Condom Acceptability Research Articles

Condoms in the age of AIDS

While gynecological journals are almost absent in the Pub Med list on condoms you will find that pediatric journals seem to be more concerned. Their theme is adolescent sexuality where prophylaxis against sexually transmitted diseases (STDs) is as important as contraception. Indeed this dual function seems to be lost on proponents of more sophisticated contraceptive modalities. In our age of AIDS it is high time that this age-old (nobody knows how old) prophylactic is brought to the fore when we counsel patients in their choice of protection. In a series of WHO-initiated case studies the mean age at male sexual debut in some developing countries ranged from below 15 to approximately 20 years with Argentina and Peru at the younger end of the scale and the Republic of Korea at the higher. Not surprisingly high percentages of young men reported having had two or more partners whereas young women reported less promiscuity. Because infection with the human immunodeficiency virus (HIV) is a matter of life and death the situation in HIV-infested countries obviously receives prime attention. In Scandinavian countries the risk of acquiring the HIV during heterosexual intercourse is very low but other STDs are rife and may largely be prevented if condoms are used consistently and correctly. Condoms have been shown to be impenetrable to the herpes virus and HIV but in the case of herpes protection is less certain because the lesions may be widespread. (excerpt)

The acceptability of the female condom: perspectives of family planning providers in New York City, South Africa, and Nigeria.

This article seeks to fill the gap in female condom acceptability research by examining family planning (FP) providers' attitudes and experiences regarding the female condom in three countries (South Africa, the US, and Nigeria) to highlight providers' potential integral role in the introduction of the female condom. The case studies used data drawn from three independent projects, each of which was designed to study or to change FP providers' attitudes and practices in relation to the female condom. The case study for New York City used data from semistructured interviews with providers in one FP consortium in which no special female condom training had been undertaken. The data from South Africa were drawn from transcripts and observations of a female condom training program and from interviews conducted in preparation for the training. The Nigerian study used observations of client visits before and after providers were trained concerning the female condom. In New York City, providers were skeptical about the contraceptive efficacy of the female condom, with only 8 of 22 providers (36%) reporting they would recommend it as a primary contraceptive. In South Africa, providers who had practiced insertion of the female condom as part of their training expressed concern about its physical appearance and effects on sexual pleasure. However, they also saw the female condom as a tool to empower clients to increase their capacity for self-protection. Structured observations of providers' counseling interactions with clients following training indicated that Nigerian providers discussed the female condom with clients in 80% of the visits observed. Despite the lack of a uniform methodology, the three case studies illuminate various dimensions of FP providers' perceptions of the acceptability of the female condom. FP providers must be viewed as a critical factor in female condom acceptability, uptake, and continued use. Designing training programs and other interventions that address sources of provider resistance and enhance providers' skills in teaching female condom negotiation strategies may help to increase clients' use of the female condom.

Barriers to condom use: results from a study in Mumbai (Bombay), India.

The consistent and correct use of condoms coupled with risk reduction education strategies, continue to play an important role in the reduction and prevention of HIV/AIDS transmission. Therefore understanding and incorporating strategies to overcome barriers to condom use in such education and prevention efforts are critical. This is particularly necessary in countries such as India, where HIV/AIDS has become a serious public health crisis. The current study documents and provides preliminary data on the use of condoms, reasons for and barriers to condom use, and sources of information about safer sex practices among a sexually active adult sample of 49 women and 203 men in Mumbai, India. Despite limitations such as the use of a nonrandom sample of participants composed predominantly of young, English-speaking males, the study findings provide some insights into the importance of and the need to address issues of privacy regarding condom purchase and use in India. Most notably, the lack of privacy in stores and the social stigma associated with condom use were indicated as the most significant barriers. These and other study findings suggest the need to ease the social costs and constraints to safe behaviors through increased acceptance of condoms and promotion of their consistent use. This could serve as an important means to curb the epidemic of HIV/AIDS in India.

Acceptability evaluation of a natural rubber latex, a polyurethane, and a new non-latex condom

After more than a century of reliance on latex condoms, male condoms fabricated from new materials are finally becoming commercially available to consumers. This study was an open label acceptability study that compared three lubricated condom products during vaginal intercourse: a natural rubber latex condom, a polyurethane condom, and a new non-latex (styrene ethylene butylene styrene, SEBS) condom. Fifty-four couples who were using condoms for birth control were enrolled in this three-way crossover study. Each couple tested three condoms of each type in a randomized sequence. Couples reported condom performance after each use and rated condom acceptability after use of three condoms of each type. At the completion of the study, participants selected their preferred condom type for overall acceptability, sensitivity, ease of use, appearance, and comfort. All three condom types had low clinical breakage and slippage rates (≤ 3.3%) although the polyurethane condom did not perform as well in other measures of performance including unrolling, discomfort, stretching, bunching, and sliding along the penis during intercourse. None of the condom types were statistically preferred overall [males: natural rubber latex 37%, polyurethane 24%, new non-latex (SEBS) 37%, no preference 2%; females: natural rubber latex 33%, polyurethane 27%, new non-latex 37%, no preference 2%]. A statistically higher proportion of couples preferred both the natural rubber latex condom and the new non-latex condom above the polyurethane condom for ease of unrolling, and the natural rubber latex condom above the other condom types for perceived safety. Approximately two-thirds of both male and female participants preferred one of the two condoms made of synthetic materials suggesting that consumers will appreciate the availability of these products.

Care for a dying continent.

In Zimbabwe where AIDS is prematurely killing a generation of adults counselors and researchers struggle against social customs viral resourcefulness and despair. It is estimated that 20-25% of the population is HIV-infected. Apart from poverty and lack of general medical care Zimbabwean culture has other vulnerabilities that HIV can exploit including polygamy and commercial sex. Sexual and hygienic practices also contribute to the high rate of infection. Swabbing of the vaginal walls with fingers cloth paper or cotton to achieve dry sex as well as intravaginal practices increase the HIV risk for women. While the male condom is the best-known means of stemming the spread of HIV negotiating condom use is tricky for most Zimbabwean women. So far roughly half the women who have participated in the condom acceptability study have been able to convince their husbands to use condom. When compared with the female condom the male condom is more acceptable. But whether the man or woman wears a condom family and sexual politics complicate the issue of condom use. The development of nonoxynol-9 gel is offering hope to women who cannot negotiate condom use. The urgency of the problem has prompted some people to propose drastic actions to address HIV/AIDS. Despite difficulties surrounding condom use however Zimbabwe seems to be the African country that has best understood the importance of condom use.

Condom acceptance is higher among travelers in Uganda.

To examine the role played by mobile residents in the spread of HIV through rural Uganda. Travel history and sexual network data were collected from a random sample of 1627 residents aged 15-49 years in Rakai District, Uganda during 1994. Travelers and non-travelers are compared with respect to socio-demographic attributes, risk exposure, knowledge, attitudes and use of condoms using descriptive statistics and multivariate logistic regression. A demographic profile of travelers' partners is developed using information from a local network survey module. The population is highly mobile, with over 70% reporting travel to a potentially higher risk destination in the past year. Travelers are somewhat more likely to have higher levels of sexual risk behavior, but the risk appears to be offset by significantly greater knowledge, acceptance, and use of condoms. In multivariate analysis, the sexual risk differential for travelers is explained by occupational exposure and higher socio-economic status. The differential in condom acceptance, by contrast, appears to be associated with travel itself. Condom use with non-spousal partners is three times higher among travelers than non-travelers (P< 0.001), and travel remains a significant predictor after controlling for age, education, residence, occupation and multiple partners. Travelers are more likely to use condoms with both their local and non-local partners. Partners of male travelers are likely to be younger and better educated than those of male non-travelers. The mobile population in this rural region appears willing to adopt risk reduction measures appropriate to their exposure. This suggests that targeting condom promotion programs to travelers and their partners is likely to be effective in reducing the spatial diffusion of HIV, and may be an efficient method for spreading behavioral change into rural areas.

Condom shape: a neglected factor influencing use and acceptability? UK Family Planning Research Network.

Improving condom acceptability amongst users is one way to enhance efficacy. This study aimed to test whether or not the shape of a condom influenced users' perceptions of condom acceptability as measured through their ratings of condom comfort, sensitivity and security. Four types of condoms were tested which had 3 different shapes, and one of which also had a small diameter. Participants were recruited at 15 UK Family Planning Research Network Clinics and one Student Health Centre in England and Wales in late 1997. A total of 1193 people initially volunteered to take part and of these 204 men and 251 women completed the trial, giving an overall response rate of 38%. Results suggest that both men and women were able to detect differences in the shapes of the condoms and that differences led to preference for a particular condom type. Similar proportions preferred a straight-sided, a flared and a contoured condom, whilst the smaller, contoured condom was preferred by a minority of respondents. To optimize consistent condom use, providers should consider encouraging users to try a range of condoms to ensure that they are using the one most suitable for them.

Beliefs about sexual relationships and behaviour among commercial farm residents in Zimbabwe.

To describe beliefs of farm residents about sexual relationships and sexual behaviours within these relationships, as a basis for understanding how these beliefs may influence sexual behaviour; and to document gender differences in these beliefs. Cross sectional descriptive study. Three commercial farms in Mashonaland Central Province, Zimbabwe. Purposive convenience sample of 218 adult (age 18+, or ever-married) residents on the commercial farms. Views towards celibacy, wife inheritance, condom use, infertility, extra-marital affairs. 85% of respondents felt marriage was a cushion against HIV/AIDS. The majority (87.6%) viewed wife inheritance as improper; 37.6% felt that it facilitated the spread of HIV. Sixty two percent viewed condom use in marriage as unacceptable, and the majority of respondents felt that infertility was a problem in a person's life, with men being less likely than women to indicate this (OR: 0.26; 95% CI: 0.10 to 0.67). Male respondents expressed greater ability than their female counterparts to take protective steps in the event of suspecting STD/HIV/AIDS in their spouse. More male than female respondents felt they could leave marriage against perceived risk of infection with HIV from their partner (OR: 2.20; 95% CI: 1.22 to 4.00). Perceptions of wife inheritance are positive when viewed against known ways of HIV transmission. There is need for further work to allow women to express their integrity as individuals in their relationship with men, as a strategy to promote their reproductive health. Determinants of condom acceptance need further understanding because condom use is one of the effective ways of curbing the spread of HIV/AIDS.

Contraceptive knowledge, attitude and practices of men in rural Maharashtra.

Since men are the dominant decision makers in India, it is prudent to discover the knowledge, perception, attitudes and contraceptive practices of men to improve their involvement in the reproductive health needs of families. Three thousand and seventy-two married men from a tribal Primary Health Centre (PHC) area in Thane district of Maharashtra State, India were surveyed with special emphasis on investigating the reasons for not accepting male methods. The majority of them not only had no concept of family spacing, but had not even taken any initiative to improve their knowledge or acceptance of condom/ vasectomy. Men who were aware of contraceptive methods had little knowledge of their correct use. Of the men, 53.7% had positive views about their role in family planning while 66.2% of men stressed the need to improve the acceptance of male methods by providing knowledge and information through sources such as radio, television, door-to-door campaigning and interpersonal communications. Thirty per cent emphasized the need to improve the availability and quality of services. This study indicates a pressing need for effective intervention strategies, both at the community and the clinic level, backed with efficient counselling, motivation and provision of services in rural and remote areas.

Sexual negotiation in the AIDS era: negotiated safety revisited.

To test the safety of the 'negotiated safety' strategy-the strategy of dispensing with condoms within HIV-seronegative concordant regular sexual relationships under certain conditions. Data from recently recruited cohort of homosexually active men (Sydney Men and Sexual Health cohort, n = 1037) are used to revisit negotiated safety. The men were surveyed using a structured questionnaire and questions addressing their sexual relationships and practice their own and their regular partner's serostatus, agreements entered into by the men concerning sexual practice within and outside their regular relationship, and contextual and demographic variables. The findings indicate that a significant number of men used negotiated safety as an HIV prevention strategy. In the 6 months prior to interview, of the 181 men in seroconcordant HIV-negative regular relationships, 62% had engaged in unprotected anal intercourse within their relationship, and 91% (165 men) had not engaged in unprotected anal intercourse outside their relationship. Of these 165 men, 82% had negotiated agreements about sex outside their relationship. The safety of negotiation was dependent not only on seroconcordance but also on the presence of an agreement; 82% of the men who had not engaged in unprotected anal intercourse outside their regular relationship had entered into an agreement with their partner, whereas only 56% of those who had engaged in unprotected anal intercourse had an agreement. The safety of negotiation was also related to the nature of the safety agreement reached between the men and on the acceptability of condoms. Agreements between HIV-negative seroconcordant regular partners prohibiting anal intercourse with casual partners or any form of sex with a casual partner were typically complied with, and men who had such negotiated agreements were at low risk of HIV infection. The adoption of the strategy of negotiated safety among men in HIV-seronegative regular relationships may help such men sustain the safety of their sexual practice.

Assessment of condom use acceptability, Hoima district, Uganda, July 1996

Assessment of condom use acceptability, Hoima district, Uganda, July 1996

Improving condom use in Sichuan, China: Findings from a qualitative study

This study examines condom use in Sichuan, China from the perspectives of policymakers, providers, condom users and non-users, and the programme and service delivery factors which influence condom acceptability and use. Although some people are satisfied condom users, dislikes and misconceptions about condom use were more often expressed. There was a lack of information about correct use and only a few people knew that condoms provide protection against sexually transmitted diseases. Improvements have been made in quality control during manufacture in some factories, and there is a network for service delivery and an increasing range of condom types. Yet access to condoms is still inadequate for many people, especially in rural areas. Many service providers strongly prefer to promote only the most effective methods, ie. vasectomy for men. The use of emergency contraception if a condom fails would increase condom efficacy and acceptability, including from a programmatic point of view, and should become standard practice.

The vaginal use of herbs/substances: an HIV transmission facilitatory factor?

Heterosexual intercourse accounts for 80% of HIV transmission in sub-Saharan Africa. Factors facilitating cross-infection may include sexual practices such as the vaginal use of herbs/substances to dry, contract and heat the vagina for enhancement of sexual pleasure. The behavioural-analytic study investigated the use of different types of herbs/substances used by 75 HIV positive and 76 negative sexually active females and the perceived effects of these agents. Individual in-depth interviews were conducted. 99% of all subjects admitted using herbs/substances mainly to contract (94%), dry (58%) and heat (28%) the vagina. There was no significant difference in the pattern of use of herbs and reasons given for using the agents by HIV positive and negative women. 69% of HIV negative and 80% of positive subjects had used a mean of 4 difference types of herbs and/or substances during the last 5 years. 39% negative and 25% positive subjects had experienced intra-vaginal pain and lower abdominal pains during and after sexual intercourse, laceration of the vagina and excessive vaginal secretions after using herbs. These effects were attributed to Wankie (herb or substance) in 70% of the complaints. 14 HIV positive subjects compared with 7 in the negative group had used Wankie. The role of Wankie and similar substances in transmitting HIV cross-infection requires further investigations. From the point of view of AIDS prevention, expectations of a dry and contracted vagina in sexual intercourse may reduce acceptability and use of female and male condoms.

Interaction of condom design and user techniques and condom acceptability

In 1991, the source of public sector condom supplies in an African country changed from USAID to WHO. Following a complaint, the two types of condoms were sampled and compared. Laboratory tests indicated that the new-style condoms were of adequate quality, but a number of differences were noted between the two types. Complaints that the condoms were short and broke frequently could not be reconciled with measurements. Lubricant quantities on the WHO-supplied condoms were found to be lower than on the USAID condoms, but still within the range found on the commercial market. Also, the WHO condoms were marginally narrower and thicker. WHO asked the authors to conduct field interviews to seek reasons for the reported problems. These revealed that the relative dissatisfaction with the WHO condoms was largely confined to a group of sex workers in a follow-up programme conducted by two educators funded by a European agency. The instructions for use being given by the educators magnified the risk of incorrect application of the condom. Design changes to the WHO condoms (regarding lubricant, size and thickness) were subsequently made to minimise the chance of wrong use.

Traditional vaginal agents: use and association with HIV infection in Malawian women

To assess the prevalence of traditional vaginal agent use in Malawian women and its association with HIV infection. Consenting, consecutive antenatal women were administered a questionnaire and screened for sexually transmitted diseases (STD) including HIV. Of the 6603 consenting women, 886 (13%) reported using intravaginal agents for tightening and 2222 (34%) for self-treatment of vaginal discharge and itching. A higher proportion of HIV-infected than uninfected women (17% versus 14%) reported use of intravaginal agents for treatment (odds ratio, 1.29; 95% confidence interval, 1.05-1.57), but no difference in HIV status was found when these agents were used for tightening. In multivariate analysis, vaginal agent use for treatment was independently associated with HIV seropositivity. The association of HIV infection with vaginal agents for self-treatment, but not for tightening, suggests that STD may play a role or that vaginal agents are used differently for the two purposes. In addition to a small increased risk of HIV infection associated with vaginal agent use, these agents may interfere with condom effectiveness or acceptability of vaginal microbicides.

Condom use among criminally-involved adolescents.

Condom use was studied for 421 sexually active, minority male adolescents who were currently in jail in New York City. Over three-quarters of the youths were users of alcohol and marijuana and about one-quarter were users of cocaine or crack, but drug injectors were rare. In the six months before arrest they had multiple sexual partners and about one-third had engaged in anal intercourse. Inconsistent condom use was the norm, with 17% reporting that they never used condoms and only 15% reporting that they used condoms every time for insertive sex. In multivariate analysis, more frequent condom use was independently predicted by gay/bisexual preference, greater acceptability and accessibility of condoms, partners' receptivity to use, self-initiation of use, and self-efficacy of avoiding AIDS. Condoms were used less frequently with steady than with causual partners, and rarely for anal or oral sex. AIDS prevention curricula addressing these factors should be delivered to high risk adolescents while they are temporarily accessible in jail.

Condoms: a wider range needed.

In England 281 men attending a genitourinary clinic in south London completed a questionnaire designed to allow researchers to better understand condom failure. This area has one of the highest incidences in the UK of HIV seropositive pregnant women. 25% (70) faced difficulties putting on condoms. 52 of these men (19% of all men) said the condoms were too tight. These men were more likely to have condoms slip off than those who did not find condoms to be too tight (73% vs. 52%). Some men frequently had condoms coming off (8% for Blacks 2% for Whites and 21% for Asians). Condom splitting occurred sometimes for 18% of Blacks and 7% of Whites but not for Asians. During the last year 56% of all men especially Black men (70% vs. 53% for Whites and 36% for Asians) had had intercourse with at least two partners. 22% of all men always used condoms. Black men were less likely to always use condoms than Whites and Asians (9% vs. 27% and 36% respectively). These results indicate that many men may have penises too large for condoms to be placed on with ease. These men tend to experience the condom slipping off or splitting. These difficulties may affect their acceptability of condoms. Condom failure linked to tightness reinforces negative images of condoms. WHOs guidelines show that more than 33% of penises are larger than the British Standard Institutes standard dimensions for condoms (a flat width of 52 [SD 2] mm). Thus the standard limits the production of an appropriate range of condom sizes. Further research is needed in condom design. The findings suggest that Blacks are at particular risk of HIV infection and that condom promotion efforts should target them.

Effects of prebehavioral cognitive work on adolescents' acceptance of condoms.

Effects of prebehavioral cognitive work on adolescents' acceptance of condoms.

Determinants of consistent condom use by adolescents: the impact of experience of sexual intercourse

The determinants of consistent condom use were investigated in a cross-sectional study of 1018 students 12-19 years of age from 18 Dutch secondary schools. The study was prompted by concern over the lack of acceptance of condoms on the part of young people in The Netherlands despite extensive acquired immunodeficiency syndrome (AIDS) prevention campaigns. Components of the variance in behavioral intention to use condoms included intuitive attitude regarding personal consequences 34%; self-efficacy (degree to which students considered themselves able to obtain and negotiate condom use) 12%; subjective social norms derived from parents peers and sexual partners 3%; perceived vulnerability to AIDS 2%; and perceived beliefs and behaviors of peer 2%. Adolescents with significant sexual experience (intercourse more than 5 times) were less likely than their inexperienced counterparts to respond positively to condom use as a means of avoiding transmission of AIDS. Students with extensive sexual experience were less likely to express discomfort with the idea of raising the subject of condom use with a new partner than their inexperienced peers but were likely to anticipate problems with consistent condom use with a well-known sexual partner. Those who reported consistent condom use also expressed confidence in their ability to use condoms even when drunk and to interrupt lovemaking to apply a condom. In addition consistent users were less likely to focus on the unpleasant aspects of condom use (decreased sexual stimulation messiness) and to perceive a positive social norm regarding this method of AIDS prevention. Given the finding that condoms decline in popularity as adolescents gain sexual experience behavioral skills programs that increase confidence in purchasing condoms and negotiating their use with sex partners should be implemented.

Condom Use Among Male Injecting-Drug Users—New York City, 1987-1990

As part of the Centers for Disease Controls AIDS Community Demonstration Projects a study on the condom use of male intravenous drug users was conducted in New York Citys Lower East Side in 1987-90. The overall aim of the study was identification of ways of reducing the heterosexual transmission of HIV. In 1991 22% of women in the US with AIDS reported sexual intercourse with male intravenous drug users as their major risk factor. The 450 study subjects were recruited by former addictions outreach workers and were offered monetary compensation as well as a variety of medical and social services. 37% were white 32% were black and the remaining 31% were Hispanic. 53% were 30-39 years of age and 74% had not completed high school. Of the 165 participants who consented to HIV testing 85 (52%) were HIV seropositive. 1913 respondents (43%) reported never use of condoms 139 (31%) claimed to always use condoms and 118 (26%) used condoms some of the time. Men with steady and casual sex partners were more likely to report occasional condom use than those with only steady or only casual sex partners. Consistent condom use was more common (72%) among men with casual partners than those with steady partners (30%). The factors most strongly associated with steady condom use were having peers who engaged in safe sex practices and the adoption of regimens aimed at reducing the risk of injection-related HIV transmission e.g. cleaning needles with bleach or use of only new needles. These findings suggest that need for 3 strategies: 1) greater emphasis on condom use promotion among men who are in primary relationships; 2) use of peer outreach and group methods to maximize the positive impact of social influence on condom acceptance and 3) messages that link both drug injected-related and sexual modes of HIV prevention.