Male and Female Condom Use
The role of condom use in prevention of sexual transmission of HIV is clear. According to the WHO and the U.S. National Institutes of Health, male condoms that are intact are essentially impermeable to even the smallest sexually transmitted virus (UNAIDS, 2004). The effectiveness of male condoms has been shown to be between 80–95 percent, depending on how correctly they are used (Weller and Davis-Beaty, 2007; Holmes, Levine and Weaver, 2004; Hearst and Chen, 2004).
While the efficacy of the female condom in preventing HIV transmission has yet to be studied (IOM, 2001), mathematical modeling indicates that consistent use of female condoms, even at lower rates of efficacy, can play an important role in HIV prevention, especially for women whose partners will not use male condoms (Musaba et al., 1998). The efficacy of the female condom in preventing HIV transmission may never be fully determined. “While all evidence points to the effectiveness of female condoms to prevent HIV transmission and acquisition, it would be ethically impossible to test female condoms for HIV prevention: one cannot conduct a trial and give participants only female condoms and female and male condoms cannot be combined during the same sexual act. There is no possibility of doing a true gold standard randomized controlled clinical trials for female condoms” (Gabelnick, 2007, cited in CHANGE, 2008). Still, with laboratory and modeling studies indicating that the female condom is likely as effective as the male condom, the female-controlled female condom is a critical component to HIV prevention for women.
Consistent Condom Use is Effective in Reducing HIV Transmission
Consistency is key. Women’s lifetime risk of infection decreases with the consistent use of condoms. A microsimulation in Malawi found that if men always use male condoms with women who are not their wives, women’s lifetime risk falls to 9 percent and that if both men and women always use condoms with partners other than their spouses, women’s lifetime risk of infection falls to 8 percent (Bracher et al., 2004). Findings from Rakai, Uganda, showed that among 350 women who reported consistent male condom use, none became HIV-positive, but annual HIV incidence was 4.6 percent among women who reported inconsistent condom use (Kiddugavu et al., 2003). Conversely, many studies have shown that inconsistent condom users are at higher risk of HIV transmission than those who never use condoms. This may be because their behavior is riskier in other ways. Mathematical models suggest that a small number of people who use male condoms consistently can have a greater impact on reducing HIV transmission than a larger number who use them inconsistently (Hearst and Chen, 2004). Interventions promoting consistent condom use are therefore paramount in reducing the incidence of HIV.
Variations in condom use across regions, countries and populations indicate that condom promotion should address barriers (socio-cultural, legal and policy, economic and financial and structural barriers) faced by different groups of women such as youth, married women, discordant couples, sex workers, and IDUs, among others (Drezin, Torres and Daly, 2007).
Female Condoms Are The Only Female-Initiated HIV Prevention Method
The female condom is also woefully under-programmed in prevention programs. While attention is drawn to work on AIDS vaccines and microbicides, in fact, the female condom is the first HIV prevention technology developed since the beginning of the AIDS epidemic (Brown et al., 2007). In fact, “twenty years into the HIV epidemic, female condoms are the only currently available female initiated method of HIV…prevention (Napierala et al., 2008: 121).
Evidence shows that female condom use increases the total number of protected sex acts (Vijayakumar et al., 2006) and reduces sexually transmitted infections (Hoke et al., 2007), reducing the risk of HIV acquisition and transmission. An analysis of five randomized controlled trials on effectiveness of the female condom found that the female condom increased the number of protected sex acts (Vijayakumar et al., 2006). A systematic review of 237 articles found that ten studies found long-term use of the female condom, suggesting that the female condom reaches women less likely to use other dual protection methods (Vijayakumar et al., 2006).
Increasing Consistent Condom Use in Regular Partnerships is Key to Prevention
Promoting the use of condoms for high-risk sex is an effective approach to reducing HIV transmission, and studies indicate that interventions can achieve high rates of condom use in casual and commercial sex (Bollinger et al., 2004). However, promoting condom use for high-risk sex has contributed to the association of condom use with illicit sex (Feldman and Masophere, 2003), making it more difficult for women to negotiate condom use with regular sexual partners. Condom use among married couples is universally low, and normalizing condom use for all sex acts, including within marriage, is a challenge (Ali and Cleland, 2005; Hearst and Chen, 2004). Despite substantial risk within many primary relationships, condom use is low (Morrison et al., 2009: 265). [See also Chapter 11B. Strengthening the Enabling Environment: Addressing Violence Against Women]
Consistent condom use remains largely uncommon among married couples and regular partners. A review of published literature on patterns of incident infection, risk factors for HIV infections, and rates of condom use used in regular partnerships found that a large proportion of incident HIV infection in some settings is in regular partnerships. For example, several epidemiological studies find marriage to be the main risk factor for infections in women. An analysis of 23 Demographic and Health Surveys (DHS) from low- and middle-income countries conducted between 1994 and 2000 found that in eight of the 23 countries, fewer than five percent of women aged 15 to 49 used condoms to prevent STIs (Snelling et al., 2006). Married women particularly find it difficult to discuss condom use with their husbands as doing so touches on sensitive issues including fidelity and trust (Smith, 2007; Maharaj and Cleland, 2004; Nyblade et al., 2003; and Chimbiri, 2007).
Condom use can be increased among all groups, including youth, discordant couples and sex workers. Promoting condoms to prevent STIs that may result in infertility may be a promising way to make condom use more socially acceptable within long-term or married relationships (Delvaux and Nöstlinger, 2007). In addition, promoting condoms for pregnancy prevention as well as for HIV prevention can increase condom use. “For women who do not currently desire pregnancy, the dual method approach – combining condoms for HIV/sexually transmitted disease (STD) prevention with longer-acting, more effective contraceptives for added protection against pregnancy – simultaneously prevents both heterosexual and perinatal HIV transmission” (Mark et al., 2007:1201). However, increasing condom use among women ultimately requires the cooperation of men (Foss et al., 2007), who need to be persuaded to use male condoms or to support women’s use of female condoms.
Limited access to condoms and inadequate supplies of condoms are also a challenge to prevention of sexual transmission of HIV (Haddock et al., 2008). In 2004, the Global HIV Prevention Working Group noted that only 42 percent of people who wanted to use a condom during sex could obtain one. Of the estimated 18 billion condoms needed in 2006, donors provided just 2.3 billion (UNFPA, 2008 cited in Haddock et al., 2008). In addition, campaigns which discredit condom use for HIV prevention can have negative impacts. For example, a study in Russia using qualitative, quantitative and epidemiological data found an increase of new HIV cases where a government media campaign stated that condoms were unreliable as compared to other regions where campaigns promoted condom use. In the area that used the slogan, “Condom protects but does not guarantee,” the numbers of new HIV cases was higher (Alekseeva et al., 2008b).
Condom Distribution and Programming is Critical to HIV Prevention
Evidence from South Africa demonstrates that condoms distributed to the public are in fact used in sex and not wasted. Public sector male condom distribution rose from six million in 1994 to 198 million in 1999 as part of the government’s condom promotion efforts for HIV/AIDS prevention. The government is the largest distributor of condoms in South Africa, with social marketing programs and commercial retailers together distributing an additional 10 to 20 million male condoms in 1997. A prospective study was undertaken during 1998-1999 at 12 representative public health facilities where a total of 384 participants and the 5,528 condoms they received were followed successfully. After five weeks, 43.7% of the condoms had been used or broken in sex, 21.8% had been given away, 8.5% had been lost or discarded, and 26% were still available for use. Those who had actively procured condoms (rather than passively receiving them) had increased rates of use. After five weeks, less than 10% had been wasted (Myer et al., 2001).
Expanding access to female condoms allows women greater control over protecting themselves and could even be preferred by some men as well. “Men may prefer using the female condom if it gives them more pleasure than does use of the male condom and some men may prefer not being responsible for HIV protection” (Agha, 2001: 55). Programs must pay more attention to increasing access to the female condom, along with education about proper use. “As a currently available device that women might use to protect themselves against HIV, the female condom stands alone” (Barbosa et al., 2007: 261).
Condom use is a critical component to HIV prevention (Cohen, 2002 cited in Feldblum et al., 2003) and remains the best method of protection for women. Interventions that increase condom availability and use are urgently needed to prevent HIV among women and girls. Additional condom promotion interventions are needed to address barriers (socio-cultural, legal and policy, economic and financial, and structural) faced by different groups of women such as youth, married women, discordant couples, sex workers, and women drug users, among others.