Please note: This archive was last updated in 2005.
RHO archives : Topics : HIV/AIDS
Special Focus: Condoms and HIV/AIDS
When the HIV pandemic first became visible in the early 1980s, global concern about the gravity of the virus began to fuel research on how to prevent transmission. Both HIV/AIDS and efforts to respond to the disease surfaced early in Uganda. One prevention effort in Uganda, which has since spread to other countries in sub-Saharan Africa and beyond, was the “ABC” campaign: “Abstinence, Be faithful, or use Condoms.” While the idea of abstaining from sex had some success among young, unmarried people, the refusal of many married men to remain faithful to their often-monogamous wives made the “C” option essential: a physical barrier was often the only option available to women to avoid HIV infection from their male partners. At the same time, condoms were critical to stemming the spread of HIV between men and sex workers or other casual partners.
Condom Effectiveness
The male condom is a sheath worn on the erect penis to prevent the exchange of body fluids during sexual intercourse. The use of condoms to prevent pregnancy can be traced as far back as the 16th century. Technology developed in the 1930s is the basis for the modern natural rubber latex condom (WHO/UNAIDS 2001).
To be effective in preventing both pregnancy and HIV/STIs, condoms must be used correctly and consistently. The following guidelines are instrumental in maximizing condom effectiveness:
- Do not open the condom package with a sharp object.
- Do not unroll the condom before putting it on.
- Do not use an oil-based lubricant.
- Put the condom on before any genital contact takes place.
- Use a condom for each act of sexual intercourse.
- Do not use the same condom twice (Lamptey and Goodridge 2002; WHO/UNAIDS 2001).
The effectiveness of condoms has been the subject of a great deal of research. One recent review of multiple studies found that the consistent use of condoms during sexual intercourse results in an 80 percent reduction in HIV incidence, a level of protection slightly less effective than for pregnancy (Weller and Davis 2003). In 2001, the United States Department of Health and Human Services concluded that male latex condoms are effective in reducing the transmission of HIV/AIDS. Studies analyzed for this conclusion demonstrated “an 85 percent decrease in risk of HIV transmission among consistent condom users versus non-users” (US DHHS 2001).
The most conclusive evidence of condom effectiveness in reducing HIV/AIDS transmission has come from studies of serodiscordant couples, in which one person is infected with HIV and one person is not. One study in Italy followed 305 sexually active HIV-negative female partners of HIV-positive men for approximately two years. Within the study, a total of 3.9 infections occurred per 100 person-years, and the incidence of HIV diminished by 84 percent in women who always used condoms as opposed to those who used them occasionally or never. Less than two percent of the 171 women who always used a condom became infected. In a multi-country European study of serodiscordant couples, none of the HIV-negative partners of HIV-positive men or women became infected when using condoms at every intercourse. In a Haitian study, the infection rate among serodiscordant couples who always used condoms was 1 per 100 couples (McNeill et al. 2001).
On a larger scale, evidence in favor of condom effectiveness is supported by the experience of the government of Thailand. The Thai government's “100-percent condom policy,” which required commercial sex workers and their clients to use condoms for every act of intercourse, led to an increase in the use of condoms from 14 percent in 1989 to 94 percent in 1994, and a decrease in cases of bacterial STIs from 410,406 in 1987 to 29,362 in 1994. Countries such as Ethiopia, Uganda, and Vietnam have also achieved a dramatic increase in condom use through national programs promoting condoms for HIV/STI prevention (WHO/UNAIDS 2001).
Female Condoms
One disadvantage of the male latex condom lies in the fact that, by definition, men control its use. When it became clear that women were both biologically and socioculturally more vulnerable to HIV infection, efforts began to identify HIV/STI-prevention methods that women could control. One result was the female condom, currently distributed by the Female Health Company in Chicago, Illinois, USA. The female condom is a loose-fitting polyurethane sheath with a flexible sheath at either end. The inner, closed ring is pushed into the vagina, while the outer, open ring rests outside the vagina (Macaluso et al. 2003).
The female condom has raised several questions about usefulness and effectiveness. Its retail price is about ten times that of a male latex condom, a significant problem in countries with high HIV prevalence and limited resources (Kerrigan et al. 2000). Studies have also revealed difficulties related to the use of the female condom: users reported that the condom sometimes came out of the vagina; the penis entered to the side of the condom; the outer ring was pushed inside the vagina; the condom clung to the penis and moved with it; and the inner ring was uncomfortable. However, many of these problems decreased with experience, and the female condom prevented semen exposure in 79 to 93 percent of condom uses (Macaluso et al. 2003).
In response to the problem of expense, some initiatives are underway to promote the female condom through heavy subsidization and social marketing (such as a five-year partnership between the Zimbabwe National AIDS Coordination Programme and the United States-based Population Services International). The Zimbabwe program resulted in increased protection for women against HIV and other sexually transmitted infections (Kerrigan et al. 2000). Additional research found that washing and disinfecting female condoms enable them to be reused up to four times (Potter et al. 2003). However, additional data needs to be gathered; re-use of the female condom is not recommended at this time. For more information on re-use of the female condom, see RHO's Contraceptive Methods section.
Product development teams at PATH and elsewhere around the world are working to design second-generation female condoms. Meanwhile, it seems clear that any safe prevention method that increases a woman’s ability to protect herself against HIV infection is better than none.
The Condom Gap
Despite the increased emphasis on condom use that has accompanied the spread of HIV/AIDS, procuring and distributing a sufficient number of condoms to protect people against HIV and other STIs remains challenging. One analyst found that 24 billion condoms per year are the minimum requirement to protect sexually active people against HIV/AIDS, while only 6 to 9 billion are actually used (Gardner 1999). Other experts estimated the need for an additional 1.9 billion condoms for all African countries to reach the level of provision of the six African countries that currently provide the highest level of condoms per man per year. Yet these countries—Botswana, Democratic Republic of Congo, Kenya, South Africa, Togo and Zimbabwe—provide an average of only 17 condoms per man per year (for men aged 15 to 59) (Shelton and Johnston 2001).
Social Marketing and Informal Distribution
Social marketing is one strategy that has greatly reduced the gap between the need for and the supply of condoms. Condom social marketing takes the form of programs that promote the use of condoms through widespread communication campaigns combined with subsidies to reduce the price of condoms and efficient distribution networks to guarantee their availability (WHO/UNAIDS 2001). HIV/AIDS-prevention programs that promote the use and availability of condoms also need to educate their intended beneficiaries by explaining the correct use of condoms; providing voluntary HIV counseling and testing services, when possible; and keeping people informed about local sources for free or subsidized condoms (Lamptey and Goodridge 2002). Social marketing programs can make condoms available in nightclubs, bars, hotels, kiosks, factories, mines, and specific outlets for adolescents and women (WHO/UNAIDS 2001). A recent study conducted in South Africa found that many people distribute condoms informally among their friends (especially men) and family members (especially women), and concluded that the strategy of informal condom distribution should be encouraged as an HIV/AIDS prevention measure (Myer et al. 2002).
Social and Behavioral Factors
Even in the presence of social marketing programs, promoting the use of condoms as a means of protection against HIV and other STIs is not always easy. Some religious doctrines, for example, oppose the use of condoms for any purpose. In addition, there is still a widespread lack of knowledge about condom effectiveness and proper use, and obstacles to procuring condoms, especially for young people. Men, encouraged by their peers, are often resistant to condom use and opt to take sexual risks; women, hampered by traditional gender roles, find it difficult to discuss sex or ask for condoms, even when they know their health is at risk (Gardner 1999). In Cambodia, which adopted a 100-percent condom policy, use of condoms among sex workers increased from 53.4 percent in 1998 to 78.1 percent in 1999. Yet one study in Cambodia found that female sex workers in Siem Reap tended to use condoms with their clients but not with their non-paying partners. In the latter case, their main reason for non-use of condoms was "love for their boyfriends" (Wong et al. 2003).
Although obstacles to condom use exist, evidence of the effectiveness of both male and female condoms for HIV/STI prevention points to the need for continued condom promotion to contain the spread of HIV/AIDS.
RHO's HIV/AIDS section provides more information on issues and resources relevant to this topic. In addition, be sure to visit the Men and Reproductive Health, Gender and Sexual Health, and Adolescent Reproductive Health sections for additional discussion and exploration.
Annotated bibliography
Please note that PDF files require Adobe Acrobat Reader software, which can be downloaded for free at www.adobe.com/products/acrobat/readstep.html.
Gardner, R. et al. Closing
the condom gap. Population Reports, Series H, No. 9.
Baltimore: Johns Hopkins University School of Public Health, Population
Information Program (1999). Available at: www.jhuccp.org/pr/h9edsum.shtml.
This article points to a growing need for condoms as HIV/AIDS and other
STIs continue to spread. The authors discuss reasons why more people are
not using condoms, such as traditional social norms and gender roles. Programs
can take a number of measures to encourage more widespread, correct, and
consistent use of condoms, including increasing their accessibility, offering
condoms at subsidized prices through social marketing, and improving the
image of condoms through promotion.
Kerrigan, D. et al. The
Female Condom: Dynamics of Use in Urban Zimbabwe.
New York: Horizons/Population Council (2000). Available at: www.popcouncil.org/horizons/fcz.html.
This report describes a partnership between the Zimbabwe National AIDS Coordination
Programme and Population Services International to promote the female condom
through a five-year social marketing program. The report outlines such issues
as who uses the female condom; reasons for female condom use; perception
of and problems with the female condom; negotiating the female condom; consistency
of female condom use; increased STI/HIV protection among some female-condom
users; and continued male-condom use among female-condom users. The report
also discusses policy issues that emerged from the program.
Lamptey, P. and Goodridge, G. "Condoms."
In: Dallabetta, G., Laga, M., and Lamptey, P., eds. Control of Sexually
Transmitted Diseases. Durham, North Carolina: Family Health International
(FHI) (2002). Available at: www.fhi.org/en/aids/aidscap/aidspubs/handbooks/std/stdhndbkchap5.html.
This chapter, part of a section on managing sexually transmitted disease
programs, addresses the efficacy and effectiveness of the male latex
condom; improving condom promotion and access; condom logistics management;
and other barrier contraceptives. The chapter concludes with the affirmation
that male latex condoms continue to be the best option currently available
for preventing HIV and other STIs.
Macaluso, M. et al. Efficacy of the female
condom as a barrier to semen during intercourse. American Journal
of Epidemiology 157(4):289–297 (2003).
This article is based on an efficacy study carried out in Alabama, USA.
After testing the use of the female condom with 175 sexually active women,
the authors concluded that the female condom prevented semen exposure in
79 to 93 percent of uses. Semen exposure was usually associated with usage
problems, but such problems, along with semen exposure, decreased with users'
experience.
McNeill, E. et al., eds. The
Latex Condom: Recent Advances, Future Directions.
Durham, North Carolina: FHI (2001). Available at: www.fhi.org/en/fp/fpother/conom/index.html.
This monograph covers a wide range of condom-related topics, including pregnancy
and STI prevention; acceptability of condoms; product development; user
behaviors and characteristics related to condom failure; using a condom
correctly; recent advances in the research, development, and manufacture
of latex condoms; how condoms are made; standards, specifications, and tests;
comparing laboratory tests with human use; and the development of non-latex
condoms. The monograph concludes with suggestions for research priorities
and "ten reasons why we should have confidence in condoms."
Myer L. et al. Improving the accessibility of condoms
in South Africa: the role of informal distribution.
AIDS Care 14(6):773–778 (2002).
This article is based on the results of a questionnaire administered to
554 people procuring condoms at 12 public health facilities in four regions
of South Africa. Nearly half of the people interviewed reported having given
or received condoms informally during the month prior to the survey. Informal
condom distribution was positively associated with increased education,
male gender, multiple sex partners and recent condom use. Giving or receiving
condoms tended to occur among male friends or female family members. The
authors recommend utilizing informal condom distribution to improve condom
accessibility and HIV prevention.
Potter, B. et al. Structural integrity of the
polyurethane female condom after multiple cycles of disinfection, washing,
drying and relubrication. Contraception 67:65–72
(2003).
This article examines the possibility of reusing the female condom to offset
the obstacle of its relatively high price. Researchers found that the female
condom could be safely used up to five times, provided that the following
procedures occurred: disinfecting the condom as soon as possible after use
for up to 30 minutes in a solution of one part bleach to at least four parts
water; subsequently washing the condom using diluted dishwashing liquid
or plain bar soap; air-drying or gently drying the condom with disposable
paper towels or tissue; visually inspecting the condom for tears; storing
the condom dry and relubricating it just prior to use with vegetable oil
or a water-based lubricant.
Shelton, J. and Johnston, B. Condom
gap in Africa: evidence from donor agencies and key informants.
British Medical Journal 323:139 (2001). Available at: http://bmj.com/cgi/content/full/323/7305/139.
This article reports on research into the number of condoms currently provided
in sub-Saharan Africa. The authors found that donors' provision of condoms
remained essentially constant over a five-year period, and that the total
supply of condoms from 1995 to 1999 amounted to 724 million, or 4.6 condoms
per year per man aged 15 to 59 in all of sub-Saharan Africa. To reach the
level of the six countries with the highest level of provision (17 condoms
per year per man aged 15 to 59), an additional 1.9 billion condoms per year
would be required for the rest of the region.
United States Department of Health and Human Services.
Scientific
review panel confirms condoms are effective against HIV/AIDS, but epidemiological
studies are insufficient for other STDs [press release].
(July 20 2001). Available at: www.hhs.gov/news/press/2001pres/20010720.html.
This press release reports the conclusion of a special review panel of the
United States Department of Health and Human Services, National Institutes
of Health that male latex condoms are effective in reducing the transmission
of HIV/AIDS. "Meta-analysis of several studies showed an 85 percent
decrease in risk of HIV transmission among consistent condom users versus
non-users." However, the review panel was unable to comment on the
effectiveness of condoms in preventing the spread of other sexually transmitted
infections, due to insufficient epidemiological evidence.
Weller, S. and Davis, K. Condom effectiveness
in reducing heterosexual HIV transmission. The
Cochrane Library, Issue 2. Oxford: Update Software (2003).
This article reviewed 14 studies with data about sexually active HIV serodiscordant
heterosexual couples and information about condom usage with the goal of
determining condom effectiveness in reducing heterosexual HIV transmission.
The review focused in particular on seroconversions (people with HIV-infected
partners who became HIV-positive over the course of the studies) among people
who "always" used condoms and those who "never" used
condoms. The reviewers concluded that consistent use of condoms results
in an 80 percent reduction of HIV transmission.
WHO/UNAIDS. The
Male Latex Condom: Condom Programming Fact Sheets. Geneva: WHO (2001).
Available at: www.unaids.org/publications/documents/care/mcondoms/JC003-MaleCondom-FactSheets.pdf.
[CAUTION: This PDF has a file size of more than 4.5 MB. Download may be
slow on some internet connections.]
These fact sheets, designed to enhance condom programming, cover the following
topics: scientific facts on the male natural rubber latex condom; condom
programming; condom quality assurance; condom promotion; logistics management;
research; improving staff performance; social marketing of condoms; male
and female synthetic condoms; and further resources.
Wong, M. et al. Social and behavioural factors
associated with condom use among direct social workers in Siem Reap, Cambodia.
Sexually Transmitted Infections 79:163–165 (2003).
This article reports on a study conducted among female sex workers in Siem
Reap, Cambodia, to determine which social and behavioral factors are associated
with condom use. The authors found that 78 percent of sex workers reported
using condoms consistently with their clients, but only 20 percent used
them consistently with non-paying partners. The reason most often given
for the low rate of condom usage with non-paying partners was "love
for their boyfriends." The authors recommend innovative health education
messages designed to increase condom use among sex workers while respecting
the romantic values in relationships.
Links to resources
Listed below are some useful resources on condoms and HIV/AIDS.
Male Latex
Condoms and Sexually Transmitted Diseases
www.cdc.gov/hiv/pubs/facts/condoms.htm
The website of the National Center for HIV, STD and TB Prevention of the
U.S. Centers for Disease Control offers a fact sheet on male latex condoms
and sexually transmitted infections. The fact sheet gives detailed recommendations
about using condoms to avoid STIs, as well as discussing laboratory studies,
the theoretical basis for protection, and epidemiologic studies for condoms
as they relate to several categories of STIs.
Population
Reports
www.jhuccp.org/pr/h9/h9chap3.shtml
Condoms are the subject of volume 27, issue no. 1 of Population Reports,
published by the Population Information Program of the Johns Hopkins School
of Public Health. The online publication explores condoms and sexual behavior;
knowledge of condoms and AIDS; condom effectiveness; new types of condoms;
improving access; condom promotion; and policies related to condom use.
A "highlights" section examines such issues as changing the image
of condoms; behavior change; ensuring condom quality; protecting young people;
and female condoms.
Population Services International
www.psi.org
The website of Population Services International, the worlds leading social
marketing organization, offers extensive information about the effectiveness
and social marketing of male
condoms (www.psi.org/our_programs/products/male_condom.html) (in Guatemala,
Mozambique, and Myanmar, among other countries) and female
condoms (www.psi.org/our_programs/products/female_condom.html) (in South
Africa, Zambia, and Zimbabwe).
UNAIDS
www.unaids.org
The website of the Joint United Nations Programme on HIV/AIDS offers several
documents on male
condoms (www.unaids.org/publications/documents/care/index.html#male)
and female
condoms (www.unaids.org/publications/documents/care/index.html#female).
USAID:
HIV/AIDS and Condoms
www.usaid.gov/pop_health/aids/TechAreas/condoms/condomfactsheet.html
This page of the website of the United States Agency for International Development
is devoted to the issue of condoms in the context of HIV/AIDS. Topics covered
include condom effectiveness in preventing STIs (HIV, gonorrhea, chlamydia,
trichomoniasis, genital herpes, syphilis, and chancroid); condoms contribution
to HIV prevention success; and USAID support for condom promotion. Two brief
case studies discuss the success of condom promotion in controlling HIV
prevalence in Cambodia and Senegal.
