Condom Distribution as a Structural Level Intervention

Scientific Support for Condom Distribution

There are several ways to promote condom use among people at high risk for sexual transmission of HIV. Individual and group-level interventions help do this by directly addressing individual’s knowledge, attitudes, skills, and behaviors related to condom use, while community-level interventions give a strong emphasis to changing social norms. Although, individual-level, group-level, and community-level interventions demonstrate moderate to high success in promoting condom use, they show the greatest effect in reducing the risk of HIV infection when combined with structural-level interventions.

Structural-level interventions, such as distributing free condoms in diverse venues, social marketing campaigns, or policy change, can address the social, economic, and political environments that shape and constrain individual, community, and societal health outcomes. CDPs become structural interventions when the environment is changed so that there is increased availability, accessibility, and acceptability of condom use.

Recent research reported that CDPs as structural interventions:

• Increased condom use, condom acquisition, and condom carrying.
• Promoted delayed sexual initiation or abstinence among youth.
• Provided cost-effective and cost-saving outcomes on future medical care costs by preventing HIV infections.
• Significantly affected condom use behaviors and helped reduce HIV/STD risk among a wide range of at-risk groups (i.e., youth, adults, commercial sex workers, high STD populations, and males).

Considerations for Implementing Structural-Level Condom Distribution Programs

To design and implement an effective structural-level CDP, organizations are encouraged to adhere to the following elements:

• Provide condoms free of charge.
• Conduct wide-scale distribution.
• Implement social marketing campaigns to promote condom use. Consider using messaging that increases awareness of condom benefits and normalizes condom use within communities.
• Conduct both promotion and distribution activities at the individual, organizational, and environmental levels.
• Supplement the CDP with more intense risk-reduction interventions or health services for individuals at highest risk.
• 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.
• Integrate CDP activities within other community-level intervention approaches to promote condom use and other risk-reduction behaviors.

Strategic Planning of Your CDP

Identify the internal and external factors that will help build an effective CDP:

1. Select your audience:
   • Individuals at high risk;
   • Venues frequented by high-risk individuals;
   • Communities at greatest risk for HIV infection, especially those marginalized by social, economic, or other structural conditions;
   • The general population within jurisdictions with high HIV incidence.
2. Resources and partners – Develop a process for identifying and engaging appropriate community partners and agencies that plan, implement, manage, or provide resources to support your program.
3. Define your obstacles – Identify difficulties, such as reaching members of vulnerable or hard-to-reach populations and strategies to overcome those challenges.
4. Assessment – Conduct an evaluation to identify any structural barriers and ensure that condoms are:
   • Available in the locations where members of the target population are found (e.g., pharmacies, condom dispensing machines, outreach workers).
   • Accessible in venues frequented by the target population (e.g. massive distribution of free condoms).
   • Acceptable to community members and in alignment with social norms (e.g. social marketing of condoms).
5. Cost and Scale – Calculate the costs and determine the scale of your CDP.
6. Policy – Identify the laws, policies, or practices that may support or hinder a CDP.
7. Define objective, goals, and measurements – Define your programmatic objectives, key indicators for measuring the program’s performance, and define how 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

What CDC Is Doing

In 2012, the CDC began a five-year HIV prevention funding cycle with health departments across the United States and its territories in a new approach to advance high-impact HIV prevention. The $339 million in funding supports health departments in conducting comprehensive HIV prevention programs and requires, as one of four requirements, that all 67 grantees establish and maintain CDPs for people with HIV and people at highest risk of acquiring HIV. Between 2012 and 2014, the programs have distributed over 248 million condoms.

Training and technical assistance on condom distribution is available to health departments, community-based organizations, and healthcare organizations through four CDC-funded capacity building assistance programs.

Examples of Successful CDPs

CDC has identified effective large-scale CDPs whose experience may be useful to other organizations:

• New York City’s Department of Health and Mental Hygiene (DOHMH) launched NYC Condom in 2007, the first municipally branded male condom in the United States. The program distributes free safer sex products (i.e., male condoms, female condoms, and water-based lubricants) to NYC-based social service organizations, businesses and individuals. In 2013, the program distributed 38.5 million free male condoms to over 3,500 venues city-wide. For more information, visit www.nyc.gov/condoms and www.facebook.com/nyccondom.

• The District of Columbia (DC) Department of Health HIV/AIDS, Hepatitis, STD, and TB Administration (HAHSTA) focuses on promoting the availability and accessibility of condoms, educating and promoting their correct use, and distributes free male and female condoms and lubricants to partnering organizations and DC residents. For more information, visit https://doh.dc.gov/service/condoms-and-condom-information, www.rubberrevolutiondc.com, www.facebook.com/RubberRevolutionDC, www.twitter.com/freecondomsdc, www.youtube.com/user/RubberRevolutionDC, and www.wrapmc.wordpress.com.