Over 3 million female condoms have been distributed in France since its introduction in 1997. FC has enjoyed a success there which has not been mirrored in other countries in Europe and 2003 saw sales of FC in the commercial sector expand threefold, as well as a substantial increase in FC distribution in the public sector – 290k FCs were distributed in the first 5 months of 2004 as compared to 290k for the whole of 2003. Factors common to other countries which have successfully introduced and maintained FC programmes over time can also be identified in France; strong government commitment and allocation of resources, a comprehensive training programme and a combination of public and private sector distribution.

The female condom was first introduced in France in 1997, as part of a pilot study implemented in the Bouche du Rhone region of South Eastern France. This region was selected on the basis of its high HIV prevalence rates. In the same year heterosexual transmission became the primary route of HIV/AIDS transmission for the first time in France. The intervention aimed to reduce HIV/STD risk through counselling on a variety of protection methods, including the female condom. Thirteen Community Based Organisations (CBOs) were selected to take part in the study and participated in five group sessions to learn more about protection skills, their bodies and to prompt further diffusion of this information at a community level.

The intervention “Femme mon corps et moi” - was extremely successful and 56% of respondents reported trying the female condom at least once. The most highly rated aspects of the study were the group process and interpersonal communications. Research from Zimbabwe and Brazil has also confirmed that those people most likely to use and continue to use the female condom are those reached through community based outreach.

In 1999, building on the success of this model and in response to a growing need to focus HIV prevention strategies on women, the intervention was scaled up to a national level with an emphasis on providing education on and access to the female condom as a new prevention method for women. Training was implemented at 3 levels – health professionals, NGOs and at a community level. The effect of this cascade training approach has been that many women have benefited from this programme – 4800 women had already participated in these groups at the end of 2000. More importantly follow-up groups were held bi-annually to discuss any problems or issues with female condom usage. At the same time a campaign began in the La Seine-Saint Denis region to raise awareness amongst service providers of the advantages and need for the female condom. Again, addressing service provider bias has been a key factor in the success of female condom programmes world-wide.

From 1999, the Government pledged to provide Family Planning Associations and other related organisations with a free supply of female condoms. This commitment continues today. Educational materials were developed by Terpan, a social marketing organisation in France, who have also generated a high demand for the female condom in the commercial sector and who have worked in partnership with the Ministry of Health in the public sector. Terpan’s strategy to explain the advantages of the female condom, discuss obstacles to its use, address gender inequalities and the need for additional prevention options highlight that the marketing of the female condom is not a simple selling exercise. As mentioned above there was a threefold increase in female condom sales in the commercial sector in 2003.

Parallel to these activities, pharmacists in the Essonne region have been promoting FC at a price of 0,15 euros annually since 2000 for a limited period each year, funded by the Ministry of Health. Research from this campaign has shown a 1000% increase in FC sales related to the campaign. As a result, in 2003, with funding from the Ministry of Health, SIDA Information Service (SIS) co-ordinated a national campaign to promote the female condom in pharmacists.

The SIS campaign’s objective was to promote FC as a valuable HIV prevention choice for women at an attractive price. The campaign strapline “Plouf-Plouf” was selected to reinforce the idea of choice while being original and humorous. Additionally the strategy was to increase awareness of FC as a HIV prevention device and make it accessible to the public by promoting it through pharmacies in selected regions across France. The campaign ran between November and December 2003 and it is almost certain that the campaign will run again this year to coincide with World AIDS day 2004.

SIDA Info Service (SIS) headed up the campaign and chaired a steering committee made up of representatives from Family planning associations and other organisations working in the field of HIV prevention, as well as pharmacists. This public/private sector partnership proved very successful as the associations acted as campaign “relays” in the regions where FC was sold and helped to mobilise support and raise awareness of the campaign, as well as providing information on FC to pharmacies. There was also use of the mass media and one-off regional events to launch the campaign.

Around 15,000 pharmacists took part in the promotion, although this figure is only approximate given that some did not inform SIS of their participation. Geographically, there were more pharmacists in urban areas as well as those regions where Family planning/prevention associations have traditionally been most proactive in France. All 100k FCs supplied to pharmacists were sold within 3 weeks and further stocks were needed.

Individual regions are still evaluating their campaigns and final research results will be available in September 2004. Preliminary findings are:

• 92% of questionnaires were completed by women.  Over half of these respondents were between 15 and 29 years of age.
• 80% of respondents knew of FC – 34% from the media and 23% from pharmacists.  
• 18.6% of the respondents had used FC before. 
•  56% of women liked FC because it didn’t interrupt sexual activity
• 36% of women felt it was empowering.  
• Those who had used FC had a more positive perception of it than those who had never used it at all. 67% of users expressed their satisfaction with FC.

 
Pharmacists witnessed a strong distrust of FC by their customers. Respondents felt that the lack of information and visibility of FC had made it an “obscure” device. Certain women who were users of the male condom felt that FC burdened them with “additional responsibilities”. Certain women were worried about the lack of visibility of FC once in place and its effectiveness as a contraceptive device. A big factor in whether women continued to use FC or not was whether their partners liked it. There was the same level of apprehension towards FC, whether FC users were users of the male condom or not.

Importantly and in keeping with FC research from around the world, initial results indicate that the more prevention options available, the greater the number of protected sexual acts.

An offshoot of the campaign took place in the Alsace region where the 1 FC 1 Euro campaign was launched to coincide with International Women’s Day 2004. However, an important distinction between the 2 campaigns was that SIS decided to work with Drs and Gynaecologists rather than pharmacies to distribute FC. SIS adopted this strategy as calls to the SIS helpline from the Alsace region were extremely low and they wanted to remotivate prevention efforts in the region. SIS felt that Drs and gynaecologists had an important role to play in achieving this. FC posters with the words “Do you recognise me?” were displayed in over 20 railway stations in Alsace and encouraged women to get more information on FC from their Drs. A pack of information on FC and a patient questionnaire was sent to 220 Drs and 40 gynaecologists.

Distribution of the female condom has steadily increased in France since its introduction in 1997. 1 million female condoms have already been distributed to date this year, 2004. Undoubtedly the Government’s commitment to actively promote FC as an additional means of protection for women has contributed to FCs success and their allocation of resources to achieve this end has ensured a consistent supply. Training and educational materials have also successfully addressed obstacles to use and follow up groups have allowed for a revision of these materials. Private and public distribution sites have increased access to FC and it is now widely accepted that FC provides a necessary alternative for women and has increased the number of protected sexual acts nationwide.