Condoms and condiments: compatibility and safety of personal lubricants and their use in Africa

Clinical use and implications of sexual devices and sexually explicit media

Given that sexual pleasure is a core component of sexual health, devices that are designed to enhance and diversify sexual pleasure are particularly useful in clinical practice. Despite their growing popularity and widespread use in various biopsychosocial circumstances, many taboos still seem to exist, as indicated by the paucity of scientific literature on the prevalence, application and effectiveness of sexual devices for therapeutic use. However, sex toys and sexual devices are commonly used and have a variety of indications to expand individual and partnered sexuality and to treat sexual difficulties. Different devices are associated with specific advantages and potential risks, opportunities, barriers and ethical challenges when used in a clinical context. Increased knowledge about the aim and functional possibilities of sexual devices might help health-care professionals overcome potential embarrassment, preconceptions and other barriers, learn which patients might benefit from which products, consider their use in treatment programmes, educate about correct use and safety issues, and facilitate open communication about sexual pleasure with their patients.

Factors Associated With Condom Failure in a Longitudinal Cohort of Men Who Have Sex With Men and Transgender Women in Abuja and Lagos, Nigeria

BACKGROUND

Effective condom use is a critical intervention to limit the spread of HIV and other sexually transmitted infections, particularly among individuals in high-risk networks who practice anal sex. We characterized condom failures in cisgender men who have sex with men and transgender women in Nigeria.

SETTING

The TRUST/RV368 cohort provided condoms, compatible lubricants, and safer sex education to men who have sex with men and transgender women at community-engaged health centers in Abuja and Lagos, Nigeria.

METHODS

Participants completed structured interview questions about condom usage and failure every 3-6 months. Robust Poisson regression models with generalized estimating equations were used to estimate relative risks and 95% confidence intervals for prespecified factors potentially associated with condom failure in the previous month.

RESULTS

From September 2013 to September 2019, 2221 of 2737 participants (81.1%) reported condom use for anal sex with a male partner in the last month, and 305 (13.7%) reported condom failure during this time. Multivariate analyses demonstrated an increased risk of condom failure at postenrollment visits, as well as in participants who reported frequent Internet use, 2 or more casual sexual partners, and 2-4 main sexual partners. Those who cohabited with a woman had reduced risk.

CONCLUSIONS

Condom failure was common in this population despite freely available condoms, compatible lubrication, and education. Increased risk of condom failure over time could reflect message fatigue a ceiling for effective condom use, or new uptake of condoms by inexperienced users.

Lubrication and Vaginal Sex: Lubricant Use and Preferences in General Population Women and Women at Risk of HIV

Personal or additional lubricants are used by individuals to enhance sexual experience. Lubrication norms during sex are linked to factors including sociocultural norms, gender dynamics, age, and education. This article provides an overview of literature, exploring thematic areas of interest and relevance to the topic. In some regions/countries, lubricated sex is preferable, and in others, a dry/tight vagina is preferred. Women may use a variety of products to achieve these states. There is little research on lubrication preferences during sex; however, microbicide gel acceptability and adherence studies have provided some insight into these preferences. There is a need for more information on lubrication preferences, including volumes, frequency of use, and site of application. In addition, condom use with lubricants needs further exploration. Context, gender, and individual preferences have implications for acceptability and use of personal additional lubricants and should be taken into account during marketing and dissemination of these products.

Barriers to condom use among key populations in Namibia

Key populations (KPs), particularly female sex workers (FSWs) and men who have sex with men (MSM), are at increased risk for HIV. Namibia is a global priority for HIV prevention interventions. Marginalized communities must be provided effective and culturally appropriate means to prevent HIV, namely condom use. This cross-sectional analysis of data collected by The Society for Family Health was conducted from 2016 to 2017 in Namibia. Demographics and consistent condom use (CCU) barriers were analyzed among 621 FSWs, MSM, and Other KPs. From the data, 37% FSWs, 24% MSM, and 28% Other KPs were HIV-positive. One-quarter of FSWs and Other KPs reported CCU, while 46% MSM reported CCU. Consistent condom users were more likely to be HIV-negative, have achieved a higher education and use condom-compatible lubricant (CCL). In a multivariate model, higher education, being HIV-negative, and always using CCL remained independent correlates of CCU. Substance use and condom unavailability were the most commonly identified barriers to CCU. FSWs reported client-focused reasons for not using condoms. To the best of our knowledge, this is the first peer-reviewed study assessing condom use behavior and associated factors among FSWs and MSM in Namibia.

Prevalence and correlates of anal intercourse among female sex workers in eSwatini

INTRODUCTION

As HIV is very effectively acquired during condomless receptive anal intercourse (AI) with serodiscordant and viremic partners, the practice could contribute to the high prevalence among female sex workers (FSW) in eSwatini (formerly known as Swaziland). We aim to estimate the proportion reporting AI (AI prevalence) among Swazi FSW and to identify the correlates of AI practice in order to better inform HIV prevention interventions among this population.

METHODS

Using respondent-driven sampling (RDS), 325 Swazi FSW were recruited in 2011. We estimated the prevalence of AI and AI with inconsistent condom use in the past month with any partner type, and inconsistent condom use during AI and vaginal intercourse (VI) by partner type. Univariate and multivariable logistic regression models were used to identify behavioural and structural correlates associated with AI and AI with inconsistent condom use.

RESULTS

RDS-adjusted prevalence of AI and AI with inconsistent condom use was high, at 44%[95% confidence interval (95%CI):35-53%]) and 34%[95%CI:26-42%], respectively and did not vary by partner type. HIV prevalence was high in this sample of FSW (70%), but knowledge that AI increases HIV acquisition risk low, with only 10% identifying AI as the riskiest sex act. Those who reported AI were more likely to be better educated (adjusted odds ratio(aOR) = 1.92[95%CI:1.03-3.57]), to have grown up in rural areas (aOR = 1.90[95%CI:1.09-3.32]), have fewer new clients in the past month (aOR = 0.33[95%CI:0.16-0.68]), and for last sex with clients to be condomless (aOR = 2.09[95%CI:1.07-4.08]). Although FSW reporting AI in past month were more likely to have been raped (aOR = 1.95[95%CI:1.05-3.65]) and harassed because of being a sex worker (aOR = 2.09[95%CI:1.16-3.74]), they were also less likely to have ever been blackmailed (aOR = 0.50[95%CI:0.25-0.98]) or been afraid to walk in public places (aOR = 0.46[95%CI:0.25-0.87]). Correlates of AI with inconsistent condom use were similar to those of AI.

CONCLUSIONS

AI is commonly practised and condom use is inconsistent among Swazi FSW. Sex act data are needed to determine how frequently AI is practiced. Interventions to address barriers to condom use are needed, as are biomedical interventions that reduce acquisition risk during AI.

Correlates of Water-Based Lubricant Use Among Men Who Have Sex with Men in Blantyre, Malawi

Condom compatible lubricants (CCLs), including water-based lubricants (WBL) represent one strategy to prevent the breakage of latex condoms and thus decrease the risk of HIV transmission during anal intercourse. The analyses presented here characterize the correlates of WBL use during anal sex among men who have sex with men (MSM) in Blantyre, Malawi enrolled from April 2011 to March 2012 using respondent-driven sampling (RDS). Bivariate and multivariable logistic regression analyses with RDS-weighting were conducted on a total sample of 338 MSM. With RDS-weighting, 25.4% [95% confidence interval (CI): 20.3-31.4] of MSM (106/329) reported primarily using WBL during anal sex. In multivariable analysis, higher income [adjusted odds ratio (aOR): 5.9; 95% CI: 2.48-14.19], family being aware of their sexual practices (aOR: 2.52; 95% CI: 1.29-4.92), and reporting consistent condom use in the last 6 months (aOR: 1.27; 95% CI: 1.06-1.52) were positively associated with WBL use. Increasing age (per 1 year increase in age; aOR: 0.89; 95% CI: 0.83-0.95) was negatively associated with WBL. Taken together, these data highlight the limited uptake of WBL among MSM in Blantyre, Malawi, especially among older men and those belonging with lower income. Older MSM in Malawi are known to have a higher prevalence of HIV and lower reported use of WBL, suggesting significant risks of onward HIV transmission. Separately, the limited use among those with lower incomes suggests the need for free or subsidized distribution of CCL together with condoms and counseling about their use specifically for MSM in Malawi.

How common and frequent is heterosexual anal intercourse among South Africans? A systematic review and meta-analysis

BACKGROUND

HIV is transmitted more effectively during anal intercourse (AI) than vaginal intercourse (VI). However, patterns of heterosexual AI practice and its contribution to South Africa's generalized epidemic remain unclear. We aimed to determine how common and frequent heterosexual AI is in South Africa.

METHODS

We searched for studies reporting the proportion practising heterosexual AI (prevalence) and/or the number of AI and unprotected AI (UAI) acts (frequency) in South Africa from 1990 to 2015. Stratified random-effects meta-analysis by sub-groups was used to produce pooled estimates and assess the influence of participant and study characteristics on AI prevalence. We also estimated the fraction of all sex acts which were AI or UAI and compared condom use during VI and AI.

RESULTS

Of 41 included studies, 31 reported on AI prevalence and 14 on frequency, over various recall periods. AI prevalence was high across different recall periods for sexually active general-risk populations (e.g. lifetime = 18.4% [95%CI:9.4-27.5%], three-month = 20.3% [6.1-34.7%]), but tended to be even higher in higher-risk populations such as STI patients and female sex workers (e.g. lifetime = 23.2% [0.0-47.4%], recall period not stated = 40.1% [36.2-44.0%]). Prevalence was higher in studies using more confidential interview methods. Among general and higher-risk populations, 1.2-40.0% and 0.7-21.0% of all unprotected sex acts were UAI, respectively. AI acts were as likely to be condom protected as vaginal acts.

CONCLUSION

Reported heterosexual AI is common but variable among South Africans. Nationally and regionally representative sexual behaviour studies that use standardized recall periods and confidential interview methods, to aid comparison across studies and minimize reporting bias, are needed. Such data could be used to estimate the extent to which AI contributes to South Africa's HIV epidemic.

Occupational and demographic factors associated with drug use among female sex workers at the China-Myanmar border

BACKGROUND

Within the last decade, the use of amphetamine type stimulants (ATS) has swelled in Myanmar. Regionally, female sex workers have reported turning to ATS for occupational reasons. In doing so, drug-using female sex workers (FSW) face compounded risks for HIV and other sexually transmitted infections (STI). Here, we examine the factors that impact FSW drug use in Muse, a town along the China-Myanmar border.

METHODS

In 2012, 101 FSW were recruited from entertainment venues and brothels along the Myanmar-Chinese border. Participants participated in a self-administered behavioral survey covering demographics, drug use, sex work, and risk behaviors. Bivariate and regression analyses were conducted in SPSS.

RESULTS

Thirty four percent of respondents indicated current drug use. ATS derivatives were the most commonly used drugs (87.5%) with injection drug use being nearly non-existent in the sample. Drug using FSWs were older, had engaged in sex work longer, had more Chinese clients, and were more likely to have a previous boyfriend who had used drugs. They were also 3.5 times more likely to report a STI. Client condom use, HIV testing rates, and familiarity with public health resources did not statistically differ by drug use status.

CONCLUSION

More research is needed to examine how romantic and professional sexual relationships push-and-pull FSW into using drugs. Our results suggest that diverse safer sex strategies, beyond client condom use, should be promoted with drug using FSWs, including strategies that acknowledge the impact of ATS use.

Condoms, Lubricants and Rectal Cleansing: Practices Associated with Heterosexual Penile-Anal Intercourse Amongst Participants in an HIV Prevention Trial in South Africa, Uganda and Zimbabwe

We investigated condom and lubricant use, rectal cleansing and rectal gel use for penile-anal intercourse (PAI), during in-depth interviews with women from South Africa, Uganda and Zimbabwe who formerly participated in VOICE, a five-arm HIV prevention trial of two antiretroviral tablets and a vaginal gel. Few studies have addressed practices related to PAI among women; existing data from Africa on condom and lubricant use for PAI, as well as preparatory practices of PAI such as rectal cleansing, are limited to men who have sex with men. Women demonstrated a lack of awareness of HIV transmission risks of PAI and none of the participants reported using condom-compatible lubricants for PAI. Participants described a variety of preparatory rectal cleansing practices. Some participants disclosed rectal use of the vaginal study gel. Understanding practices related to PAI in Africa is critical to microbicide development, as these practices are likely to influence the acceptability, feasibility, and use of both vaginal and rectal microbicide products.

Male circumcision for protection against HIV infection in sub-Saharan Africa: the evidence in favour justifies the implementation now in progress

This article responds to a recent 'controversy study' in Global Public Health by de Camargo et al. directed at three randomised controlled trials (RCTs) of male circumcision (MC) for HIV prevention. These trials were conducted in three countries in sub-Saharan Africa (SSA) and published in 2005 and 2007. The RCTs confirmed observational data that had accumulated over the preceding two decades showing that MC reduces by 60% the risk of HIV infection in heterosexual men. Based on the RCT results, MC was adopted by global and national HIV policy-makers as an additional intervention for HIV prevention. Voluntary medical MC (VMMC) is now being implemented in 14 SSA countries. Thus referring to MC for HIV prevention as 'debate' and viewing MC through a lens of controversy seems mistaken. In their criticism, de Camargo et al. misrepresent and misinterpret current science supporting MC for HIV prevention, omit previous denunciations of arguments similar to theirs, and ignore evidence from ongoing scientific research. Here we point out the flaws in three areas de Camargo et al. find contentious. In doing so, we direct readers to growing evidence of MC as an efficacious, safe, acceptable, relatively low-cost one-off biomedical intervention for HIV prevention.

Characterization of commercially available vaginal lubricants: a safety perspective

Vaginal lubricants are widely used by women to help solve intercourse difficulties or as enhancers, but recent reports raise questions about their safety. Twelve commercially available gel products were tested for pH value, pH buffering capacity, osmolality and cytotoxicity relevant to vaginal delivery. Obtained data were analyzed in light of the recent Advisory Note by the World Health Organization (WHO) for personal lubricants to be concomitantly used with condoms. Results showed that most products do not comply with pH and osmolality recommended standards, thus posing a potential hazard. Four products presented values of osmolality around three-times higher than the maximum acceptable limit of 1200 mOsm/kg. In vitro cell testing further identified substantial cytotoxicity even at 1:100 dilutions for three products, contrasting with no significant effect of up to at least a 1:5 dilution of a Universal Placebo gel. However, no direct correlation between these last results and pH or osmolality was found, thus suggesting that the individual toxicity of specific formulation components plays an important role in the outcome of a particular product. Although further assessment is required, these results highlight potential safety issues related to the formulation of commercially available vaginal lubricants.

Formulation and delivery of anti-HIV rectal microbicides: advances and challenges

Men and women engaged in unprotected receptive anal intercourse (RAI) are at higher risk of acquiring HIV from infected partners. The implementation of preventive strategies is urgent and rectal microbicides may be a useful tool in reducing the sexual transmission of HIV. However, pre-clinical and first clinical trials have been able to identify limitations of candidate products, mostly related with safety issues, which can in turn enhance viral infection. Indeed, the development of suitable formulations for the rectal delivery of promising antiretroviral drugs is not an easy task, and has been mostly based on products specifically intended for vaginal delivery, but these have been shown to provide sub-optimal outcomes when administered rectally. Research and development in the rectal microbicide field are now charting their own path and important information is now available. In particular, specific formulation requirements of rectal microbicide products that need to be met have just recently been acknowledged despite additional work being still required. Desirable rectal microbicide product features regarding characteristics such as pH, osmolality, excipients, dosage forms, volume to be administered and the need for applicator use have been studied and defined in recent years, and specific guidance is now possible. This review provides a synopsis of the field of rectal microbicides, namely past and ongoing clinical studies, and details on formulation and drug delivery issues regarding the specific development of rectal microbicide products. Also, future work, as required for the advancement of the field, is discussed.