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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.

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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.

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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.

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