Definition of the Prevention Area
Unprotected sex is the leading cause of HIV transmission, accounting for more than 80 percent of the total number of infections. Male and female condoms, when worn correctly, serve as an impermeable barrier to the sexual exchange of secretions that carry HIV and a number of other sexually transmitted infections (STIs), providing protection against transmission.
In recent guidance on HIV prevention, the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) recommends programming that combines multiple, evidence-based approaches to increase availability, accessibility, acceptability, and use of condoms in targeted groups and in the general population. Comprehensive condom programming remains an essential component of combination prevention programs.
Epidemiological Justification for the Prevention Area
Condoms, both male and female versions, are the most effective barrier method currently available to sexually active individuals who require protection from HIV and other STIs and from unwanted pregnancies. Male condoms reduce the risk of HIV by 80 percent or more when used correctly and consistently. Modeling studies indicate female condoms can provide the same level of protection against HIV infection, although evidence is limited.
Consistent and correct use of male latex condoms is associated with lower rates of transmission among higher-risk groups, notably sex workers, men who have sex with men, and serodiscordant couples. In countries with concentrated epidemics (e.g., Thailand), programs promoting 100 percent condom use in the commercial sex industry have lowered overall prevalence levels. While the impact of condom use is unknown at the population level in mixed and generalized epidemics, condom programming remains an important aspect of the overall prevention portfolio.
Core Programmatic Components
Components of comprehensive condom programs are identified by the United Nations Population Fund as well as by PEPFAR in its recent guidance on prevention:
- Create demand: Understanding the local environment and characteristics of specific client groups is necessary to target individuals at higher risk and the venues they frequent. Demand can be accelerated by promoting condoms along with treatment and prevention, particularly for serodiscordant couples and for dual protection.
- Increase supply and availability: This is important for both male and female condoms in low and middle income countries. Managing the pipeline is critical to maintaining a constant supply of condoms. Advocacy for female condoms at both the international and national levels will increase demand, reduce production costs, and increase supply.
- Ensure high quality and low cost: Making high quality male and female condoms available for free or at very low cost at key distribution points frequented by men and women (e.g., marketplaces, hair salons, and workplaces) can increase use.
- Address acceptability: Confront prevailing cultural myths and inaccuracies using media campaigns and behavior change strategies—education and individual training—to target specific groups and communities, as well as larger audiences. Female condoms have unique advantages for women (greater control and dual protection) and men (increased sexual pleasure). Programs can capitalize on these features.
- Conduct monitoring and evaluation.
Current Status of Implementation Experience
Meta-analyses and well-designed evaluations have shown that when coupled with education and counseling, condom promotion programs can be effective in increasing male condom use among youth and among such marginalized groups as sex workers, men who have sex with men, and serodiscordant couples. Successful condom programs employ multiple strategies, such as ensuring high coverage in accessible venues, training people on how to use condoms, building negotiation skills and self-efficacy, and working within social networks.
Condom programs have been implemented using mass media campaigns, community-level initiatives, and interpersonal outreach. They have also targeted people in the general population who engage in higher-risk sex (e.g., multiple partners, concurrent partners, commercial sex) in high-prevalence settings. Although these initiatives have shown success, male condom use between longstanding sexual partners, such as married couples, does not persist over time.
Demand for condoms exceeds availability; only a quarter of the total number of male condoms needed is available. Female condoms are even less available, due primarily to high cost and policymaker bias. Greater international funding and support for both male and female condoms must be increased to reduce the current gap and meet future needs.