- Email: [email protected]
HIV prevention
Journal Pre-proof Male and female condoms: Their key role in pregnancy and STI/HIV prevention Mags Beksinska, Rachel Wong, Jenni Smit
PII:
S1521-6934(19)30177-4
DOI:
https://doi.org/10.1016/j.bpobgyn.2019.12.001
Reference:
YBEOG 1994
To appear in:
Best Practice & Research Clinical Obstetrics & Gynaecology
Received Date: 2 October 2019 Revised Date:
26 November 2019
Accepted Date: 2 December 2019
Please cite this article as: Beksinska M, Wong R, Smit J, Male and female condoms: Their key role in pregnancy and STI/HIV prevention, Best Practice & Research Clinical Obstetrics & Gynaecology, https:// doi.org/10.1016/j.bpobgyn.2019.12.001. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier Ltd.
Male and female condoms: Their key role in pregnancy and STI/HIV prevention Mags Beksinska1 Rachel Wong2 Jenni Smit1
1
MatCH Research Unit (MRU), Department of Obstetrics and Gynaecology, Faculty of Health
Sciences, University of the Witwatersrand, Johannesburg, South Africa. 2
Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada.
Corresponding author: Mags Beksinska, MRU, Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa. [email protected] +00 27 31 001 1916
Declarations of interest: none
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Abstract Male and female condoms are the only available multi-purpose technology (MPT) that can prevent unintended pregnancy and sexually transmitted infections including HIV. If used correctly and consistently, condoms can provide levels of pregnancy protection similar to many hormonal methods. Condoms remain one of the most common methods used at first sexual intercourse and are relied on as a current use of contraception by adolescents in many regions of the world. Male and female condoms are safe and require no prescription, in particular male condoms are generally easy to access at low cost. Female condoms are more expensive than male condoms and less accessible, however, they have the advantage of being a female-initiated method. Condom users may experience some common challenges, however recent advances in condom technology have led to new designs and modifications of existing products to improve quality and make them more attractive, acceptable and pleasurable for consumers and increase use. Key words Male condom; female condom; multi-purpose technologies (MPTs); contraception, STI/HIV prevention.
Keywords: Male condom; female condom; multi-purpose technologies (MPTs); contraception, STI/HIV prevention.
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Introduction
Condoms in some form have been used for centuries to prevent pregnancy and STIs [1]. The first rubber male condom was produced in 1855, with teat-ended condoms holding the ejaculate Available later in 1901[1]. Skin (intestine or bladder) or linen condoms were more popular and cheaper than “rubber” condoms, eventually, mass production of rubber condoms lowered price and improved quality [1-2]. By the end of the 19th century the male condom was the Western world's most popular contraceptive method [2].Two surveys conducted in New York in 1890 and 1900 found that 45% of the women surveyed were using male condoms to prevent pregnancy [2]. In the 1930s it became possible to use liquid latex, an emulsion of tiny rubber particles in water and directly obtained from the rubber tree. Liquid latex required less labour to produce than cement-dipped rubber condoms which needed to be smoothed by rubbing and trimming. This resulted in the discontinuation of rubber condoms and made way for mass produced and widely available latex condoms [2].
From 1955 to 1965, 42% of Americans relied on male condoms for contraception and from 1950 to 1960, 60% of married couples in the United Kingdom used male condoms [2]. Male condom use continued to be the primary method of contraception globally until the introduction of the contraceptive pill in 1960 which quickly became the world's most popular method of contraception in the following years [3]. However, male condoms continued to be the primary method in some groups of women based on a survey conducted between 1966 and 1970 among British women which found that that the male condom was the most popular method among single women [2].
The emerging HIV epidemic in the 1980s refocused the need for condoms as disease prevention. In 2018, AIDS-related illnesses claimed 770,000 lives which could have largely been preventable by the use of condoms [4] and condom use has averted an estimated 50 million new HIV infections since the onset of the HIV epidemic [5]. Where country data is available, between 2000 and 2016 there has been a notable decrease in incident adult HIV infections which has been associated with steady increases of condom use at last sex with a non-regular partner and condom use by men at last paid sex. However, UNAIDS noted that despite the increased use of condoms, condom availability and use gaps remain, in particular, in Sub-Saharan Africa, where the gap between availability and need is estimated to be more than 3 billion condoms. The estimated condom need in 47 countries in SubSaharan Africa in 2015 was 6 billion male condoms; however, only an estimated 2.7 billion condoms were distributed [5].
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An analysis published in 2017 [6], made the case for investment in the male condom by quantifying the cost and combined health impact of condom use as a means to prevent unwanted pregnancy and to prevent transmission of STIs including HIV. An annual gap between current and desired use of 10.9 billion male condoms was identified (4.6 billion for family planning and 6.3 billion for HIV and STIs). The findings demonstrated the cost-effectiveness of the male condom in preventing unintended pregnancy and new HIV and STI infections and called for policy makers to increase budgets for condom programming.
As the HIV/AIDS epidemic spread globally, the urgent need for a wider range of female-controlled barrier methods rekindled efforts to develop a female condom. Several patents were filed for female condom products before the 1980s, however few were commercially developed or viable [7]. The polyurethane 'Femidom’ (Reality) female condom advanced in terms of development with laboratory studies and clinical trials indicating that its contraceptive efficacy was similar to that published for the male condom. However, no comparative contraceptive efficacy clinical trials between the male and female condom have been published to date [8].
Although female condoms have been promoted for many years as a woman-initiated, dual protection method for pregnancy and STI/HIV prevention, they have been neglected as a significant player in the field [9]. Lack of commitment by major donors to support female condom programming has meant they have not been an accessible prevention option in many of the countries hardest hit by HIV and unintended pregnancy. A comprehensive analysis of why the female condom has not reached its full potential is attributed to a lack of acceptability in the international policy arena [10]. This has led to a reticence to support its introduction, rather than its acceptability among users [10]. The Reproductive Health Supplies Coalition- a global partnership dedicated to ensuring that all people in low- and middle-income countries can access and use affordable, highquality supplies to ensure their better reproductive health, has identified the female condom as one of several under-used reproductive health technologies [11].
One of the concerns of introducing female condoms into countries hard hit by the HIV epidemic is that their use may simply substitute male condom use and there will be no overall gain in protection, yet at greater cost to prevention programs. There are a number of studies that have looked at this issue and evidence shows that adding female condoms in a broader prevention strategy can increase overall protection rates [12-17]. These prospective studies have suggested that provision of the
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female condom can decrease the number of unprotected sex acts in a population. This increase in protection was achieved through increased male condom use, increased female-condom use, or, more commonly, a combination of the two. A review published in 2006 of studies reporting on patterns of use and impact on protected sex acts and STI incidence concluded there was evidence that the female condom increased the number of protected sex acts [18].
Condom standards, specifications and regulatory issues
All currently available male condoms on the market can maintain their quality for five years or more if stored properly. Over the years, condoms have been manufactured more consistently, have better formulations of materials, and have design modifications to improve their acceptability and functionality [19]. This is important information for users to feel confident that they are using a quality product.
The WHO/UNFPA Prequalification Scheme is a process that assesses condom manufacturers’ ability to produce a product that meets stringent standards [20]. A list of prequalified male and female condom manufacturers is posted on the WHO and UNFPA prequalification websites [20]. It is recommended that condoms distributed in the public-sector be procured only from prequalified manufacturers to ensure the protection of purchasers and end users [20]. WHO/UNFPA have published specifications for both male and female condoms to guide manufacturers who wish to gain prequalification in order to supply condoms in the public sector [21-22]
In 2018, the US Food and Drug Administration moved forward with recommended changes to regulations for the female condom and announced three significant changes to how these devices are regulated by the federal government [23]. Firstly, the female condom was renamed as a “singleuse internal condom,” a change that was welcomed by many advocates and country programs to move towards a more inclusive description of who is encouraged to use and benefit from it. Secondly, it was approved for both vaginal and anal intercourse, thus endorsing use of this tool for a wider spectrum of sexual activities. Thirdly, it transitioned from the regulatory Class III to a Class II, a move that will reduce the burden on manufacturers when seeking FDA approval for existing and newly developing versions of internal condoms.
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Who uses condoms and when?
Condoms as primary contraceptive method Male condoms protect against pregnancy 98% of the time when used correctly and consistently, and 87% of the time during common use. Female condoms protect against pregnancy 95% of the time when used correctly, and 79% of the time during common use [24]. Because condoms can be used for both pregnancy and STI/HIV prevention, it can be difficult to disaggregate what proportion of users are using them as their main method of contraception and which ones generally use it only for STI/HIV protection. However global national surveys including Demographic and Health Surveys [25], collect this information.
A report published in 2016 by UNFPA [Figure 1] shows the breakdown of modern contraceptive use by region [26]. Male condom use clearly leads the way as the primary method of use in unmarried adolescent girls.
Figure 1 Condom use at first sex
Reported condom use at first intercourse among adolescent women in the USA aged 15 to 19 years increased from 23% in 1982 to 47% in 1988 [27]. This figure increased further between 2006 and 2010 with condoms named as the contraceptive method most commonly used at first intercourse in USA by 68% of females and 80% of males aged 15–19 [28]. In Sub-Saharan Africa most data on condom use at first sex is from South Africa. A national South African survey reported that in 15-24 year olds, 62.2% females and 41.3 % males used a condom at first sex [29]. A Panel Study in the Cape area of South Africa conducted in 2002 found that most (81%) of adolescents aged 14-22 used a condom at first sex [30]. In the 1999 survey “Transition to adulthood in the context of AIDS in South Africa” 61.8% of girls said they used a condom at first sex of which most used it for dual protection [31].
Condom use at last sex Tracking condom use (male and female) at last sex is an important indicator for contraception and HIV prevention. Male condoms are one of the few male-controlled contraceptive methods and collecting this indicator can reveal changes in men taking responsibility for contraception. Because condom use is a key HIV indicator [32], it can also signify changes in HIV prevention behaviour.
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Information on condom use is regularly collected in global Demographic Health Surveys although it is understood that it may be subject to reporting bias [33]. However, condom use at last sex disaggregated by type (male or female) is rarely reported. Rates of condom use at last sex show a positive trend in some regions with some Latin American and European countries reporting rates amongst 15 to 24 year-olds of more than 80%, however, in some West African countries it is less than 30% [33]. In particular, condom use at last higher-risk sex has increased over the past three decades in most countries across the world and is as high as 80–90% in some countries [5].
Condoms as multipurpose technologies The pressing need to address both pregnancy, and STIs/HIV prevention has focused interest in recent years on methods that could allow women to address multiple sexual and reproductive health issues with one product [34]. Multipurpose Prevention Technologies (MPTs) are products that deliver varying method combinations to simultaneously prevent HIV, STIs, and unplanned pregnancies. Some combine contraception with STI prevention, while others aim to provide women who want to get pregnant with protection from HIV and other STIs. Research is underway to develop these new biomedical interventions including sustained-release forms such as intravaginal rings and co-formulated long-acting injectables. Additionally, fast-dissolving vaginal films, and gels and diaphragms carrying a drug for HIV and/or STI protection are being developed that are used at or around the time of intercourse. Although progress in development is promising, many products are still many years from being available [35]. The only currently approved MPT products available are male or female condoms. Although users of both condoms may experience some common challenges (perspective that they decrease sexual pleasure as compared to no condom, requirement for negotiation with partners, stigma, and a lack of knowledge or experience with condoms) they provide high levels of protection as MPTs and should not be overlooked whilst waiting for newer products [36].
Yet barriers to condom use continue, including poor access, age restrictions, gender norms, religious norms, stigma, insufficient supply, provider attitudes and, in some places, laws that make it an offence to carry condoms. Many countries also prohibit condom promotion and distribution in schools and other venues where adolescents socialize [5]. Of the 100 countries that reported having a national plan or strategy related to condoms in 2017, only 26 reported that the plan included condom promotion in secondary schools [5]. No matter how effective condoms may be, they can have little impact in preventing HIV and pregnancy if people do not want to use them [37]. Effective condom programming can promote and advocate, deal with condom myths and ensure supply and 7
access. However, there is also a need to ensure that condoms are desirable products, maximise user experience if they are to be used consistently, and provide quality, choice and variety as detailed further in the next section.
New condom technologies: increasing effectiveness and acceptability
Male condom promotion in developing countries continues to be seen as challenging as it is often associated with lack of trust between partners, high failure rates, and reduction in pleasure [38]. Many male and female condom manufacturers as well as country condom programmes are striving for improvements to make condoms more desirable to users which in turn will increase acceptability and uptake. Condom companies are continuously looking to new designs and modifications of existing products that will be more attractive, acceptable, and pleasurable to consumers. Key focus areas include condoms that have better heat transference between partners, are thinner to increase sensitivity, more breakage resistant, fit better, and are easier to insert or put on. To suit consumer preferences, different appearance, flavour, shape, texture, sensation, materials, substances added to condoms, as well as applicators to aid the user and decrease the time needed to put on the condom, can increase choice and variety. Table 1 summarizes the different modifiable condom properties currently on the market primarily for male condoms; however, several apply to female condoms.
Table 1: Male and female condom attributes Attribute
Options
Condom type
Colour
Extensive colour variety
Male & female
Flavour and/or scent
Mint, Chocolate, Strawberry, Vanilla, etc.
Male & female
Texture
Ribbed, Grooved, Studded, Dotted
Male
Shape
Straight, Flared, Close fit, Loose fit, Contoured,
Male
Pouch-like tip, Reservoir tip Sensation
Warming, Cooling
Male
Tingling Numbing- Benzocaine anaesthetic Spermicidal
Nonoxynol-9*
Male
Lubrication
Silicone oil
Male and female
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No pre-lubrication Material
Application (male
-
Synthetic
Male and female
o
Polyisoprene
o
Polyurethane
o
Polyethylene
o
Nitrile (synthetic rubber)
-
Natural rubber latex
-
Silicone
-
Lambskin
Tabs, Clips, applicator stick
Male
Insertion device
Ring
Female
(female condoms)
Sponge
condoms)
Capsule Size (length/width)
Male:- Length 170-220mm, width 40-60 mm
mm
Female:- length 125-180mm, width 70-83 mm
Thickness (microns)
Male:- 4-9
Male & female**
Male & female
Female:- 6.5-15 Other features
Glow in the dark
Male
*Not recommended or promoted for use in high HIV prevalence many settings **One female condom brand comes in two sizes
Colour Male condoms have been available in a range colours for many years, and more recently several female condom products have expanded their range to include different colours. Pigments are available that are compatible with condoms and those that do not affect the integrity (strength) of the condom should be used [21-22].
Flavours and scents The smell of rubber latex is unattractive to many users. The odour can be masked by flavoured and/or scented lubricants. Both male and female condoms are available with different flavours (male) and scents (male and female) [21-22].
Texture 9
Ribbed, grooved, studded, and dotted textures on male condoms give both partners stimulation as the textures increase friction and sensation for enhanced pleasure [39-40] Figure 2 shows a range of male condom designs and features. Some condoms incorporate several features including the 3 in 1 condom which has 3 attributes in one condom. It is ribbed at the head of the penis, dotted along the shaft, and contoured. The 4 in 1 condom has the same attributes as the 3 in 1 condom with the addition of a chemical to prolong the sex act.
Shape The classic straight shaft male condoms have the same width from the base to the top of the condom, typically with a reservoir tip, but there are also some without. Bulbous end male condoms are wider near the tip to increase friction and stimulate both partners. Flared condoms are wider at the base and have a contoured head, allowing more space for the head of the penis and a closer fit as the condom indents below the head of the penis. Male baggy condoms may offer greater stimulation to the partner and more room and comfort for the penis and have been found to be more acceptable than standard fitted condoms [40-41](Figure 2). Female condoms are not fitted and therefore their shapes are very similar [22].
Material Natural rubber latex containing natural rubber proteins can induce latex allergies [42]. A small proportion (7%) of the general population may have latex sensitivity with up to a quarter (25%) of health care workers regularly exposed to latex products developing a latex allergy [43]. Although most male and some female condoms are made of natural rubber latex, condoms can be made with synthetic materials including silicone polyisoprene, polyurethane, polyethylene, and nitrile (synthetic latex), or natural materials like lamb skin. Users with latex sensitivity can use male and female condoms made of polyisoprene, polyurethane, and lambskin (sheep intestines) without having allergic reactions. Lambskin condoms however do not protect against pregnancy or STIs because of the porosity of the material [44].
Figure 2:
Sensation Condom manufacturers are producing male condoms that provide users with warming, and tingling sensations. The substance to achieve this can be added to the inside and outside of the male condom via a lubricant that produces this effect for additional stimulation for both partners.
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Premature ejaculation is a common male sexual disorder, occurring in about 4-39% of men [45]. To address this condition, some male condoms have the chemical Benzocaine or Lidocaine at the tip in gel form, which dissolves and becomes activated when in contact with heat. These chemicals are local anaesthetics that numb the penis, but do not affect the erection process. The numbing effect delays climax, prolonging the pleasure of both partners.
Lubrication Most male and female condoms are available pre-lubricated although additional lubrication is typically applied to the condom, vagina, penis, or rectum before or during intercourse to moisten and make intercourse more comfortable [46]. There are four types of lubricants: oil-based, waterbased, silicone oil-based, and glycol-based. There is evidence that shows that using additional waterbased lubricant for anal intercourse decreases condom breakage rates to 3%, as compared to 21.4% without the usage of additional lubricant [46]. For vaginal intercourse, there are mixed results regarding male condom failure rates with the use of additional water-based lubricant [44]. Oil-based lubricants should not be used with latex condoms, as the lubricant weakens the latex, leading to increased breakage risks [46]. Water-based personal lubricants are the most widely available. Other lubricants are glycol based and are commonly added to water-based lubricants to reduce the loss of moisture. Water-based lubricants, glycol-based lubricants, and silicone oil-based lubricants are compatible with natural rubber latex; however, silicone oil-based lubricants are more expensive and less widely available than water and glycol-based lubricants. Many approved lubricants can be used with polyurethane male and female condoms, though synthetic condoms, such as polyisoprene weaken when they come into contact with oil-based lubricants.
Reusable silicone male condoms are available for purchase online but are not approved by regulatory bodies. The majority of these reusable condoms are contoured and have different textures and tickers to enhance sensation of the female partner.
Applicators (male condoms) Some condoms have developed methods that allow users to apply the condom quickly and correctly without the need to touch the condom, which aims to simplify application and reduce the risk of tears. One male condom has pull-down tabs [47], while another brand has a plastic clip that allow users to unroll the condom with one hand. A logo on the top of the clip indicates the correct position of the condom. When the condom has been unrolled, the clip can be taken off and discarded.
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Insertors (female condom) A female condom requires a method of insertion to ensure the condom body is placed inside the vagina (Figure 4). There are several different products available using flexible rings, medical grade sponges and one using a polyvinyl alcohol capsule which encases the body of the condom and dissolves rapidly once inserted into the vagina. [19]
Size Poor male condom fit has been associated with breakage, slippage, condom-associated erection loss, incomplete use of condoms, and lack of sexual pleasure [48]. In a large survey of almost 1000 participants in the USA, 15.5% complained about condom size and problems associated with condom width, length, and shape [48]. Male condom manufacturers have been producing condoms with various lengths and widths to address this issue. Male condom lengths vary between 170 -220 mms and width between 40-60 mm., while female condom lengths vary between 125 and 180 mms and width between 70-83 mm. Female condom manufacturers have historically only produced one size as the fit is loose. However, two sizes are now available for one brand with the shorter version having a length 125mm while the standard is 155mm[49]. Size of male condoms is based on length and width, however there are no standard sizes and manufacturers may differ considerably. Male condom specifications exist which guide manufacturers seeking WHO/UNFPA prequalification [21]. These specifications lay down requirements for minimum widths depending on the length [21]. The WHO/UNFPA specifications for female condoms do not have specific requirements on size [22].
Thickness Male condoms come in different thicknesses for different user preferences. Thinner condoms are associated with increased sensation for both partners during sex, though some users prefer thicker condoms because the decreased sensation allows them to delay climax. An extra thin condom is approximately 4 microns thick, while an average condom is around 7 microns thick, and an extra thick condom is about 9 microns thick. No significant differences were found between thick and average condoms regarding clinical or non-clinical failure (including breakage and slippage) [50]. Female condoms are generally of a similar thickness (6.5-15 microns thick)
Special features A common error in male condom application is to apply the condom upside down [51]. This occurs when a user tries to roll on the male condom the wrong way around. If the condom is then correctly turned around and reapplied it may no longer be safe to use as a result of pre-ejaculatory fluid
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residue remaining on the condom. A glow in the dark FDA approved male condom aids condom application in light or dark settings to reduce the risk of incorrect application. The O-Ring Condom have a luminescent ring on the underside of the rolled condom [52].
Packaging / Marketing
To increase the prevalence of condom use, condom packaging needs to appeal to users. Condoms should boost users’ confidence when using them and not cause them to doubt the quality of the condom. In particular, condom packaging needs to appeal to young people, be stylish and be visually appealing to all genders. Attractive packaging can minimize the stigma associated with condom use. Condom manufacturers have been producing appealing packaging with good graphic design, using a variety of colours and changing the type of material of packaging used, such as round packaging or small round tins, mimicking breath mint containers. Renda et al. analysed condom packaging from around the world and found that different colours were used to arouse different feelings, such as masculinity, romance, safety, and prestige, and that different package design emphasized on different aspects, such as the sensory experience, pleasure, safety, and quality [53].
Rebranding has been shown to be an effective demand-creation strategy for the male condom. For more than 10 years, the South African government promoted and branded male condoms as “Choice”, which were freely distributed. However, their reputation as a quality product was called into question, along with its appeal to young people [54]. The rebranding of “Choice” as “Max” was based on market research that confirmed that potential condom users wanted something new and more desirable. The 2016 launch of the new Max condom available in four different scents highlighted the importance of condom use as part of the wider launch of the national HIV campaign to reduce HIV, teenage pregnancy, school drop-out, and gender-based violence among young women and adolescent girls [55]. Similarly, the FC2 female condom will shortly be available as “Maxima”. Figure 5 shows the the new Max and Maxima packaging designs.
Figure 5: The South African male and female condom public health sector branded condoms
Conclusion and recommendations
Unintended pregnancies, HIV and other sexually transmitted infections continue to pose a high health burden for millions of people, especially young women and key populations [32]. More than 13
one-third of pregnancies in developing countries are reported as unplanned [56]. Male and female condoms are highly effective MPTs which provide triple protection in preventing HIV and other sexually transmitted infections (STIs) and pregnancy. Condoms do not need prescriptions to be purchased and are widely available outside of health facilities.
Although female condom distribution rates lag far behind those of male condoms, there has been significant progress in product technology. Since 2000, new female condom products have become available or are in development, with the aims of reducing unit cost and improving acceptability. Several new designs offer choice of female condoms to suit user preferences [19]. The recent FDA down classification of female condoms from class III medical device to the same class as male condoms (class II) has levelled the playing field between the two condoms. This may encourage further development and innovation that was previously stifled by concerns of development costs.
If new investments are to be made in condom programmes, with accompanying demand creation, condoms must be made available that are of the highest quality and have the potential to attract new users and motivate existing users to continue using condoms. Manufacturers have demonstrated that condoms as the first MPT can be improved on in numerous ways to deliver a better experience for users and there are several evidence-based initiatives worldwide, that have addressed or are addressing quality, performance and acceptability of both male and female condoms in order to promote condom use. Although it remains crucial to continue to advocate and fund new MPTs, there is a need to ensure that male and female condoms are not side-lined or overlooked in the quest for new products, few of which are likely.
This article did not receive any specific grant from funding agencies in the public, commercial or notfor-profit sectors.
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Practice points • New condom users should be counselled in the correct and consistent use of both male and female condoms • Condoms are classified as a modern method of contraception and if used correctly are highly effective to prevent pregnancy/STIs and HIV • Condoms are now available in a variety of sizes, designs and colours. • Condoms are normally available pre-lubricated but compatability with additional lubricants should be confirmed before added.
Research Agenda Contraceptive effectiveness data available for the female condom is limited to one product that has changed material from polyurethane to synthetic latex. Contraceptive data on other female condom products is lacking.
References
1. Amy JJ, Thiery M. The condom: A turbulent history. Eur J Contracept Reprod Health Care. 2015;20(5):387-402. doi: 10.3109/13625187.2015.1050716. Epub 2015 ; Jun 11.
2. Collier A. The humble little condom: A history. Buffalo: Prometheus Books; 2007. 371 p.
3. Christin-Maitre S. History of oral contraceptive drugs and their use worldwide. Best Pract Res Clin Enocrinol Matab.2013 Feb; 27 (1):3-12.doi:10.1016/j.beem.2012.11.004 4. WHO: Key Facts 25th July 2019. https://www.who.int/news-room/fact-sheets/detail/hiv-aids 5. UNAIDS. A condom crisis at the centre of the HIV prevention crisis [Internet]. 2018 Jul 7 [cited 2019 Aug 24]. Available from: https://www.unaids.org/en/resources/presscentre/featurestories/2018/july/20180723_con doms-AIDS2018 6. Stover J, Rosen JE, Carvalho MN, Korenromp EL, Friedman HS, Cogan M, et al. The case for investing in the male condom. PLoS One [Internet]. 2017 [cited 2019 Aug 12]; 12(5). Available from: https://doi.org/10.1371/journal.pone.0177108
15
7. Bounds W. Female condoms, Eur J Contracept Reproductive Health Care [Internet]. 1997 [cited 2019 Jul 13]; 2(2): 113-116. Available from: https://doi.org/10.3109/13625189709167464 8. Bounds W, Guillebaud J, Newman GB. Female Condom (Femidom). A clinical study of its useeffectiveness and patient acceptability. Br J Fam Plann; 1992; 18(2):36-41.
9. Center for Health and Gender Equity. Female condoms and US foreign assistance: an unfinished imperative for women’s health. Washington, DC; 2011.
10. Peters A, Jansen W, van Driel F. The female condom: the international denial of a strong potential. Reprod Health Matters [Internet]. 2010 [cited 2019 Sep 8];18 (35):119-128. Available from: https://doi.org/10.1016/S0968-8080(10)35499-1
11. Reproductive Health Supplies Coalition. Caucus on new and underused reproductive health technologies. Product brief: female condom. Reproductive Health Supplies Coalition [Internet]. 2013 [cited 2019 Sep 8]. Available from: https://www.rhsupplies.org/fileadmin/uploads/rhsc/Working_Groups/New_Underused_RH _Technologies_Caucus/Documents/Technical_Briefs/rhsc-brief-female-condom_A4.pdf
12. Hoke TH, Feldblum PJ, Van Damme K, Nasution MD, Grey TW, Wong EL, et al. Temporal trends in sexually transmitted infection prevalence and condom use following introduction of the female condom to Madagascar sex workers. Int J STD AIDS [Internet]. 2007 [cited 2019 Aug 3]; 18(7): 461-466. Available from: https://doi.org/10.1258/095646207781147175
13. Latka M, Gollub E, French P, Stein Z. Male-Condom and Female-Condom Use Among Women After Counseling in a Risk-Reduction Hierarchy for STD Prevention. Sex Transm Dis [Internet]. 2001 [cited 2019 Aug 25]; 27(8):431-437. Available from: https://doi.org/10.1097/00007435-200009000-00002
14. Welsh M, Feldblum P, Kuyoh M, Mwarogo P, Kungu D. Condom Use During a Community Intervention Trial in Kenya. Int J STD AIDS [Internet]. 2001 [cited 2019 Aug 16]; 12(7):469474. Available from: https://doi.org/10.1258/0956462011923363
16
15. Fontanet AL, Saba J, Chandelying V, Sakondhavat C, Bhirleus P, Rugpao S, et al. Protection against sexually transmitted diseases by granting sex workers in Thailand the choice of using the male or female condom: Results from a randomized controlled trial. AIDS [Internet]. 1998 [cited 2019 Aug 15]; 12(14):1851-1859. Available from: https://doi.org/10.1097/00002030-199814000-00017
16. Artz L, Macaluso M, Brill I, Kelaghan J, Austin H, Fleenor M, et al. Effectiveness of an Intervention Promoting the Female Condom to Patients at Sexually Transmitted Disease Clinics. Am J Public Health [Internet]. 2000 [cited 2019 Sep 8]; 90(2): 237-244. Available from: https://doi.org/10.2105/AJPH.90.2.237
17. Beksinska M, Nkosi P, Mabude Z, Smit J, Zulu B, Phungula L et al. Twenty years of the female condom programme in South Africa: past, present, and future. In: Padarath A, Barron P, editors. South African Health Review 2017 [Internet]. Durban: Health Systems Trust. 2017 [cited 2019 Jul 3]; 2017(1): 147-156. Available from: http://www.hst.org.za/publications/south-african-health-review-2017
18. Vijayakumar G, Mabude Z, Smit J, Beksinska M, Lurie M. A review of female-condom effectiveness: Patterns of use and impact on protected sex acts and STI incidence. Int J STD AIDS [Internet]. 2006 [cited 2019 Sep 8]; 17(10):652-659. Available from: https://doi.org/10.1258/095646206780071036
19. Beksinska M, Smit J. Condoms, past present and future. https://www.sahivsoc2018.co.za/wp-content/uploads/2018/11/8C_MagsBeksinska_Condom-presentation-SA-clinicians-24th-Oct-Updated.pdf
20. WHO/ UNFPA Prequalification programmes. [cited 2019 Oct 30 ]; Available from: https://www.unfpaprocurement.org/prequalification-programme
21. World Health Organization, UNFPA and Family Health International. Male Latex Condom: Specification, Prequalification and Guidelines for Procurement, 2010. World Health Organization [Internet];. 2013 Apr [cited 2019 Sep 8]; Available from: https://apps.who.int/iris/bitstream/handle/10665/44383/9789241599900_eng.pdf;jsessioni d=CE3C2CA5BE73F58834C59186C88A122D?sequence=1 17
22. World Health Organization, United Nations Population Fund and FHI360 . Female Condom: Generic Specification, Prequalification and Guidelines for Procurement. 2012. https://www.who.int/reproductivehealth/publications/family_planning/female_condom_sp ecification.pdf?ua=1
23. Food and Drug Administration. Obstetrical and Gynecological Devices; Reclassification of Single-Use Female Condom, To Be Renamed Single-Use Internal Condom [Internet]. 2018 Sep [cited 2019 Jul 18]; p. 48711–14. Report No.: 2018–20144. Available from: https://www.federalregister.gov/documents/2018/09/27/2018-21044/obstetrical-andgynecological-devices-reclassification-of-single-use-female-condom-to-be-renamed
24. World Health Organization Department of Reproductive Health and Research (WHO/RHR), Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs (CCP). Family Planning: A Global Handbook for Providers (2018 update) [Internet]. Baltimore and Geneva: CCP and WHO; 2018 [cited 2019 Jun 20]. 442 p. Available from: http://apps.who.int/iris/bitstream/10665/260156/1/9780999203705-eng.pdf?ua=1
25. Demographic and Health Surveys. The DHS Program [Internet]. Rockville: The DHS Program; 2019 [cited 2019 Sep 8]. Available from: https://dhsprogram.com
26. UNFPA. 2016Universal Access to Reproductive Health: Progress and Challenges. https://www.unfpa.org/publications/universal-access-reproductive-health-progress-andchallenges
27. Forrest JD, Singh S. The sexual and reproductive behavior of American women, 1982–1988. Fam Plann Perspect. 1990 Sep-Oct;22(5):206–214.
28. Martinez G, Copen CE, Abma JC. Teenagers in the United States: Sexual activity, contraceptive use, and childbearing, 2006–2010 National Survey of Family Growth. Vital 18
Health Stat [Internet]. 2011 [cited 2019 Sep 8]; 23(31). Available from: https://www.cdc.gov/nchs/data/series/sr_23/sr23_031.pdf
29. Shisana O, Rehle T, Simbayi LC, et al. South African national HIV prevalence, incidence, behaviour and communication survey 2017: Health and wellbeing: Human Science Research Council Press; 2017.
30. Muchiri E, Odimegwu E, DeWet N. HIV risk perception and consistency in condom use among adolescents and young adults in urban Cape Town, South Africa: a cumulative risk analysis. S Afr J Infect Dis [Internet]. 2017 [cited 2019 Sep 8]; 32(3):105–110. Available from: https://doi.org/10.1080/23120053.2017.1332800
31. Manzini, N. Sexual initiation and childbearing among adolescent girls in KwaZulu Natal, South Africa, Reprod Health Matters [Internet]. 2001 [cited 2019 Sep 8]; 9(17): 44-52. Available from: https://doi.org/10.1016/S0968-8080(01)90007-2
32. UNAIDS. Global AIDS Monitoring 2018: Indicators for monitoring the 2016 United Nations Political Declaration on Ending AIDS. Geneva: UNAIDS; 2017 [cited 2019 Sep 8]. Available from: https://www.unaids.org/sites/default/files/media_asset/2017-Global-AIDSMonitoring_en.pdf
33. UNFPA, WHO and UNAIDS 2015. Position statement on condoms and the prevention of HIV, other sexually transmitted infections and unintended pregnancy [Internet]. 2015 [cited 2019 Sep 8]. Available from: https://www.unaids.org/en/resources/presscentre/featurestories/2015/july/20150702_con doms_prevention
34. Cates W, Steiner M. Dual protection against unintended pregnancy and sexually transmitted infections: what is the best contraceptive approach? Sex Transm Dis [Internet]. 2002 [cited 2019 Sep 8]; 29(3): 168–74. Available from: https://doi.org/10.1097/00007435-20020300000007
19
35. Friend D, Clark M. Product development workshop 2013: HIV and multipurpose prevention technologies. Antiviral Res [Internet]. 2013 [cited 2019 Sep 8]; 100: S1–2. Available from: https://doi.org/10.1016/j.antiviral.2013.09.024
36. Warren M. Condoms: the multipurpose prevention technologies that already exist. B JOG [Internet]. 2014 [cited 2019 Sep 8]; 121 (Suppl. 5): 9–11. Available from: https://doi.org/10.1111/1471-0528.12913
37. UNAIDS. Making condoms work for HIV prevention: cutting-edge perspectives [Internet] Geneva: UNAIDS; 2004 [cited 2019 Sep 8]. Available from: http://data.unaids.org/publications/irc-pub06/jc941-cuttingedge_en.pdf
38. Mundigo AI. Condom promotion and use: family planning versus HIV protection. IPPF Med Bull ; 1989 Dec; 23(6):1-3.
39. Darden C. Promoting Condoms in Brazil to Men Who Have Sex with Men. Reproductive Health Matters, 2006.14:28, 63-67, DOI: 10.1016/S0968-8080(06)28257-0 40. Steinberg J. Working through a Paradox about Sexual Culture in South Africa: Tough Sex in the Twenty-First Century, Journal of Southern African Studies 2013. 39:3, 497-509, DOI: 10.1080/03057070.2013.818848
41. Macaluso M, Blackwell R, Carr B, Meinzen-Derr J, Montgomery M, Roark M, Lynch M, Stringer EM. Safety and acceptability of a baggy latex condom. Contraception. 2000 Mar;61(3):217-23.
42. Pumphrey RS. Allergy to Hevea latex. Clin Exp Immunol [Internet]. 1994 Dec [cited 2019 Jul 8];98(3):358–60. Available from: https://doi.org/10.1111/j.1365-2249.1994.tb05497.x
43. Steiner MJ, Dominik R, Rountree RW, Nanda K, Dorflinger LJ. Contraceptive effectiveness of a polyurethane condom and a latex condom: a randomized controlled trial. Obstet Gynecol [Internet]. 2003 Mar [cited 2019 Jul 3];101(3):539–47. Available from: https://doi.org/10.1016/s0029-7844(02)02732-1
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44. CDC. Male Condoms | HIV Risk Reduction Tool [Internet]. Atlanta: CDC; [unknown date] [cited 2019 Sep 8]. Available from: https://wwwn.cdc.gov/hivrisk/decreased_risk/barriers/male_condoms.html
45. McMahon CG. Premature ejaculation. Indian J Urol [Internet]. 2007 [cited 2019 Jul 8];23(2):97–108. Available from: https://doi.org/10.4103/0970-1591.32056
46. World Health Organization. Use and procurement of additional lubricants for male and female condoms: WHO/UNFPA/FHI360 Advisory note [Internet]. 2012 [cited 2019 Jul 5]. Available from: https://apps.who.int/iris/bitstream/handle/10665/76580/WHO_RHR_12.33_eng.pdf;jsessio nid=6A379F478EF33CB0CBEBD7D90E832EF1?sequence=1
47. Stacey D. Sensis Condoms With QuickStrips Review [Internet]. [Place unknown]: Verywell Health; 2019 [cited 2019 Sep 8]. Available from: https://www.verywellhealth.com/sensiscondoms-906883
48. Crosby RA, Yarber WL, Graham CA, Sanders SA. Does it fit okay? Problems with condom use as a function of self-reported poor fit. Sex Transm Infect. [Internet]. 2010 Feb [cited 2019 Jul 8]; 86(1):36-38. Available from: https://doi.org/10.1136/sti.2009.036665
49. Cupid Limited. Cupid Limited [Internet]. Malegaon: Cupid Limited; 2019 [cited 2019 Jul 8]. Available from: https://www.cupidlimited.com/
50. Golombok S, Harding R, Sheldon J. An evaluation of a thicker versus a standard condom with gay men. AIDS [Internet]. 2001 Jan 26 [cited 2019 Jul 15];15(2):245–50. Available from: https://https;//doi.org/10.1097/00002030-200101260-00015
51. Crosby R, Sanders S, Yarber WL, Graham CA. Condom-use errors and problems: a neglected aspect of studies assessing condom effectiveness. Am J Prev Med. 2003 May;24(4):367-70.
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52. O-Ring Condom [Internet]. O-Ring Condom. [Place unknown]; O-Ring Condom; 2016 [cited 2019 Sep 8]. Available from: https://www.o-ringcondom.com
53. Renda G, Newbury B, Ill R. A Design-Led Approach to Evaluating Condom Packaging. In: Design 4 Health [Internet]. Sheffield; 2015 [cited 2019 Jun 20]. Available from: https://research.shu.ac.uk/design4health/wpcontent/uploads/2015/07/D4H_Renda_et_al.pdf
54. Ashmore J, Henwood R. Choice or no choice? The need for better branded public sector condoms in South Africa. South Afr J HIV Med [Internet]. 2015 [cited 2019 Aug 25]; 16 (1):353. Available from: https://doi.org/10.4102/sajhivmed.v16i1.353 55. UNFPA South Africa. MAX Condom launched in South Africa with UNFPA support. [Internet]. 2016 [cited 2019 Sep 8]. Available from: https://southafrica.unfpa.org/en/news/maxcondom-launched-south-africa-unfpa-support
56. Moore L, Beksinska M, Rumphs A, Festin M, Gollub EL. Knowledge, attitudes, practices and behaviors associated with female condoms in developing countries: a scoping review. Open Access J Contracept [Internet]. 2015 Sep 21 [cited 2019 Jul 8];6:125–42. Available from: https://doi.org/10.2147/OAJC.S55041
22
Figure 1 Percentage of unmarried sexually active adolescent girls using modern contraception, by region, 2005-2014
Source: http://www.unfpa.org/publications/universal-access-reproductive-health-progress-andchallenges
Figure 2: Condom variety in shape size and features
Figure 3 The Wingman condom https://wingmancondoms.com/
FC2:Flexible inner
Cupid: Medical
Woman’s Condom:
Phoenurse: Plastic
ring
grade sponge
Dissolving cap of
insertion stick
polyvinyl alcohol
Figure 4: Female condom products with different insertion mechanisms
Figure 5: The South African male and female condom public health sector branded condoms
Highlights Condoms are highly effective in preventing pregnancy, STIs and HIV Condoms continue to be widely used by adolescents New technology has led to new and improved existing products
PII:
S1521-6934(19)30177-4
DOI:
https://doi.org/10.1016/j.bpobgyn.2019.12.001
Reference:
YBEOG 1994
To appear in:
Best Practice & Research Clinical Obstetrics & Gynaecology
Received Date: 2 October 2019 Revised Date:
26 November 2019
Accepted Date: 2 December 2019
Please cite this article as: Beksinska M, Wong R, Smit J, Male and female condoms: Their key role in pregnancy and STI/HIV prevention, Best Practice & Research Clinical Obstetrics & Gynaecology, https:// doi.org/10.1016/j.bpobgyn.2019.12.001. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier Ltd.
Male and female condoms: Their key role in pregnancy and STI/HIV prevention Mags Beksinska1 Rachel Wong2 Jenni Smit1
1
MatCH Research Unit (MRU), Department of Obstetrics and Gynaecology, Faculty of Health
Sciences, University of the Witwatersrand, Johannesburg, South Africa. 2
Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada.
Corresponding author: Mags Beksinska, MRU, Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa. [email protected] +00 27 31 001 1916
Declarations of interest: none
1
Abstract Male and female condoms are the only available multi-purpose technology (MPT) that can prevent unintended pregnancy and sexually transmitted infections including HIV. If used correctly and consistently, condoms can provide levels of pregnancy protection similar to many hormonal methods. Condoms remain one of the most common methods used at first sexual intercourse and are relied on as a current use of contraception by adolescents in many regions of the world. Male and female condoms are safe and require no prescription, in particular male condoms are generally easy to access at low cost. Female condoms are more expensive than male condoms and less accessible, however, they have the advantage of being a female-initiated method. Condom users may experience some common challenges, however recent advances in condom technology have led to new designs and modifications of existing products to improve quality and make them more attractive, acceptable and pleasurable for consumers and increase use. Key words Male condom; female condom; multi-purpose technologies (MPTs); contraception, STI/HIV prevention.
Keywords: Male condom; female condom; multi-purpose technologies (MPTs); contraception, STI/HIV prevention.
2
Introduction
Condoms in some form have been used for centuries to prevent pregnancy and STIs [1]. The first rubber male condom was produced in 1855, with teat-ended condoms holding the ejaculate Available later in 1901[1]. Skin (intestine or bladder) or linen condoms were more popular and cheaper than “rubber” condoms, eventually, mass production of rubber condoms lowered price and improved quality [1-2]. By the end of the 19th century the male condom was the Western world's most popular contraceptive method [2].Two surveys conducted in New York in 1890 and 1900 found that 45% of the women surveyed were using male condoms to prevent pregnancy [2]. In the 1930s it became possible to use liquid latex, an emulsion of tiny rubber particles in water and directly obtained from the rubber tree. Liquid latex required less labour to produce than cement-dipped rubber condoms which needed to be smoothed by rubbing and trimming. This resulted in the discontinuation of rubber condoms and made way for mass produced and widely available latex condoms [2].
From 1955 to 1965, 42% of Americans relied on male condoms for contraception and from 1950 to 1960, 60% of married couples in the United Kingdom used male condoms [2]. Male condom use continued to be the primary method of contraception globally until the introduction of the contraceptive pill in 1960 which quickly became the world's most popular method of contraception in the following years [3]. However, male condoms continued to be the primary method in some groups of women based on a survey conducted between 1966 and 1970 among British women which found that that the male condom was the most popular method among single women [2].
The emerging HIV epidemic in the 1980s refocused the need for condoms as disease prevention. In 2018, AIDS-related illnesses claimed 770,000 lives which could have largely been preventable by the use of condoms [4] and condom use has averted an estimated 50 million new HIV infections since the onset of the HIV epidemic [5]. Where country data is available, between 2000 and 2016 there has been a notable decrease in incident adult HIV infections which has been associated with steady increases of condom use at last sex with a non-regular partner and condom use by men at last paid sex. However, UNAIDS noted that despite the increased use of condoms, condom availability and use gaps remain, in particular, in Sub-Saharan Africa, where the gap between availability and need is estimated to be more than 3 billion condoms. The estimated condom need in 47 countries in SubSaharan Africa in 2015 was 6 billion male condoms; however, only an estimated 2.7 billion condoms were distributed [5].
3
An analysis published in 2017 [6], made the case for investment in the male condom by quantifying the cost and combined health impact of condom use as a means to prevent unwanted pregnancy and to prevent transmission of STIs including HIV. An annual gap between current and desired use of 10.9 billion male condoms was identified (4.6 billion for family planning and 6.3 billion for HIV and STIs). The findings demonstrated the cost-effectiveness of the male condom in preventing unintended pregnancy and new HIV and STI infections and called for policy makers to increase budgets for condom programming.
As the HIV/AIDS epidemic spread globally, the urgent need for a wider range of female-controlled barrier methods rekindled efforts to develop a female condom. Several patents were filed for female condom products before the 1980s, however few were commercially developed or viable [7]. The polyurethane 'Femidom’ (Reality) female condom advanced in terms of development with laboratory studies and clinical trials indicating that its contraceptive efficacy was similar to that published for the male condom. However, no comparative contraceptive efficacy clinical trials between the male and female condom have been published to date [8].
Although female condoms have been promoted for many years as a woman-initiated, dual protection method for pregnancy and STI/HIV prevention, they have been neglected as a significant player in the field [9]. Lack of commitment by major donors to support female condom programming has meant they have not been an accessible prevention option in many of the countries hardest hit by HIV and unintended pregnancy. A comprehensive analysis of why the female condom has not reached its full potential is attributed to a lack of acceptability in the international policy arena [10]. This has led to a reticence to support its introduction, rather than its acceptability among users [10]. The Reproductive Health Supplies Coalition- a global partnership dedicated to ensuring that all people in low- and middle-income countries can access and use affordable, highquality supplies to ensure their better reproductive health, has identified the female condom as one of several under-used reproductive health technologies [11].
One of the concerns of introducing female condoms into countries hard hit by the HIV epidemic is that their use may simply substitute male condom use and there will be no overall gain in protection, yet at greater cost to prevention programs. There are a number of studies that have looked at this issue and evidence shows that adding female condoms in a broader prevention strategy can increase overall protection rates [12-17]. These prospective studies have suggested that provision of the
4
female condom can decrease the number of unprotected sex acts in a population. This increase in protection was achieved through increased male condom use, increased female-condom use, or, more commonly, a combination of the two. A review published in 2006 of studies reporting on patterns of use and impact on protected sex acts and STI incidence concluded there was evidence that the female condom increased the number of protected sex acts [18].
Condom standards, specifications and regulatory issues
All currently available male condoms on the market can maintain their quality for five years or more if stored properly. Over the years, condoms have been manufactured more consistently, have better formulations of materials, and have design modifications to improve their acceptability and functionality [19]. This is important information for users to feel confident that they are using a quality product.
The WHO/UNFPA Prequalification Scheme is a process that assesses condom manufacturers’ ability to produce a product that meets stringent standards [20]. A list of prequalified male and female condom manufacturers is posted on the WHO and UNFPA prequalification websites [20]. It is recommended that condoms distributed in the public-sector be procured only from prequalified manufacturers to ensure the protection of purchasers and end users [20]. WHO/UNFPA have published specifications for both male and female condoms to guide manufacturers who wish to gain prequalification in order to supply condoms in the public sector [21-22]
In 2018, the US Food and Drug Administration moved forward with recommended changes to regulations for the female condom and announced three significant changes to how these devices are regulated by the federal government [23]. Firstly, the female condom was renamed as a “singleuse internal condom,” a change that was welcomed by many advocates and country programs to move towards a more inclusive description of who is encouraged to use and benefit from it. Secondly, it was approved for both vaginal and anal intercourse, thus endorsing use of this tool for a wider spectrum of sexual activities. Thirdly, it transitioned from the regulatory Class III to a Class II, a move that will reduce the burden on manufacturers when seeking FDA approval for existing and newly developing versions of internal condoms.
5
Who uses condoms and when?
Condoms as primary contraceptive method Male condoms protect against pregnancy 98% of the time when used correctly and consistently, and 87% of the time during common use. Female condoms protect against pregnancy 95% of the time when used correctly, and 79% of the time during common use [24]. Because condoms can be used for both pregnancy and STI/HIV prevention, it can be difficult to disaggregate what proportion of users are using them as their main method of contraception and which ones generally use it only for STI/HIV protection. However global national surveys including Demographic and Health Surveys [25], collect this information.
A report published in 2016 by UNFPA [Figure 1] shows the breakdown of modern contraceptive use by region [26]. Male condom use clearly leads the way as the primary method of use in unmarried adolescent girls.
Figure 1 Condom use at first sex
Reported condom use at first intercourse among adolescent women in the USA aged 15 to 19 years increased from 23% in 1982 to 47% in 1988 [27]. This figure increased further between 2006 and 2010 with condoms named as the contraceptive method most commonly used at first intercourse in USA by 68% of females and 80% of males aged 15–19 [28]. In Sub-Saharan Africa most data on condom use at first sex is from South Africa. A national South African survey reported that in 15-24 year olds, 62.2% females and 41.3 % males used a condom at first sex [29]. A Panel Study in the Cape area of South Africa conducted in 2002 found that most (81%) of adolescents aged 14-22 used a condom at first sex [30]. In the 1999 survey “Transition to adulthood in the context of AIDS in South Africa” 61.8% of girls said they used a condom at first sex of which most used it for dual protection [31].
Condom use at last sex Tracking condom use (male and female) at last sex is an important indicator for contraception and HIV prevention. Male condoms are one of the few male-controlled contraceptive methods and collecting this indicator can reveal changes in men taking responsibility for contraception. Because condom use is a key HIV indicator [32], it can also signify changes in HIV prevention behaviour.
6
Information on condom use is regularly collected in global Demographic Health Surveys although it is understood that it may be subject to reporting bias [33]. However, condom use at last sex disaggregated by type (male or female) is rarely reported. Rates of condom use at last sex show a positive trend in some regions with some Latin American and European countries reporting rates amongst 15 to 24 year-olds of more than 80%, however, in some West African countries it is less than 30% [33]. In particular, condom use at last higher-risk sex has increased over the past three decades in most countries across the world and is as high as 80–90% in some countries [5].
Condoms as multipurpose technologies The pressing need to address both pregnancy, and STIs/HIV prevention has focused interest in recent years on methods that could allow women to address multiple sexual and reproductive health issues with one product [34]. Multipurpose Prevention Technologies (MPTs) are products that deliver varying method combinations to simultaneously prevent HIV, STIs, and unplanned pregnancies. Some combine contraception with STI prevention, while others aim to provide women who want to get pregnant with protection from HIV and other STIs. Research is underway to develop these new biomedical interventions including sustained-release forms such as intravaginal rings and co-formulated long-acting injectables. Additionally, fast-dissolving vaginal films, and gels and diaphragms carrying a drug for HIV and/or STI protection are being developed that are used at or around the time of intercourse. Although progress in development is promising, many products are still many years from being available [35]. The only currently approved MPT products available are male or female condoms. Although users of both condoms may experience some common challenges (perspective that they decrease sexual pleasure as compared to no condom, requirement for negotiation with partners, stigma, and a lack of knowledge or experience with condoms) they provide high levels of protection as MPTs and should not be overlooked whilst waiting for newer products [36].
Yet barriers to condom use continue, including poor access, age restrictions, gender norms, religious norms, stigma, insufficient supply, provider attitudes and, in some places, laws that make it an offence to carry condoms. Many countries also prohibit condom promotion and distribution in schools and other venues where adolescents socialize [5]. Of the 100 countries that reported having a national plan or strategy related to condoms in 2017, only 26 reported that the plan included condom promotion in secondary schools [5]. No matter how effective condoms may be, they can have little impact in preventing HIV and pregnancy if people do not want to use them [37]. Effective condom programming can promote and advocate, deal with condom myths and ensure supply and 7
access. However, there is also a need to ensure that condoms are desirable products, maximise user experience if they are to be used consistently, and provide quality, choice and variety as detailed further in the next section.
New condom technologies: increasing effectiveness and acceptability
Male condom promotion in developing countries continues to be seen as challenging as it is often associated with lack of trust between partners, high failure rates, and reduction in pleasure [38]. Many male and female condom manufacturers as well as country condom programmes are striving for improvements to make condoms more desirable to users which in turn will increase acceptability and uptake. Condom companies are continuously looking to new designs and modifications of existing products that will be more attractive, acceptable, and pleasurable to consumers. Key focus areas include condoms that have better heat transference between partners, are thinner to increase sensitivity, more breakage resistant, fit better, and are easier to insert or put on. To suit consumer preferences, different appearance, flavour, shape, texture, sensation, materials, substances added to condoms, as well as applicators to aid the user and decrease the time needed to put on the condom, can increase choice and variety. Table 1 summarizes the different modifiable condom properties currently on the market primarily for male condoms; however, several apply to female condoms.
Table 1: Male and female condom attributes Attribute
Options
Condom type
Colour
Extensive colour variety
Male & female
Flavour and/or scent
Mint, Chocolate, Strawberry, Vanilla, etc.
Male & female
Texture
Ribbed, Grooved, Studded, Dotted
Male
Shape
Straight, Flared, Close fit, Loose fit, Contoured,
Male
Pouch-like tip, Reservoir tip Sensation
Warming, Cooling
Male
Tingling Numbing- Benzocaine anaesthetic Spermicidal
Nonoxynol-9*
Male
Lubrication
Silicone oil
Male and female
8
No pre-lubrication Material
Application (male
-
Synthetic
Male and female
o
Polyisoprene
o
Polyurethane
o
Polyethylene
o
Nitrile (synthetic rubber)
-
Natural rubber latex
-
Silicone
-
Lambskin
Tabs, Clips, applicator stick
Male
Insertion device
Ring
Female
(female condoms)
Sponge
condoms)
Capsule Size (length/width)
Male:- Length 170-220mm, width 40-60 mm
mm
Female:- length 125-180mm, width 70-83 mm
Thickness (microns)
Male:- 4-9
Male & female**
Male & female
Female:- 6.5-15 Other features
Glow in the dark
Male
*Not recommended or promoted for use in high HIV prevalence many settings **One female condom brand comes in two sizes
Colour Male condoms have been available in a range colours for many years, and more recently several female condom products have expanded their range to include different colours. Pigments are available that are compatible with condoms and those that do not affect the integrity (strength) of the condom should be used [21-22].
Flavours and scents The smell of rubber latex is unattractive to many users. The odour can be masked by flavoured and/or scented lubricants. Both male and female condoms are available with different flavours (male) and scents (male and female) [21-22].
Texture 9
Ribbed, grooved, studded, and dotted textures on male condoms give both partners stimulation as the textures increase friction and sensation for enhanced pleasure [39-40] Figure 2 shows a range of male condom designs and features. Some condoms incorporate several features including the 3 in 1 condom which has 3 attributes in one condom. It is ribbed at the head of the penis, dotted along the shaft, and contoured. The 4 in 1 condom has the same attributes as the 3 in 1 condom with the addition of a chemical to prolong the sex act.
Shape The classic straight shaft male condoms have the same width from the base to the top of the condom, typically with a reservoir tip, but there are also some without. Bulbous end male condoms are wider near the tip to increase friction and stimulate both partners. Flared condoms are wider at the base and have a contoured head, allowing more space for the head of the penis and a closer fit as the condom indents below the head of the penis. Male baggy condoms may offer greater stimulation to the partner and more room and comfort for the penis and have been found to be more acceptable than standard fitted condoms [40-41](Figure 2). Female condoms are not fitted and therefore their shapes are very similar [22].
Material Natural rubber latex containing natural rubber proteins can induce latex allergies [42]. A small proportion (7%) of the general population may have latex sensitivity with up to a quarter (25%) of health care workers regularly exposed to latex products developing a latex allergy [43]. Although most male and some female condoms are made of natural rubber latex, condoms can be made with synthetic materials including silicone polyisoprene, polyurethane, polyethylene, and nitrile (synthetic latex), or natural materials like lamb skin. Users with latex sensitivity can use male and female condoms made of polyisoprene, polyurethane, and lambskin (sheep intestines) without having allergic reactions. Lambskin condoms however do not protect against pregnancy or STIs because of the porosity of the material [44].
Figure 2:
Sensation Condom manufacturers are producing male condoms that provide users with warming, and tingling sensations. The substance to achieve this can be added to the inside and outside of the male condom via a lubricant that produces this effect for additional stimulation for both partners.
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Premature ejaculation is a common male sexual disorder, occurring in about 4-39% of men [45]. To address this condition, some male condoms have the chemical Benzocaine or Lidocaine at the tip in gel form, which dissolves and becomes activated when in contact with heat. These chemicals are local anaesthetics that numb the penis, but do not affect the erection process. The numbing effect delays climax, prolonging the pleasure of both partners.
Lubrication Most male and female condoms are available pre-lubricated although additional lubrication is typically applied to the condom, vagina, penis, or rectum before or during intercourse to moisten and make intercourse more comfortable [46]. There are four types of lubricants: oil-based, waterbased, silicone oil-based, and glycol-based. There is evidence that shows that using additional waterbased lubricant for anal intercourse decreases condom breakage rates to 3%, as compared to 21.4% without the usage of additional lubricant [46]. For vaginal intercourse, there are mixed results regarding male condom failure rates with the use of additional water-based lubricant [44]. Oil-based lubricants should not be used with latex condoms, as the lubricant weakens the latex, leading to increased breakage risks [46]. Water-based personal lubricants are the most widely available. Other lubricants are glycol based and are commonly added to water-based lubricants to reduce the loss of moisture. Water-based lubricants, glycol-based lubricants, and silicone oil-based lubricants are compatible with natural rubber latex; however, silicone oil-based lubricants are more expensive and less widely available than water and glycol-based lubricants. Many approved lubricants can be used with polyurethane male and female condoms, though synthetic condoms, such as polyisoprene weaken when they come into contact with oil-based lubricants.
Reusable silicone male condoms are available for purchase online but are not approved by regulatory bodies. The majority of these reusable condoms are contoured and have different textures and tickers to enhance sensation of the female partner.
Applicators (male condoms) Some condoms have developed methods that allow users to apply the condom quickly and correctly without the need to touch the condom, which aims to simplify application and reduce the risk of tears. One male condom has pull-down tabs [47], while another brand has a plastic clip that allow users to unroll the condom with one hand. A logo on the top of the clip indicates the correct position of the condom. When the condom has been unrolled, the clip can be taken off and discarded.
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Insertors (female condom) A female condom requires a method of insertion to ensure the condom body is placed inside the vagina (Figure 4). There are several different products available using flexible rings, medical grade sponges and one using a polyvinyl alcohol capsule which encases the body of the condom and dissolves rapidly once inserted into the vagina. [19]
Size Poor male condom fit has been associated with breakage, slippage, condom-associated erection loss, incomplete use of condoms, and lack of sexual pleasure [48]. In a large survey of almost 1000 participants in the USA, 15.5% complained about condom size and problems associated with condom width, length, and shape [48]. Male condom manufacturers have been producing condoms with various lengths and widths to address this issue. Male condom lengths vary between 170 -220 mms and width between 40-60 mm., while female condom lengths vary between 125 and 180 mms and width between 70-83 mm. Female condom manufacturers have historically only produced one size as the fit is loose. However, two sizes are now available for one brand with the shorter version having a length 125mm while the standard is 155mm[49]. Size of male condoms is based on length and width, however there are no standard sizes and manufacturers may differ considerably. Male condom specifications exist which guide manufacturers seeking WHO/UNFPA prequalification [21]. These specifications lay down requirements for minimum widths depending on the length [21]. The WHO/UNFPA specifications for female condoms do not have specific requirements on size [22].
Thickness Male condoms come in different thicknesses for different user preferences. Thinner condoms are associated with increased sensation for both partners during sex, though some users prefer thicker condoms because the decreased sensation allows them to delay climax. An extra thin condom is approximately 4 microns thick, while an average condom is around 7 microns thick, and an extra thick condom is about 9 microns thick. No significant differences were found between thick and average condoms regarding clinical or non-clinical failure (including breakage and slippage) [50]. Female condoms are generally of a similar thickness (6.5-15 microns thick)
Special features A common error in male condom application is to apply the condom upside down [51]. This occurs when a user tries to roll on the male condom the wrong way around. If the condom is then correctly turned around and reapplied it may no longer be safe to use as a result of pre-ejaculatory fluid
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residue remaining on the condom. A glow in the dark FDA approved male condom aids condom application in light or dark settings to reduce the risk of incorrect application. The O-Ring Condom have a luminescent ring on the underside of the rolled condom [52].
Packaging / Marketing
To increase the prevalence of condom use, condom packaging needs to appeal to users. Condoms should boost users’ confidence when using them and not cause them to doubt the quality of the condom. In particular, condom packaging needs to appeal to young people, be stylish and be visually appealing to all genders. Attractive packaging can minimize the stigma associated with condom use. Condom manufacturers have been producing appealing packaging with good graphic design, using a variety of colours and changing the type of material of packaging used, such as round packaging or small round tins, mimicking breath mint containers. Renda et al. analysed condom packaging from around the world and found that different colours were used to arouse different feelings, such as masculinity, romance, safety, and prestige, and that different package design emphasized on different aspects, such as the sensory experience, pleasure, safety, and quality [53].
Rebranding has been shown to be an effective demand-creation strategy for the male condom. For more than 10 years, the South African government promoted and branded male condoms as “Choice”, which were freely distributed. However, their reputation as a quality product was called into question, along with its appeal to young people [54]. The rebranding of “Choice” as “Max” was based on market research that confirmed that potential condom users wanted something new and more desirable. The 2016 launch of the new Max condom available in four different scents highlighted the importance of condom use as part of the wider launch of the national HIV campaign to reduce HIV, teenage pregnancy, school drop-out, and gender-based violence among young women and adolescent girls [55]. Similarly, the FC2 female condom will shortly be available as “Maxima”. Figure 5 shows the the new Max and Maxima packaging designs.
Figure 5: The South African male and female condom public health sector branded condoms
Conclusion and recommendations
Unintended pregnancies, HIV and other sexually transmitted infections continue to pose a high health burden for millions of people, especially young women and key populations [32]. More than 13
one-third of pregnancies in developing countries are reported as unplanned [56]. Male and female condoms are highly effective MPTs which provide triple protection in preventing HIV and other sexually transmitted infections (STIs) and pregnancy. Condoms do not need prescriptions to be purchased and are widely available outside of health facilities.
Although female condom distribution rates lag far behind those of male condoms, there has been significant progress in product technology. Since 2000, new female condom products have become available or are in development, with the aims of reducing unit cost and improving acceptability. Several new designs offer choice of female condoms to suit user preferences [19]. The recent FDA down classification of female condoms from class III medical device to the same class as male condoms (class II) has levelled the playing field between the two condoms. This may encourage further development and innovation that was previously stifled by concerns of development costs.
If new investments are to be made in condom programmes, with accompanying demand creation, condoms must be made available that are of the highest quality and have the potential to attract new users and motivate existing users to continue using condoms. Manufacturers have demonstrated that condoms as the first MPT can be improved on in numerous ways to deliver a better experience for users and there are several evidence-based initiatives worldwide, that have addressed or are addressing quality, performance and acceptability of both male and female condoms in order to promote condom use. Although it remains crucial to continue to advocate and fund new MPTs, there is a need to ensure that male and female condoms are not side-lined or overlooked in the quest for new products, few of which are likely.
This article did not receive any specific grant from funding agencies in the public, commercial or notfor-profit sectors.
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Practice points • New condom users should be counselled in the correct and consistent use of both male and female condoms • Condoms are classified as a modern method of contraception and if used correctly are highly effective to prevent pregnancy/STIs and HIV • Condoms are now available in a variety of sizes, designs and colours. • Condoms are normally available pre-lubricated but compatability with additional lubricants should be confirmed before added.
Research Agenda Contraceptive effectiveness data available for the female condom is limited to one product that has changed material from polyurethane to synthetic latex. Contraceptive data on other female condom products is lacking.
References
1. Amy JJ, Thiery M. The condom: A turbulent history. Eur J Contracept Reprod Health Care. 2015;20(5):387-402. doi: 10.3109/13625187.2015.1050716. Epub 2015 ; Jun 11.
2. Collier A. The humble little condom: A history. Buffalo: Prometheus Books; 2007. 371 p.
3. Christin-Maitre S. History of oral contraceptive drugs and their use worldwide. Best Pract Res Clin Enocrinol Matab.2013 Feb; 27 (1):3-12.doi:10.1016/j.beem.2012.11.004 4. WHO: Key Facts 25th July 2019. https://www.who.int/news-room/fact-sheets/detail/hiv-aids 5. UNAIDS. A condom crisis at the centre of the HIV prevention crisis [Internet]. 2018 Jul 7 [cited 2019 Aug 24]. Available from: https://www.unaids.org/en/resources/presscentre/featurestories/2018/july/20180723_con doms-AIDS2018 6. Stover J, Rosen JE, Carvalho MN, Korenromp EL, Friedman HS, Cogan M, et al. The case for investing in the male condom. PLoS One [Internet]. 2017 [cited 2019 Aug 12]; 12(5). Available from: https://doi.org/10.1371/journal.pone.0177108
15
7. Bounds W. Female condoms, Eur J Contracept Reproductive Health Care [Internet]. 1997 [cited 2019 Jul 13]; 2(2): 113-116. Available from: https://doi.org/10.3109/13625189709167464 8. Bounds W, Guillebaud J, Newman GB. Female Condom (Femidom). A clinical study of its useeffectiveness and patient acceptability. Br J Fam Plann; 1992; 18(2):36-41.
9. Center for Health and Gender Equity. Female condoms and US foreign assistance: an unfinished imperative for women’s health. Washington, DC; 2011.
10. Peters A, Jansen W, van Driel F. The female condom: the international denial of a strong potential. Reprod Health Matters [Internet]. 2010 [cited 2019 Sep 8];18 (35):119-128. Available from: https://doi.org/10.1016/S0968-8080(10)35499-1
11. Reproductive Health Supplies Coalition. Caucus on new and underused reproductive health technologies. Product brief: female condom. Reproductive Health Supplies Coalition [Internet]. 2013 [cited 2019 Sep 8]. Available from: https://www.rhsupplies.org/fileadmin/uploads/rhsc/Working_Groups/New_Underused_RH _Technologies_Caucus/Documents/Technical_Briefs/rhsc-brief-female-condom_A4.pdf
12. Hoke TH, Feldblum PJ, Van Damme K, Nasution MD, Grey TW, Wong EL, et al. Temporal trends in sexually transmitted infection prevalence and condom use following introduction of the female condom to Madagascar sex workers. Int J STD AIDS [Internet]. 2007 [cited 2019 Aug 3]; 18(7): 461-466. Available from: https://doi.org/10.1258/095646207781147175
13. Latka M, Gollub E, French P, Stein Z. Male-Condom and Female-Condom Use Among Women After Counseling in a Risk-Reduction Hierarchy for STD Prevention. Sex Transm Dis [Internet]. 2001 [cited 2019 Aug 25]; 27(8):431-437. Available from: https://doi.org/10.1097/00007435-200009000-00002
14. Welsh M, Feldblum P, Kuyoh M, Mwarogo P, Kungu D. Condom Use During a Community Intervention Trial in Kenya. Int J STD AIDS [Internet]. 2001 [cited 2019 Aug 16]; 12(7):469474. Available from: https://doi.org/10.1258/0956462011923363
16
15. Fontanet AL, Saba J, Chandelying V, Sakondhavat C, Bhirleus P, Rugpao S, et al. Protection against sexually transmitted diseases by granting sex workers in Thailand the choice of using the male or female condom: Results from a randomized controlled trial. AIDS [Internet]. 1998 [cited 2019 Aug 15]; 12(14):1851-1859. Available from: https://doi.org/10.1097/00002030-199814000-00017
16. Artz L, Macaluso M, Brill I, Kelaghan J, Austin H, Fleenor M, et al. Effectiveness of an Intervention Promoting the Female Condom to Patients at Sexually Transmitted Disease Clinics. Am J Public Health [Internet]. 2000 [cited 2019 Sep 8]; 90(2): 237-244. Available from: https://doi.org/10.2105/AJPH.90.2.237
17. Beksinska M, Nkosi P, Mabude Z, Smit J, Zulu B, Phungula L et al. Twenty years of the female condom programme in South Africa: past, present, and future. In: Padarath A, Barron P, editors. South African Health Review 2017 [Internet]. Durban: Health Systems Trust. 2017 [cited 2019 Jul 3]; 2017(1): 147-156. Available from: http://www.hst.org.za/publications/south-african-health-review-2017
18. Vijayakumar G, Mabude Z, Smit J, Beksinska M, Lurie M. A review of female-condom effectiveness: Patterns of use and impact on protected sex acts and STI incidence. Int J STD AIDS [Internet]. 2006 [cited 2019 Sep 8]; 17(10):652-659. Available from: https://doi.org/10.1258/095646206780071036
19. Beksinska M, Smit J. Condoms, past present and future. https://www.sahivsoc2018.co.za/wp-content/uploads/2018/11/8C_MagsBeksinska_Condom-presentation-SA-clinicians-24th-Oct-Updated.pdf
20. WHO/ UNFPA Prequalification programmes. [cited 2019 Oct 30 ]; Available from: https://www.unfpaprocurement.org/prequalification-programme
21. World Health Organization, UNFPA and Family Health International. Male Latex Condom: Specification, Prequalification and Guidelines for Procurement, 2010. World Health Organization [Internet];. 2013 Apr [cited 2019 Sep 8]; Available from: https://apps.who.int/iris/bitstream/handle/10665/44383/9789241599900_eng.pdf;jsessioni d=CE3C2CA5BE73F58834C59186C88A122D?sequence=1 17
22. World Health Organization, United Nations Population Fund and FHI360 . Female Condom: Generic Specification, Prequalification and Guidelines for Procurement. 2012. https://www.who.int/reproductivehealth/publications/family_planning/female_condom_sp ecification.pdf?ua=1
23. Food and Drug Administration. Obstetrical and Gynecological Devices; Reclassification of Single-Use Female Condom, To Be Renamed Single-Use Internal Condom [Internet]. 2018 Sep [cited 2019 Jul 18]; p. 48711–14. Report No.: 2018–20144. Available from: https://www.federalregister.gov/documents/2018/09/27/2018-21044/obstetrical-andgynecological-devices-reclassification-of-single-use-female-condom-to-be-renamed
24. World Health Organization Department of Reproductive Health and Research (WHO/RHR), Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs (CCP). Family Planning: A Global Handbook for Providers (2018 update) [Internet]. Baltimore and Geneva: CCP and WHO; 2018 [cited 2019 Jun 20]. 442 p. Available from: http://apps.who.int/iris/bitstream/10665/260156/1/9780999203705-eng.pdf?ua=1
25. Demographic and Health Surveys. The DHS Program [Internet]. Rockville: The DHS Program; 2019 [cited 2019 Sep 8]. Available from: https://dhsprogram.com
26. UNFPA. 2016Universal Access to Reproductive Health: Progress and Challenges. https://www.unfpa.org/publications/universal-access-reproductive-health-progress-andchallenges
27. Forrest JD, Singh S. The sexual and reproductive behavior of American women, 1982–1988. Fam Plann Perspect. 1990 Sep-Oct;22(5):206–214.
28. Martinez G, Copen CE, Abma JC. Teenagers in the United States: Sexual activity, contraceptive use, and childbearing, 2006–2010 National Survey of Family Growth. Vital 18
Health Stat [Internet]. 2011 [cited 2019 Sep 8]; 23(31). Available from: https://www.cdc.gov/nchs/data/series/sr_23/sr23_031.pdf
29. Shisana O, Rehle T, Simbayi LC, et al. South African national HIV prevalence, incidence, behaviour and communication survey 2017: Health and wellbeing: Human Science Research Council Press; 2017.
30. Muchiri E, Odimegwu E, DeWet N. HIV risk perception and consistency in condom use among adolescents and young adults in urban Cape Town, South Africa: a cumulative risk analysis. S Afr J Infect Dis [Internet]. 2017 [cited 2019 Sep 8]; 32(3):105–110. Available from: https://doi.org/10.1080/23120053.2017.1332800
31. Manzini, N. Sexual initiation and childbearing among adolescent girls in KwaZulu Natal, South Africa, Reprod Health Matters [Internet]. 2001 [cited 2019 Sep 8]; 9(17): 44-52. Available from: https://doi.org/10.1016/S0968-8080(01)90007-2
32. UNAIDS. Global AIDS Monitoring 2018: Indicators for monitoring the 2016 United Nations Political Declaration on Ending AIDS. Geneva: UNAIDS; 2017 [cited 2019 Sep 8]. Available from: https://www.unaids.org/sites/default/files/media_asset/2017-Global-AIDSMonitoring_en.pdf
33. UNFPA, WHO and UNAIDS 2015. Position statement on condoms and the prevention of HIV, other sexually transmitted infections and unintended pregnancy [Internet]. 2015 [cited 2019 Sep 8]. Available from: https://www.unaids.org/en/resources/presscentre/featurestories/2015/july/20150702_con doms_prevention
34. Cates W, Steiner M. Dual protection against unintended pregnancy and sexually transmitted infections: what is the best contraceptive approach? Sex Transm Dis [Internet]. 2002 [cited 2019 Sep 8]; 29(3): 168–74. Available from: https://doi.org/10.1097/00007435-20020300000007
19
35. Friend D, Clark M. Product development workshop 2013: HIV and multipurpose prevention technologies. Antiviral Res [Internet]. 2013 [cited 2019 Sep 8]; 100: S1–2. Available from: https://doi.org/10.1016/j.antiviral.2013.09.024
36. Warren M. Condoms: the multipurpose prevention technologies that already exist. B JOG [Internet]. 2014 [cited 2019 Sep 8]; 121 (Suppl. 5): 9–11. Available from: https://doi.org/10.1111/1471-0528.12913
37. UNAIDS. Making condoms work for HIV prevention: cutting-edge perspectives [Internet] Geneva: UNAIDS; 2004 [cited 2019 Sep 8]. Available from: http://data.unaids.org/publications/irc-pub06/jc941-cuttingedge_en.pdf
38. Mundigo AI. Condom promotion and use: family planning versus HIV protection. IPPF Med Bull ; 1989 Dec; 23(6):1-3.
39. Darden C. Promoting Condoms in Brazil to Men Who Have Sex with Men. Reproductive Health Matters, 2006.14:28, 63-67, DOI: 10.1016/S0968-8080(06)28257-0 40. Steinberg J. Working through a Paradox about Sexual Culture in South Africa: Tough Sex in the Twenty-First Century, Journal of Southern African Studies 2013. 39:3, 497-509, DOI: 10.1080/03057070.2013.818848
41. Macaluso M, Blackwell R, Carr B, Meinzen-Derr J, Montgomery M, Roark M, Lynch M, Stringer EM. Safety and acceptability of a baggy latex condom. Contraception. 2000 Mar;61(3):217-23.
42. Pumphrey RS. Allergy to Hevea latex. Clin Exp Immunol [Internet]. 1994 Dec [cited 2019 Jul 8];98(3):358–60. Available from: https://doi.org/10.1111/j.1365-2249.1994.tb05497.x
43. Steiner MJ, Dominik R, Rountree RW, Nanda K, Dorflinger LJ. Contraceptive effectiveness of a polyurethane condom and a latex condom: a randomized controlled trial. Obstet Gynecol [Internet]. 2003 Mar [cited 2019 Jul 3];101(3):539–47. Available from: https://doi.org/10.1016/s0029-7844(02)02732-1
20
44. CDC. Male Condoms | HIV Risk Reduction Tool [Internet]. Atlanta: CDC; [unknown date] [cited 2019 Sep 8]. Available from: https://wwwn.cdc.gov/hivrisk/decreased_risk/barriers/male_condoms.html
45. McMahon CG. Premature ejaculation. Indian J Urol [Internet]. 2007 [cited 2019 Jul 8];23(2):97–108. Available from: https://doi.org/10.4103/0970-1591.32056
46. World Health Organization. Use and procurement of additional lubricants for male and female condoms: WHO/UNFPA/FHI360 Advisory note [Internet]. 2012 [cited 2019 Jul 5]. Available from: https://apps.who.int/iris/bitstream/handle/10665/76580/WHO_RHR_12.33_eng.pdf;jsessio nid=6A379F478EF33CB0CBEBD7D90E832EF1?sequence=1
47. Stacey D. Sensis Condoms With QuickStrips Review [Internet]. [Place unknown]: Verywell Health; 2019 [cited 2019 Sep 8]. Available from: https://www.verywellhealth.com/sensiscondoms-906883
48. Crosby RA, Yarber WL, Graham CA, Sanders SA. Does it fit okay? Problems with condom use as a function of self-reported poor fit. Sex Transm Infect. [Internet]. 2010 Feb [cited 2019 Jul 8]; 86(1):36-38. Available from: https://doi.org/10.1136/sti.2009.036665
49. Cupid Limited. Cupid Limited [Internet]. Malegaon: Cupid Limited; 2019 [cited 2019 Jul 8]. Available from: https://www.cupidlimited.com/
50. Golombok S, Harding R, Sheldon J. An evaluation of a thicker versus a standard condom with gay men. AIDS [Internet]. 2001 Jan 26 [cited 2019 Jul 15];15(2):245–50. Available from: https://https;//doi.org/10.1097/00002030-200101260-00015
51. Crosby R, Sanders S, Yarber WL, Graham CA. Condom-use errors and problems: a neglected aspect of studies assessing condom effectiveness. Am J Prev Med. 2003 May;24(4):367-70.
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52. O-Ring Condom [Internet]. O-Ring Condom. [Place unknown]; O-Ring Condom; 2016 [cited 2019 Sep 8]. Available from: https://www.o-ringcondom.com
53. Renda G, Newbury B, Ill R. A Design-Led Approach to Evaluating Condom Packaging. In: Design 4 Health [Internet]. Sheffield; 2015 [cited 2019 Jun 20]. Available from: https://research.shu.ac.uk/design4health/wpcontent/uploads/2015/07/D4H_Renda_et_al.pdf
54. Ashmore J, Henwood R. Choice or no choice? The need for better branded public sector condoms in South Africa. South Afr J HIV Med [Internet]. 2015 [cited 2019 Aug 25]; 16 (1):353. Available from: https://doi.org/10.4102/sajhivmed.v16i1.353 55. UNFPA South Africa. MAX Condom launched in South Africa with UNFPA support. [Internet]. 2016 [cited 2019 Sep 8]. Available from: https://southafrica.unfpa.org/en/news/maxcondom-launched-south-africa-unfpa-support
56. Moore L, Beksinska M, Rumphs A, Festin M, Gollub EL. Knowledge, attitudes, practices and behaviors associated with female condoms in developing countries: a scoping review. Open Access J Contracept [Internet]. 2015 Sep 21 [cited 2019 Jul 8];6:125–42. Available from: https://doi.org/10.2147/OAJC.S55041
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Figure 1 Percentage of unmarried sexually active adolescent girls using modern contraception, by region, 2005-2014
Source: http://www.unfpa.org/publications/universal-access-reproductive-health-progress-andchallenges
Figure 2: Condom variety in shape size and features
Figure 3 The Wingman condom https://wingmancondoms.com/
FC2:Flexible inner
Cupid: Medical
Woman’s Condom:
Phoenurse: Plastic
ring
grade sponge
Dissolving cap of
insertion stick
polyvinyl alcohol
Figure 4: Female condom products with different insertion mechanisms
Figure 5: The South African male and female condom public health sector branded condoms
Highlights Condoms are highly effective in preventing pregnancy, STIs and HIV Condoms continue to be widely used by adolescents New technology has led to new and improved existing products