In Masaka District in Southwest Uganda, the Medical Research Council's Programme on AIDS assessed the acceptability of the female condom and a range of formulations in which virucides could be delivered*. Although the male condom offers a safe, cheap and effective means of preventing conception and transmission of HIV/STDs, men and women in many high HIV-prevalent Sub-Saharan countries view it with mixed feelings. This is because condoms are often used in casual partnerships and less frequently in regular relationships. Furthermore, men largely determine their use. Studies show that women are more likely to practise safer sex using female controlled methods. In some African settings, the female condom appears acceptable to women and, to a lesser extent, their partners.

The female condom, however, shares some of the disadvantages associated with the male condom. Also, many women prefer methods that they can use secretly. Women's chances of avoiding HIV/STDs may be improved by expanding their range of choice.

Once available, an effective vaginal microbicide could be delivered in various formulations, the success of which will depend on their cultural acceptability. For example, in some cultures men prefer "dry sex" and in such contexts formulations that are perceived to be too wet (such as gels) may not be acceptable. Even if product use is controlled by women, male acceptance makes their use more likely. Women's and men's needs and preferences in different geographic and cultural settings must be studied.

The study was carried out in a rural village, a roadside trading centre and a large town. Pilot interviews ( 55 with women and 50 with men) and focus group discussions (FGDs)(18 with women and 7 with men) investigated attitudes towards the male condom and female-controlled methods of protection against pregnancy and HIV/STDs, as well as the traditional use of substances before sex to make the vagina tighter, dryer or wetter.

A total of 146 women (aged 17-54, median 27) and 35 male partners (aged 20-59, median 34) who participated in the focus group discussions, were then recruited in the trial. All products were demonstrated. Participants then selected two products which they used for two periods of five weeks respectively. Having used two products, they then used their favourite product for another three months. They were interviewed at regular intervals. After the trial, participants discussed their experiences in focus groups.

The results revealed a strong demand for female-controlled methods of protection. The most popular formulations were the  sponge and the foaming tablets, followed by the female condom and the foam. The women were ambivalent about the female condom: they did not like its size and shape and they complained about discomfort during use and about not being able to use it secretly. On the other hand many women liked it because it offered more certain protection against pregnancy and HIV/STDs compared to the other products. They did not like the film because they were afraid it would accumulate in the body; they found the gel too wet.

Preferences for products were not homogeneous, and age, level of education and location did have some effect. For example, more of the highly educated women chose the sponge than the women with little or no education; the female condom was more popular among the older women than among the younger women; and the foaming tablets were more popular in the roadside trading centre than among the rural women.

Most men and women said that the products did not interfere with their enjoyment of sex. Those who said that products did interfere with their enjoyment referred almost exclusively to the female condom, because of the pain and discomfort caused by the inner ring, or interference with certain sexual techniques caused by the outer ring. People in the study area did not generally value qualities such as tightness or dryness of the vagina during intercourse, as has been reported from many other parts of subSaharan Africa. A quarter of the women and more than half the men said that the product they used increased their enjoyment of sex, mainly because it increased lubrication to an optimum level.

During the initial focus group discussion, women expressed concern about the unreliability of male condoms: they said that they might tear and get stuck in the woman's body, and they claimed that men deliberately put holes in them in order to make their partners pregnant or even deliberately infect them with HIV (in the focus groups some of the men actually admitted to putting holes in condoms to make their partner pregnant). The women said they preferred products they could use secretly.

During the initial focus group discussions, men expressed ambivalent attitudes towards female control. When they discussed it as an abstract possibility they said it was a good thing; but when discussing actual products, the idea of female control worried them. On the one hand, they wanted their partners to be protected from HIV/STDs, but on the other hand they believed the  threat of infection ensured that their partners remained faithful. In practice, however, they did generally allow their partner to use the products.

Secrecy is also an important issue for women. It is not easy for women in regular relationships to use products secretly. In this study, the possibility of secrecy, and particularly female ownership of the products, did appear to give women greater control. When the women had control over the product the men seemed to accept its use, albeit anxiously. In a more "natural" environment, outside the context of a trial, the scope for female control might be reduced. More will need to be done to reduce male anxiety, as well and increase men's share of responsibility in reproductive matters. Finally, because complete secrecy of use is not feasible in regular relationships in the long term, the attitudes of male partners will need to be taken into account in promoting such products.

Robert Pool, Head of Social Science, Medical Research Council (UK) Programme on AIDS in Uganda, P.O. Box 49, Entebbe, Uganda; Tel: 256-481-21211/ 21082; Fax: 256-41-321137; e-mail:rpool@mrc.uu.imul.com