Fourteen years ago I was asked to prepare the following document. After it was completed, the contractor asked me to re-do it because they had made a mistake in the age they wanted covered. [They seemed to believe the information was too sensitive politically] and buried the report. I'm submitting it here now to learn what the LinkedIn audience thinks. Is it time to update it?

1. Condom Programming as an Effective Strategy
for HIV Prevention
among Young People (ages 10 – 14)
Steven C. Mobley
Consultant
January, 2003

2. 11
Call to Action
The United Nations General Assembly Special Session (UNGASS) on HIV/AIDS in June
2001 resulted in a Declaration of Commitment (DoC) by the Member States to
implement measures to empower women and adolescent girls to better protect
themselves [from HIV/AIDS]. An important target is to develop and /or strengthen
national efforts in educating and guiding children to reduce their vulnerability, to expand
youth-friendly information and sexual health education and counseling services by 2003.
The commitment to children and youth is ambitious and is supportive of The Convention
on the Rights of the Child, e.g. right to survive, to develop, and to self-protection in a non-
discriminatory environment. Equally supportive was the International Conference on
Population and Development 5th
year review, which presented clear goals for member
states.
The UNGASS DoC 2001 repeated these specific global goals for access of young
people to education, information and services along with access to male and female
condoms. Has any of this been realized to its fullest?
HIV/AIDS Condom Programming
To realize the UNs commitment, condom programming strategies must be enacted
across the globe. Condom Programming includes all of the efforts necessary to get
condoms from the factory to the user when and where they are needed, and include
communications strategies that not only encourage consistent use but inform on correct
usage as well, promotion strategies, and tie-ins to reproductive health and general health
education programs, family planning programs, workplace programs, research
programs, policy advocate programs, and STI treatment programs.
Procurement and quality assurance are some of the first steps needed in developing a
condom programming strategy. Once quality product is in a country, it must be
distributed in an equitable manner to those with the greatest need and capacity to get it
to end users in a timely manner. It can be allocated through the existing public sector
commodity distribution network or it can be passed through a Social Marketing
organization or both mechanisms can be utilized. Each mechanism could in turn utilize
Community Based Networks (NGOs), Peer Networks, Schools, and Workplace settings
while the Social Marketing mechanism could also utilize commercial networks.
Regardless of the mechanism used to get the product to the user, the user has to want
the product (Demand) and know how to use it for the effort to be worthwhile.
Communications programming is the key to making condom programming successful,
regardless of the targeted age group. An added problem with early adolescence is
possibly cultural/legal barriers related to local “age of majority” considerations. Condom
Programming communications can effect the enculturation of condom use which
empowers women and men to use condoms without the stigma oftentimes associated
with contemporary use. Once the condom enculturation process is completed, stigma is
transferred from use to non-use.

3. 22
In many cases condoms are in such short supply that their availability alone stimulates
trial usage if not more. Public sector condoms, misperceived by some to be of inferior
quality, are rarely if ever found to be in excess supply due to a lack of demand. Demand
generation is still necessary for public sector generic condoms and for commercial
brands.
The commitments are in place. Rights have been established. Youth have been
identified as a vulnerable population. Resources have been allocated. A Call to Action
has been made.
The Forgotten Ones
Although the UN Convention on the Rights of the Child is supportive of children’s rights
as mentioned above and which includes ages 10 to 24, the early adolescence group (10
-14) is greatly overlooked. Puberty can start well before the teen years and sexual
initiation is experienced by many boys and girls before age 15, as demonstrated by
pregnancy rates and STI reporting as well as DHS surveys. The Alan Guttmacher
Institute reports that 8 of 10 girls and 7 of 10 boys have not experienced intercourse prior
to the age of 15. Conversely, 2 of 10 girls and 3 of 10 boys have in the United States.
Nearly 50% of boys in Hungary, Brazil, and Gabon are reported by Measure DHS to
have experienced sex before age 15 as have approximately 30% of the girls in Niger,
Tanzania, Finland, Brazil, and Hungary. The global health community is obligated to find
ways of meeting this groups needs in the area of HIV prevention through education and
access to protection.
Sexuality of Youth 10 -14 years of age: Sexual Debut -
Estimates by UNAIDS and WHO are that approximately 400,000+ children under the
age of 15 have been infected with HIV, absent of MTCT. And to date there is no
evidence that any significant intervention has been carried out focusing on 10-14 year
old adolescents involving condom use or condom promotion.
“…services for prevention and care of STDs are frequently not accessible,
acceptable or appropriate to this section of the population. It is essential, therefore,
that adolescents are recognized as an important target group for STD prevention
and care programmes. STD programmes should put in place mechanisms to
address the issue of curable and non-curable STD in children and adolescents, with
particular attention to those below the legal age of majority.” UNAIDS Best Practice
Collection, Sexually Transmitted Diseases: Policies and Principles for Prevention and Care

4. 33
Youth-Adolescent-Young People-Adult-Child
Karen Pittman of the International Youth Foundations is quoted as saying “I am struck by
the amazing diversity in the basic definition of youth around the globe1
” The age range
varies from 8 to 402
. How we reference things either helps clarify our thoughts or, when
we inconsistently use descriptive terms, confuse them. WHO has reported that the
Convention on the Rights of the Child (CRC) defines a child as all persons under the age
of 183
. UNAIDS reports that WHO defines adolescents as 10-19 years, youth as 15-24
years, and the two groups together (10-24) as young people4
. In other publications
UNAIDS refers to “young people aged 15-24”5
. Yet another UNAIDS publication uses
“children” and “young people” interchangeably6
. UNICEF talks about adults aged 15-497
.
For the purpose of this paper “early adolescence” refers to 10-14 year olds and youth will
represent 15-24 year olds, while “young people” covers the entire range from 10-24.
Every effort has been made to qualify terms when used in this paper.
Causes of HIV in Early Adolescence
The causes of HIV and other STI in early adolescence are the same as for older groups
of reproductive age. The primary causes are still sexual transmission and unclean
needles associated with IDU. Adolescents, however, have less access to information,
treatment, care, and prevention interventions. Sexual debut in early adolescence is on
the rise and often times from economical, cultural, or physical coercion. Adolescents are
placed in additional harm because health services that include safe and supportive
environments that are protective against violence and coercion, and enforcement of
rights are not available to the very young.
Sub-Saharan Africa youth have earlier sexual experiences than their counterparts in
other regions of the world according to a joint UNICEF, UNAIDS, and WHO publication
“Young People and HIV/AIDS: Opportunity in Crisis.”
Many young women have been encouraged to marry early to reduce their exposure to
HIV/AIDS. However, the risk persists with spouses maintaining multiple relations or
entering the marriage already infected8
. The end result according to University of
Chicago, former Population Council researcher Shelley Clark is that married adolescent
girls face higher risks of HIV than sexually active unmarried girls of the same age. This is
a more difficult audience to reach with Condom Programming other than possibly via the
condom dual protection message sometimes delivered via family planning services. Men
1
Pittman, K. (1996, January/February). Aging Out or Aging In? Youth Today, 5(1). 47
2
Food and Agriculture Organization of the United Nations: http://www.fao.org/ruralyouth/faqs.html
3
Convention on the Rights of the Child: http://www.who.int/child-adolescent-health/right.htm
4
UNAIDS Best Practice Collection Sexually transmitted diseases: policies and principles for prevention and care
5
UNAIDS Brochure Implementation of the Declaration of Commitment on HIV/AIDS: Core Indicators August 2002
6
UNAIDS Best Practice Digest Mith Samlanh/Friends: work with street children
7
UNICEF End Decade Databases – HIV/AIDS http://www.childinfo.org/eddb/hiv_aids/young.htm
8
Schuler, Peter: Safety of early marriage in Sub-Saharan Africa is a faulty presumption, The University of Chicago
Chronicle Vol. 22 No. 3 Oct 24, 2002

5. 44
need to adopt responsible behaviors before monogamous relationships can serve as a
deterrent to HIV transmission.
The growing numbers of AIDS orphans are placed at increased risk of HIV due to the
lack of support systems. Due to their growing numbers and the diminishing numbers of
qualified caretakers, some children are forced into abusive situations including sex for
hire situations for the sake of survival. This is also the case for many young people
simply because of poverty and lack of economic opportunity.
Cultural Bias
The difficulty in obtaining useful data from the early adolescence age group is the
inability to survey them directly. Laws vary widely as can be seen from the designation of
Age of Majority or Age of Consent by national and/or local law. Although the countries
represented in the following table acknowledge early adolescence as having rights of
consent regarding sexual activity, answering a sexually oriented questionnaire or
distributing/selling a condom may have different legal constraints.
Donor organizations and program implementers in most cases are restricted by
mandates from Ethics Review Boards and legal advisors to honor the laws of their
homeland regardless of what might be permitted in the local culture, making it illegal to
obtain “sensitive” information from “minors” or to target them with condom promotion
activity.
Age of Consent
According to a report by Kristin Moore, Director of Research at Child Trends, Inc.,
“Adolescent Sexual Behavior, Pregnancy and Parenthood,” the majority of first
sex experiences by girls 14 years of age and younger is by coercion9
. The Age of
Consent is an arbitrary time in a person’s life when it has been decided by
sociopolitical and religious leaders that a person may consent voluntarily to
sexual intercourse with another person. Only those countries which have laws
giving the Age of Consent to persons 14 years of age and less are included in the
table below:
9
Moore, Kristin A. et al, Beginning too Soon. http://aspe.os.dhhs.gov/hsp/cyp/xsteesex.htm

6. 55
Age of Consent by Country and Sexual Orientation
Country Male-Female Sex Male-Male Sex Female-Female Sex
Albania 14 14/18?? 14
Argentina Rev 01/2001 12/15/16 12/15/16 12/15/16
Austria Rev 07/2002 14 Struck Down 14 14
Botswana Rev 01/2001 16-F/14-M illegal
Brazil Rev 01/2001 14/18 14/18 14/18
Brunei Rev 01/2001 14/16 illegal illegal
Bulgaria Rev 01/2001 14/15 14/18 14/18
Burkina Faso Rev 1/2001 13 21 21
Canada Rev 07/2002 14 18 14
Chile Rev 04/2002 12 18 18
China Rev 01/2001 14 not defined not defined
Colombia Rev 01/2001 12/14 14 14
Croatia Rev 01/2001 14 14/18? 14/18?
Estonia Rev 07/2002 14 16? 16?
Germany Rev 01/2001 14/16 14/16 14/16
Guyana Rev 01/2001 13 illegal illegal
Honduras Rev 03/2002 14/17 14 14
Hungary Rev 01/2001 14 18 18
Iceland Rev 03/2002 14 14 14
Italy Rev 06/2001 14 14 14
Korea Rev 03/2002 13 13 13
Kosovo 14 18 14
Liechtenstein 14 14/18 14
Malta Rev 01/2001 12/18 12/18 12/18
México Rev 07/2002 12 18 18
Montenegro Rev 01/2001 14 14 14
Netherlands Rev 03/2002 12/16 12/16 12/16
Nigeria Rev 06/2001 13
Panama Rev 01/2001 12/18?
Paraquay Rev 07/2002 12
Peru Rev 06/2001 14 14 14
Portugal Rev 01/2001 14/16?
Philippines Rev 03/2002 12/18 18 18
Puerto Rico Rev 01/2001 14 Illegal (under appeal) Illegal (under appeal)
Romania Rev 01/2001 14 illegal illegal
Russia Rev 06/2002 14/16? New Law?? 14/16? 14/16?
San Marino Rev 01/2001 14/16 14/16 14/16
Serbia Rev 07/2002 14 18 14
Singapore Rev 07/2002 14/16 illegal illegal
Slovenia Rev 01/2001 14 14 14
South Korea 13 13 13
Spain Rev 01/2001 13 13 13
St. Kitts/Nevis Rev 01/2001 14/16
Syria Rev 01/2001 13/15 illegal illegal
Togo Rev 08/2000 14
Vojvodina 14 18 14
Zimbabwe Rev 01/2001 12/16 illegal illegal
Note: Information gathered from http://www.ageofconsent.com
Multiple figures in a column pertain to different conditions under which an age is “legal” – check with the
website for details.

7. 66
Stigma and Denial
Condom access for disease prevention and avoidance of unwanted pregnancy is
needed at every age from puberty onward. There is a fear among some
concerned citizens that condom programming might stimulate greater sexual
activity among unmarried partners, especially youth. Thus far there has been no
evidence that condom promotion stimulates sexual activity in anyone although it
has been successful in encouraging safer sexual practices among those who are
sexually active10
,11
. According to a Kids Count special report12
“When Teens
Have Sex,” 47 different programs found that sex education delayed the onset of
sexual activity and also reduced the number of sexual partners, the number of
unplanned pregnancies, and the rates of sexually transmitted infections. The fear
of loosing our youth to promiscuity and the denial that HIV/AIDS impacts
everyone increases the risks for all.
The increased risk can be seen at health facilities where condoms are not
available to the very young or that are not discretely dispensed. It can be
witnessed at pharmacies and drug stores where condoms require special
attention to the customer. It can be seen in testing and NGO counseling facilities,
especially in small communities where existing anonymous protocols are
impossible to maintain. Examples are too numerous to list them all. The bottom
line is that once closely examined, one should be able to see clearly that fear of
the process of children growing up could actually prevent it, without proper
education and prevention practices in place.
In this context, there are two sides of stigma. Both involve fear of rejection by
one’s peers and the community at large. One however relates to condom use and
the other to non-condom use. According to The Guttmacher Report, August 2001
“The most powerful ‘protective’ factors for most subgroups [are] the perceived
personal and social costs of having sex or getting pregnant or causing a
pregnancy.13
” Condom promotion campaigns must and can accomplish what the
no-smoking advocates are accomplishing in making it “cool” to adopt responsible
/safer behaviors.
Once condoms are enculturated and accepted by the community at large as an
act of social responsibility, condom use will no longer be “stigmatized,” non-use
will.
10
Moore, Kristin A. et al, Beginning too Soon. http://aspe.os.dhhs.gov/hsp/cyp/xsteesex.htm
11
Child Trends, Summary Table: Review of Research Studies for Targeted Activities to Improve Adolescent RH,
http://www.chiltrends.org/what_works/youth_development/doc/ReproTables.pdf
12
When Teens have Sex: Issues and Trends. A Kid's Count Special Report from the Annie E. Casey Foundation,
c1998
13
Dailard, Cynthia, Recent Findings from The ‘Add Health’ Survey, The Guttmacher Report on Public Policy, Aug 2001

8. 77
Gender
As reported by Youth Coalition at the International Conference on Population and
Development (ICPD)14
“Girls and young women are biologically, socially and
economically more vulnerable, both to infection and to unprotected and coercive
sex.” Young women are often lured into sexual relations with older men who
believe they are safer partners.
The Ministry of Health in Jamaica reports that 10-14 year old females are twice to
three times more likely to be infected with HIV than boys of the same age15
. In
Cambodia, over 30% of 13 to 19 year old sex workers are infected with HIV16
and
the Cambodia Women’s Development Agency reports on a UNFPA website that
2 out of 10 female sex workers aged 10-14 are HIV positive17
.
Ethics, Public Policy, Legal, and Programmatic Considerations
Do we breech the rights of children in early adolescence by not including them in
condom use interventions and sexual behavior surveys? Have they been harmed
by exclusion or does inclusion potentially harm them in an equally significant
way? The latter situation seems unlikely and would be, in essence, giving
credence to the saying “ignorance is bliss.” Below is a passage from a report of a
seminar by Population Council on Informed Consent practices of researchers.
14
Youth Coalition for ICPD: http://www.acpd.ca/factsheets/HIV-AIDS.pdf
15
JAMAICA: Women Twice as Vulnerable to HIV/AIDS, Inter Press Service October 2001
16
“Many Youth Face Grim STD Risks” Network: 2000, Vol. 20, No. 3
17
UNFPA website News & Events – HIV/AIDS http://www.un.org.kh/unfpa/news/hiv-aids.html
Nearly 60 children are raped every day in South Africa and while experts agree to
disagree as to the cause, or whether the pervasive belief in the so-called "Virgin Cure"
prevents/cures HIV/Aids is possibly responsible for this deeply disturbing phenomenon
…. Moreover, infant rape appears to be unique to South Africa, however, the Virgin
Cure is not. Earl-Taylor, Mike, “HIV/AIDS, the stats, the virgin cure and infant rape”
Science in Africa Apr 2002
Children and adolescents cannot fully benefit from research unless they are
allowed to participate in it. The lack of research involving young people has
resulted in their exposure to unknown risk; for example, some 70 percent of
medicines used in pediatrics have never been tested on children. The literature
on the cognitive development of young people suggests that by the age of 12–13
years, they begin to understand abstract concepts, and that at approximately 14
years, their cognitive abilities roughly equal those of an adult. Wood, Susan Y. et
al; Informed Consent: From Good Intentions to Sound Practices A Report of a Seminar
24–25 May 2001 Population Council New York, NY

9. 88
Perhaps it is time to re-evaluate 10-14 year old adolescents, their risks, and the
benefits of early intervention. An evaluation of the benefits and liabilities of the
current definitions associated with all young people (10-24) is critically important
for the rational segmentation needed for research and intervention purposes.
Access to condoms by all segments of society will come much easier in all
countries which have a government policy of including condoms on “Essential
Medicines/ Commodities” lists, which generally place a priority on the items listed
and allows the listed commodities to enter the country free of import duty and
other taxes.
There are a number of “guidance tools” to assist policy makers and programmers
in ensuring access to condoms. Some helpful guidebooks, manuals, and best
practice case studies are listed below. All are assumed to be useful to some
degree in planning and implementing strategies to make condoms more
accessible to youth, either directly or peripherally. It is unknown if any of these
presented have been independently evaluated.
 Condom Procurement Guide, a World Bank publication by Tom Merrick and Joanne Epp
 The Female Condom: A guide for planning and programming by the Female Health
Company
 A Guide for GPs to Improve Young Peoples Access to Health Care by Access SERUs, Centre
for Health Program Evaluation, University of Melbourne, July 1997
 A conceptual framework and basis for action: HIV/AIDS stigma and discrimination, UNAIDS
2002
 A Step-by-step Methodological Guide for Costing HIV/AIDS Activities by Phillips, Margaret;
Huff-Rousselle, Maggie 2001
 AIDS Prevention: Guidelines for MCH/FP Programme Managers – I. AIDS and Family
Planning World, Health Organization
 Design and Application of a Costing Framework to Improve Planning and Management of
HIV/AIDS Programs Telyukov, Alexander; Sture, Francesca; Krasovec, Katherine
2000
 Designing HIV/AIDS Intervention Studies – An Operations Research Handbook Fisher,
Andrew; Foreit, James R. 2002
 Developing and Implementing an HIV/AIDS Plan at District Level Pillay, Yogan et al. 2000
 Hands On! A Manual for Working with Youth and Sexual Reproductive Health Deutsche
Gesellschaft fur Technische Zusammenarbeit(GTZ) GmbH 2002
 HIV/AIDS NGO/CBO Support Toolkit: A CD-ROM and Website International HIV/AIDS
Alliance 2002
 HIV/AIDS – related Stigma and Discrimination: A Conceptual Framework and an Agenda for
Action Population Council 2002
 Lessons Learned from Uganda HIV/AIDS Prevention (Powerpoint Presentation) TvT/ The
Synergy Project 2001
 National AIDS Control Programme Management: A Training Course 1993
 Programas Nacionales de SIDA – Guia para el monitoreo y la evaluacion UNAIDS 2000
 Strategic Management Tools to Support HIV/AIDS Policy Change Center for Democracy and
Governance, USAID 2001
 The Logistics Handbook: A Practical Guide for Supply Chain Managers in Family Planning and
Health Programs, John Snow Inc, Arlington, VA 2000

10. 99
 Facilitating Sustainable Behavior Change: A Guidebook for designing HIV Programs, Parnell,
Bruce; Benton, Kim 1999
 Developmentally Based Interventions and Strategies: Promoting Reproductive Health and
Reducing Risk among Adolescents – Early Adolescence (10-14), FOCUS on Young Adults,
February 2001
The bulleted material is focused on one area or another requiring a programmer
to review a multitude of “guidebooks” or manuals before a comprehensive
program could be developed. A guide or workbook that would contain the
essential elements of a “comprehensive” condom program would be highly
useful. We are then faced with the task of labeling “comprehensive.” UNFPA has
a diagram labeled “Comprehensive Condom Programming” at the web address
http://www.unfpa.org/aids/prevention/hivprev6b.htm . The components of the
diagram “Advocacy for political awareness and commitment,” “Effective
coordination at all levels,” and “Institutional Strengthening” are important
considerations. Elements of Demand, such as user motivators and behavior
influencers, need greater attention in a workable comprehensive planning/
implementation guide (see recommendations).
Unfortunately there isn’t an easy boilerplate survey to administer that would
determine condom use rates among young people. There possibly could be. It
doesn’t seem too unreasonable to think that a short (5 to 10 question?) survey
could be developed that would be simple enough to administer globally and
effective enough to provide a good baseline and follow-up indicator for successful
programming. Ex: Age, economic indicator, 1st
sexual experience with a condom,
condom used in last 5 sex acts?, estimate of friends condom usage in last 5 sex
acts, brand of last condom used, cost of last condom used, number of sexual
partners in past 6 months. The problem with short and simple surveys is that
everyone wants to add just a few more questions.
Availability of Condoms
Condom availability varies widely in Africa, Latin America, and Asia. The social sector,
including public health facilities, is the principal provider of condoms in Africa, while most
Latin Americans purchase their condoms from pharmacies and other retail sources.
(Source: DHS database search) Even where condoms are in abundance in the public
and private sector, the early adolescence group may still be unable to acquire them.
Overall, according to UNAIDS, there is a need for 24 billion condoms globally while
current availability lies in the range of 6 to 9 billion.
There are some peer education networks that may possibly reach 10-14 year olds, but
they are rare and their reach is minimal. School programs that include condom
availability target ages15-19. There are also a few programs that make condoms
available to street kids that fall within the 10-14 age range.

11. 1010
There are effective approaches to ensure quality condom availability to young people.
Effectiveness depends largely on access to those in need of information and product
although each programmer must review their country’s regulations regarding the specific
age group of the proposed activity. There have been a number of successful school
based programs targeting 15-19 year old youth, which provide condoms. Condoms have
been made available to school age children through health workers, teachers,
counselors, bowls and baskets, vending machines, and peers. However, in many
settings, parental consent is required before a student can acquire a condom.
Confidentiality is difficult to maintain. (Advocates for Youth National School Condom
Availability Clearinghouse) Street kids and other out of school adolescents have
obtained condoms through NGO networks, neighborhood centers, health clinics, vending
machines, peer educators, and the commercial marketplace.
Accessibility of Condoms
There is no literature on the accessibility of condoms by 10-14 year old adolescents.
Although there are reports in which one can surmise that some have access. A small
percentage of DHS survey participants have said their sexual debut came before their
15th
birthday and claimed to use condoms18
.
Pricing –
Commercial Private Sector condoms are typically too costly for the working poor and this
would probably pertain to early adolescence up through upper middle income groups.
Social Marketing supplies condoms to economically disadvantaged segments of the
population that can not afford consistent use of condoms due to the private commercial
sector’s relatively high cost. Social Marketing pricing, in most cases, is established to
reflect a year’s supply that would not exceed 1% of an individual’s annual income. This
pricing structure has been very effective in reaching social marketing’s target audience.
However, the 10-14 age group is unlikely to have an adult level income and therefore the
pricing structure would be too high for them to purchase condoms even in a Social
Marketing environment. There is no known study which has investigated young people’s
ability or willingness to pay for condoms for HIV/AIDS prevention.
Distribution -
Social Sector condom distribution, including public health networks, is the best (not only)
way to make condoms accessible to10-14 year old youth, given potential legal and cost
issues. Discreet systems need to be put in place to make adolescents and youth feel
comfortable in obtaining condoms. School programs that include condom provision
should be expanded downward to include early adolescence.
18
Measure DHS: STAT Compiler http://www.measuredhs.com/data/indicators

12. 1111
Social Marketing distribution can play an important role in making condoms accessible to
young people. To address the 10 to14 age group, it will be necessary to expand peer
networks to include younger kids and make sure the pricing strategy is appropriate to the
age group. Vending machines may also be an option in some cultures and economies
which would allow discreet purchases of condoms for all ages. Single unit sales in kiosks
or through other street vendors, where legally allowed, could also make condoms
discreetly available. Commercial Private Sector condom distribution will most likely
remain outside of the financial capability of the younger age groups. At the very least,
social marketing condom promotions could make sample product available in those
areas where this special target group is known to congregate.
Utilization of Condoms
Size of Condoms has been an issue for some time. Whether it is a real problem or a
perception of programmers is unknown and un-researched. The smallest condom on the
market measures 42mm just beneath the head of the penis, while the shaft measures
49mm. 49mm and 52mm are standard condom sizes.
A boy’s penis is not fully developed until age 17. At age 10 he is about half the size that
he will become at maturity. There are small differences in average size from culture to
culture (research by Ansell, makers of Lifestyle condoms) yet the smallest penis when
erect is larger than 49mm according to a global web survey on penis size at
http://www.sizesurvey.com. The size issue, although insufficiently researched, is
probably more perception than reality.
Early Adolescence has not been documented regarding condom use or sexual
practices. DHS data show that 15-19 year old youth that had sex prior to their 15th
birthday did, in some cases, use condoms on that first experience19 20
. Mothers can
facilitate the delay of onset and/or condom use by communicating to their children their
wishes21 22
.
Utilization of condoms can be stimulated and sustained. Marketing strategies have been
successful in changing the way the world looks at smokers and smoking. It has been
successful in changing hairstyles, clothing styles, what we drive, and what we aspire to.
Children are especially vulnerable to subtle messaging delivered by key influencers in
their environment, locally or globally. Make it “cool” and it will “rule!” Joe Camel has been
very successful with this strategy as has the Anti-Smoking counter-campaign. “Cool”
comes in various ways. For example, it has become “cool” in global culture to own a
SUV (sport utility vehicle) while branded products of the same genre have their own
“cool” factor.
19
Measure DHS: Survey Indicators STAT Compiler http://www.measuredhs.com/data/indicators
20
Abma J, A. Chandra, W. Mosher, L. Peterson, and L. Piccinino, “Fertility, Family Planning, and Women’s Health: New
Data from the 1995 National Survey of Family Growth,” Vital and Health Statistics, 1997, Series 23, No. 19.
21
Kirby, D. (2001) Emerging answers: Research findings on Programs to reduce teen pregnancy, Washington, DC
National Campaign to prevent teen pregnancy.
22
Miller, K.S., Levin, M.L., and Whitaker, D.J. Patterns of condom use among adolescents: The impact of mother-
adolescent communication. American Journal of Public Health 88(10): 1542. Oct. 1998.

13. 1212
Research Opportunities
We know too little. The gap in knowledge, regarding condom use and programming,
especially among early adolescence, is severe. Most programs and research surveys fail
to include individuals below age 15 due to strict ethics review boards and fear that local
communities would not support the activity. Some useful information could be gained
from:
 Condom KAP surveys of age 10-14 in countries where they can be legally carried
out
 Case studies of projects which have addressed early adolescence and included
them in activities related to condom access, condom use and condom promotion
 Holding community level all-stakeholder HIV prevention strategic planning
workshop focused on age 10-14
 Operations Research on School Based programs promoting ABC’s of HIV
prevention and those promoting A & B only and those with C only
 Demand Studies for specially sized male condoms for age 10-19 among in-
school and out of school kids
 Situational analysis of health services networks ability to discreetly address needs
of early adolescence and provide contraception including condoms for HIV/STI
prevention
 Policy assessment of countries with most severe HIV/AIDS rates regarding their
ability and shortcomings to address the prevention needs of early adolescence
and youth
 Survey of early adolescence in multiple cultural settings to determine if there are
any key influencers common to them all and learn of any other widespread
behavioral motivators
This is not intended to be an exhaustive list of research possibilities but rather a starting
point for discussion amongst stakeholders.

14. 1313
SUMMARY AND RECOMMENDATIONS
Summary
The “bottom line” for effective condom programming rests with the enculturation of
condoms into society, eliminating the stigma associated with condom use, and
popularizing responsible sexual behavior in the population. Behavior Change Social
Marketing is the key to accomplishing this objective23
. Public and social sector condom
programmers must embrace the full potential of commercial marketing and utilize all of
the tools that have proven to be successful in smoking and anti-smoking campaigns, in
fashion, and in music.
The dynamics of use of male and female condoms is not fully understood and it may just
be an academic exercise to attempt to understand. The key to acceptance and use is
the device’s and the associated usage behavior’s “cool” factor, which can be generated
by mobilizing key influencers at multiple levels of the user’s cognitive universe, which
could be anyone from local “hero” to TV superstar. Learning who the key influencers are
in a given population and learning that populations other behavior motivators are critical
to an effective communications’ component of the overall Condom Programming
strategy. Price could be an important factor in the uptake of the desired behavior pattern
which increases the need for public sector distribution and social marketing pricing
strategies.
Male and female condoms are effective as HIV/AIDS/STI prevention devices. Condom
Programming accompanied by behavioral skills-oriented sex education, encouraging
adolescents to delay the onset of sexual intercourse and to consistently use condoms, if
and when they become sexually active, is the most effective means of controlling the
sexual transmission of HIV amongst this age group. Instilling correct and consistent
condom use habits at the initiation of one’s sexual life is anticipated to last through
adulthood.
The 10-14 year old age group, Early Adolescence, is being largely ignored by the
HIV/AIDS community except for orphan and street kids programs. Kids are having sex
earlier and earlier and most do not have access to condoms, nor are they sufficiently
aware of their risks. Condom-programming targeting this group is greatly needed.
Making 49mm condoms available through public sector distribution networks and
accessible by early adolescence could save many lives regardless of whether the need
is psychological or physical.
Communications programs have not been directed at the younger age group when it is
at this stage of sexual curiosity that they are at their most vulnerable. Nor has there been
an AIDS prevention intervention directed at this especially vulnerable age group. The
development of good habits now could stay with them the rest of their lives. A campaign
to instill a positive image (“cool”) of sexually responsible behavior (consistent condom
use and/or delay of onset) is needed globally.
23
Mobley, S.C. [Behavior Change Marketing Strategy Design] Mar 2002, The Synergy Project, TvT Associates, Inc.

15. 1414
Ages 10 to14 have almost entirely been left out of the AIDS prevention literature.
Superficially at least they appear to have been forgotten in the struggle against AIDS.
They get pregnant, they get STIs, they have abortions and they die and yet too many
communities look at them as if they were too fragile to hear and deal with the facts and
expectations of responsible behavior.
Girls in early adolescence, as in other age groupings, are significantly more vulnerable to
HIV infection than boys. Orphans too are at increased risk due to the shortage of
qualified caretakers and their inability to care for themselves without submitting to
abusive relationships with adults.
Condom programming has not included early adolescents. They have not been included
in research to facilitate the condom programming strategic process. Distribution networks
are not set up to accommodate them. Education programs are too few in number and
are likely to start at grade 9 (15 year age group) again leaving early adolescents behind.
Research is needed to identify any special characteristics of this population set and their
unique behavior motivators.
The effectiveness of condom programming as a strategy for HIV/AIDS prevention
among young people is directly related to one’s ability to involve them, to engage them,
to include them in all of the prevention programming efforts from research through
intervention and evaluation. We must learn their behavior motivators and learn who in
their world stimulates them to consider new possibilities (cognitive and subliminal) and
adopt new practices and behaviors.