Condom Promotion and Distribution to Prevent HIV/AIDS

This is an interim intervention report. We have spent limited time to form an initial view of this program and, at this point, our views are preliminary.

Published: April 2019

Previous version of this page:

• 2009 report

  Table of Contents

  • Summary
  • What is the problem?
  • What is the program?
  • Does the program have strong evidence of effectiveness?
    • Do condoms, when used properly, reduce HIV transmission rates?
    • Do interventions to promote condom use increase condom use and reduce STIs?
    • Evidence from past large-scale programs
  • Are there any potential negative impacts of the program?
  • Cost-effectiveness
  • Organizations that implement this program
  • Our process
  • Sources

  Table of Contents 1) Summary 2) What is the problem? 3) What is the program? 4) Does the program have strong evidence of effectiveness? 4.1) Do condoms, when used properly, reduce HIV transmission rates? 4.2) Do interventions to promote condom use increase condom use and reduce STIs? 4.3) Evidence from past large-scale programs 5) Are there any potential negative impacts of the program? 6) Cost-effectiveness 7) Organizations that implement this program 8) Our process 9) Sources

  What is the problem?

  The Human Immunodeficiency Virus (HIV) weakens an individual's immune system,1 making him or her susceptible to life-threatening diseases such as tuberculosis.2 In 2017, 940,000 people died from HIV-related causes globally.3

  According to the World Health Organization (WHO), "the most advanced stage of HIV infection is Acquired Immunodeficiency Syndrome (AIDS), which can take from 2 to 15 years to develop depending on the individual. AIDS is defined by the development of certain cancers, infections, or other severe clinical manifestations."4

  Condoms may also reduce other sexually transmitted infections, but in this report we particularly focus on HIV due to its large health burden.

  What is the program?

  The program is the promotion and distribution of condoms in order to prevent the transmission of HIV.
  As of 2006, the primary transmission mechanism for HIV is sexual intercourse, which accounts for more than 90% of infections in adults in sub-Saharan Africa.5 Condoms can reduce the likelihood of transmission during sexual intercourse.6

  HIV can also be transmitted by exposure to infected blood, or from mother to child through birth or breast milk.7

  The use of condoms can be encouraged by their promotion or distribution. Condoms can be promoted through mass media, schools, testing centers, targeted distribution points, and many other channels. Condoms can be distributed either by giving them to specific high-risk groups for free (as in Thailand's 100% condom program8 ), or by selling them at subsidized prices through the private, retail sector (as in the program run by Population Services International).9

  Does the program have strong evidence of effectiveness?

  It is our understanding that, when used correctly, condoms are highly effective at reducing the probability of HIV transmission. For the purposes of this report we have taken this high effectiveness as given. We have not reviewed the literature on the subject beyond lightly reviewing a single meta-analysis (Weller and Davis-Beaty 2002), described below. This is because reviewing the full evidence base would be time-consuming, and it would be surprising if the conventional wisdom were incorrect.

  We have reviewed three Cochrane Collaboration meta-analyses of condom promotion and distribution programs, and have found no strong evidence that they are effective at reducing the transmission of HIV.

  Details follow.

  Do condoms, when used properly, reduce HIV transmission rates?

  In 2002, the Cochrane Collaboration published a meta-analysis of 14 studies that examined the effects of condom use on the probability of HIV transmission.10 The authors of the meta-analysis estimated that consistent condom use by a couple in which one partner was infected with HIV and the other was not resulted in an 80% reduction in the rate of transmission of HIV to the uninfected partner.11 The authors note that the studies were not randomized controlled trials, and that this reduction may therefore have been caused by systematic, unmeasured differences between the types of couples who always and never use condoms.12

  As mentioned above, we have not thoroughly reviewed the rest of the literature on the general effectiveness of condoms. We are aware of several other papers and meta-analyses that might give us a more accurate and reliable picture of the effectiveness of condoms, were this to become an important question to us.13

  Do interventions to promote condom use increase condom use and reduce STIs?

  We know of three Cochrane Collaboration meta-analyses that have reviewed the effect of condom promotion interventions on rates of condom use or sexually transmitted infection (STI) prevalence. The meta-analyses focus on a range of populations, interventions, and outcomes. We have not carefully reviewed which individual studies are included in each meta-analysis, but our rough understanding is that the three meta-analyses cover slightly different evidence bases. We report on results from all three meta-analyses for completeness.

  Overall, they find no strong evidence that any type of condom promotion or distribution intervention is effective at reducing rates of transmission of HIV or any other STI.

  The first of these meta-analyses was published in 2011. The Cochrane Collaboration reviewed 5 RCTs (with a total of 725 participants) that studied behavioural interventions to promote consistent condom use in HIV-positive women.14 The authors found that the programs had no significant effect on rates of condom use when compared to standard care or minimal HIV-related support.15 The authors note that the trials were small and comprised entirely of HIV-positive women, so the results may not be widely generalizable.16

  The second meta-analysis was published in 2013. The Cochrane Collaboration reviewed 7 RCTs of condom promotion programs that aimed to prevent pregnancy and disease.17 The trials studied heterosexual men and women in the general population, and were not targeted at any particularly high-risk group.18 Of the 7 trials, 5 studied pregnancy, 4 studied HIV and herpes, and 3 studied other STIs.19 Overall there was no evidence that the programs reduced rates of pregnancy or HIV.20 There was mixed evidence for the effect of the programs on rates of other STIs. In two studies the treatment group had fewer cases of herpes, but in another study the treatment group had more cases of gonorrhea.21 The authors of the review conclude:22

  We found little clinical effect of improving condom use. The studies provided moderate to low quality information. Losses to follow up were high. We need good programs on condom use to prevent pregnancy and HIV/STI. Programs should be useful for settings with few resources. Interventions should be tested with valid outcome measures.

  The final meta-analysis was published in 2014. The Cochrane Collaboration reviewed 9 RCTs (with a total of 75,891 participants) that studied community condom promotion programs that had the goal of reducing the spread of HIV and STIs.23 24 Most trials studied the general population, rather than specific high-risk groups.25 The authors concluded that community condom promotion interventions did cause an increase in reported condom use, but that there was no clear evidence that they caused a decrease in transmission of HIV or other STIs.26 These findings are surprising to us, given our belief that condoms are generally effective at preventing the spread of STIs if they are used correctly. We can imagine a range of possible explanations for the results, for example that people report using condoms more often than they actually use them, or that condom usage really does increase, but not consistently or correctly. The authors of this meta-analysis note that their results should be interpreted with caution due to imprecise estimates and possible attrition bias.27

  Evidence from past large-scale programs

  Several large-scale condom promotion and distribution programs appear to have coincided with reductions in the rate of HIV infection in countries in the developing world. Examples include programs implemented in Thailand and Uganda during the 1990s.28 However, we have not investigated the extent to which the programs were causally responsible for these reductions.

  Are there any potential negative impacts of the program?

  It is possible that increased condom promotion and distribution could lead to increased frequency of sexual activity. This could lead to higher rates of HIV transmission, especially if the sexual activities are particularly high-risk. The Disease Control Priorities in Developing Countries report raises this concern and states that available data suggest that "sex education, including condom promotion, does not encourage or increase sexual activity (Kirby 2001)."29

  Cost-effectiveness

  We have not produced a cost-effectiveness analysis of this program. This is because our initial assessment of its evidence base suggests that there is no strong evidence that condom promotion programs have reduced transmission of HIV and other STIs. We have not yet deeply assessed the underlying reasons why such programs may not have achieved these outcomes.

  Organizations that implement this program

  We have not searched for organizations that implement this intervention since we do not see it as a priority program.

  Our process

  We first reviewed condom promotion and distribution programs in 2009. In our 2019 update of this review, we searched the Cochrane Collaboration database for "condom promotion" and found three meta-analyses, which we describe in the section titled "Do interventions to promote condom use increase condom use and reduce STIs?" We also reviewed the sections of the WHO's website on HIV/AIDS.

  We have not attempted to find individual RCTs that were released after 2014, when the most recent of the three Cochrane Collaboration reviews was published.

  Sources

  Document	Source
  Carvalho et al. 2011	Source (archive)
  Giannou et al. 2016	Source (archive)
  Jamison et al. 2006	Source
  Johnson et al. 2018	Source (archive)
  Levine 2007	Source
  Lopez et al. 2013	Source (archive)
  Moreno et al. 2014	Source (archive)
  Population Services International, Male Condom	Source
  Weller and Davis-Beaty 2002	Source (archive)
  WHO et al, Health: A Key to Prosperity, 2000	Source (archive)
  WHO, Condoms for HIV prevention	Source (archive)
  WHO, HIV/AIDS Fact Sheet	Source (archive)

  • 1

    "The Human Immunodeficiency Virus (HIV) targets the immune system and weakens people's defence systems against infections and some types of cancer." WHO, HIV/AIDS Fact Sheet

  • 2

    "As the infection progressively weakens the immune system, an individual can develop other signs and symptoms, such as swollen lymph nodes, weight loss, fever, diarrhoea and cough. Without treatment, they could also develop severe illnesses such as tuberculosis, cryptococcal meningitis, severe bacterial infections and cancers such as lymphomas and Kaposi's sarcoma, among others." WHO, HIV/AIDS Fact Sheet

  • 3

    "In 2017, 940 000 people died from HIV-related causes globally." WHO, HIV/AIDS Fact Sheet

  • 4

    WHO, HIV/AIDS Fact Sheet

  • 5
    • "Worldwide, sexual intercourse is the predominant mode of transmission, accounting for approximately 80 percent of infections (Askew and Berer 2003). Sexual intercourse accounts for more than 90 percent of infections in Sub-Saharan Africa." Jamison et al. 2006, Pg 334.
    • Note: the source above claims that "Sexual intercourse accounts for more than 90 percent of infections in Sub-Saharan Africa" but we assume it was focused on infections in the adult population since our rough impression is that a meaningful fraction of HIV infections are due to mother-to-child transmission of HIV (more here). However, we have not yet attempted to find detailed statistics on this point since the broader point about the importance of HIV transmission via sexual intercourse still stands.

  • 6

    “Condoms, when used correctly and consistently, are highly effective in preventing HIV and other sexually transmitted infections (STIs).“ WHO, Condoms for HIV prevention

  • 7

    "HIV transmission predominantly occurs through three mechanisms: sexual transmission, exposure to infected blood or blood products, or perinatal transmission (including breastfeeding)." Jamison et al. 2006, Pg 333.

  • 8

    "Health officials provided boxes of condoms free of charge, and local police held meetings with sex establishment owners and sex workers, despite the illegality of prostitution. Men seeking treatment for sexually transmitted infections (STIs) were asked to name the sex establishment they had used, and health officials would then visit the establishment to provide more information." Levine 2007, Pg 1.

  • 9

    "In nearly 60 countries, we market attractively packaged, high-quality, latex male condoms at prices that low-income populations can afford, as part of our Total Market Approach (TMA)." Population Services International, Male Condom

  • 10

    “Of the 4709 references that were initially identified, 14 were included in the final analysis. There were 13 cohorts of "always" users that yielded an homogeneous HIV incidence estimate of 1.14 [95% C.I.: .56, 2.04] per 100 person-years. There were 10 cohorts of "never" users that appeared to be heterogeneous. The studies with the longest follow-up time, consisting mainly of studies of partners of hemophiliac and transfusion patients, yielded an HIV incidence estimate of 5.75 [95% C.I.: 3.16, 9.66] per 100 person-years. Overall effectiveness, the proportionate reduction in HIV seroconversion with condom use, is approximately 80%.” Weller and Davis-Beaty 2002

  • 11

    “Of the 4709 references that were initially identified, 14 were included in the final analysis. There were 13 cohorts of "always" users that yielded an homogeneous HIV incidence estimate of 1.14 [95% C.I.: .56, 2.04] per 100 person-years. There were 10 cohorts of "never" users that appeared to be heterogeneous. The studies with the longest follow-up time, consisting mainly of studies of partners of hemophiliac and transfusion patients, yielded an HIV incidence estimate of 5.75 [95% C.I.: 3.16, 9.66] per 100 person-years. Overall effectiveness, the proportionate reduction in HIV seroconversion with condom use, is approximately 80%.” Weller and Davis-Beaty 2002

  • 12

    "The lack of random assignment of individuals to use or not use condoms can result in an unequal distribution of HIV risk factors across those categories and can bias estimates of condom effectiveness. Factors associated with both seroconversion and condom use can bias estimates of condom effectiveness. Differences between "always" and "never" users in duration and frequency of exposure or in infectivity and susceptibility can bias estimates. Because condom use is associated with HIV risk factors, the association between condom use and seroconversion is biased by the self-selection of individuals into the always and never condom usage groups. Notably, condom non-users in recent studies may be more likely to be IDUs (Padian 1997) and may be more likely to engage in other risky behaviors (Skurnick 1998; Kennedy 1993; Pinkerton 1995; Ross 1988). Higher HIV transmission among partners of IDUs (Padian 1997) and a preponderance of partners of IDUindex cases among condom non-users, can inflate incidence estimates for condom nonusers and result in an overestimation of condom effectiveness." Weller and Davis-Beaty 2002

  • 13

    Potentially relevant papers that we have not read include Giannou et al. 2016 and Johnson et al. 2018.

  • 14

    “Five primary studies that collectively researched a total of 725 women living with HIV were analysed.” Carvalho et al. 2011

  • 15

    “Based on five eligible studies, we found that behavioral interventions promoting consistent condom use in HIV-positive women did not have a significant impact on outcomes, when compared to standard care or minimal HIV-related support.” Carvalho et al. 2011

  • 16

    “However, these findings should be used with caution since results were based on a few small trials that were targeted specifically towards HIV‐positive women.” Carvalho et al. 2011

  • 17
    • "We found seven randomized trials. Six assigned groups (clusters) and one randomized individuals. Four trials took place in African countries, two in the USA, and one in England. The studies were based in schools, community settings, a clinic, and a military training setting." Lopez et al. 2013
    • “The studies had a clinical outcome such as pregnancy, HIV, or STI tests. We did not use self-reports of condom use.” Lopez et al. 2013

  • 18

    “The studies were based in schools, community settings, a clinic, and a military training setting.” Lopez et al. 2013. The paper makes no reference to specific populations.

  • 19

    "Five trials examined pregnancy, four studied HIV and HSV-2 (herpes), and three assessed other STI." Lopez et al. 2013

  • 20

    "We found few studies and little clinical evidence of effectiveness for interventions promoting condom use for dual protection. We did not find favorable results for pregnancy or HIV, and only found some for other STI." Lopez et al. 2013

  • 21

    "Some results were seen for STI outcomes. Two studies showed fewer HSV-2 cases with the behavioral program compared to the control group. One also reported fewer cases of syphilis and gonorrhea with the behavioral program plus STI management. Another study reported a higher gonorrhea rate for the intervention group. The researchers believed the result was due to a subgroup that did not have the full program." Lopez et al. 2013

  • 22

    Lopez et al. 2013

  • 23
    • "We obtained nine studies, involving 75,891 participants and with a duration raging from one to nine years." Moreno et al. 2014
    • "It is believed that by modifying the environment in which people live, it is possible to improve access and use of condoms on a large scale so that the transmission of HIV and other STIs decreases. This review aimed to assess if this theory was correct." Moreno et al. 2014

  • 24

    "[Selection criteria were] Randomized control trials (RCTs) featuring all of the following:

    1. Community interventions ('community' defined as a geographical entity, such as cities, counties, villages).
    2. One or more structural interventions whose objective was to promote condom use. These type of interventions can be defined as those actions improving accessibility, availability and acceptability of any given health program/technology.
    3. Trials that confirmed biological outcomes using laboratory testing.

    " Moreno et al. 2014

  • 25

    "The studies were conducted in Tanzania, Zimbabwe, South Africa, Uganda, Kenya, Peru, China, India and Russia, comprising 75,891 participants, mostly including the general population (not the high‐risk population)." Moreno et al. 2014

  • 26
    • “Our results did not provide clear evidence that condom promotion in these specific contexts led to a decrease in the transmission of HIV and other STIs. However, knowledge about HIV and other STIs increased, as did reported condom use.” Moreno et al. 2014
    • "Main results
      We included nine trials (plus one study that was a subanalysis) for quantitative assessment. The studies were conducted in Tanzania, Zimbabwe, South Africa, Uganda, Kenya, Peru, China, India and Russia, comprising 75,891 participants, mostly including the general population (not the high‐risk population). The main intervention was condom promotion, or distribution, or both. In general, control groups did not receive any active intervention. The main risk of bias was incomplete outcome data.

      In the meta‐analysis, there was no clear evidence that the intervention had an effect on either HIV seroprevalence or HIV seroincidence when compared to controls: HIV incidence (risk ratio (RR) 0.90, 95% confidence interval (CI) 0.69 to 1.19) and HIV prevalence (RR 1.02, 95% CI 0.79 to 1.32). The estimated effect of the intervention on other outcomes was similarly uncertain: Herpes simplex virus 2 (HSV‐2) incidence (RR 0.76, 95% CI 0.55 to 1.04); HSV‐2 prevalence (RR 1.01, 95% CI 0.85 to 1.20); syphilis prevalence (RR 0.91, 95% CI 0.71 to 1.17); gonorrhoea prevalence (RR 1.16, 95% CI 0.67 to 2.02); chlamydia prevalence (RR 0.94, 95% CI 0.75 to 1.18); and trichomonas prevalence (RR 1.00, 95% CI 0.77 to 1.30). Reported condom use increased in the experimental arm (RR 1.20, 95% CI 1.03 to 1.40). In the intervention groups, the number of people reporting two or more sexual partners in the past year did not show a clear decrease when compared with control groups (RR 0.90, 95% CI 0.78 to 1.04), but knowledge about HIV and other STIs improved (RR 1.15, 95% CI 1.04 to 1.28, and RR 1.23, 95% CI 1.07 to 1.41, respectively). The quality of the evidence was deemed to be moderate for nearly all key outcomes.

      Authors' conclusions
      There is no clear evidence that structural interventions at the community level to increase condom use prevent the transmission of HIV and other STIs. However, this conclusion should be interpreted with caution since our results have wide confidence intervals and the results for prevalence may be affected by attrition bias. In addition, it was not possible to find RCTs in which extended changes to policies were conducted and the results only apply to general populations in developing nations, particularly to Sub‐Saharan Africa, a region which in turn is widely diverse." Moreno et al. 2014

  • 27

    "Main results
    We included nine trials (plus one study that was a subanalysis) for quantitative assessment. The studies were conducted in Tanzania, Zimbabwe, South Africa, Uganda, Kenya, Peru, China, India and Russia, comprising 75,891 participants, mostly including the general population (not the high‐risk population). The main intervention was condom promotion, or distribution, or both. In general, control groups did not receive any active intervention. The main risk of bias was incomplete outcome data.

    In the meta‐analysis, there was no clear evidence that the intervention had an effect on either HIV seroprevalence or HIV seroincidence when compared to controls: HIV incidence (risk ratio (RR) 0.90, 95% confidence interval (CI) 0.69 to 1.19) and HIV prevalence (RR 1.02, 95% CI 0.79 to 1.32). The estimated effect of the intervention on other outcomes was similarly uncertain: Herpes simplex virus 2 (HSV‐2) incidence (RR 0.76, 95% CI 0.55 to 1.04); HSV‐2 prevalence (RR 1.01, 95% CI 0.85 to 1.20); syphilis prevalence (RR 0.91, 95% CI 0.71 to 1.17); gonorrhoea prevalence (RR 1.16, 95% CI 0.67 to 2.02); chlamydia prevalence (RR 0.94, 95% CI 0.75 to 1.18); and trichomonas prevalence (RR 1.00, 95% CI 0.77 to 1.30). Reported condom use increased in the experimental arm (RR 1.20, 95% CI 1.03 to 1.40). In the intervention groups, the number of people reporting two or more sexual partners in the past year did not show a clear decrease when compared with control groups (RR 0.90, 95% CI 0.78 to 1.04), but knowledge about HIV and other STIs improved (RR 1.15, 95% CI 1.04 to 1.28, and RR 1.23, 95% CI 1.07 to 1.41, respectively). The quality of the evidence was deemed to be moderate for nearly all key outcomes.

    Authors' conclusions
    There is no clear evidence that structural interventions at the community level to increase condom use prevent the transmission of HIV and other STIs. However, this conclusion should be interpreted with caution since our results have wide confidence intervals and the results for prevalence may be affected by attrition bias. In addition, it was not possible to find RCTs in which extended changes to policies were conducted and the results only apply to general populations in developing nations, particularly to Sub‐Saharan Africa, a region which in turn is widely diverse." Moreno et al. 2014

  • 28
    • "In 1991, the national AIDS committee led by Thailand's prime minister implemented the '100 percent condom program,' in which all sex workers in sex establishments were required to use condoms with clients...The number of new STI cases fell from 200,000 in 1989 to 15,000 in 2001; the rate of new HIV infections fell fivefold between 1991 and 1995." Levine 2007, Pg 1.
    • “Uganda, one of the first countries in sub-Saharan Africa to experience the devastating impact of HIV/AIDS and to take action to control the epidemic, is one of the rare success stories in a region that has been ravaged by the HIV/AIDS epidemic. While the rate of new infections continues to increase in most countries in sub-Saharan Africa, Uganda has succeeded in lowering its very high infection rates. Since 1993, HIV infection rates among pregnant women, a key indicator of the progress of the epidemic, have been more than halved in some areas and infection rates among men seeking treatment for sexually transmitted infections have dropped by over a third.” WHO et al, Health: A Key to Prosperity, 2000 Pg. 20

  • 29

    Jamison et al. 2006, Pg 344.