Condom distribution in SA has declined drastically over the past five years, found a Spotlight analysis of data recently published in the Health System Trust’s District Health Barometer, with various factors being blamed, including the rise in PrEP measures.
Catherine Tomlinson writes that the government distributed 45% fewer male condoms in 2022 than it did in 2018. The total number distributed dropped by more than 300m – from 728m in the financial year from March 2018 to February 2019 to 403m in 2022/2023.
Female condom supply also declined, but not as sharply.
The full extent of the actual decline in supply countrywide over the past five years has not previously been reported, although the DA raised the alarm over supply challenges in Gauteng in April 2023.
Provincial Departments of Health have blamed the time required for certification by the South African Bureau of Standards (SABS) after the start of a new condom tender in 2022.
However, Health System Trust’s District Health Barometer (DHB) data show that distribution figures have, in fact, been steadily declining for five years.
Similarly, while Covid-19-related supply chain interruptions were a contributing factor to shortages at the pandemic’s peak, the decline in government-supplied condoms started earlier, and continued after Covid-19 supply chain disruptions were resolved.
The large decline in distribution is alarming. While other interventions are now available to protect against HIV, the WHO says condoms should remain a cornerstone of HIV prevention strategies.
Research by the University of Witwatersrand’s Health Economics and Epidemiology Research Office (HE2RO) has found that condoms are not only the cheapest intervention to combat HIV, but that provision is, in fact, cost-saving for the health system.
DHB data show that all provinces, except for the Free State, saw a decline in distribution in 2022/2023, compared with 2018/19 levels.
The Eastern Cape distributed 65% less in 2022/23 than it did in 2018/19, Gauteng and the Northern Cape around 60% fewer; Limpopo 52% fewer, and the Western Cape around 46% fewer.
With a reduction of around 19% over the five years, the decrease was much less pronounced in KwaZulu-Natal than in other provinces with large populations.
What caused the decline?
Condoms are tendered nationally by the National Department of Health (NDoH) for a three-year period and must be tested and certified by the SABS first.
Neither the NDoH nor the Gauteng Department of Health (GDoH) responded to questions from Spotlight.
The GDoH previously blamed SABS certification processes for its condom supply shortages. According to an April 2023 media statement, suppliers were unable to supply product because of a delay in SABS certification in 2022.
Eastern Cape shortages
Eastern Cape Health Department of Health spokesperson Sizwe Kupelo said that in 2022/23, “for most of the year there were no condoms to distribute”.
Various factors were responsible, he said.
“It was the end of the supply contract and the period to award a new contract effective from 1 April 2022… This transition experienced a delay … due to SABS quality assurance process that could be finalised only around September 2022.”
He said the province started to receive condoms from October that year.
The second reason was that suppliers found it difficult to deliver to Eastern Cape areas “due to the high cost of transportation to the 26 sites”. All suppliers are based in Gauteng.
However, Kupelo said supplies had improved and the Eastern Cape had reached 96.7% of its target to distribute 17m condoms in quarter 3 of 2023/24 (quarter 3 of 2023/24 is September to November 2023).
Lungelo Ntobongwana, acting CEO of the SABS, told Spotlight that all condoms distributed by the NDoH are tested at the SABS condom lab in Pretoria.
“Downtime or challenges from unplanned disruptions are rare, and the SABS has incorporated contingency plans to ensure testing processes and deliverables are not affected.
“When there is a shortage, it could be due to several reasons. The SABS can categorically state there are currently no challenges in its laboratory or deliverables regarding the testing of samples,” said Ntobongwana.
Did clinics run out of condoms?
The NDoH insisted in April 2023 that while Gauteng was facing low stocks of condoms, there were no serious shortages.
Surveys by community-led clinic monitoring group Ritshidze show that condoms remained available in most facilities throughout the year, but also indicate a pattern of rationing by staff. In some cases, condoms are only available on request, and key populations often face stigma and discrimination when asking for condoms and lubricant.
Anele Yawa, general secretary of the Treatment Action Campaign (a member of Ritshidze), told Spotlight the organisation battled to get condoms for its community outreach efforts, and that often, people were told they could take only a limited number because of stock availability.
There are some concerning indicators that condom usage is declining, which may partly be related to the drastic decline in supply.
The Human Science Research Council (HSRC), which conducts regular surveys of HIV knowledge and sexual behaviour, recently released early data from its 2022 survey, showing teenagers and young adults aged15 to 24 reported lower rates of condom use at last sex than in previous years.
The data did not give a cause for the decline – apart from supply constraints, other factors like a decrease in the perceived risk of contracting and dying of HIV may also play a role.
The HSRC will release its full survey results this month.
Another concerning indicator of declining condom usage is the reported rise in sexually transmitted infections (STIs) in Gauteng, a wake-up call that control and management strategies are not keeping pace with the growing disease burden in SA’s most populous province.
Gauteng’s Health MEC Nomantu Nkomo-Ralehoko attributed the rise in STIs and people opting for Pre-Exposure Prophylaxis (PrEP) to the non-use and inconsistent use of condoms.
But Professor Linda-Gail Bekker, director of the Desmond Tutu Health Foundation, said there was no evidence to support the claim that PrEP is leading to reduced condom use. She said the rise in STI diagnoses could be due to increased rates of testing, which has increased in the PrEP era.
“The notion that sexually transmitted infections have suddenly increased in the era of PrEP has no basis – we have no strong evidence to suggest that people are having more condomless sex than before.
“The value of condoms as a measure against STIs and unwanted pregnancy is not disputed, and condoms remain the cornerstone of the HIV response,” added Bekker.
“However, we know that for many people, and particularly young women and young men who have sex with men, the choice to use male condoms is not always a given and negotiating condom use may not be easy, and can be dangerous.”
See more from MedicalBrief archives:
Condom shortage places Mpumalanga sex workers, truckers at risk
HIV cases drop in SA, but so does condom use
Condoms out of stock in Gauteng
Alarm at low condom use among SA youth