CATIE News

20 March 2012 

High prevalence of condom use errors and problems—implications for HIV prevention messaging

Condoms are the cornerstone of HIV prevention efforts and are widely promoted as the most effective method of preventing the sexual transmission of HIV and other sexually transmitted infections (STIs). However, the effectiveness of condoms depends on how consistently and correctly they are used.

Many studies have investigated how consistently condoms are used and the barriers to consistent condom use. Fewer studies have looked at how often condoms are used correctly. Incorrect use of condoms may compromise the effectiveness of condoms and lead to exposure to HIV or STIs.

A recent systematic review investigated the prevalence of different types of condom use errors and problems. The review found that there is a variety of ways in which condoms are being used incorrectly and the prevalence of incorrect condom use is surprisingly high.

The results of this review have implications for front-line messaging on the use of condoms for HIV and STI prevention.

Systematic review

The systematic review identified 50 studies, published after 1995, that investigated the prevalence of condom use errors and problems among a variety of different populations, including sex workers, STI clinic attendees, monogamous married couples and college students. The review only included studies of condoms worn externally (more commonly known as the “male condom”) and not condoms worn internally (more commonly known as the “female condom”). Almost all of the studies were conducted in Canada or the U.S.

The studies included in the review reported on the prevalence of errors and problems in two different ways:

  1. The proportion of study participants reporting the condom use error or problem.
  2. The proportion of condom use events where an error or problem occurred.

The prevalence of different types of condom use errors and problems among participants in these studies was as follows:

1. Condom use errors

  • Late application of condom during intercourse – 17% to 51% of participants; 2% to 25% of events
  • Early removal of condom during intercourse – 14% to 45% of participants; 1% to 27% of events
  • Completely unrolling condom before putting it on – 2% to 25% of participants
  • Not leaving space at the tip of the condom – 24% to 46% of participants
  • Putting the condom on inside out and then flipping it over to use – 4% to 30% of participants
  • Starting sex before the condom is unrolled to the base of the penis – 9% to 11% of participants
  • Using a sharp object to open package – 2% to 11% of participants; 4% to 8% of events
  • Knowingly using a damaged condom – 0 to 0.6% of participants; 1.5% of events
  • Not checking condom for physical damage – 75% to 83% of participants
  • Using a condom that was not lubricated – 16% to 26% of participants
  • Using an oil-based lubricant – 3% to 5% of participants; 4% of events
  • Incorrect withdrawal or not holding the base of the condom during withdrawal – 27% to 31% of participants; 43% to 57% of events
  • Reuse of a condom – 1% to 3% of participants; 1.5% of events
  • Storage and expiration date issues – 3% to 19% of participants

2. Condom Problems (potentially resulting from condom use errors)

  • Breakage – 1% to 41% of participants; 0 to 33% of events
  • Slippage during intercourse – 13% to 19% of participant; 0 to 7% of events
  • Slippage during withdrawal – 12% to 15% of participants; 0 to 13% of events
  • Slippage at any point during intercourse or withdrawal – 1% to 36% of participants; 0 to 78% of events
  • Leakage – 8% to 13% of participants; 0 to 7% of events
  • Breakage and slippage or complete failure – 25% to 45% of participants; 1% to 8% of events

3. Condom Problems (potentially leading to condom use errors/problems or inconsistent use)

  • Erection problems during application – 14% to 28% of participants; 5% to 9% of events
  • Erection problems during intercourse – 10% to 20% of participants; 6% to 20% of events
  • Problems with fit and feel of condom – 7% to 30% of participants; 9% to 45% of events

Conclusion

The prevalence estimates of condom use errors and problems varied widely across the studies included in this review and in some cases were quite high. The wide prevalence range for some errors and problems reflects the diverse populations enrolled in these studies and the different lengths of time participants were followed. Also, some estimates were based on only one or two studies while others were derived from multiple studies.

The authors of this review concluded that “condom use errors and problems are common events worldwide.” HIV prevention efforts need to address condom use errors and problems by educating individuals on the correct use of condoms. Education can help prevent incorrect use and increase the effectiveness of condoms in preventing HIV and STI transmission.

Key messages

The authors of the review outlined a number of key messages that front-line service providers can provide to clients on the correct use of condoms.

1. Before intercourse

  • Plan ahead to use condoms and discuss condom use with sexual partner(s).
  • Have an adequate supply of condoms and water-based lubricant.
  • Do not reuse condoms.

2. At time of intercourse

Opening the condom:

  • Check the date and do not use expired condoms.
  • Push the condom away from the corner of the package you are going to tear.
  • Carefully avoid contact with sharp objects, including teeth and fingernails.
  • Without unrolling it, inspect the condom for damage.
  • Do not use a damaged or deteriorated condom.
  • Store condoms in a cool, dry place.

Putting the condom on:

  • Put the condom on before any contact with partner’s mouth, genitals or anus.
  • If penis is uncircumcised, pull foreskin back before putting on condom.
  • Do not unroll the condom before putting it on.
  • Place the condom on the tip of the erect penis and unroll a short distance to make sure it is being unrolled in the right direction.
  • If the condom does not unroll easily, it is on upside-down.
  • If the condom is put on erect penis upside-down, dispose of condom and start with a new one.
  • If the condom is unrolling properly, squeeze the tip to leave some space and unroll condom to the base of the penis.

Lubrication is important:

  • Even when lubricated condoms are used, additional lubricant can help avoid damaging the condom.
  • For latex condoms, only water-based lubricants should be used.
  • For polyurethane condoms, any type of lubricant can be used.
  • In addition to placing additional lubricant on the outside of the condom, some may find it helpful to place a small amount of lubricant in the tip of the condom before placing it on the penis.

Protect the entire act of intercourse:

  • The condom should be put on the penis before intercourse and remain on the penis throughout intercourse.
  • Avoid condom contact with sharp objects, such as genital or mouth piercings, throughout use.
  • Put on additional lubricant or change to a new condom for prolonged intercourse if desired.
  • Change condoms between different types of intercourse (vaginal, anal, oral) within a session.

3. After intercourse

  • Soon after ejaculation or when intercourse is over, hold base of the condom during withdrawal to make sure it does not slip off or leak semen.
  • Do not let the penis get soft before withdrawing or semen may leak out.
  • Check the condom for visible damage.
  • Wrap the condom in tissue and discard (do not discard in toilet).

If the condom breaks, falls off, leaks or is not used during intercourse:

  • If the condom breaks or slips off during intercourse but before ejaculation, stop and put on a new condom before continuing intercourse.
  • Even if ejaculation has not occurred, you or your partner might have been exposed to HIV or STIs.
  • Do not douche.
  • Discuss the possibility of pregnancy or infection, and consult a health care provider as soon as you can to determine what action should be taken (post-exposure prophylaxis, or PEP, to reduce the risk of HIV infection may be an option for high risk exposures).

—James Wilton

Resources

Condoms

Post-exposure prophylaxis CATIE fact sheet

REFERENCE

Sanders SA, Yarber WL, Kaufman EL, Crosby RA, Graham CA, Milhausen RR. Condom use errors and problems: a global view. Sexual Health. 2012 Feb 17;9(1):81–95.