Planning for Microbicide Access in Developing Countries

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Planning for Microbicide Access in Developing Countries

has declined thus far to introduce Jadelleinto the US market, but the product has beenapproved in Europe and has significant levelsof acceptance in several European countries. Anew programme to introduce Jadelle at no costinto developing countries has been initiatedby the provider, through a new entity, the ICAFoundation.Another second-generation implant, Implanon,was approved by the FDA in 2006. It is a singlerod device containing another progestin,etonogestrel, and is effective for threeyears. As a single implant pre-loaded in itsinserter, it is easier to use. A Chinese implant,Sinoplant, which is similar to Jadelle has alsobeen developed. It is available in China andIndonesia. Side-effects of all three types ofimplant are similar.From 1984 to 2002 an estimated 10.5 millionNorplant sets had been used. Jadelle hasnow largely displaced Norplant in developedcountries. Limited efforts are ongoing toexpand Jadelle, Implanon and Sinoplant use indeveloping countries. It is possible that thesethree improved implants could renew interestin implant contraception and expand use insome developing countries, but this remains tobe seen.Factors Hampering the Uptake of ImplantsMost of the problems and constraints inherentin the application of implant technology indeveloping countries were identified beforewide-scale use. However, overall enthusiasmfor the method was so strong that positivemomentum was maintained for many years.The major constraints were:Cost: The cost of Norplant was a major issuefrom the outset, but donor enthusiasm andfinancial support for introduction activitiesenabled the work to go forward, andminimised initial governmental concerns aboutthe high cost of Norplant and the substantialprogrammatic costs for training. Over five toseven years, it was argued, the cost of Norplantwould approach that of oral contraceptivesover a similar period. In practice, however,average duration of use ranged from 2.5 to 3.5years.Health care provider support and training:Like the IUD, implants must be inserted bya health professional. Many countries havehad difficulty training sufficient numbers ofproviders. In addition to insertion techniques,providers need training in good counsellingskills and positive provider-client relations.Side-effects: While side-effects were wellknownand carefully measured, they were notconsidered to be major problems in the earlyphase of research and initial introduction, aslong as women were thoroughly counselledbefore accepting the method. This proved tobe difficult in many settings, and side-effects– while generally mild – still remain limitingfactors in some countries.Directive and coercive behaviour: While thesponsoring agencies made every effort to ensurevoluntary acceptance and informed choice,isolated instances of coercive use resultedin much negative publicity. In developingcountries, the sponsoring agencies insisted thatimplants be offered by well-trained providers ina voluntary fashion as one of several availablecontraceptive options. However, high levels ofPLANNING FOR MICROBICIDE ACCESS IN DEVELOPING COUNTRIES: Lessons from the Introduction of Contraceptive Technologies 9

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