, T; Van Damme, K; Nasution, M; Rasamindrakotroka, A; Grey, TW. Results of a randomised trial of male condom promotion among Madagascar sex workers. Sexually Transmitted Infections 2005; 81:166-172.
  15. Hoke, et. al. Randomised controlled trial of alternative male and female condom promotion strategies targeting sex workers in Madagascar. Sexually Transmitted Infections 2007; 83(6):448-453.
  16. Pettifor, A. Perceived control over condom use among sex workers in Madagascar: a cohort study. BMC Women’s Health 2010; 10:4.
  17. Weller, S; Davis-Beaty, K. Condom effectiveness in reducing heterosexual HIV transmission. Cochrane Database of Systematic Reviews 2002, 1:4.
  18. Warner, L Condom use and risk of gonorrhea and Chlamydia: a systematic review of design and measurement factors assessed in epidemiological studies. Sexually Transmitted Diseases 2006; 33(1):36-51.
  19. Thomsen, S; Stalker, M; Toroitich-Ruto, C. Fifty ways to leave your rubber: how men in Mombasa rationalise unsafe sex. Sexually Transmitted Infections 2004; 80:430-434.
  20. Stoebenau, K. “…But Then He Became My Sipa”: The Implications of Relationship Fluidity for Condom Use Among Women Sex Workers in Antananarivo, Madagascar. American Journal of Public Health 2009; 99(5):811-819.
  21. Population Services International: HIV Department. Madagascar Condom Use BCC Catalogue. PSI/Madagascar.
  22. UNAIDS Best Practices Collection. Sex work and HIV/AIDS: Technical Update. Geneva, Switzerland: UNAIDS, 2002.
  23. French, P.P. MD,MPH, et al. Use-Effectiveness of the Female Versus Male Condom in Preventing Sexually Transmitted Diseases in Women. Sexually Transmitted Diseases 2003; 30(5):433-439.
  24. Tucker, J. et. al. Female Sex Worker Social Networks and STI/HIV Prevention in South China. PLoS One 2011; 6(9).

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