Male and Female Condom Use

“Male latex condoms, when used consistently and correctly, are highly effective in preventing sexual transmission of HIV” (Cochrane Collaborative Review Group on HIV Infection and AIDS, 2004: 4). Conclusions were based on systematic reviews and meta-analysis of high methodological quality, which met pre-determined criteria of methodological rigor. Cochrane reviews are the “gold standard” of study synthesis. 60 reviews met the criteria.  

Information on condom usage and HIV serology was obtained from 25 published studies of serodiscordant heterosexual couples in the United States, Europe, Haiti, Brazil, Thailand, Zaire, Rwanda, and Zambia. Condom efficacy was calculated from the HIV transmission rates for always-users and never-users. For always-users, 12 cohort samples yielded a consistent HIV incidence of .9 per 100 person years. For 11 cohort samples of never-users, incidence was estimated at 6.8 per 100 person years for male-to-female transmission and 5.9 per 100 female-to-male transmissions. The condom’s effectiveness at preventing HIV transmission is estimated to be 87% with consistent use, but it may be as low as 60% or as high as 96%. Condom efficacy for HIV reduction is similar to, although perhaps lower than that for pregnancy, which is 97%. However, the condom may be less efficacious in preventing HIV transmission than in preventing pregnancy for a number of reasons. Pregnancy results only from vaginal sex, but HIV can be transmitted through vaginal, oral, and anal routes. In addition, conception can only take place during a few days of a woman’s menstrual cycle, while HIV may be transmitted at any time.

A study done in Eastern and Southern Africa showed that HIV transmission per coital act among serodiscordant couples is similar between sexes while condom use reduced HIV transmission. A total of 3,297 serodiscordant couples were included in the prospective study. The HIV-1 positive partner was also infected with HSV-2. After the initial examination uninfected partners had a quarterly visit consisting of a genital examination and an HIV test. The clients received prevention measures and risk-reduction counseling, quarterly syndromic STI treatment and free condoms. Plasma viral level of the infected partner was measured at enrollment, 3, 6, 12 months and at study exit (at 24 months). HIV-positive clients were interviewed every month on the number of coital acts with or without condoms. Secondary source information was sought from their non-infected partners to confirm the number of coital acts and condom use. HIV transmission was confirmed by Western blot if a rapid test was positive. Timing of infection was determined by PCR before seroconversion. The time of HIV infection was defined as the earlier positive PCR. Each confirmed transmission between the study partners was classified as “linked.” It was “unlinked” if HIV was acquired from another person other than the study partner confirmed with sequencing of plasma samples between the source and infected partner. Analysis was done only for linked transmissions. Sixty-seven percent of the HIV infected partners were women. Thirty-four percent of the HIV infected and 55% of the HIV-uninfected males were circumcised. Eighty-six linked HIV transmissions occurred in the study period. Condom use reduced infectivity by 78% and was similar in both sexes. In cases of unprotected sex the risk of male-to-female transmission was 1.95 times greater than female-to-male transmission. However, the increased male-to-female transmission was largely explained by higher viral loads in male partners. The study found that HIV transmission risk per sexual act among serodiscordant couples is similar between sexes. For each 10-fold increase in plasma viral RNA, increased transmission of HIV by 2.9 fold was observed.

Low HIV prevalence in Brazil coincides with aggressive government efforts to promote and distribute condoms, resulting in high levels of reported use of condom in first sexual encounter among the general population.  Condom use increased from 4% to 55% between 1986 and 2003, according to Ministry of Health statistics (Gauri et al., 2007). HIV prevalence has remained low in Brazil at 0.6% of the population between 2001 and 2007 (UNAIDS, 2008).

Laboratory studies have shown that the female condom is impermeable to various STI organisms, including HIV (PATH and UNFPA, 2006; Drew et al., 1990 cited in Hoke et al., 2007). 

Male and female condoms, when used consistently and correctly, are comparable in effectiveness.

Correct use of the female condom has been estimated to reduce the per-act probability of HIV transmission by 97%.

“Studies of female condoms show that their…ability to prevent disease transmission are similar to those of male condoms” (Nelson, 2007: 637).

A study in Brazil on the introduction of the female condom also showed that making the female condom available increased the number of protected sex acts (Barbosa et al., 2007). A 1998 to 1999 preparatory study at 20 sites in six cities in Brazil preceded a national effort to introduce the female condom into public health services. The State and Municipal Health Departments in each city signed an agreement to ensure female condom availability at the end of the study. The twenty sites represented a range of different HIV epidemics within Brazil. Professional teams generated educational and training materials to use in the clinics, with availability publicized in the media. The health workers received a standardized 48-hour training program three times at each clinic. Following an educational session, 2,832 women volunteered to use the female condom and report their experiences. Of those seen fifteen days later, 1,782 had used the female condom at least once. Among those seen at the 90-day follow-up, 1,453 women had used female condoms at least once, with 1,296 stating that they liked the female condom and wanted to continue to use it, an acceptability rate of 54% (1,296 out of the original 2,342). Among these 1,296 women, barrier use at last intercourse, either with a male or female condom, increased from 33% at baseline to 70%.  “The advent of the female condom substantially raised the proportion of sexual intercourse acts that were protected... The reasons are...not well understood, but may be due to the dialogue between partners stimulated by introduction of the female condom...or couples may prefer to alternate the method of protection …Access to an alternative to the male condom makes it possible to increase women’s capacity to negotiate their protection from HIV and other STIs” (Barbosa et al., 2007: 265).

A study with sex workers in Kenya found that adding female condoms to a male condom promotion and distribution peer education program for 151 sex workers over the course of a year led to small but significant increases in consistent condom use with all sexual partners (a declining mean number of unprotected coital acts with all partners from 1.7 before female condom introduction to 1.4 after), verified by a biological marker. Sex workers also stated that they could secretly use the female condom.

A cost-effectiveness analysis assessed HIV infections averted annually and incremental cost per HIV infection averted for country-wide distribution of the nitrile female condom (FC2) among sexually active individuals, 15-49 years, with access to publicly distributed condoms in Brazil and South Africa. In Brazil, expansion of FC2 distribution to 10% of current male condom use would avert an estimated 604 HIV infections at 20,683 US dollars per infection averted. In South Africa, 9,577 infections could be averted, at 985 US dollars per infection averted. The estimated cost of treating one HIV-infected individual is 21,970 US dollars in Brazil and 1,503 US dollars in South Africa, indicating potential cost savings. The incremental cost of expanded distribution would be reduced to 8,930 US dollars per infection averted in Brazil and 374 US dollars in South Africa by acquiring FC2s through a global purchasing mechanism and increasing distribution threefold. Sensitivity analyses show model estimates to be most sensitive to the estimated prevalence of sexually transmitted infections, total sexual activity, and fraction of FC2s properly used.  Expanded distribution of FC2 in Brazil and South Africa could avert substantial numbers of HIV infections at little or no net cost to donor or government agencies. FC2 may be a useful and cost-effective supplement to the male condom for preventing HIV.

A 2007 study of 818 female sex workers in Madagascar for 18 months found that short and medium term promotion of both male and female condoms increased the total number of protected sex acts and reduced STI prevalence. “This trial provides moderate but promising evidence of public health benefits gained from adding the female condom to male condom distribution” (Hoke et al., 2007: 465). Provision of female condoms allows women to “substantially reduce risk of STI acquisition” (Hoke et al., 2007: 465), as STI rates were significantly lower in periods of both male and female condom availability. Participants were tested for three different STIs (chlamydia, gonorrhea and trichomoniasis) every six months. Peer educators trained by the study promoted condoms and counseled participants on risk reduction. Sex workers were counseled to use female condoms only when the male condom could not be used. Both male and female condoms were available for the same price. Following six months of male condom distribution, participants used protection in 78% of sex acts; with the addition of the female condom, protected sex acts increased to 83% at twelve months and 88% at 18 months. STI prevalence declined from a baseline of 52% to 50% with male condoms only at 6 months. With the female condom added, STI prevalence dropped to 41% at month 12 and 40% at month 18.

A study in China found that including female condom outreach, distribution and promotion as well as male condoms resulted in over one-fifth of 301 sex workers had tried the female condoms one year later and 10% had used the female condom more than once. Introduction of the female condom led to an increase of 15% of women reporting 100% condom use with all partners (clients and boyfriends) and the proportion of those reporting no protected sex in the last thirty days decreased by 13%. Educational sessions with a demonstration of female condom insertion using a plastic vagina model were conducted, with 234 educational sessions held during one year. Women who used female condoms were more likely to be exposed to the intervention. Prior to this study, no female condoms had not been available in any of the study sites (Liao et al., 2011a; Liao et al., 2011b). 

A two month prospective study from 2000 to 2001 of male and female condom use among sexually active women in Zimbabwe found that reported use of female condoms increased from 1% to over 70% two months later. Women were given a thirty-minute one-on-one counseling program about HIV and safer sex conducted by a trained counselor, with practice on how to insert the female condom and condom negotiation skills and were give a one month supply of no cost male and female condoms. Women reported more than 28% of sex acts were protected by female condoms. Women reported using female condoms for both HIV prevention and for pregnancy prevention. Over 8% used only the female condom to protect all sex acts, with 67% using the female condom for at least a portion of sex acts. However, most of the women in the study used hormonal contraception so that exclusive female condom use was lower.

A qualitative and quantitative study in three districts in rural Malawi that analyzed data collected in 1998, 1999, and 2001 found that both informal and formal sources of information on HIV/AIDS were important factors influencing AIDS-related communication between spouses. 1,541 ever been married women ages 15-49 and 1,065 husbands were surveyed in 1998, a randomly chosen sub-sample of the original cohort was interviewed in 1999, and a follow-up interview was conducted in 2001 among 80 men and 76 women. Study findings indicated that couples where both the husband and wife had accessed accurate information about AIDS from sources such as health clinics and social networks were significantly more likely to have discussed risk of HIV infection with their spouses. Greater levels of exposure and involvement with social programs were significantly associated with the likelihood of having discussed HIV with partners. The size of the woman’s social network was a significantly determinant in whether or not HIV discussions among couples took place. Discussion between spouses about HIV was more likely to have occurred when both spouses had reported being concerned about infection. Women most often initiated discussion, in response to concern over infidelity. It is important to note that both women and men reported believing that their fates were directly joined with those of their spouses: if one became HIV-positive than the other would as well.  Discussions related to HIV were usually initiated with HIV/AIDS-related information discussed over the radio or in a health clinic. When asked, however, if an individual could be satisfied with only one sexual partner, 40% of men and 33% of women did not think it was possible. Lastly, while the importance of fidelity in marriage was discussed between couples, condoms were never presented as an option for HIV prevention within marriage.  In the one instance where a wife did report discussing condoms with her husbands, she claimed to have advised him to use condoms with his “other partners.”

A nationally representative survey of young women in South Africa found that those who discussed condom use with their partners were more likely to use condoms for dual protection, and to use them consistently.

A qualitative study conducted among 39 married couples in Uganda who reported 100 percent condom use in the last three months suggests that stable couples should not be ignored in condom promotion campaigns – particularly those that promote the dual protection nature of condoms.  The study found that wives promoted condom use among 22 of the 39 couples, in six cases use was initiated by the husband and among the remaining couples there was disagreement as to which partner initiated discussions. Women were able to convince their partners to agree to consistent condom use by being insistent and persuasive, refusing sex, or proposing condom use for family planning or to safeguard their children from becoming orphans. Men reported agreeing to condom use to please their wives, to protect their wives and children, to protect themselves, and to be able to maintain other partnerships.

A study in three countries assessed the feasibility of a group-based couples intervention to increase condom use in HIV-serodiscordant couples in India, Thailand and Uganda. The intervention focused on communication, problem solving, and negotiation skills. Forty-three couples enrolled in the intervention (15 in India, 14 in Thailand, and 14 in Uganda) and 40 couples completed all study activities. Participants were interviewed at baseline and at one- and three-months post- intervention. The intervention consisted of two same sex sessions and two couples sessions with 'homework' to practice skills between sessions. The same intervention modules were used at each site, tailored for local appropriateness. Participants at each site were enthusiastic about the intervention, citing information about HIV serodiscordancy and the opportunity to meet couples 'like us' as important features. Participants reported increased comfort discussing sex and condoms with their partner, although some participants remain concerned about situations when condoms might not be used (e.g. when drunk). At baseline, the majority of Thai and Ugandan participants and one-third of Indian participants reported having 'ever' used a condom with their regular partner. The percent of sexual contacts with condom use reportedly reached 100% at all sites by the first follow up visit. Although social acceptability bias cannot be ruled out, researchers note that participants also reported that a primary benefit of the intervention was condom information, including demonstrations of correct condom use, and increased confidence in their ability to discuss and use condoms with their partner.

A three-armed randomized controlled trial at a VCT clinic in Lusaka, Zambia with 251 couples found a three-fold higher contraceptive initiation rate where family planning education and offer of contraceptives where available on site rather than by referral to an outside clinic. All couples receive a presentation on family planning methods and the advantages of dual method use, along with a free, unlimited supply of condoms. HIV discordant and concordant couples are advised to use condoms with every act of intercourse, with this information given during initial post-test counseling and repeated at each subsequent visit. Trained nurses help couples overcome barriers to condom use. The control group was referred to the Lusaka Planned Parenthood Association of Zambia for family planning methods, with all fees paid by the research project. Women in the intervention group who desired Norplant or surgical sterilization were referred to University Teaching Hospital, with transport and service fees paid. Self reported condom use was assessed. Approximately half of the couples eventually wanted to have children. Self reported condom use remained consistent at between 58 to 63%.

A study of 372 sex workers in Ethiopia, of whom 73% were HIV-positive, found more consistent and correct condom use when used primarily for pregnancy prevention rather than for STI prevention. Sex workers who were using condoms for contraception were compared with others, more likely to use condoms consistently (65% compared to 24% and less likely to be HIV-positive (55% compared to 86%).

A randomized study in 2007 and 2008 with 737 married women (353 in the peer education HIV intervention group; 384 in the control group) in rural North Anhui, China found that peer education programs for married women increased condom use. The percentage of married women who used condoms in the past three months rose from 4.5% to 21.5% in the intervention group, with no significant increase in the control group.

A study in Malawi with 2,242 rural adults using a quasi-experimental design to evaluate a six-session peer group intervention resulted in increased condom use. More intervention district adults reported ever using condoms in the past two months, 12.7% compared to 7.4% in the non-intervention communities. Surveys were conducted at six months and 18 months following the completed intervention. Having ever used condoms in the past two months among sexually active adults was higher in the intervention district than the control group at both six months and 18 months. The six two-hour sessions discussed sexuality; HIV; condoms; partner negotiation and guided discussion about social norms. Each peer group had two co-facilitators and between ten and twelve community members. Groups were either all male or female. Following the 18-month intervention, health workers were offered the intervention and encouraged to bring the intervention to rural communities with additional two week training. The project worked closely with village headmen and headwomen.

A meta-analysis of 42 studies with 67 separate interventions from North America, Asia, Africa, Europe and South America found that providing HIV education, with face-to-face delivery both with individuals and groups, which addressed motivation, attitudes, skills training and/or putting condoms on models, as well as providing condoms, found that those exposed to the intervention significantly increased condom use and reduced HIV incidence, with duration up to four years. Group interventions met for a median of four sessions of 120 minutes each with a median of two facilitators and ten participants per session. Individuals met for a median of one session for 39 minutes each with one facilitator. Studies used a randomized controlled trial or a quasi-experimental design. The meta-analysis covered studies from 1991-2010. However, simply providing condoms was insufficient to increase condom use.

A randomized trial in South Africa with 583 women found that training in condom negotiation skills significantly increased condom use at three and six months follow-up for women who did not know their serostatus and women who had tested HIV-positive. The training consisted of two private one-on-one, hour-long sessions including role-playing within a two week period. Those who did not receive the intervention received information on HIV, HIV testing and a condom demonstration. Of the 584 women, 384 were sex workers and 199 were not sex workers.

A 2000-2001 study of 394 married women in Harare, Zimbabwe found that condom use increased from 1% prior to the intervention to almost 50% after a half-hour one-on-one HIV education program by trained counselors that emphasized negotiation skills; practice using male and female condoms; and education about HIV transmission, and safer sex. VCT was offered. The intervention provided a booster session after one month and results were collected after two months. Of the women (aged 17-47, mean age of 28), 60% suspected their husbands of having other sexual partners. Initial condom usage was low: only one woman reported using condoms consistently and only 40 (10%) reported using condoms at last sex. After two months, consistent condom usage had increased to 48.5% while 87% of women had used condoms during their last sexual encounter. Overall, feelings of self-efficacy increased: the proportion of women who felt that they had control over condom usage increased from 47% to 72%, and the proportion who felt that they could refuse sex without a condom increased from 23% to 57%.

In association with to a national multi-year campaign, HIV prevalence in Uganda fell from 15% in 1991 to 5% in 2001. Among those who had had sex in the past four weeks, the proportion of women using condoms increased from 0% in 1989 to 8% in 1995; among men, it increased from 1% to 11%. Among unmarried women, the proportion using the condom increased from 1% to 14% and among unmarried men, it rose from 2% to 22%. From 1995-2000, condom use increased from 5% to 25% among women aged 15-17 and from 3% to 12% for women ages 18-19. Among sexually active men from 15 to 17, condom use rose from 16% in 1995 to 55% in 2000, and among those aged 18 and 19, it increased from 20% to 33%. Among unmarried sexually active women, condom use increased from almost nothing to 37% by 2000. Condom use rose significantly among unmarried sexually active men from 29% in 1995 to 57% in 2000.

A qualitative study conducted from 2001 to 2003 in rural and urban Ethiopia, Tanzania, and Zambia with structured text analysis of more than 650 interviews and 80 focus group discussions and quantitative analysis of 400 survey respondents found that preventive methods such as condom use are hampered when condom use was considered an indication of “HIV infection or immoral behaviors and are thus stigmatized” (Nyblade et al., 2003: 2). In all three countries most respondents think that women are to be blamed for acquiring HIV, particularly if this behavior is associated with "immoral" sexual behavior. “Gender-based power relationships also play a more direct role in the blame women face” (Nyblade et al., 2003: 26), as women’s transgressions tend to be more severely regarded than men’s.

A survey of 209 women affected by HIV/AIDS and in-depth interviews with 59 women in Zimbabwe found that women perceived condoms for use only with sex workers. “...My husband and I never used condoms. We thought they were only for prostitutes” (Feldman and Maposhere, 2003: 165).

A study of trends from Demographic and Health Surveys in 1993 and 2001 in 18 countries in sub-Saharan Africa shows condom promotion has increased condom use among for single women: from 5% in 1993 to 19% in 2001. Preventing pregnancy is a major motive for single women, suggesting that marketing campaigns positioning condoms for pregnancy, rather than disease, prevention may be more successful. Condoms are also beginning to permeate into marriage in East and Southern Africa (“occasional use” reported in 10-21% of both husbands and wives in three national settings—Kenya, South Africa and Uganda), suggesting that promoting condom use within marriage can save lives by preventing HIV transmission within serodiscordant married couples.

A systematic review of 21 studies from Tanzania, Cameroon, Ghana, China, Indonesia, Thailand, the Caribbean, Mexico and Central America published from 1998 to 2007 found that increasing condom availability and accessibility increased condom use behaviors. Condom availability and accessibility was increased through mass media campaigns and community mobilization, expanding publicly funded condom distribution via mobile vans, etc., and making condoms available in prisons. Studies were included if they reported a HIV behavioral intervention with data collected on at least one behavioral outcome or biological outcome with sufficient data.

A study that surveyed 630 people in Kenya found that condoms were 8.1 times more likely to be used by those who did not experience supply-side or demand side barriers. Supply side barriers were measured by self-reported time to the nearest health facility to obtain no cost condoms and ability to pay for commercial condoms. Demand-side barriers were measured based on self-reported attitudes towards condoms, partner attitudes towards condoms and have never been given or shown how to use a condom. The study found that 19% of potential condom outlets were out of stock. Among individuals with no supply side barriers, condom use was three times greater; among individuals with no demand side barriers were 3.8 times more likely to use condoms. Women experienced the highest rates of supply side barriers.

A literature review found that integrating elements of pleasure and the erotic into HIV prevention interventions could increase safer sexual practices and empower women to negotiate safer sex. A meta-analysis (Scott-Sheldon and Johnson, 2006 cited in Knerr et al., 2009) found 21 studies measuring effectiveness of sexual risk reduction interventions that integrated a safer sex eroticization component and found that where eroticization was incorporated, participants showed significant risk reduction behavior in condom use; communication with sexual partners and a decrease in the number of sexual partners. The meta-analysis included studies with randomized control trials or those that had a quasi-experimental design. Of the 21 studies, one took place in Brazil, with the rest in North America and New Zealand. Erotic was defined as tending to arouse sexual desire or excitement. Literature from PubMed, Medline and IAC conferences was used from 2001 to 2007 for the review.

Public health outcomes may benefit from adopting more positive views of safer sex. Citing grey literature and personal accounts of programs in Cambodia, Namibia, South Africa, Senegal, Zimbabwe, Sri Lanka, Mongolia, India and the UK, the Pleasure Project contends that focusing on sexual pleasure—particularly eroticizing male and female condoms to increase use—can play a key role in the prevention of STIs/HIV.