Petrol tankers parked nose-to-tail line the five-kilometre stretch of road from the southern Nigerian town of Eleme to its refinery, waiting to fuel up and begin their long journey home.

If the trip runs smoothly, a tanker leaving the big cities of the north at dawn should arrive at Eleme, in the troubled oil-rich delta region, by early evening. The following day the fuel company's representative fights to get a "ticket" for the driver, authorising the consignment. With the allotted load on board, the gear-grinding exhaust-belching trucks nudge their way out of the depot and into the traffic.

But because things do not usually go to plan, there is a thriving roadside service industry taking care of stalled truckers, refinery workers, fuel dealers and anybody else looking for accommodation, banks, butchers, bars, mechanics, places of worship, restaurants, laundry services, film halls, cell phone kiosks – and sex.

More than 100 women from all over Nigeria work out of the tiny wooden shacks at the heart of the community. They pay N300 (US$2) a day for their rooms - not much bigger than the space taken by a single mattress, without electricity or running water - and charge a minimum of N300 for sex.

Eleme, on the southern rim of Rivers State, one of the four core delta states, is one of the largest of a string of eight truck stops along the 800km route into the north where commercial sex is available.

Rivers has an HIV prevalence rate of 5.4 percent, above the national average of 4.4 percent, but not the worst result in the country; that position is held by the state of Benue, in central Nigeria, with an infection rate of 10 percent.

Rivers, however, is at the centre of delta militancy, in which armed young men have proved themselves willing and able to take on the armed forces of the federal government to press their demands for a fairer sharing of Nigeria's wealth, almost exclusively derived from the oil and gas of the region.

AIDS and insecurity

Dr C. Okeh, head of the State Action Committee on HIV/AIDS in Rivers, worries that the unrest will have an impact on the fight against the virus. At the very least, "a crisis situation means that you don't have time to listen to [AIDS] messages – you're thinking of your immediate survival," he told IRIN/PlusNews.

Queen Henry is the peer educator for the sex workers in Eleme, part of a community-based organisation supported by the Society for Family Health, Nigeria's largest AIDS service provider. For her, the most pressing concern is the insecurity in the area.

Soldiers based at the nearby river jetty, where cargo ships take on fuel pumped from the refinery through a bundle of pipes, each the width of a man's waist, have decreed an unofficial 9 p.m. curfew on the sex trade. Enforcing it has meant regular raids on the shacks, kicking out customers and beating women not inside their rooms.

But the AIDS message is sinking in, condoms are cheap and available, and the sex workers are organised. Henry has no doubt that all the women she reaches know in theory the importance of protection. "But the problem is you're not in the room with the girls when they are alone with a customer," she explained. "If eager for money, you do it [without a condom]; if you want to protect your life, you don't," was her matter-of-fact assessment.
That triggered a mini-debate among the women gathered outside her small kiosk, where she sells tonics and douches. "Two thousand naira [roughly US$17, what some women charge for sex without a condom] cannot cure the sickness inside my body [as a result of HIV]. I have seen money [had a lot of it]; I'm too young to die. It's not because of [greed that] I'll go and mess up my life," said Patience Orkah, wearing black hot-pants and a lot of make-up.

All the women agreed, except Charity Ekiti. "All I know is I [get the] money, I f***," she chipped in. "If I [don't die as a result of AIDS], I still go die. I only know God [won't] let that happen." Loud and outrageous, it was hard to tell if she was serious. But what she made clear was that she did not bother using condoms with her boyfriend: "It's not sweet like that."

Why condoms are still an issue is because of men like Umoru, 36, who has a wife in the north but works from Eleme as a tanker driver hauling fuel to the southern cities. He visits his wife every three months or so, and in the interim – "just two or three times" - calls on sex workers and offers double the normal rate not to use a rubber. "They tell me [to wear one] but I no fit do am [I can't do it] with condom."

He said some of the women would refuse bareback sex, "even if you give them one million naira". But he knows some who are less fastidious, and they are his regular partners. "I fear [but everything that happens] is through God" was how he rationalised the risk.

Chinenye Imoh sits at a table under an umbrella all day, handing out information pamphlets to truckers for the Arewa Society Against HIV/AIDS, a community-based organisation. She has heard all the excuses before, especially by drivers from the more conservative Muslim north, where discussion about sex is less open, literacy is low, and girls often quit school and marry early.

"Some say people [in the past also became] emaciated and died. Others say, 'no sickness wey no get medicine' [every ailment has a cure] ... but we're trying," was her upbeat message.

PlusNews 

There is a growing belief among men in Swaziland that circumcision provides complete protection against HIV, a perception that worries non-governmental organisations (NGOs) battling the highest HIV prevalence rate in the world.

In recent years circumcision has been lauded by Swazi public health officials as a procedure that reduces the rate of HIV transmission by about 50 percent, but it is far from the silver bullet solution some men see it as.

"The problem is not with the procedure, but the way it is abused by men, so that men think they are now immune from HIV contagion," said Siphiwe Hlope, an HIV-positive woman and founder of the support group, Swazis for Positive Living (SWAPO).

Hlope said SWAPO members were becoming increasingly aware of an attitude that circumcision protected men from HIV infection, while also providing an excuse not to use condoms; something Swazi men have long loathed doing.

Joy Magongo, a mother of two whose husband moved out to live with his second wife after the couple discovered they were both HIV-positive, told IRIN: "Men say, 'I've been circumcised. I don't have to wear a condom.' They get infected, and they give us HIV.
"He [my husband] was circumcised and felt he didn't have to wear a condom. When we found we had HIV after testing, he blamed me. He said, 'You brought HIV into this house.' It was because I tested first, when I was pregnant with my second child," she said.

"My husband did not believe he could be HIV-positive because he was circumcised. I did all I could to convince him to test, and he finally did. That was the end. He took another wife and left us," Magongo said. Polygamy is legally recognised in Swaziland.

"AIDS in Africa has a woman's face," Hlope said. "People think the disease originates with women. Why? Because it is the women who are tested first, when they are about to give birth."

She said Magongo's story was an unintended consequence of the circumcision campaign by the country's health ministry and AIDS NGOs. "Families blame women when HIV comes into the house, and it results in all sorts of abuse, from physical abuse to denial of spousal and child support, and loss of property rights."

While not disputing the advantages of male circumcision in reducing the rate of HIV transmission, Hlope said the gender dynamics of Swaziland's culture should be taken into account. The incorrect belief that circumcision was a panacea for the disease was making life more difficult and dangerous for women.

Law of unintended consequences

"It's the law of unintended consequences," said a Zambian doctor who treats HIV/AIDS patients at government hospitals, and who declined to be named. "Introducing the procedure, there was insufficient attention given to cultural factors, attitudes and human psychology.

"Many of the men I speak with think circumcision is like an AIDS vaccine. It's not. It's a useful tool to reduce chances of infection at a time and place where few other tools are available, but you can still contract HIV and pass it onto a partner," he said.
Jackson Dlamini, 25, a strapping man taking a break from weight training at a local gym, told IRIN he was considering circumcision as a way to protect himself from HIV. "This AIDS is bad. Nobody admits they are HIV [positive], but so many people are dying. I don't want to give up sex, so I am getting circumcised," Dlamini said.

When told that counsellors at Mbabane Government Hospital would advise him to carry on using condoms even after the operation, Dlamini said, "It is painful to get circumcised. If I have to wear a condom anyway, what is the point?"

HIV counsellor Henry du Pont is used to hearing men express similar sentiments. "The problem with male circumcision is not the procedure, but communications," he told IRIN. "We always end up against men's stubborn dislike of condoms."

A recent study by the UN Development Programme found only 20 percent of Swazi men consistently used condoms, which Hlope said probably indicated that circumcised men did not stop using condoms after circumcision, but had never used them in the first place.

Education about circumcision should stress a clear and consistent message that the procedure should be part of the HIV prevention measures, she said. "Until that happens, women will be infected with HIV this way, and ... male circumcision may do more harm than good if it is misused to deny women full protection."

IRIN

Results from three randomised controlled trials in South Africa, Kenya and Uganda, in 2006 showed that following circumcision, the incidence of HIV infection was reduced in men by more than half.

According to the new policy document, circumcision will be rolled out for males of all ages in a culturally sensitive way and in a clinically safe setting.

The programme will involve some strengthening of the health infrastructure, but according to Peter Mutie, head of communications at the National AIDS Control Council (NACC), the existing health centres are sufficiently equipped for the rollout.

"We are trying to fast track it so that by mid-2008 we can start rolling it out," Mutie told IRIN/PlusNews.

Although a handful of ethnic communities in Kenya - including the Luo, Suba and Teso in western Kenya and the Turkana in northwestern Kenya - do not practice circumcision culturally, Mutie said the government's programme would focus on the whole country.

"Most of our tribes practice circumcision as a rite of passage, but many do it traditionally, using the same blade for several boys, a practice we would like to eradicate; others don't remove the entire foreskin, which is the medical way to do it - they just cut off a bit of it," he said.

Mutie added that in order to limit resistance to the programme, social mobilisation exercises would precede the rollout, with community members being trained to educate their peers on the benefits of male circumcision.

"This is a programme that needs very careful implementation, and education is key - for instance, people need to know that it is not in any way a guarantee of protection from HIV," Mutie said. "

He stressed that traditional circumcisers would play a key role in re-educating their communities. "We cannot totally remove their role - they are useful advisers whom people look up to, so they can be taught to advise the young initiates on safe sex and other healthy practices," he added.

The news about a national policy will be good news for many NGOs and medical practitioners who have been awaiting guidance on male circumcision. Among these is Marie Stopes Kenya, which started a pilot project on male circumcision in western Kenya a year ago using World Health Organization guidelines. The organisation is part of the national male circumcision task force.

Testing the waters

"Our pilot is a free mobile outreach, where a team of five members - a doctor, clinical officer, care assistant, nurse and driver - goes into various communities and sets up camp in a room at a local medical centre or in a tent, and invites people to come or bring their children for circumcision," said George Obhai, monitoring and evaluation manager at Marie Stopes Kenya.

Before the mobile team arrives, the local hospital or clinic is contacted to conduct community mobilisation, and on the day every man getting circumcised receives counselling from a trained member of staff before the procedure is carried out.

"Interestingly, many of the ideas people have about male circumcision work in our favour, even among the Luo; for example, people believe that it improves the sexual experience and that ladies prefer circumcised men," he added.

Obhai noted that male circumcision has not been a hard sell in western Kenya because the Luo, Teso and Suba are surrounded by circumcising communities, and many of them know people who have been circumcised. The HIV prevention benefits it offers, also made the practice popular in the region.

In four districts of Nyanza Province, more than 2,700 men have volunteered for circumcision through Marie Stopes since April 2007, and the numbers are increasing every month; 80 percent of the men and boys being circumcised are from traditionally non-circumcising communities.

But this success is not uniform; among the Turkana of northwestern Kenya, an isolated and very traditional society, it has been much harder to push the circumcision agenda.

"When we took the mobile team to Turkana last year, we got two cases on one outreach day, on another day we got three cases," Obhai said. "We pulled out because we simply didn't have the financial resources to justify continuing at the time, but once we are able to set up some more mobile teams we will go back to the region."

Marie Stopes also uses people from within the community as peer educators, and hopes to incorporate the traditional circumcisers into their programmes.

"In the past we have experienced resistance from them [traditional circumcisers], as we are perceived as trying to take away their source of income or their role in society," Obhai said. "For instance, in many areas, this coming August is a circumcising period, so we'd like to encourage them to maintain their role as counsellors and even pay them an allowance for that, but to bring the boys to the clinic for circumcision."

The pilot has been particularly successful in reaching rural populations with little access to modern medical facilities, and prisoners, who also lack access to healthcare. The social mobilisation is also being used as an entry point for education about the traditional ABC - Abstinence, Be faithful and use a Condom - prevention strategy, as well as as an avenue for promoting voluntary counselling and testing.

Marie Stopes' outreach has recorded five complications with the procedure in the year it has been operational - two adverse reactions to the anaesthetic and three post-op infections.

The organisation intends to replicate its mobile outreach across the country following the success of the Nyanza experience.

Before you wrap it up, meet the people who check it out. IRIN/PlusNews went inside the condom testing facilities of the South African Bureau of Standards (SABS) to see what it takes to ensure condoms really are the frontline of HIV/AIDS prevention.

The SABS tests everything from disposable nappies (diapers) to sardines at its facility in the country's capital, Pretoria. The building itself is a maze of hallways and laboratories, decked out with all the trappings of science - white coats, glass instrument cases, beakers and microscopes.

Outside, past the expansive gardens, next to a heap of discarded equipment, lies the institution's condom testing lab - and Isabella Masemola.

With a background in electrical engineering, Masemola, now a senior testing officer, came to the SABS in the late 1990s and began testing household water meters, but an urge to see something different soon landed her a spot testing radiation badges.

She came to the condom testing lab in April 2007, just months before the lab and the SABS were rocked by allegations that testing manager Sphiwe Fikizolo had accepted money from a condom manufacturer in return for certifying defective condoms. He was later charged with fraud and corruption.

In a country with an HIV prevalence of nearly 20 percent, the Department of Health was forced to recall 20 million condoms. "It was a very stressful time because it was something you couldn't expect," Masemola recalls.

"I mean, if you could have expected it, you could have blown the whistle, but you couldn't expect it; you couldn't expect the immorality of one individual who would put peoples' lives at risk."

Risk, like error, isn't something you can associate with a lab like this. For example, air in the lab is purified twice.

Temperature, humidity and pressure are carefully controlled and logged to ensure conditions remain as constant as possible while lab technicians do random sample testing of about five batches - 4,000 condoms - a day, putting that rubber in your back pocket through hell and, well, high iodated water.

A gauntlet of tests

The barrage of tests, based on World Health Organisation guidelines, begins with a weigh-in to determine whether there is enough lubrication. Condoms and packaging are electronically weighed before the unwrapped condoms are dumped into a bath of isopropanol that is heated to 40 degrees Celsius, stripping them of their lubrication before the isopropanol is allowed to evaporate, and condom and wrapper are re-weighed.
Next, the measuring stick - or rather rod - is whipped out and condoms are measured against the minimum specifications - 180mm in length and 52mm wide. Thickness is also checked.

From here the condoms are thrown into the lab oven and heated to a scorching 70 degrees C to test the lifespan of the latex, before going into what Masemola and her staff jokingly refer to as the pressure cooker. Here packaged condoms are subjected to extreme pressure in a glass container resembling the familiar kitchen appliance, simulating conditions at different altitudes to test package integrity.

If just one condom in a batch of 800 fails this test, the entire batch will fail. "These condoms travel to different countries, are stored on different shelves, sometimes end up in people's wallets," she said. "We have to make sure they will last."

She motions to a strip of prophylactics that didn't make it past the pressure cooker and now lie oozing lubricant onto her desk: "The manufacturers might give you stories and say it was only one (strip of condoms that failed) but you have to ask how many more have they made in their factory?"
But the pulling and prodding, the heat and the pressure pale in comparison to the most important tests awaiting the condoms - those checking for holes and bursting points.

Condoms are suspended from mechanical arms above a tank containing a solution of iodated water, and also filled with this water to check for any visible holes before being plunged into the tank, where sensors detect any minute perforations and where they are.

If a hole is detected 28mm from the condom's opening, the condom is acceptable; 29mm from the top and it fails. Two failures on this test and the entire batch is out, Masemola said.

Not far from the tank is the burst test apparatus, where condoms are filled with purified air until they stretch to roughly a meter in length.

But for Masemola the job is about more than just the measurements: "If you come across a condom that's SABS approved, you can rest assured because it came from my hands," she said. "I'm a woman and I know what women want."

PlusNews

Condom resistance remains a real problem among HIV discordant couples in Uganda, new research has found.

The study, whose results were presented at the 15th conference on retroviruses and opportunistic infections in Boston, Massachusetts, found that of  36,000 couples tested, 96 percent of those in sexually active discordant relationships (where only one partner is HIV positive) reported not using condoms during their last sexual encounter.

"The people we studied were in stable relationships - usually man and wife - and thus they did not feel the need to use condoms," said Dr Elioda Tumwesigye, the lead researcher. "Even after testing, many continued to practice unprotected sex, saying that discordance was fate or that one partner must be immune."

The research was as a result of a United States Centers for Disease Control (CDC) initiative to provide home-based voluntary counselling and testing to 250,000 people in in the western district of Bushenyi between 2004 and 2006.

Tumwesigye added that knowledge of HIV prevention was high in the community, but people felt condoms did not belong in the marital bed.

The men in the Bushenyi sample were more likely to be infected than the women, something Tumwesigye said was likely to be as a result of the age difference between men and women in the couples; on average, women were 30 years old while their spouses had a median age of 40.

"It's possible that these older men, with more sexual experience and higher exposure to HIV, married young girls with relatively little sexual experience," he said. "It is important to send a strong message to these couples that condoms will protect them and their relationships."

He noted that it was particularly urgent because in the study, discordant couples represented over 60 percent of the couples in which one or both partners was HIV-positive.

According to James Kigozi, spokesman for the Uganda AIDS Commission, resistance to and inconsistent use of condoms is a pattern replicated across the country.

"It is a real challenge trying to get married couples to use condoms because of the way they are perceived, as a tool for single people," he said.

"We routinely encourage couples to come for testing together but usually only the women come as part of their ante-natal care; if they test negative their husbands will feel like they too must then be negative and thus won't come," he added. "Another challenge is that women are often not in apposition to negotiate safer sex, so they continue to be put at risk in discordant relationships."

Kigozi said the government was using radio programmes, billboards and other media to encourage couples to jointly test. CDC's home-based care initiative in Bushenyi is also using radio and home visits to pass on the importance of VCT and condom use in discordant relationships.

The HIV/AIDS sero-behavioural survey of 2004-5 found that about five percent of about 4,000 cohabiting couples in Uganda were discordant. An estimated three percent of the couples were both HIV-positive.

Night falls early along the equator. When darkness creeps across the bay of Santa Ana and sets over the town of Sao Tome, the girls appear in twos or threes, or alone. They wait for clients behind the Farol bar and the Dolores disco, the hubs of evening buzz in the capital of the tiny archipelago of Sao Tome and Principe, which straddles the equator off the coast of Africa.

Around 7 p.m., Angela*, robust and friendly, wearing a black tank top, tight jeans and beads in her short dreadlocks, has just hit the street. Her usual clients are "Portuguese construction workers, sailors from Malabo [Equatorial Guinea], and Saotomese," she tells IRIN/PlusNews.

Her best clients are sailors from the foreign fishing fleets. "They come onshore, hot for wild sex and with gifts of dry fish, rice, clothes and toys," she says. But the Portuguese hold the best promise: "If one fell in love with me, I could leave this life and move to Portugal."

Angela, 28, has a 7-year-old child. She started selling sex at the age of 14, following in her older sister's footsteps. She stopped when she got pregnant and lived with the father of her child until his sudden death three years ago. Her current boyfriend has been in jail for five months, so Angela is back on the streets.

Not for long, she hopes. "I am getting too old, men prefer the young ones. We get wet when it rains, some nights we earn nothing ... not a nice life," she says ruefully.

Growing sex trade

Seroprevalence on the islands is relatively low at 1.5 percent in a population of some 150,000. However, the growing influx of oilmen, sailors and fishermen from neighbouring countries is causing concern, especially considering that half the population is poor, according to the United Nations.

Locals agree that prostitution in the capital has risen the last three years. More girls hang around the streets at night; more men prowl the bars and discos, coming alone and leaving accompanied.

An observant client of some sex workers might notice that they take a condom out of a pretty box crafted from a local precious wood, which means they have been through the sexual health education programme the Italian non-governmental organisation (NGO), Alisei, has been running since 2006.

"The box is something special that says, 'I am special, I take care of myself'," said Alisei coordinator Mariangela Reina.

The diffuse nature of sex work in Sao Tome makes it hard to reach the meninas (girls in Portuguese), as the young sex workers are known, with life-saving, AIDS-preventing information. Alisei has problems recruiting and retaining peer educators.

"The meninas don't want to be associated with sex work or AIDS," said Reina. "It is a hidden phenomenon, and reaching them requires time and patience."

Reina distinguishes between the "mobiles" - the more upmarket sex workers who sell sex occasionally - and the "fixed", or regulars, who are more obvious about what they do and are easier to reach with condoms and information.

Streetwalkers are found only in the capital. Elsewhere, sex work is mainly done out of bars and discos, with the variant of "maritime prostitution", which is tied to the arrival of ships in the capital and the fishing ports.

First ever survey

This year, Alisei, with funding from the Global Fund to Fight AIDS, Malaria and Tuberculosis, interviewed 120 people in the first ever survey of the sex trade in Sao Tome. The information will form the cornerstone of a strategic protection plan for sex workers.

The study found that the overall knowledge of AIDS was high, and nine out of 10 respondents mentioned the male condom as the preferred protection against sexually transmitted infections (STIs) and unwanted pregnancy.

In more than half the sexual encounters both partners had brought condoms. However, mistrustful of men, most women surveyed preferred to use their own. Ten percent reported problems fitting a drunk or older man with a condom.

The women obtain condoms from health posts and NGOs but would like to have them available in shops, bars and discos that are open at night. Worryingly, 17 percent of the women surveyed had agreed to have sex without a condom and 24 percent usually drank alcohol before sex. Roughly half said they did not feel good about earning a living from sex.

Most were aged between 15 and 24, and most of the younger workers viewed commercial sex as temporary until they could find a man or a job or had acquired some possessions.

One-third reported having one client per day; another third had two or more clients per day, and the rest had a variable number of clients daily. Just under half said they had foreign clients, but most clients were local.

In focus groups, the sex workers listed European tourists as the best clients. "They pay in forex, do it faster, are more romantic, and pay for drinks, food and breakfast without discounting it from the total price," said Alisei educator Babica Dias. Prices varied from US$8-10 for a local client to US$20-30 for foreigners.

The Associacao Saotomense de Planejamento Familiar (ASPF), a local NGO, occasionally distributed condoms among customs officers at the capital's harbour, but none in the fishing ports. "We should have programmes there," said Amado Vaz, head of ASPF.

Pink clogs and gold earrings

Tete*, 18, hangs out at a tiny but lively bar near the Alisei office in Sao Tome and rents a room in a nearby house. She wears shocking pink clogs, denim shorts, a white-and-gold top and big gold earrings, and has followed her older sister into the sex trade.

The Alisei staff has gained her trust, and Tete has gained information and condoms. She has tested twice for HIV: "I was afraid," she says.

Alisei's Dias and Dina Zolda Cruz, a peer educator, pursue the meninas with dogged patience and good humour, in spite of their initial reticence and failure to keep appointments. "They are shy, they don't want to talk and don't want to listen," says Dias.

Eventually trust sets in and peer educators teach them negotiating skills. According to Cruz, "The best moment to discuss a condom is once [they are] inside the car, but before sex. The best approach is to emphasise the client's protection."

Equipped with these skills and their pretty boxes, the meninas will be safer when night falls in Sao Tome.

* Not her real name

The problem of HIV in Kenya's prisons - where prevalence is about twice the national average - will remain unsolved as long as homosexuality is illegal, and prevention efforts remain out of reach, experts have warned.

"We know homosexuality exists in the prisons, but our hands are tied because of the illegal nature of sodomy under our laws," Mary Chepkong'a, head of the Kenya Prisons Service AIDS Control Unit, told IRIN/PlusNews. "Because of the law, we cannot provide them with condoms to ensure they can protect themselves."

In Kenyan law, male-to-male sex is a criminal offence that carries a jail sentence of five to 14 years, although it is rarely used, but the legislation also excludes men who have sex with men (MSM) from the government's HIV programmes.

Chepkong'a said the reasons for male-to-male sex included consensual sex between inmates who were gay, forced sex, and sex between men who resorted to homosexual sex because their "basic sexual needs" were not being met.

"When a man is molested in prison, rather than getting the proper care he deserves, he is often taken back to court and given more jail time," she said. "We are not addressing the real issues."

The prisons service, which has collected data from 13 of the nation's more than 90 jails over a two-year period, found an HIV-infection level of almost 10 percent among inmates.

"There is no doubt about the high prevalence of HIV and TB [tuberculosis] infection in Kenya's penal institutions," Dr Zebedee Mwandi, coordinator of the US Centers for Disease Control programme that focuses on uniformed personnel, told IRIN/PlusNews. "The phenomenally high transmission rate can be attributed to homosexuality, sodomy, increasing injection drug use, and overcrowding."

The Oscar Foundation Free Legal Aid Clinic Kenya (OFFLACK), which promotes legal literacy and offers legal advice to the poor, said in a 2007 report that prisoners did not have "their basic right of conjugal contacts with their spouses", which, "coupled with the congested sleeping patterns where the old, middle and young sleep together", encouraged new infections.

Kenyan law prohibits sex in prison, so conjugal visits are also banned. "The inmates resort to sodomy and lesbianism, a situation that aggravates the spread of HIV/AIDS, and since none of them wants to admit that they practise the same openly it is hard to ask them to use condoms, as this will again encourage the practice considered a norm," OFFLACK commented.

However, it appears the government may be realising the need for programmes for MSM. "Intravenous drug users, MSM and prison inmates are a population in Kenya of epidemiologic importance," said the National AIDS Control Council (NACC).

In April the council admitted that "current policy and programming are not adequately targeting these populations for prevention and treatment of HIV/AIDS" in a report presented at a national prevention summit in the capital, Nairobi.

Turning the tide

The report blamed the slow response to high HIV/AIDS levels in prison on weak and outdated legislation, as well as religious and cultural inhibitions, but also reflected a changing attitude and greater willingness to tackle the problem.

"The creation of effective HIV prison prevention programmes are dependant on establishing the existence and understanding the nature and prevalence of 'prison sex', the construction of sex and power in the prison setting, the nature and prevalence of intravenous drug-use, and the use of cutting instruments," it commented.

Other signs of a change in thinking include intense debate among stakeholders and in the media over whether prisons should contain special rooms for conjugal visits.

While releasing data on trends in Kenya's HIV pandemic on 13 August, Prof Alloys Orago, director of NACC, said despite the fact that sodomy remained illegal, the NACC recognised the need to step up interventions targeting men who have sex with men.

The lives of millions of South Africans could be at risk, and South Africa's health department has recalled 20 million government condoms as it scrambles to do damage control after allegations of corruption in the country's quality-assurance and standards body.

The condoms were recalled on 23 August after media reports alleged that Sphiwe Fikizolo, a testing manager at the South African Bureau of Standards (SABS), which is responsible for assuring that all condoms produced in the country conform to World Health Organisation standards, had accepted money from the manufacturer in return for certifying defective condoms.

Jeffery Hurwitz, executive director of Latex Surgical Products (Pty) Limited (LSP), which manufactured the condoms, Sajeev Joseph, an employee, and Fikizolo have been charged with fraud and corruption.

Despite the recall, health department spokesperson Sibani Mngadi maintained that only Choice condoms bearing the serial number 4308/ZLX had been affected, and 90 percent of government condoms were of good quality: of the 20 million LSP condoms recalled, only an estimated seven million would have been directly compromised by the alleged corruption.

Mngadi said the department distributed 400 million condoms annually, sourced from seven suppliers, including LSP, which supplied nine percent of the total.

SABS spokesman Erno Botes said the bureau had begun a full audit of all condom manufacturers in the country in response to the allegations, and had also reviewed all available test records for LSP condoms for the past year.

"When the case broke, we revisited the files; we still have records of the performance of batches," Botes said. "Under normal circumstances, these condoms would not have passed."

The audit included the test results for 91 batches, but Mike McNerney, the SABS general manager of food and health, admitted that the bureau had been unable to locate the results for 14 batches and said this was highly unusual.

He said it was important to understand what was meant by a failed batch. "If a batch fails, that means the risk of failure increases, but not that all condoms [in the batch] will fail. But the bottom line is that the products failed and never should have been released."

McNerney said laboratory tests, which often placed condoms under stresses above and beyond those of normal usage circumstances, might produce a worst-case scenario picture of the problem.

"We can't specifically quantify the increase in risk in terms of human use, we can only go off laboratory tests," he commented.

As of 28 August, the government had quarantined 4.5 million Choice condoms while it continued its public awareness campaign, the main intervention in the wake of the recall.

"We are trying to minimise the possibility of risk, which means we are trying to get through to as many people as possible about the recall," Mngadi said. "We are encouraging people who may really be uncertain about what this means for them to contact the AIDS helpline."

The recall is a blow to what has been a hard-fought condomisation campaign in the country. "It's definitely a setback. We've done a lot of work promoting this brand. The rebranding of the grey government condoms with the AIDS ribbon into Choice condoms meant an increase in annual distribution."

Mngadi said the recall had left communities suspicious of the government's free condoms. "We are working to find the best strategy to manage the damage done to the brand's reputation and the public's confidence in the product."

David Nowitz, senior marketing manager of the Society for Family Health (SFH), which has partnered the government for several years in branding and distributing the Choice condoms, said, "I think those behind the scandal have done the AIDS prevention cause a huge disservice. However, it's important for people to remember that we're talking about the actions of a couple of individuals, and not a whole public healthcare system."

At the Centre for AIDS Development, Research and Evaluation (CADRE), director Dr Warren Parker suggested that this series of events might provide an opportunity to rethink prevention.

"It's unfortunate that the selfish economic interests of people who put the programme in place ... have put the public at risk," he said. "The recall undermines what has been an overall very successful condom campaign with very strong logistics and increased in demand over time."

Parker praised the department's courage in dealing openly with the problem and added the recall might be food for thought. "It stresses the importance of multi-dimensional prevention programmes: for example, there is still a need to reduce concurrent and multi-partner sexual partnerships. In that sense, the recall may be an opportunity to refocus prevention efforts."

Anti-AIDS campaigners in Uganda have denounced the government's decision to halt the distribution of female condoms as poorly informed and dangerous.

The Ugandan Ministry of Health announced last week that it would no longer supply female condoms because of poor uptake by women, who complained that it was difficult to use.

"We have halted their distribution because the women who are supposed to use them have complained that they were not user-friendly," said James Kigozi, spokesman for the Uganda AIDS Commission (www.aidsuganda.org). "Many who have used them complain that they make a lot of noise during sexual intercourse," he told IRIN/PlusNews.

Beatrice Were, HIV/AIDS coordinator for the anti-poverty NGO, ActionAid, said the move was "disappointing", and not enough had been done to ensure that all Ugandan women were aware of the benefits of the female condom.

"I would be interested to know how many women they surveyed said the condom was noisy or was not user-friendly," she said. "One prominent woman activist at a recent conference I attended confessed that she had never even seen one, so what about a poor rural woman? How can they stop providing them if people don't even know what they look like?"

The female condom is a 16.5cm long polyurethane sheath inserted into a woman's vagina before sexual intercourse; it lines the vagina and prevents pregnancy and sexually transmitted infections.

Kigozi said hundreds of thousands of the prophylactics were imported between 2002 and 2004, but few women had used them. "Even those few who tried to use them said they were painful during insertion and uncomfortable during intercourse."

Most women also did not have much say over contraception. "Research shows that one of the reasons why the female condoms were not popular is [lack of] women empowerment in society, as their husbands and boyfriends were forcing them to remove them after they had inserted them," he said. "A woman is yet to have the power and courage to say, 'I have to use it'."

However, Were said Ugandan women were not a homogenous group, and the same standard could not be applied across the country. Some women might not have the power to negotiate safe sex or find the condom noisy, but others might find it entirely acceptable, so a blanket decision to halt national provision was unfair.

AIDS campaigners said women-driven initiatives such as the female condom were a vital tool in the fight against the disease. Were said the decision put in question the government's commitment to eradicating the pandemic among women, who carry a higher HIV burden than men. Women make up almost 60 percent of Uganda's one million HIV-positive people.

"Take, for example, male circumcision, a male-driven prevention strategy; since it was recently confirmed as a method of prevention, all roads lead to huge male circumcision programmes, yet they want us to believe that the female condom, which has been scientifically proven for years, is being stopped because it's not user-friendly - I don't think so," she said.
Dr Margaret Muganwa, of the Global Campaign for Microbicides, said the female condom had not been widely distributed as it could have: "The condoms have been made unpopular because they were inaccessible to the users, who could only get them from government stores, compared to male condoms that can be accessed from all outlets, including hotels."

Female condoms had been less accessible and more expensive than the male condom, said Elizabeth Bukusi, of the Kenya Medical Research Institute (www.kemri.org), but complaints about user-friendliness were trivial.

"Some people have said that it [the female condom] is noisy, but who told them that sex has to be a quiet event?" she said at a meeting on gender equity and development in the capital, Kampala.

Uganda's HIV prevention programme is based on the 'ABC' model of Abstinence, Be faithful and use a Condom, but the 'C' has tended to focus on male condoms.

The male condom has also suffered some bad press: in 2004 there was a nationwide shortage after the government imported defective condoms. The situation has since been rectified, and Kigozi said the health ministry and private firms imported at least 120 million male condoms every year, a quantity that is expected to increase.