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Country-Wide Distribution of the Nitrile Female Condom (FC2) in Brazil and South Africa: A Cost-Effectiveness Analysis
Global Health Sciences Literature Digest
Published November 16, 2006
Journal Article

Dowdy DW, Sweat MD, Holtgrave DR. Country-Wide Distribution of the Nitrile Female Condom (FC2) in Brazil and South Africa: A Cost-Effectiveness Analysis. AIDS. 2006 Oct 24;20(16):2091-8.


To assess the cost-effectiveness and potential impact of expanded female condom distribution in the countries of Brazil and South Africa.

Study Design

This cost-effectiveness analysis estimated annual HIV infections and cost per infection averted if the nitrile female condom (FC2) were distributed in high volume and used frequently. The model assumed that the FC2 would be distributed through existing public programs to sexually active men and women in Brazil and South Africa.


Brazil and South Africa. Both countries have established public sector programs providing condoms and AIDS treatment, and represent different stages in the HIV pandemic.


Modeled population sizes were estimated from population-based surveys providing data on age, HIV status, and sexual activity in the past year. The model for Brazil estimated 25,300,000 sexually active persons aged 15-49 years of age, with an HIV prevalence of 0.9% for males and 0.5% for females. For South Africa, the number of sexually active 15-49 year-olds was estimated to be 16,800,000, with an HIV prevalence of 15.9% for males and 21.6% for females.


The nitrile female condom was released on October, 2005. Although it offers similar protection and pricing to the existing polyurethane female condom, manufacturing and acquisition costs could be reduced if it were distributed in larger volumes. Present acquisition costs per FC2 are $0.69 in Brazil and $0.87 in South Africa. This could be reduced to $0.40 with high volume distribution and $0.20 with global purchasing. Distribution costs would also be reduced. Incremental cost-effectiveness was estimated by comparing FC2 distribution at existing levels in each country with hypothetical programs in which FC2 would be purchased and distributed more widely, such that FC2 use would comprise 3%, 10%, and 30% of current estimated male condom use. Multiple HIV transmission parameters and proportion of correctly used condoms were included in model estimates. Modeling evaluated the impact of one year of condom distribution. Costs are reported in 2005 US dollars, with future costs and benefits (i.e., averted cost of treating individuals with incident HIV) discounted at 3%, including sensitivity analysis for 0% and 7% discounting.

Primary Outcomes

The primary outcome was the incremental cost of FC2 expansion per HIV infection averted. This was compared to the estimated annual cost of antiretroviral therapy (ART) per HIV-infected individual. Prevention of pregnancy and of sexually transmitted infections (STIs), and costs/savings unrelated to the public sector (such as patient time to attend clinic, or savings due to averted hospitalizations) were not considered.


In Brazil, expansion of FC2 distribution to comprise 10% of current male condom use would avert an estimated 604 (412-831) HIV infections, at an incremental cost of $20, 683 ($13,497- $29,521) per infection prevented. (All ranges are for 5-95th percentiles). This compares to an annual treatment cost of $21,970 ($18,369-$25,719). In South Africa, 9,577 (6,539-13,270) infections could be averted annually, at an incremental cost of $985 ($633-$1,412) per infection prevented, compared to the cost of treating one HIV-infected individual of $1,503 ($1,245-$1,769) per year. Acquiring FC2s through a global purchasing mechanism and increasing distribution threefold would reduce the incremental cost to $8,930 ($5,864-$13,163) per infection averted in Brazil, and to $374 ($237-$553) in South Africa. Model estimates were most sensitive to changes in the estimated prevalence of STIs, total sexual activity, and fraction of FC2s properly used.


The authors concluded that country-wide distribution of FC2 at higher volumes would be cost-saving and would avert substantial numbers of HIV infections. Thus, FC2 might be a useful and cost-effective supplement to the male condom for preventing HIV transmission.

Quality Rating

The study score was evaluated using the Quality of Health Economic Studies (QHES) instrument and scored 79 out of 87 applicable points. This study was limited somewhat by the following: 1) the model did not incorporate potential savings from averted transmission of STIs other than HIV, or savings in HIV treatment costs other than ART, such as hospitalizations or treatment for opportunistic infections); 2) important variables to which the model was sensitive could not be estimated accurately, such as the proportion of FC2 that would be correctly used; 3) the model used in this study may oversimplify the factors influencing HIV transmission; 4) the most cost-effective model assumes that high volumes of FC2 could be manufactured on a global scale.

In Context

Presently, no country distributes female condoms free of charge to a large proportion of the at-risk population. Female condoms are often considered cumbersome to use and too expensive to be widely practical. However, this study assumes that if female condoms were freely available, they would be used more frequently and their cost to public programs would be reduced due to high volume purchasing and manufacture. Thus, increased availability of female condoms could potentially have a positive and cost-effective impact on HIV transmission. Another modeling study evaluated the impact of a hypothetical female condom program among South African sex workers, and likewise determined that FC would be cost-effective.(1)

Programmatic Implications

This cost-effectiveness analysis suggests that expanded distribution of FC2 in countries with both high- and low-prevalence epidemics could avert hundreds to thousands of HIV infections annually, and would cost less than providing ART. However, it has never been demonstrated that female condoms, even if they were freely availably, would be widely accepted and used frequently enough. These findings argue for further research to determine whether and how female condoms would be used if they were distributed at high volume.


  1. Marseille E, Kahn JG, Billinghurst K, Saba J. Cost-effectiveness of the female condom in preventing HIV and STDs in commercial sex workers in rural South Africa. Soc Sci Med. 2001 Jan;52(1):135-48.