Lessons from the evaluation of the South African National Female Condom Programme

Background Understanding of the facilitators and challenges to female condom (FC) uptake has been limited due to lack of evaluation of national FC programmes. Setting The FC has been an integral component of South Africa's (SA) HIV prevention programme for 20 years and is the largest government-funded FC programme worldwide. Methods The national FC evaluation used a mixed-methods approach and consisted of key informant interviews and a telephone survey in a national sample of public and non-public sites. A sub-sample of sites participated in client and provider interviews, and a self-administered client survey. A review of distribution statistics from South Africa's District Health Information System was also conducted. Results All 256 public-sector and 28 non-public-sector facilities reported having ever distributed FCs. Less than 5% of these facilities reported stock-outs and less than 3% reported they had a supply of expired female condoms. Systems for male condom (MC) and FC distribution were complementary, with similar ordering, delivery and reporting processes. FC promotion by providers (n = 278) varied with regard to FC training, whether attitudes about FCs influenced providers offer of FCs, and how they counselled clients about FCs. Of the 4442 self-administered client surveys in 133 facilities, similar proportions of women (15.4%) and men (15.2%) had ever used FCs. Although FCs were available at almost all sites surveyed, only two-thirds of clients were aware of their availability. Conclusion Data highlight the role of providers as gatekeepers to FC access in public and non-public sectors and provide support for further FC programme expansion in SA and globally.