Tag: contraception

Dramatic Decline in Condom Distribution in SA, New Figures Show

Photo by Reproductive Health Supplies Coalition on Unsplash

By Catherine Tomlinson for Spotlight

Condom distribution in South Africa has dropped dramatically over the last five years, finds a Spotlight analysis of data recently published in the Health System Trust’s District Health Barometer.


The South African government distributed 45% fewer male condoms in 2022 than it did in 2018. The total number of male condoms distributed dropped by over 300 million from 728 million in the financial year from March 2018 to February 2019 to 403 million in 2022/2023. Female condom supply also declined over this period, but not as sharply.

The full extent of the actual decline in condom supply across the country over the past five years has not previously been reported. The Democratic Alliance, though, did raise the alarm bells about condom supply challenges in Gauteng in April 2023.

Provincial departments of health have pin-pointed the time required for certification of condoms by the South African Bureau of Standards (SABS) following the start of a new condoms tender in 2022 as a key driver of the decline, yet Health System Trust’s District Health Barometer (DHB) data shows that condom distribution figures have in fact steadily declined over the past five years. Similarly, while COVID-19-related supply chain interruptions were a contributing factor to supply shortages at the height of the pandemic, the decline in government supplied condoms started before the pandemic and continued after COVID-19 supply chain disruptions were resolved (as shown in the below graph).

The large decline in condom distribution in South Africa is alarming in the context of the country’s ongoing fight against HIV. While other biomedical interventions are now available to protect against HIV (such as HIV prevention pills), condoms should remain a cornerstone of countries’ HIV prevention strategies according to the World Health Organization.

Research conducted by the University of Witwatersrand’s Health Economics and Epidemiology Research Office (HE2RO) has found that condoms are not only the most cost-effective intervention available to government to combat HIV, but that provision of condoms is in fact cost saving for the country’s health system.

Where did condom distribution fall the most in 2022?

According to the DHB data, all provinces except for the Free State saw a decline in condom distribution in 2022/2023 compared with 2018/19 levels (as shown in the below graph).

The Eastern Cape distributed 65% fewer condoms in 2022/23 than it did in 2018/19, Gauteng and the Northern Cape distributed 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 South Africa’s other provinces with large populations.

Male condoms distributed by province

Province2018/192019/202020/212021/222022/23
Eastern Cape73 672 41678 817 15751 122 50945 839 58825 490 700
Free State50 756 15053 246 00052 248 00055 352 80052 469 700
Gauteng172 953 486135 857 486146 303 254129 075 30369 220 678
KwaZulu-Natal111 028 599108 503 92096 529 200106 967 00089 664 600
Limpopo82 563 32267 818 20053 325 90052 862 90038 910 442
Mpumalanga67 150 60051 749 40038 316 00031 364 06635 627 000
Northern Cape13 934 96012 959 40010 825 9299 518 0005 194 000
North West50 820 28355 579 92139 841 97142 361 09730 810 803
Western Cape103 322 80082 055 96053 632 22672 031 60055 420 700
*This table shows a breakdown of male condoms distributed by province, according to data from the Health Systems Trust’s District Health Barometer.

What caused the decline in condom supply?

Condoms are tendered nationally by the National Department of Health for a three-year period. Condoms procured by government must be tested and certified by the SABS before distribution.

Neither the National Department of Health, nor the Gauteng Department of Health responded to questions from Spotlight about the reasons for the decline in condom distribution. However, Gauteng’s Department of Health has previously pinpointed SABS certification processes as the culprit for condom supply shortages in the province. According to an April 2023 media statement by the Gauteng Department of Health, suppliers that received tenders to supply condoms to the public sector were unable to supply condoms to the province while awaiting SABS certification in 2022 – resulting in low condom stock in the province.

Spokesperson for the Eastern Cape Health Department, Sizwe Kupelo, told Spotlight in response to questions for this article that in 2022/23 “for most of the year there were no condoms to distribute”.

Kupelo said that the decline in condom distribution in the Eastern Cape was due to a combination of lags in supply availability while condom suppliers were awaiting SABS certification and challenges in delivering condoms to distribution sites in the province.

“2022/23 was the end of the condom supply contract and the period to award a new contract effective from 1st April 2022. This transition experienced a delay in availing the condoms due the SABS quality assurance process that could be finalised only around September 2022,” said Kupelo, adding that the province started to receive condoms from October of the same year.

“The second reason were related to suppliers who were not finding it easy to deliver to Eastern Cape areas due to the high cost of transportation to the identified 26 delivery distribution sites across the province. Suppliers are all based in Gauteng,” said Kupelo.  This matter he said was now resolved.

Kupelo added that condom supply in the province is now improving. He said that the province had reached 96.7% of its target to distribute 17 million condoms in quarter 3 of 2023/24 (quarter 3 of 2023/24 is September to November 2023).

The SABS’ response

Lungelo Ntobongwana, acting CEO of the SABS, told Spotlight that all condoms that are distributed nationally by the Department of Health are tested at the SABS condom laboratory in Groenkloof, Pretoria. “The laboratory is an accredited and dedicated laboratory for the testing of condoms,” he said.

“Downtime or challenges to operations as a result of unplanned disruptions have been experienced on rare occasions and the SABS has incorporated contingency plans to ensure that the testing processes and deliverables would not be negatively impacted.

“The value chain, from the production of condoms to the distribution and usage of condoms, requires the intervention of various role players. When there is a shortage of condoms, it could be due to several reasons and chinks in the value chain.  The SABS can categorically state that there are currently no challenges in its laboratory or deliverables regarding the testing of samples,” said Ntobongwana.

Did clinics run out of condoms in 2022/23?

The National Department of Health insisted in April 2023 that while Gauteng was facing low stocks of condoms, there were no serious condom shortages in the country.

Surveys conducted by community-lead clinic monitoring group Ritshidze also show that condoms remained available in most facilities – but not all – throughout the year, but also indicate a pattern of rationing by health care workers and clinics. In some cases, they say condoms are only available in public clinics on request, and key populations often face stigma and discrimination when seeking to access condoms and lubricant.

Surveys conducted by Ritshidze in 2022, found that only 55% of sex workers could get enough condoms at public facilities. Ritshidze recommends that “condoms and lubricants should be available at all facilities and can easily be placed in the toilets or other areas of the clinic where people could take them without the fear of being seen and judged by others, or being told to put some back”.

Anele Yawa, General Secretary of the Treatment Action Campaign (a member of Ritshidze), told Spotlight that the organisation faced challenges in accessing adequate condoms for its community outreach efforts. He said when TAC undertakes community outreach efforts, its members request condoms from public health facilities for distribution in communities but are sometimes told that there are not enough condoms for this.

Yawa added that people seeking condoms from public clinics are often told they can only take a limited number of condoms because of stock availability and that in some clinics “the condom box is empty, there are no condoms”.

Has the decline in condom availability impacted condom usage?

There are some concerning indicators that condom usage in the country is declining, which may in part be related to the drastic decline in condom supply.

The Human Science Research Council (HSRC), which conducts regular surveys of HIV knowledge and sexual behaviour in South Africa, recently released early data from its 2022 survey. The survey showed that teenagers and young adults between 15 and 24 years old reported lower rates of condom use at last sex than in previous survey years. The data presented did not pin-point a cause for the decline – apart from supply constraints, other factors like a decrease in people’s perceived risk of contracting and dying of HIV may also play a role.

The HSRC will release its full survey results in April 2024, which are expected to provide more insight into why condom use at last sex declined among 15- to 24-year-olds in 2022.

Another concerning indicator of declining condom usage is the reported rise in sexually transmitted infections (STIs) in Gauteng.  Spotlight reported in February that the worried resurgence in reported cases of STIs in Gauteng in 2023 is a wake-up call that control and management strategies are not keeping pace with the growing disease burden in South Africa’s most populous province.

In response to the increase in STIs, Gauteng’s Health MEC Nomantu Nkomo-Ralehoko recommended expanded, consistent condom use – noting a number of factors including non-use of condoms, inconsistent use of condoms, and the forgoing of condoms by people using Pre-Exposure Prophylaxis (PrEP) as contributors to the rise in STIs. PrEP refers to antiretrovirals taken to prevent HIV infection.

Dismissing the conclusion of a causal relationship between a higher number of people being initiated on PrEP and the higher recorded number of STIs, Professor Linda-Gail Bekker, director of the Desmond Tutu Health Foundation, told Spotlight that there is no evidence to back up the claim that PrEP is leading to lower rates of condom usage. She added that the increase in STI diagnoses may be attributed 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 does not have evidence to support this,” said Bekker, adding “we have no strong evidence to suggest that people are having more condomless sex than before”.

“The value of condoms as a measure against sexually transmitted infections as well as unwanted pregnancy is not disputed and condoms remain the corner stone of the HIV response” said 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,” she said.

Republished from Spotlight under a Creative Commons licence.

Source: Spotlight

Lower Oestrogen Levels may Explain Migraine Increase During Menstruation

Woman feeling dizzy and kneeling
Photo by RODNAE Productions from Pexels

New research published in Neurology may explain why migraine attacks are more common during menstruation. The researchers found that, as oestrogen levels fluctuate, for female migraine sufferers, levels of the protein calcitonin gene-related peptide (CGRP) that plays a key role in starting the migraine process also fluctuate.

“This elevated level of CGRP following hormonal fluctuations could help to explain why migraine attacks are more likely during menstruation and why migraine attacks gradually decline after menopause,” said study author Bianca Raffaelli, MD, of Charité – Universitätsmedizin Berlin. “These results need to be confirmed with larger studies, but we’re hopeful that they will help us better understand the migraine process.”

The matched cohort study involved three groups of female participants with episodic migraine, all with least three days with migraine in the month before the study. The groups were those with a regular menstrual cycle, those taking oral contraceptives, and those who had gone through menopause. Each group had 30 people, for a total of 180, and were age-matched to women without migraine history.

Researchers collected blood and tear fluid to determine CGRP levels. In those with regular menstrual cycles, the samples were taken during menstruation when oestrogen levels are low and around the time of ovulation, when levels are the highest. In those taking oral contraceptives, samples were taken during the hormone-free time and the hormone-intake time. Samples were taken once from postmenopausal participants at a random time.

The study found that female participants with migraine and a regular menstrual cycle had higher CGRP concentrations during menstruation than those without migraine. Those with migraine had blood levels of 5.95 picograms per millilitre (pg/ml) compared to 4.61pg/ml for those without migraine. For tear fluid, those with migraine had 1.20ng/ml compared to 0.4ng/ml for those without migraine.

In contrast, those taking oral contraceptives or were postmenopausal had similar CGRP levels in the migraine and non-migraine groups.

“The study also suggests that measuring CGRP levels through tear fluid is feasible and warrants further investigation, as accurate measurement in the blood is challenging due to its very short half-life,” Raffaelli said. “This method is still exploratory, but it is non-invasive.”

Raffaelli noted that while hormone levels were taken around the time of ovulation, they may not have been taken exactly on the day of ovulation, so the fluctuations in oestrogen levels may not be fully reflected.

Source: American Academy of Neurology

A New Possibility for Non-hormonal Male Contraceptives

Photo by Reproductive Health Supplies Coalition on Unsplash

Thus far, very few contraceptive options being developed target the sperm cells. Researchers are now developing approaches that target testosterone or otherwise interrupt the sperm’s ability to fertilise an egg, yet these may not work for everyone. But now, researchers publishing in ACS’ Journal of Medicinal Chemistry have identified a new candidate molecule that could become an effective non-hormonal contraceptive for males.

Previously, Gunda I. Georg and colleagues investigated non-hormonal contraceptive options, as approaches targeting testosterone produced unwanted side effects. They developed a drug targeted at a specific vitamin A receptor and found that it worked as a highly effective contraceptive with no side effects. But numerous proteins are involved in forming sperm, and exploring multiple options would maximise chances for a drug that would eventually make it to market.

Another set of proteins involved in the cell cycle are the cyclin-dependent kinases, or CDKs, which play a role in sperm cell production and tumour development. Mice without the CDK2 receptor are sterile, so a drug that targets this protein could serve as an effective contraceptive. It also has potential as a cancer therapeutic because inhibiting the enzyme slowed tumour growth in previous studies. However, CDK2 has a very similar shape to other enzymes in its family, and currently available inhibitors tend to produce undesirable off-target effects by accidentally binding the others as well. So, Georg and her team wanted to develop a drug that could selectively inhibit CDK2 to serve as another contraceptive option.

The team previously discovered an unknown binding site in CDK2 and a commercially available dye molecule that successfully bound to it. Using the dye as a starting point, the researched screened tens of thousands of different compounds in their current work to find ones that also bound the pocket well. They narrowed the list down to just three, picking one to further optimize. The best version, named EF-4-177, demonstrated a long half-life and good diffusion into the testes of mice. After a 28-day exposure, the animals’ sperm counts decreased by about 45%. Additionally, EF-4-117 bound much more strongly to the CDK2 pocket than the dye, making it the highest affinity inhibitor for this site reported to date. The researchers say that this work proves the potential of this inhibitor for future therapeutic applications.

Source: Michigan State University

A New Hormone-free Contraceptive Reinforces the Cervical Barrier

Photo by Reproductive Health Supplies Coalition on Unsplash

A new non-hormonal contraceptive may be possible with a prophylactic gel made from naturally occurring ingredients, according to researchers writing in Science Translation Medicine. The gel reinforces the cervical mucus barrier, offering the first viable alternative to spermicides and contraception pills.

In tests on ovulating female sheep, the gel resulted in a 98% average decrease in uterine sperm numbers, compared to control animals. Birth control pills are recognised to be between 91 and 99% effective.

Only one of the eight sheep tested was found to have two sperm detected in its uterus after being treated with the topical gel. Thomas Crouzier, a biopolymers researcher at KTH, says the results demonstrate the potential of an unprecedented approach to preventing unwanted pregnancies by blocking sperm by engineering mucus rather than killing sperm cells as spermicides do.

Crouzier says that mechanism taps into cervical mucus’ natural capacity as a barrier that isolates the vagina, where bacteria proliferate, from the uterus and upper reproductive tract. Cervical mucus also regulates the movement of sperm. Leading up to ovulation the mucus barrier becomes a more selective gatekeeper, making exceptions for the passage of select sperm into the uterus.

The researchers change this dynamic by crosslinking molecules of mucin (the proteins that give mucus its lubricating property) with chitosan, a fibrous natural substance commonly used in medical materials such as hydrogels, meshes and sutures. This combination temporarily thickens cervical mucus so that sperm have more difficulty getting through.

The chitosan was shown to have a similar effect in lab tests using human cervical mucus and sperm. It reinforced the mucus barrier quickly, with a reduction in sperm penetration after one minute of exposure and full sperm blockage after five minutes.

Citing studies, Crouzier says that about 50% of women consider it important that their contraceptives do not contain hormones. “This new mechanism of action has the potential to be very effective, since it is reinforcing a barrier that already exists in the women’s reproductive tract,” he says.

“Vaginal gels like this can be applied in seconds,” Crouzier says. “We imagine that a product like this should be usable from seconds to a few hours before sexual intercourse. The effect could last for hours, but diminish over time as the mucus barrier is replaced naturally.”

Source: KTH Royal Institute of Technology

Audit Finds Women are Uninformed of Common Anaesthetic’s Effect on Contraception

Women undergoing operations are not being routinely informed that a common anaesthetic may reduce their contraception’s effectiveness, putting them at risk of an unplanned pregnancy, suggests new research which is being presented at Euroanaesthesia, the annual meeting of the European Society of Anaesthesiology and Intensive Care (ESAIC).

The drug sugammadex is widely used in anaesthesia.  Administered towards the end of the operation, ahead of waking the patient up, it reverses the action of the neuromuscular blocking drugs rocuronium and vecuronium given earlier in the procedure to relax the patient’s muscles.

Sugammadex is known to interact with progesterone, possibly reducing the effectiveness of hormonal contraceptives, including the progesterone-only pill (mini-pill), combined pill, vaginal rings, implants and intra-uterine devices.

Current guidance is to inform women of child-bearing age (WCBA) that they have received the drug and, due to increased risk of contraceptive failure, advise those taking oral hormonal contraceptives to follow the missed pill advice in the leaflet that comes with their contraceptives and advise those using other types of hormonal contraceptive to use an additional non-hormonal means of contraception for seven days.

However in the experience of the authors, robust methods for identifying at-risk patients and informing them of the associated risk of contraceptive failures is not common practice across anaesthetic departments within the UK, and likely further afield. 

To find out more, Dr Neha Passi, Dr Matt Oliver and colleagues at the University College London Hospitals NHS Foundation Trust surveyed anaesthetists at their hospital trust on their use of sugammadex and carried out a retrospective audit of sugammadex use in the Trust.

A seven-question survey was sent to all anaesthetists at the Trust.  Including consultants, junior doctors and physician assistants, this numbered almost 150 professionals.

Of the 82 anaesthetists who responded, 94% said they were aware of the risk of contraceptive failure – but 70% of respondents reported they do not routinely discuss sugammadex with patients who received it.

During the audit, 65 WCBA patients were given sugammadex, and 48 of these should have received advice on the risks of contraceptive failure.  There was no record of it, however, in the medical notes of any of the 48 women. (The other 17’s medical history meant they weren’t at risk of pregnancy and so not eligible for the advice.)

Dr Passi said: “It is concerning that we are so seldom informing patients of the risk of contraceptive failure following sugammadex use.

“Use of sugammadex is expected to rise as it becomes cheaper in the future and ensuring that women this receiving medicine are aware it may increase their risk of unwanted pregnancy must be a priority.”

Dr Oliver added: “We only studied one hospital trust but we expect the results to be similar in elsewhere in the UK.”

Dr Passi adds: “It is important to note, however, that most patients receiving an anaesthetic do not need a muscle relaxant2 and that sugammadex is one several drugs available to reverse muscle relaxation.”

In response to their findings, the study’s authors have created patient information leaflets and letters and programmed the Trust’s electronic patient record system to identify ‘at-risk’ patients and deliver electronic prompts to the anaesthetists caring for them in the perioperative period.

Sugammadex is the only anaesthetic drug known to have this effect.

Source: EurekAlert!

Early Menopause and Oral Contraceptive Link

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Long-term use of oral contraceptives, as well as certain methods of tubal ligation (TL), were linked to lower levels of antimüllerian hormone, a biomarker for ovarian aging, suggesting an increased risk for early menopause, according to preliminary research.

Using data from the Nurses’ Health Study II, researchers at the UMass Amherst School of Public Health and Health Sciences examined the association of oral contraceptive use and tubal ligation with antimüllerian hormone (AMH).

Published in the journal Menopause, the results were “intriguing,” according to lead author Christine Langton, PhD candidate.

“We’re one of the larger studies to have looked at both of these contraceptive methods at the same time,” says Langton, now a post-doctoral researcher at the National Institute of Environmental Health Sciences. “We feel we’re contributing to the story, and to the literature, though nothing we did was definitive. This is a piece of the puzzle.”

Early menopause, which occurs before 45, puts women at greater risk for a range of health conditions including cardiovascular disease, osteoporosis and dementia. The researchers noted that oral contraceptives change hormone levels and prevent ovulation; tubal ligation may affect blood supply to the ovaries, and certain methods of the procedure may damage the ovary and surrounding neural tissue. 

“Recently, AMH has become an established marker for the timing of menopause and was found to be strongly associated with the risk of early menopause,” the authors wrote. “Yet, the association of reproductive and lifestyle factors with AMH levels remains unclear.”

The team focused on a subset of 1420 premenopausal women in the Nurses’ Health Study prospective cohort who had provided a blood sample between 1996 and 1999. A history of their oral contraceptive use and tubal ligation began in 1989 and was updated every two years until their blood was collected.

“Women who reported that their [tubal ligation] procedure included the use of a clip, ring or band had significantly lower AMH levels compared to women who never had a TL procedure,” the researchers wrote.

One limitation is the small number of women reporting the type of tubal ligation, Langton added.

When it came to oral contraceptives, “we saw a significant inverse association – the longer the use of oral contraceptives, the lower the AMH levels were,” Langton said. “That particular finding was a little surprising to us because it didn’t completely align with what we saw when we looked at oral contraceptives and early menopause in the larger cohort” of more than 115,000 women.

Even after adjusting for factors including BMI, smoking, alcohol, number of pregnancies and breastfeeding, the inverse association between oral contraceptive use and AMH levels remained significant.

“We think further research is warranted,” Langton said.

Source: University of Massachusetts

A New Antibody-based Contraceptive for Women

Photo by nine koepfer on Unsplash
Photo by nine koepfer on Unsplash

Researchers have developed a topical antibody-based contraceptive for use by women, which works like a glue, clumping and trapping sperm. 

Over 40 percent of pregnancies worldwide are unintended, even though multiple forms of contraception are available. As well as fuelling population growth, unintended pregnancies can negatively impact the physical, mental and economic wellbeing of mothers.

To address these problems, researchers from Boston University School of Medicine and ZabBio have developed an anti-sperm monoclonal antibody, the Human Contraception Antibody (HCA), which laboratory tests showed was safe and had potent sperm agglutination (clumping) and immobilisation activity.

“HCA appears to be suitable for contraceptive use and could be administered vaginally in a dissolvable film for a woman-controlled, on-demand birth control method,” explained senior author Deborah Anderson, PhD, professor of Medicine.

In order to assess its applicability as a topical contraceptive, the team tested HCA over a wide range of concentrations and under different physiologically relevant conditions in vitro. HCA was mixed with sperm from normal, healthy volunteers and then tested. Sperm became immobilised within 15 seconds, becoming stuck together. The researchers also found that HCA did not seem to cause vaginal inflammation in lab tissue culture tests.

Thanks to its safety and efficacy, HCA could fill current gaps in the contraception field. “HCA could be used by women who do not use currently available contraception methods and may have a significant impact on global health,” said Prof Anderson.  HCA is currently being tested in a Phase I Clinical Trial.

The researchers also believe that a combination of HCA with other antibodies such as anti-HIV and anti-HSV antibodies could make a multipurpose prevention technology, a product that would both serve as a contraceptive and prevent sexually transmitted infections.

These findings appear online in the journal EBioMedicine.

Source: Boston University School of Medicine

Journal information: Gabriela Baldeon-Vaca et al, Production and characterization of a human antisperm monoclonal antibody against CD52g for topical contraception in women, EBioMedicine (2021). DOI: 10.1016/j.ebiom.2021.103478

A Natural Compound for Male Contraception

Researchers have isolated a natural compound found in a Chinese Herb that can reversibly induce male sterility.

The compound, triptonide, can be either purified from a Chinese herb called Tripterygium Wilfordii Hook F, or produced through chemical synthesis. It is being investigated for application in various cancers.

Single daily oral doses of triptonide induce altered sperm having minimal or no forward motility with close to 100% penetrance and consequently male infertility in 3-4 and 5-6 weeks. Fertility is restored within 4-6 weeks, and no toxic effects were observed even over the long term. 

Analysis suggested that triptonide targets one of the last steps during sperm assembly, leading to the production of altered sperm with limited motility.

“Thanks to decades of basic research, which inspired us to develop the idea that a compound that targets a protein critical for the last several steps of sperm assembly would lead to the production of nonfunctional sperm without causing severe depletion of testicular cells,” said Dr Yan. “We are very excited that the new idea worked and that this compound appears to be an ideal male contraceptive. Our results using non-injurious studies on lower primates suggest triptonide will be an effective treatment for human males as well. Hopefully, we will be able to start human clinical trials soon to make the non-hormonal male contraceptive a reality.”

“Dr Yan’s discovery represents a major leap forward in the field,” said Drs Christina Wang and Ronald Swerdloff, who are TLI co-Principal Investigators helping lead NIH-supported advanced clinical trials on hormone-based birth control approaches. “The more contraceptive methods available, the better, as we will want a family of pharmaceutical products to safely and effectively meet the family planning needs of men and couples at different stages of their reproductive lives, with differing ethnic, cultural and religious backgrounds and economic means,” they concluded.

Source: Medical Xpress