Condoms Count for HIV Prevention

Programs Must Address “Myths, Misperceptions and Fears”⁸⁰ Surrounding Condoms and Other Barriers to Use

Although condoms—both male and female—are critical to safer sexual behavior, many factors inhibit peoples’ use of condoms. Evidence shows the potential to increase condom use, and the levels of use that can be achieved, are strongly influenced by the type of partnership and peoples’ perceptions of their HIV risk.⁸¹ Persistent variations in condom use across regions, countries and populations indicate that condom promotion should be targeted to address socio-cultural, legal and policy, economic and financial and structural barriers faced by different groups (e.g. youth, married women and men, discordant couples, sex workers, MSM, IDUs, etc.)⁹⁶Successful interventions highlighted in this report show that programs can bring about increases in condom use when they address the barriers and concerns experienced by different groups.

For example, programs for youth can emphasize condom use for both pregnancy prevention and protection against STIs including HIV, since sexually active youth tend to be primarily concerned with avoiding pregnancy. Public health campaigns can romanticize condom use as a sign of love and trust among married or long-term partners⁹⁷ and as a way of protecting children. Condoms can be promoted to sex workers as both safe and pleasurable. It is critical to promote condom use among various groups without stigma—promoting safe sex can be done is a sex-positive way, rather than through fear-based messages.⁹⁸ Programs must also address the misinformation surrounding condoms—including misinformation about effectiveness rates—and design effective condom promotion interventions.⁹⁹ Existing evidence, coupled with market research, can help determine the most appropriate condom promotion and distribution strategies for populations with varying needs.

Improving Condom Use among Young People, along with other Prevention Strategies, Is Critical  

"My namorado says he doesn’t want to use a condom with me because he trusts me, and he has never cheated on me. Whenever I suggest condoms he becomes very upset. He starts asking me what I have done, or if I am suspicious of him? I prefer not to suggest condoms because he will stop talking to me. The condom issue just spoils our day." Paula, age 18, Mozambique (Manuel, 2005: 297).¹⁰⁰

An analysis of successive survey data in countries worldwide shows that condom use at last sex among young people is increasing,¹⁰¹ particularly in some sub-Saharan African and industrialized countries. However, young people’s use of condoms is generally inconsistent,¹⁰² and the proportion of sexually active adolescents who report condom use remains too low to control the transmission of STIs.¹⁰³
 
Where condom use is increasing among the young, the primary motivation is pregnancy prevention. Data from three population-based surveys in Zambia show that between 1995 and 2003, the percentage of young urban women who reported using condoms at last intercourse increased from 36 to 57 percent. However, there was limited success in reaching rural and less educated young people.¹⁰⁴ An analysis of survey data from 18 African countries found that use of condoms for pregnancy prevention rose significantly in 13 of 18 countries between 1993 and 2001. Condom use among young African women increased by an average annual rate of 1.4 percent, and more than half of the users (58.5 percent) reporting that they were motivated by a desire to prevent pregnancy.¹⁰⁵ The same shift has been found among young single women in Latin America.¹⁰⁶ In South Africa, condoms have become the most commonly used contraceptive method among female students.¹⁰⁷

Avoiding pregnancy has also been shown to be of greater concern to young men in steady relationships than disease prevention.¹⁰⁸ For greater impact, condom marketing strategies and family planning services should promote condoms as a youth-friendly technology for contraception and disease prevention. The accessibility and affordability of condoms may make them particularly appealing to young people who have sex less frequently.

The double standard for sexual behavior—where multiple partners are a sign of masculinity for boys and men and virginity is expected of girls and young women—complicates condom behavior.¹⁰⁹ Social and gender norms and economic disparities can increase risky sexual behaviors among girls and young women, and compromise their ability to negotiate safer sexual practices.¹¹⁰ This is particularly true when sex is transactional, and in cross-generational relationships, in which there are often socioeconomic and power asymmetries between partners¹¹¹. In a study conducted in four sub-Saharan African countries, young men whose partner was less than four years younger were two and half times more likely to use condoms consistently than in relationships where the age gap was larger.¹¹² Young people who have experienced sexual violence are less likely to use condoms or other contraceptives in the future [see Box 5: Gender-based Violence is a Barrier to Condom Use].¹¹³ Research from sub-Saharan Africa suggests that young married women may be at a higher risk of contracting HIV than their unmarried sexually active counterparts, partly because they are more likely to want to become pregnant and therefore rarely use condoms.¹¹⁴

Box 5: Gender-based Violence is a Barrier to Condom Use

Around the world, gender-based violence is the most widespread human rights violation, undermining women’s autonomy and safety. It is also closely related to condom behaviors and thus HIV risk. A qualitative study in 15 countries found that sexual coercion most often occurs within consensual unions, by husbands, boyfriends or family members.¹⁴⁷ In a comprehensive review of the literature on intimate partner violence (IPV) and sexual health, IPV was consistently associated with inconsistent condom use, having an unplanned pregnancy or induced abortion, and having an STI, including HIV.¹⁴⁸

Among 272 South African women surveyed anonymously, 44 percent reported a history of sexual assault and were more likely to fear asking their partner to use condoms compared to women who were not sexually assaulted.¹⁴⁹ Another study in South Africa found that women who experienced forced sex were nearly six times more likely to use condoms inconsistently and 1.6 times more likely to be infected with HIV than women who used condoms consistently.¹⁵⁰ Qualitative studies from Uganda¹⁵¹ and India¹⁵² indicate that women find it difficult to suggest or insist on condom use when threatened by violence. Studies in Brazil, Jamaica, Papua New Guinea and South Africa have all found that women avoid suggesting condom use for fear of triggering a violent response. ^{153 154 155}

Young people are often more vulnerable sexual violence. A 2001 survey of 1,753 Kenyan males and females aged 10 to 24 found that 21 percent of females and 11 percent of males had experienced at least one act of sexual coercion.¹⁵⁶ A Tanzanian study found that women living with HIV reported significantly more sexual violence, a greater number of violent partners, and a greater number of violent episodes with their current partner than HIV-negative women.¹⁵⁷ Sex workers are also disproportionately affected by violence. A study conducted among female sex workers in Southwestern China found that 49 percent of women surveyed had experienced sexual violence perpetuated by clients.¹⁵⁸ A qualitative study of 32 sex workers in Moscow, Russia, all respondents reported being arrested and forced to have sex with policemen.¹⁵⁹ Likewise, transgender people, men who have sex with men (MSM) and feminized men are also victims of sexual violence in many societies.¹⁶⁰ To increase condom use, particularly among these vulnerable groups, and to protect people’s overall health and rights, greater efforts to address this global crisis of sexual and gender-based violence must be made.

Please refer to the Appendix for end notes.