Clinical breakage, slippage and acceptability of a new commercial polyurethane condom: a randomized, controlled study

Systematic Review of Peer-Reviewed Literature on Global Condom Promotion Programs

Background: Globally, 1.7 million people were newly infected with HIV in 2018. Condoms are inexpensive, cost-effective, reduce HIV/STI incidence, morbidity, mortality, and unintended pregnancies, and result in health care cost savings. Given the rapid increase in at-risk adolescent and young adult (AYA) populations in countries with high HIV/STI prevalence as well as the reductions in donor support, promoting consistent condom use remains crucial. We synthesized all peer-reviewed literature on condom promotion programs with a focus on promotion in low and lower middle income (LMIC) countries and with AYA users. Methods: We systematically reviewed the published literature. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methods, we identified 99 articles published between 2000-2019. Results: Condom promotion programs were generally effective in changing attitudes, social norms, and beliefs in favor of condom use, and 85% demonstrated positive effects on multiple condom use measures. Programs targeting AYA were at least equally as effective as those targeting others and often showed greater use of best practices, such as mass media (66%) and audience segmentation (31%). We also saw differences between programs in the intervention strategies they used and found greater effects of marketing strategies on AYA compared to the overall sample. Conclusion: Condoms remain essential to prevention, and donor support must be maintained to combat the HIV/STI epidemic.

Pilot study on functional performance and acceptability of two new synthetic adhesive male condoms (Wondaleaf): a randomized cross-over trial

OBJECTIVES

This study compared the condom failure rate, safety and acceptability of two new synthetic adhesive male condoms, Wondaleaf-Cap® (WLC) and Wondaleaf-On-Man® (WLM), with a marketed latex external condom Durex®-Together (DT).

STUDY DESIGN

We enrolled healthy married, monogamous, heterosexual condom users in a randomized controlled, cross-over, pilot trial in Malaysia. We randomized participants to six groups with different condom use-orders of the experimental WLC and WLM and control latex condom for four episodes for vaginal sex over 1 month for each condom type. We summarized the clinical and non-clinical failure rate, safety and acceptability of each condom type using descriptive statistics. We tested differences in condom failure and acceptability using generalized estimating equations and repeated measure ANOVA respectively.

RESULTS

We screened 75 couples and randomized 50 eligible couples. Two couples withdrew before receiving any condom. The remaining used 576 condoms with 192 uses for each condom variant. Clinical failure rates of WLC, WLM and DT were 1.04%, 0% and 0.52%, respectively. Non-clinical failure rates of WLC, WLM and DT were 2.08%, 3.12% and 1.04%, respectively. Removal was found more painful with Wondaleaf products than the DT. Preferences of participants for WLC, WLM and DT were 33.3%, 29.2% and 25%, respectively. Overall, WLC and DT had greater acceptances among male participants than WLM.

CONCLUSION

Results of this pilot study support that use of synthetic adhesive male condoms is associated with failure rates similar to those seen with existing latex, and with greater acceptability. A larger study to ascertain non-inferiority is underway.

IMPLICATIONS

The availability of synthetic adhesive male condoms may increase the acceptability of condom use. However, removal pain and clinical performance requires further study.

Assessing the perceived benefits of a new condom wrapper/integrated applicator: an exploratory study

Errors and problems associated with male condom use are very prevalent and increase the likelihood of inconsistent and incomplete use, thereby compromising condom effectiveness. The aim of this study was to assess the perceived benefits of a new condom wrapper/integrated applicator designed to reduce barriers to condom use and lessen the likelihood of user errors and problems. After viewing videos depicting features of the wrapper/applicator, participants (N = 547; 62.9% male, M age = 29.2) completed online questionnaires. Most participants reported that the product would make condom application easier and quicker, make them more confident that condoms had been applied correctly and make sex more pleasurable and playful. The majority of participants who had recent experience of condom use errors/problems reported that the use of the product would likely prevent these issues from occurring. Reduced chance of condom damage, the design features of the wrapper and not having to touch the condom itself during application were perceived as particular benefits of the product. The findings suggest that the product might reduce the likelihood of a range of condom user errors and problems and enhance pleasure during condom-protected sex. Future larger-scale studies that involve participants physically testing the condom wrapper/applicator are warranted.

Validation of an Event-Level, Male Sexual Pleasure Scale (EMSEXpleasure) Among Condom-Using Men in the U.S

Sexual pleasure is a key determinant of condom use. We developed and validated a male, event-level sexual pleasure scale (EMSEXpleasure) among a sample of condom-using men in the U.S. in order to facilitate improved measurement of sexual pleasure. Based on an expert panel process, a 12-item scale was developed. An online sample of 169 men who have sex with men and 162 men who have sex with women were recruited. Factor analysis yielded a two-factor solution that matched domains identified a priori by the expert panel, general pleasure and condom-specific pleasure, indicating internal validity of the instrument. One item was deleted from the scale due to poor validity performance. The overall EMSEXpleasure scale, and each subscale, had high (> 0.8) Cronbach's alpha coefficients, indicating internal reliability. The scale demonstrated convergent validity, with theoretically related constructs associated both with individual scale items and with scale totals. Overall relationship quality (b 3.0, 95% CI 2.0, 4.0), sexual relationship quality (b 2.9, 95% CI 2.0, 4.0), foreplay quality (b 7.5, 95% CI 2, 13), positive feelings about condoms (b 18.8, 95% CI 15, 23), and erection problems while using condoms (b - 17.9, 95% CI - 22, - 14) were associated with the EMSEXpleasure scale in expected directions. The validated EMSEXpleasure event-level scale may be advantageous for future assessments of the ephemeral experience of sexual pleasure, including clinical trials of condoms and other interventions, because it can be used immediately after sex, potentially limiting recall error.

"Give What the People Want": A Situational Analysis of Condom Distribution and a Feasibility Study of User-Friendly Condoms in Cape Town, South Africa

Condom use has remained low in South Africa despite efforts by the government to make condoms accessible to all. We assessed condom availability, procurement/distribution, and education practices, and explored perceptions of and interest in an expanded array of condom options, including fitted male condoms in Cape Town, South Africa. We conducted 11 key informant interviews with staff members from two sexual health organizations and four state-owned clinics. Key informants (a) were interested in their organizations offering an expanded variety of male condom options including different sizes, colors, and flavors; and (b) substantiated the capacity that their organizations had to integrate alternative condom options into existing procurement, distribution, and education programs. Challenges discussed included securing funding, educating clients, and addressing logistical issues of stocking and distributing new condom types. Further research should explore whether providing condoms with a greater array of characteristics could improve condom use in South Africa.

Risky Business: condom failures as experienced by female sex workers in Mombasa, Kenya

Limited research exists about condom failure as experienced by female sex workers. We conducted a qualitative study to examine how female sex workers in Mombasa, Kenya contextualise and explain the occurrence of condom failure. In-depth, semi-structured interviews were conducted with thirty female sex workers to ascertain their condom failure experiences. We qualitatively analysed interview transcripts to determine how the women mitigate risk and cope with condom failure. Condom failure was not uncommon, but women mitigated the risk by learning about correct use, and by supplying and applying condoms themselves. Many female sex workers felt that men intentionally rupture condoms. Few women were aware of or felt empowered to prevent HIV, STIs, and pregnancy after condom failure. Interventions to equip female sex workers with strategies for minimising the risk of HIV, STIs, and pregnancy in the aftermath of a condom failure should be investigated.

Online purchases of an expanded range of condom sizes in comparison to current dimensional requirements allowable by US national standards

Background Across studies, 35–50% of men describe condoms as fitting poorly. Rates of condom use may be inhibited in part due to the inaccessibility of appropriately sized condoms. As regulated medical devices, condom sizes conform to national standards such as those developed by the American Society for Testing and Materials (ASTM) or international standards such as those developed by the International Organisation for Standardisation (ISO). We describe the initial online sales experience of an expanded range of condom sizes and assess uptake in relation to the current required standard dimensions of condoms. Methods: Data regarding the initial 1000 sales of an expanded range of condom sizes in the United Kingdom were collected from late 2011 through to early 2012. Ninety-five condom sizes, comprising 14 lengths (83–238 mm) and 12 widths (41–69 mm), were available. Results: For the first 1000 condom six-pack units that were sold, a total of 83 of the 95 unique sizes were purchased, including all 14 lengths and 12 widths, and both the smallest and largest condoms. Initial condom purchases were made by 572 individuals from 26 countries. Only 13.4% of consumer sales were in the ASTM’s allowable range of sizes. Conclusions: These initial sales data suggest consumer interest in an expanded choice of condom sizes that fall outside the range currently allowable by national and international standards organisations.

Condom use errors and problems: a global view

Background Significantly more research attention has been devoted to the consistency of condom use, with far fewer studies investigating condom use errors and problems. The purpose of this review was to present the frequency of various condom use errors and problems reported worldwide. Methods: A systematic literature search was conducted for peer-reviewed articles, published in English-language journals between 1995 and 2011. Results: Fifty articles representing 14 countries met criteria for inclusion. The most common errors included not using condoms throughout sex, not leaving space at the tip, not squeezing air from the tip, putting the condom on upside down, not using water-based lubricants and incorrect withdrawal. Frequent problems included breakage, slippage, leakage, condom-associated erection problems, and difficulties with fit and feel. Prevalence estimates showed great variation across studies. Prevalence varied as a function of the population studied and the period assessed. Conclusion: Condom use errors and problems are common worldwide, occurring across a wide spectrum of populations. Although breakage and slippage were most commonly investigated, the prevalence of other condom use errors and problems found in this review were substantially higher. As a framework for understanding the role of condom errors and problems in inadequate protection, we put forward a new model: the Condom Use Experience model. This model can be used to generate testable hypotheses for future research. Addressing condom use errors and problems in research and interventions is crucial to closing the gap between the perfect use and typical use of condoms.

Complementary and alternative medicines: the herbal male contraceptives

For a very long time, family planning methods have paid little attention to the needs of men, but instead focused primarily on women. A bulk of contraceptives on the market today is women oriented. Probably, many providers assume that women have the greatest stake and interest as far as family planning is concerned. Worst still, there is a misconception that men are indifferent or even stand in opposition to family planning. The consequences of this long neglect of developing acceptable and reliable male contraceptives in poor developing countries has been lack of or less participation of males in family planning. Recently, it has come apparent that neglecting men in matters of family planning is a losing strategy with adverse consequences for both men and women. As Africa is grappling with rapid population growth, it is now recognized that giving attention to females only can not solve the problem.

The Contraceptive Needs for STD Protection Among Women in Jail

We assessed the contraceptive needs of women in jails and their sexually transmitted disease (STD) history and risk to determine effective contraceptive methods for this population. A survey of demographics, sexual health, contraceptive use, and preferred method of contraception was completed by participants recruited at jails in a medium-sized metropolitan area. Results from 188 women indicated high rates of STDs, inconsistent contraceptive use, and use of unreliable and user-dependent contraception methods. Intended contraceptive use following release varied depending on women’s ability to bear children. Women planning to use condoms after release were more likely to have had an STD and more sexual partners than were women not planning to use condoms. Racial differences were found for participants’ sexual health and contraception histories. These women were at high risk for STDs and appeared to need education about contraception methods. Therefore, they might benefit from education on safe sex practices provided prior to release.

Patterns of condom acquisition by condom-using men in the United States

Condom-distribution programs have striven to make condoms more accessible to sexually active individuals, particularly adolescents and populations disproportionately affected by HIV and other STIs. Despite such programs, little is known about where condom-using men in the United States acquire their condoms. The purpose of this study was to document condom-access trends among a large sample of sexually active condom-using men in the United States. Data were collected from 1,832 men from all 50 U.S. states and the District of Columbia by using an Internet-based survey in which men provided details regarding the source of condoms that they had used within the past 30 days. Men reported acquiring their condoms from a variety of sources, including free condom-distribution programs (56.7%) and from venues where they had purchased condoms for themselves (75.7%). Bivariate analyses indicated that participants who reported using free condoms tended to be younger, self-identified as not heterosexual, or not currently in a monogamous relationship. Further, results indicated that those participants who accessed only free condoms did not differ from those who used only purchased condoms, indicating that perhaps efforts to make condoms more accessible through public health distribution campaigns are reaching a more general population of condom-using men than expected. Findings illustrate the importance of continuing free condom-distribution efforts but also suggest benefits of facilitating linkages between public health and a community's retail venues to increase access to the growing diversity of condoms in the marketplace.

Problems with condoms – a population-based study among Finnish men and women

OBJECTIVE

This study evaluates men's and women's opinions of condom use and problems with it in real life.

METHODS

Random samples of men and women, aged 18-50 years, were drawn from the Finnish Population Register and were mailed a questionnaire on family planning. Response rates were 36% for men (706) and 58% for women (1136). Respondents were asked e.g. about condom use, whether they had had problems with it and why they used condoms. Moreover they were asked if they had received advice on how to use condoms.

RESULTS

Among both men and women 87% had at some time used condoms. Of all men 37% and of women 34% reported that they had at some time had a failure with condom use; among both men and women one in four had experienced condom breakage. The use of condoms with the main purpose of preventing sexually transmitted diseases was somewhat low. The proportion of respondents having received advice on condom use was greater among younger men and women.

CONCLUSION

A patient with problems in condom use is not uncommon in consultations in primary health care, and thus personnel working there hold a key position in promoting condom use. The role of school health care should be assured to offer basic sexual and reproductive counselling to every generation.

Advances in male contraception

Despite significant advances in contraceptive options for women over the last 50 yr, world population continues to grow rapidly. Scientists and activists alike point to the devastating environmental impacts that population pressures have caused, including global warming from the developed world and hunger and disease in less developed areas. Moreover, almost half of all pregnancies are still unwanted or unplanned. Clearly, there is a need for expanded, reversible, contraceptive options. Multicultural surveys demonstrate the willingness of men to participate in contraception and their female partners to trust them to do so. Notwithstanding their paucity of options, male methods including vasectomy and condoms account for almost one third of contraceptive use in the United States and other countries. Recent international clinical research efforts have demonstrated high efficacy rates (90-95%) for hormonally based male contraceptives. Current barriers to expanded use include limited delivery methods and perceived regulatory obstacles, which stymie introduction to the marketplace. However, advances in oral and injectable androgen delivery are cause for optimism that these hurdles may be overcome. Nonhormonal methods, such as compounds that target sperm motility, are attractive in their theoretical promise of specificity for the reproductive tract. Gene and protein array technologies continue to identify potential targets for this approach. Such nonhormonal agents will likely reach clinical trials in the near future. Great strides have been made in understanding male reproductive physiology; the combined efforts of scientists, clinicians, industry and governmental funding agencies could make an effective, reversible, male contraceptive an option for family planning over the next decade.

Experiences of condom fit and feel among African-American men who have sex with men

OBJECTIVE

To offer an empirical understanding of characteristics associated with the fit and feel of condoms among African-American men who have sex with men (MSM), a particularly high-risk group for HIV and other sexually transmitted infections (STI) in the United States.

METHODS

Survey data were collected from 178 adult African-American MSM attending a community event in Atlanta, Georgia.

RESULTS

Although the majority of participants reported that condoms generally fit properly and felt comfortable, a substantial number of men reported a variety of problems with the fit and feel of condoms. Specifically, 21% reported that condoms felt too tight, 18% reported that condoms felt too short, 10% reported that condoms felt too loose, and 7% reported that condoms felt too long. There were significant associations between men's reports of condom breakage and slippage, and their perceptions of condom fit and feel. Perceptions of condom fit and feel were also related to men's reports of seeking condoms for their size-specific properties.

CONCLUSIONS

The fit and feel issues that men in this sample identified may be among those that contribute to their likelihood of using, or not using, condoms consistently and correctly. A better understanding of these factors will be beneficial to both condom manufacturers and sexual health professionals who share a common goal of increasing consistent and correct condom use and reducing the incidence of HIV and other STI among this and other communities.

Non-latex versus latex male condoms for contraception

BACKGROUND

The male condom, which consists of a thin sheath placed over the glans and shaft of the penis, is designed to prevent pregnancy by providing a physical barrier against the deposition of semen into the vagina during intercourse. Beginning in the 1990s, nonlatex male condoms made of polyurethane film or synthetic elastomers were developed as alternative male barrier methods for individuals with allergies, sensitivities or preferences that prevented the consistent use of condoms made of latex.

OBJECTIVES

The review sought to evaluate nonlatex male condoms in comparison with latex condoms in terms of contraceptive efficacy, breakage and slippage, safety, and user preferences.

SEARCH STRATEGY

We searched computerized databases for randomized controlled trials of nonlatex condoms. We also wrote to the manufacturers of nonlatex condoms and known investigators in an attempt to locate any other trials not identified in our search.

SELECTION CRITERIA

The review included all randomized controlled trials identified in the literature search that evaluated a male nonlatex condom made of polyurethane film or synthetic elastomers in comparison with a latex condom.

DATA COLLECTION AND ANALYSIS

We evaluated all titles and abstracts located in the literature searches for inclusion. Two authors independently extracted data from the identified studies. We analyzed data with RevMan. The Peto odds ratio (Peto OR) with 95% confidence interval (CI) was calculated for each outcome of contraceptive efficacy, condom breakage and slippage, discontinuation of use, safety, and user preference. Contraceptive efficacy, early discontinuation, and safety outcomes were also measured with survival analysis techniques.

MAIN RESULTS

While the eZ.on condom did not protect against pregnancy as well as its latex comparison condom, no differences were found in the typical-use efficacy between the Avanti and the Standard Tactylon and their latex counterparts. The nonlatex condoms had significantly higher rates of clinical breakage than their latex comparison condoms: the Peto OR for clinical breakage ranged from 2.6 (95% CI 1.6 to 4.3) to 5.0 (95% CI 3.6 to 6.8). Few adverse events were reported. Substantial proportions of participants preferred the nonlatex condom or reported that they would recommend its use to others.

AUTHORS' CONCLUSIONS

Although the nonlatex condoms were associated with higher rates of clinical breakage than their latex comparison condoms, the new condoms still provide an acceptable alternative for those with allergies, sensitivities, or preferences that might prevent the consistent use of latex condoms. The contraceptive efficacy of the nonlatex condoms requires more research.

Surrogate end points in clinical research: hazardous to your health

Surrogate end points in clinical research pose real danger. A surrogate end point is an outcome measure, commonly a laboratory test, that substitutes for a clinical event of true importance. Resistance to activated protein C, for example, has been used as a surrogate for venous thrombosis in women using oral contraceptives. Other examples of inappropriate surrogate end points in contraception include the postcoital test instead of pregnancy to evaluate new spermicides, breakage and slippage instead of pregnancy to evaluate condoms, and bone mineral density instead of fracture to assess the safety of depo-medroxyprogesterone acetate. None of these markers captures the effect of the treatment on the true outcome. A valid surrogate end point must both correlate with and accurately predict the outcome of interest. Although many surrogate markers correlate with an outcome, few have been shown to capture the effect of a treatment (for example, oral contraceptives) on the outcome (venous thrombosis). As a result, thousands of useless and misleading reports on surrogate end points litter the medical literature. New drugs have been shown to benefit a surrogate marker, but, paradoxically, triple the risk of death. Thousands of patients have died needlessly because of reliance on invalid surrogate markers. Researchers should avoid surrogate end points unless they have been validated; that requires at least one well done trial using both the surrogate and true outcome. The clinical maxim that "a difference to be a difference must make a difference" applies to research as well. Clinical research should focus on outcomes that matter.

Changing men's involvement in reproductive health and family planning

The shift in focus on men's reproductive health was influenced by the 1994 Cairo (ICPD) Action Plan to promote gender equality and equity, empower women, and improve family health in society. Changing and improving the way in which men are involved in reproductive health can only have a positive impact on women's, men's, and children's health. Educating and counseling men about contraceptive choices is essential if they are to be supportive of women's reproductive health. Research on new male contraceptive methods must continue if the bias of women shouldering the major responsibility for contraception is to be eliminated.