Condoms create a conundrum.
By global consensus, condoms remain essential to HIV prevention and epidemic control. Nations have signed on to the multi-agency 20 x 20 Initiative, which calls for distributing 20 billion condoms by the year 2020. And there’s a problem with that.
For one thing, funding for condom programming is shrinking. For another, there’s typically no coordination among the major providers of condoms for HIV epidemic control, says Olawale Durosinmi-Etti, chief of party for the Nigeria office of the Strengthening High Impact Interventions for an AIDS-free Generation (AIDSFree) Project. Private, public, and nongovernmental agencies often work independently of each other, even when they have similar program goals.
In pursuit of the 20 x 20 goal, AIDSFree Nigeria looked to the total market approach (TMA), a strategy that integrates the needs of different consumers and the goals of diverse market segments. TMA engages and coordinates all supply sectors—public, private, and social marketing (market initiatives aimed at social change). Though brief (September 2017—September 2018), Nigeria’s TMA intervention secured not only government endorsement—including two national policies—but also enthusiastic participation among private condom sellers.
The effort yielded progress on several fronts. AIDSFree Nigeria has supported quantification and planning of condoms and lubricants for 2018–2022, and helped develop a condom logistics management information system. The project also helped develop a national TMA dashboard to make condom data available to all stakeholders. AIDSFree Nigeria also is helping to develop a communication strategy to reach vulnerable groups.
It’s a tremendous amount of work, given the project’s short timeframe, but organizers are optimistic. “For us, a key highlight is that Nigeria has gone from zero to knowing all about TMA, especially the commercial sector,” Durosinmi-Etti says.
A Large, Diverse Market for Condoms
Despite a relatively low HIV prevalence (2.9 percent), Nigeria’s large population means that 3.6 million people were living with HIV in 2016, making it the world’s second-largest epidemic. “Certain key populations carry the burden—female sex workers, injecting drug users, and men who have sex with men,” says Ijeoma Iwuora, monitoring and evaluation advisor for AIDSFree Nigeria. “We’re looking at TMA to increase the sustainability of condoms for HIV prevention, so that Nigeria won’t retrogress when funding sources diminish.”
Nigeria has a large, diverse market, with more than 400 million condoms used annually and 100 brands available through social marketing, private sales, and free distribution. However, a 2017 landscape analysis showed that the country’s condom market is failing high-risk populations. The analysis revealed high dependence on donor funding (about 50 percent in 2016), a condom gap of 600–700 million, and additional commodity costs of $18 million annually to avail 1.2 billion condoms, the total needed for full coverage.
How to Introduce TMA
To introduce TMA for condoms, AIDSFree coordinated players in the public, private, and social marketing sectors, conducted strategic engagement and information sessions, and provided research, analysis, and market intelligence.
Importantly, AIDSFree sought buy-in from the major government agencies involved in condom programming; the Federal Ministry of Health (FMOH) and the National Agency for the Control of AIDS (NACA). The result was the formation of a TMA subcommittee within NACA in November 2017.
Next, AIDSFree met with FMOH, NACA, partners, donors, and other stakeholders, including those most affected by the epidemic, to set up a sustainable TMA mechanism and secure stakeholder commitment. This process supported the formation of two policies: NACA adopted TMA as a pillars of HIV prevention and integrated the approach into the government’s National Condom Strategy for 2018–2022. And the Nigeria National Council on AIDS, the nation’s highest decision-making body on HIV, adopted TMA as a strategy for a sustainable HIV response.
“This is a major achievement, especially given the short timeframe,” Durosinmi-Etti says. He cites AIDSFree’s in-country relationships as advantages. “It helped that we’ve had field staff working with NACA, and a good relationship with the FMOH.”
Endorsing Condoms, Motivating Sellers
National buy-in for TMA is critical for forecasting need and expanded access to condoms, Durosinmi-Etti explains. “Before TMA, the focus was on distribution of free condoms, so forecasts would generally be on what donors were providing. TMA means that every policy or activity you develop will include all condoms—free, socially marketed, and commercial. This makes planning more comprehensive because it gives visibility into all sectors.”
TMA benefits the private sector by unveiling the composition of the entire condom market and creating new opportunities. “Previously, the commercial sector knew only about the sales in their sector, not in the public or social marketing sectors,” Durosinme-Etti says.
The new visibility of condom data is yielding results, he adds. “Commercial sellers are seeing that there are more gaps than they realized, and they want to do more. A key private sector player said he’d never known the volume of the market gap, and now he would like to invest. And a local manufacturer is completing a condom-production facility.”