In the UK, as with almost all other developed countries, we are used to safe sex being a paramount concern for our healthcare system. We are used to sexual health education beginning early and usually in schools, we are used to comprehensive STI screening and protection, we are used to pregnancy tests being able to detect a pregnancy before menstruation is due to take place, we are used to condoms being fully available – and we are also used to all this being free at the point of access (the NHS is a publicly funded body). If you can’t, or don’t want, to get hold of free condoms then they are still very affordable from supermarkets and chemists, or online, where you’ll find the best selections and value for money.
The HIV and STI risk in under-developed countries is a very serious one indeed. Condoms are an essential part of any sustainable and comprehensive HIV and STI prevention programme, as research has consistently shown. Because condoms are the only form of contraception that protects against both pregnancy and sexually transmitted diseases, it’s crucial that people have unhindered access to them for both their reproductive and sexual health.
This is all very well in a country where we have minimum unemployment targets and a range of accessible jobs exist, plus the minimum wage, but for people who live on less than $3 per day, spending precious money on condoms simply isn’t a priority. As you can imagine, if you have a choice between feeding your family or having safe sex, it’s not difficult to see that condom purchase is quite probably prohibitively expensive. In Madagascar for example, in the poorest areas, condoms are priced anywhere from 300-1000 ariary ($0.08 - $0.03). They are sometimes available for free in local health clinics, but it’s pretty obvious that demand almost always exceeds supply.
But it isn’t all about condoms. To use them effectively, people need to understand how and why they work, so this is where other elements of the safe sex strategy come in. To support overall efficacy of condoms, people first of all need reliable access to sexual health education, it’s no good having them and not understanding how or when to use them. This is especially true of the younger generation who might be coming across them for the first time and need some education about how, when and – crucially – why we use condoms. In conjunction with this, there needs to be a robust healthcare system in place for advise and treatment, plus support for changing potentially risky behaviours.
What are risky sexual behaviours?
Affordable contraceptives don’t stop the risks of STIs and engaging in risky sex. At the bare bones of it, humans are sexual beings and our hormones dictate that we have an irresistible urge to procreate, i.e. have sex. But in this day and age we know how to do it safely. We know what the risks are and how to avoid them. The problem is that for those living in poorer countries, they might know the consequences of unprotected sex, but they might not comprehend the magnitude of sexually transmitted infections, or how to prevent/treat them.
The problem comes when risky sex is something which is difficult to avoid. Condom use is typically highest in casual sex encounters, but very often not used at all. For lots of poorer countries there are things like market day which will attract huge numbers of ‘outsiders’ and therefore there’s a much higher incidence of casual sex, or sex with multiple partners. It becomes a choice between unprotected sex or no sex at all, and this is exactly the kind of risky behaviours that need to be discouraged – hence the desperate need for education and access to contraceptives. It can be particularly difficult for women to insist on protected sex when the unprotected kind is more immediate and financially beneficial. This is why things like stigmas, cultural norms, lack of knowledge and availability all have an impact on condom use.
There’s another problem as well. In less developed countries where local norms and cultural differences are common, introducing condom use into a long term/committed relationship can be seen as a sign of mistrust or infidelity. It’s easy to see how this comes about because why would you suddenly go from using nothing to using protection? To be protected, obviously! But for those who aren’t used to regular contraception it might strike the wrong note.
How to solve this?
There isn’t an instant, golden solution that’s just going to tip up miraculously in all under educated societies to remove the risks of unprotected sex, but it’s generally acknowledged that reliable access to contraceptives begins with bringing the price of them as low as possible, or ideally having them for free at as many clinics/health centres as possible. One such strategy is to scrap government tax on them. Removing these financial barriers is an important step forward in making sure that those living in poverty have the same access to contraceptives as those above the poverty line, so the most vulnerable people are also protected. Tax free condoms could also be a vital first step in eliminating taxes for other family planning methods – the coil, implant, hormonal injection, oral contraceptives. Clearly this would really open up the field in terms of sexual health advances.
Unfortunately, for various political reasons, helpful organisations like Population Services International and Marie Stopes International have had their funding cut drastically, meaning that condoms have become even more scarce and even more expensive where they are most needed and most often unaffordable.
There’s no magic solution to any of this, but by highlighting the realities of unprotected sex, the issue becomes more of a widely known one – and the wheels of sexual health advice, protection and treatment can begin turning.