Condoms Count for HIV Prevention

Studies from the Americas, Asia and Africa indicate that men who have sex with men (MSM) are at greater risk of infection than the general population, due to both biological vulnerability (anal sex carries a higher risk of transmission than vaginal sex)²²⁸ and social marginalization. According to UNAIDS, “at least five to10 percent of all HIV infections worldwide are due to sexual transmission between men” with variation among regions and within countries.²²⁹ In some places, including San Francisco in the United States, condom use quickly became the norm among MSM, dramatically cutting incidence of HIV and other STIs.^230 231 However, stigma and social marginalization of MSM continues to increase their vulnerability to HIV infection in many settings, for example in Jamaica as described by White and Carr (2005).²³² These problems are exacerbated by inadequate epidemiological data on these populations in most developing countries. In Africa, MSM have received little attention in HIV/AIDS programming and service delivery because of widespread denial and stigmatization of male homosexual behavior and the lack of data on these populations.²³³

While often underground, MSM communities are sizable in many countries. For example, in an Indian cross-sectional population-based survey in 2001, 774 randomly selected residents of 30 slums in Chennai were interviewed for behavioral risk factors. Forty-six (5.9 percent) of them reported having sex with other men.²³⁴ Among these, MSM were eight times more likely to be seropositive for HIV and more than twice as likely to have a history of STIs. Similarly, a risk behavior assessment of 10,785 men attending 3 STI clinics in Pune, India between 1993 and 2002 indicated that 708 (7 percent) were MSM.²³⁵

Recent studies also show high HIV prevalence and low consistent use of condoms among MSM populations in Thailand²³⁶ and China.²³⁷ Among 927 MSM in Thailand, HIV prevalence was 17 percent. Thirty-seven percent of respondents reported having unprotected sex with a male partner in the three-month period. Unprotected sex was more common in regular partnerships; however these partnerships were mostly non-monogamous. One in five of the men reported also having sex with a female in the past year. Thirty-four percent of the men were “not at all concerned” about contracting HIV, and 57 percent responded that way about other STIs.²³⁸ In Beijing, China, three serial cross-sectional surveys of MSM revealed that HIV prevalence among MSM rose from less than one percent in 2004 to greater than five percent in 2006. Surveys found no increase in consistent condom use, with 40 percent of respondents reporting unprotected receptive anal sex and more than half reporting unprotected insertive anal sex in the past six months.²³⁹

UNAIDS’ best practice collection, HIV and Men who have Sex with Men in Asia and the Pacific, published in 2006, highlights successful programs in Bangladesh, Hong Kong, India, Indonesia, New Zealand and the Philippines. Key components in these programs, together with condom promotion, include working with government and health authorities, working with the larger community to reduce stigma, increasing access to health services, conducting outreach activities, building and mobilizing communities, providing care and support, conducting programmatic research to improve programs, and promoting advocacy. As with all programming, attention to administrative and management issues is paramount.²⁴⁰

Interventions are also needed to target men who engage in bisexual behavior and their male and female partners. In many settings, stigma and social norms associated with homosexuality make it more common for MSM to also engage in heterosexual sex. Moreover, the term MSM itself has been criticized for over-simplifying the degree of variation in sexual behavior that exists among people.²⁴¹ Among men surveyed in a study conducted in Dakar, Senegal, only 23 percent of respondents reported using a condom for insertive anal sex and 14 percent for receptive anal sex. Condom use among MSM who also have sex with women was low—only 37 percent reported using a condom the last time they had sex with a woman.²⁴² In St. Petersburg, Russia, among 434 MSM, 126 had had partners of each sex in the last month and 45 percent of men reported recent unprotected anal intercourse with male partners.²⁴³

The sharing of needles for injecting drug use is one of the most direct transmission pathways, allowing HIV to explosively infect extremely marginalized communities. Interventions to encourage safer sexual practices, including condom use, are an important part of a comprehensive prevention package for injecting drug users (IDUs) and their partners, particularly in settings that lack safe needle exchange.²⁴⁴ A study in Iran found that half of IDUs are married and one-third reported having extra-marital sex.²⁴⁵ Another qualitative study conducted in Vietnam found that most wives of IDUs did not use condoms because their husbands objected.²⁴⁶

Prison populations are also at high risk of HIV, yet around the world, most efforts to provide condoms in prisons have been met with resistance.²⁴⁷ Conservative views of homosexuality and the fear that providing condoms will promote same-sex intercourse are often a driving force in the opposition to distribution in prisons.²⁴⁸ For example, in India, medical recommendations to distribute condoms in prisons are illegal based on India’s sodomy laws, which have been criticized for hindering HIV prevention efforts.²⁴⁹ In Jamaica, efforts to distribute condoms in prisons led to riots and strikes by prison wardens because of the perceived promotion of homosexual activity.²⁵⁰

Other critics of distribution in correctional settings express concern that condoms will be used to make “weapons” in prisons, as mechanisms to transport drugs, and that the provision of condoms will lead to an increase in sexual assault among inmates. However, recent evaluations of condom distribution programs in correctional settings indicate that such security concerns are not well founded.²⁵¹ With an appreciation for the health benefits of inmates and the general population, condom distribution is being carried out in prisons in Australia, Brazil, Canada, Romania, Ukraine and Western Europe, as well as in a select number of U.S. cities.²⁵² The need for condoms among prisoners has also been cited in UNGASS reports from Honduras and Romania^{. 253} 

Please refer to the Appendix for end notes.