The Latex Condom: Recent Advances, Future Directions

Chapter 2: Acceptability of Condoms -- User Behaviors and Product Attributes

See Also:

Many men and women prefer unprotected intercourse or using another contraceptive method rather than using a condom. Among currently married women of reproductive age, only 5 percent use condoms for contraception worldwide, and only 3 percent in less developed regions of the world, according to United Nations estimates of contraceptive use. (UN)

National surveys generally do not record condom use among unmarried persons and in sexual activity outside of marriage, arenas that are critical for disease prevention. Some recent Demographic and Health Surveys (DHS) have found that men report higher condom use than women and that men report higher condom use with partners other than spouses. In the Zimbabwe DHS, for example, of those men having sex in the last four weeks with their spouse, 12 percent had used a condom, while men having sex with other partners reported using a condom 60 percent of the time. (Hulton) Nevertheless, one analysis estimated that overall condom use is less than half of what is needed to protect the health and lives of men and women. (Liskin)

This chapter reviews some of the surveys that have identified why people do not use condoms. It then discusses briefly the most important issues that affect condom acceptability in terms of behavior change in the AIDS era, and summarizes research on the potential impact of condom design and manufacturing innovations on consumer acceptability.

The most frequent reasons people give for not using a condom relate to the following issues: lack of sensation or interrupted sexual pleasure; psychological and social factors, including couple communication and assumptions that condoms are for use in extramarital relationships and with prostitutes; lack of availability of condoms, including policies that prohibit condom distribution to youth; and lack of confidence in the reliability of condoms themselves. To make condoms more acceptable and more widely used, all of these issues should be addressed.

Factors affecting the acceptability of condoms can be thought of as a series of concentric circles that interact with each other -- from the individual at the center to the couple, the health-care system, the community and the entire world. An individual's knowledge, attitudes, habits, perceptions, awareness of the need and other internalized factors are critical to condom use. But what forms those belief systems and determines individual behavior? The dynamics between sexual partners play a crucial role and depend on many factors, such as whether sex is with a regular partner or not, whether the couple talks about sex and protection against disease and unwanted pregnancy, and whether sex is voluntary for both parties.

At the community level, many programmatic issues are involved, from counseling in health-care systems to condom logistics and distribution systems. National as well as local policies about condoms affect acceptability, as do attitudes and pronouncements about condom use by parents, church leaders, peers, entertainment figures, political leaders and others. Worldwide priorities for AIDS prevention campaigns influence the messages that communities receive and how they respond.

Persuading people at risk of STD/HIV to use condoms is one of the primary strategies of AIDS prevention programs throughout the world. In general, lessons from AIDS prevention campaigns show that product attributes play a minor role in initial condom acceptance compared to strategies that influence an individual's perception of the importance of condom use. Once a person starts using condoms regularly, product attributes may play a more significant role in continued use. Condoms are most effective if used consistently, which requires sustained behavior change. If preferences regarding product attributes can encourage consistent condom use over a sustained period of time, choices among various types of products may be important.   

Reasons for Non-Use

Studies in many parts of the world indicate that couples do not use condoms for many reasons, including fear of partners' reactions/partner opposition, lack of confidence in the product, decreased pleasure, and not perceiving the risk of disease.

Among 620 women interviewed at a family planning clinic in Jamaica, respondents gave three primary reasons for non-use of condoms. Most often the women said they did not need protection in addition to their primary contraceptive method because they were not at risk of STDs. Also, condoms were uncomfortable or decreased pleasure, and their partner was opposed to using condoms. (Spruyt)

A study in Uganda interviewed 130 women, half of whom were infected with HIV. "I have never used a condom and would not like to use one," said one young woman in the survey, because she incorrectly thought "it is risky since sperm can pass through the condoms." The view of the husband was also a critical factor. An HIV-positive woman, age 21, who knew that condoms can prevent HIV transmission, said, "Though I have never used a condom, I would use it if my husband is the one who suggests it." Many women also said they feared that if they requested their husbands use a condom, their partners would think that they were prostitutes or unfaithful. (Rwabukwali)

Among 544 men attending STD clinics and a university health service in Australia, about one out of five were no longer using condoms. The major reasons were that his partner(s) were using another contraceptive, he was not sexually active, he thought his partner(s) did not have an STD, and he did not like how condoms felt. (Richters)

In a nationally representative sample of more than 3,000 U.S. men interviewed about condoms, the most frequently cited negative reactions were: reduces sensation, requires being careful to avoid breakage, requires withdrawing quickly, embarrassing to buy, difficult to put on, often comes off during sex, embarrassing to discard, shows you think partner has AIDS, and makes partner think you have AIDS. (Grady)

Another U.S. study of 652 sexually active people found that 61 percent reported not using a condom with their last sexual partner. Low perceived risk of HIV infection was the main reason given, although most did not know enough about their partner to be sure. (Kusseling)

Focus groups in China's most populous province of Sichuan discussed condom use among 106 people, divided into male condom users, wives of condom users, men whose wives used other contraceptives, and women who were using other forms of contraception. Many participants thought of condoms as troublesome to use, easy to forget and causing a decrease in sexual satisfaction. (Lin)

Changing Behavior

The lessons learned from AIDS prevention efforts in the last 10 years offer a wealth of information about condom acceptability. A full discussion of behavior change and condom promotion is beyond the scope of this monograph. However, a brief review of these issues helps put the importance of condom product attributes into a full context of condom use.

Behavior change involves many issues. People need knowledge, such as what causes HIV transmission, what types of sexual behaviors can put a person at increased risk of infection, and how to change those behaviors. People have to change attitudes, such as acknowledging their risk of infection. And, they need skills, such as how to communicate with a partner about the importance of using a condom. To take the next step and begin using condoms, people must find condoms readily available and affordable.

Important factors for large-scale changes in behavior regarding condom use include promotional campaigns, reaching men and effective counseling. Promotional campaigns in particular have resulted in sharp increases in condom use in many countries. For example, in the early 1980s, there were less than 1 million annual condoms sales in sub-Saharan Africa. (PSI) In 1996, there were nearly 20 million condoms sold a year in Ethiopia alone. Experts in Africa see the pattern of large-scale condom sales across sub-Saharan Africa as evidence of major behavioral change among African men. (Finger)

By far, the most dramatic factor in this increased condom use is the international funding for AIDS prevention campaigns, and specifically, the expansion of social marketing programs in all regions of the world.

In Haiti, for example, an expanded social marketing campaign took condom sales from 250,000 per month in 1992 to 540,000 a month in 1996. In Nepal, sales went from 465,000 condoms a month in 1994 to about 1 million a month in 1997.

Social marketing is the application of commercial marketing techniques to achieve a socially beneficial goal. It involves market research, message testing, mass media advertising, consumer education, effective use of news media and public relations, product promotion at the point of purchase, increased access to products and affordable pricing. Generally, the condoms are subsidized so that prices can be kept low enough for users to buy them but high enough for merchants to have an incentive to sell them. In Nepal, for example, a sales force concentrated on the highways into the country from India, a known route for HIV transmission. From 1994 to 1997, the number of outlets stocking condoms increased from three pharmacies to 56 retail outlets, including pharmacies, tea shops, liquor shops and others.

The climate for mass media messages about AIDS and condoms has substantially improved since the early 1990s. When Archbishop Desmond Tutu, the prominent and well-respected clergyman in Africa, endorsed condom use on South African television, it affected not only social norms about condom use but also media access. For years, social marketers had battled to gain access to mass media. As recently as 1990, for example, the word "condom" was prohibited in advertising by the government of Kenya. Today, more explicit advertising is permitted in many parts of the world.

Not only does mass media offer access to vast audiences at a cost per person that is usually a fraction of what it costs to reach individuals through clinics, it also requires tightly controlled message content. It is much easier to monitor a message for accuracy in a mass media campaign than among every provider and counselor. (AIDSCAP)

Many experts in the social marketing field emphasize that condom campaigns can reach large numbers of people, particularly men. These campaigns can also promote condoms for both disease and pregnancy prevention. With such a double message, a woman can bring up pregnancy prevention as a reason for using condoms. This may reduce the chances that her husband will think she is unfaithful.

To complement mass media efforts, individual counseling can increase condom use. Illustrated brochures on correct condom use, wooden penis models for demonstrating proper condom use and other counseling approaches also contribute to increased condom acceptability.

Experts believe that changing sexual behavior, as with other personal matters, such as changing a diet, requires moving through several stages. First, a person considers making the behavior change, then may decide to use the new behavior on a sporadic basis, and finally may continue the change over time. Thus, different strategies for increasing acceptability of condoms may be more successful if applied to people at different points in these stages of behavior change.

To sustain a change in sexual behavior requires more than information, say experts. People must be encouraged to assess the stage of behavior change they are in and move toward the maintenance stage. To do this, counseling needs to help people ask themselves such questions as: What is important in my life? and What behaviors do I want to use for my life? For example, one study identified which groups of women need more intensive counseling for consistent condom use. It found that people who choose condoms as a contraceptive method require more counseling than people who use condoms as a backup method. This is because those choosing it as their primary method may have underestimated how hard it is to use condoms every time. (Oakley)

Few studies have examined what types of counseling result in sustained behavior change. Counseling does appear to increase condom use when done with both partners in a monogamous situation and when focused on skill building. For example, in a project that counseled heterosexual HIV serodiscordant couples every six months over six years, there were no HIV seroconversions. Also, condom use and abstinence increased. (Padian) Another study compared women who received several 90-minute group counseling sessions and a one-month follow-up session in skill training about condom use to women who received a general health message. Three months later, condom use had more than doubled among the first group, but had only increased marginally among those receiving the general message. (Kelly)

Political and policy decisions can also affect condom acceptability. In Thailand, a nationwide "100 percent condom" program at commercial sex establishments, requiring that sex workers always use a condom, has resulted in a sharp decrease in STD rates. Local police linked STD infections to specific brothels as a means of enforcing the policy. Condom use at commercial sex establishments has increased from about 14 percent when the program began in 1989 to 90 percent in 1994. (Rojanapithayakorn; KE Nelson)

Product Choices.

Among reasons cited for not using condoms, several are related to product attributes, including fear of breakage, inconvenience, interruption and awkwardness of foreplay, loss of sensation, inability to maintain an erection, discomfort, and allergic reaction to latex. Condom manufacturers continue to refine the product so as to increase condom acceptability and market share. Research on what product attributes condom users prefer should influence the type of products made available and development of new products.

Lubricants. The limited research on lubrication and acceptability suggests that users prefer pre-lubricated to non-lubricated condoms and, if adding a lubricant, prefer it to be water-based. (Regarding lubricants and condom failure, see Chapter 3.) In a prospective study designed to evaluate the impact of additional lubricant use on condom acceptability and failure, 268 U.S. couples were given equal numbers of condoms to be used with additional water-based lubricant, additional oil-based lubricant and no additional lubricant. A total of 3,216 latex condoms pre-lubricated with silicone were used in the study. Based on a five point scale ranging from "liked very much" to "strongly disliked," participants indicated a significant preference for water-based lubricant as compared to oil-based or no additional lubricant (p<0.001). (Steiner)

In another study, current condom users in Bangladesh, Egypt, Ghana, Honduras and Mali were recruited through family planning clinics, pharmacies and community distribution programs; more than 90 percent were using pre-lubricated condoms. A total of 633 men were provided with more than 5,000 spermicidally-lubricated condoms and returned for a one month follow-up interview. The men rated the study condoms very positively for several measures of acceptability, both in general and in comparison to the condoms they usually used. For example, if given a choice for future use, more than three fourths of the men reported they would choose the study condoms. The authors cautioned, however, that the results may have been biased in favor of the study condoms due to participants' desire to please the interviewers or due to the novelty of the spermicidally-lubricated product. Complaints most often reported about the study condoms included too much lubrication and brief discomfort. (Potter)

The U.S. magazine Consumer Reports provided information about condom preferences, based on a 1989 questionnaire sent to 3,300 of its readers, with about half responding. Approximately three of every four respondents preferred lubricated over non-lubricated condoms. In another U.S. study (Grady), about half of the current condom users who responded to a national survey of 3,000 people indicated that the right amount of lubrication is an important characteristic when choosing a condom.

Pre-lubricated condoms or the use of additional lubricants may be less acceptable among those in countries where some couples practice "dry" sex. In those cultures, some women engage in a variety of practices in order to dry out the vagina to increase sexual pleasure, as discussed further in Chapter 3. (Runganga; Brown)

Width of Condom. FHI has conducted a series of human use studies in developing countries to evaluate the acceptability of pre-lubricated latex condoms of different diameters. The size of these condoms is measured in terms of their lay-flat widths (the width of a flattened condom measured perpendicular to the length). Studies were conducted in Asian countries using smaller condoms and in African countries using larger condoms, assuming that penis size might affect acceptability of different sized condoms (see Chapter 3 for discussion of penis size).

Convenience samples of about 150 men in three Asian countries (Philippines, Sri Lanka and Nepal) compared smaller condoms (49 mm lay-flat width) with standard condoms (52 mm). More than 2,000 condoms of each width were used. Findings from all three sites suggest approximately equal proportions of men prefer each of the two condom sizes. (Andrada; Neupane) When men from the site in the Philippines rated the two condoms on a five point scale from "liked very well" to "strongly disliked," the distributions of ratings were almost identical. About equal proportions of men liked the smaller or the standard width condoms with respect to which condom stayed on better, which was more comfortable to wear, and which they would prefer for future use. Findings were similar in Sri Lanka, except that almost two-thirds of the participants preferred standard condoms for future use.

In Nepal, results were mixed: about two-thirds of the men indicated that they liked the standard condoms better, while a similar proportion reported that the smaller condoms were "more comfortable." More than half of the participants indicated no preference with respect to future use and about a third preferred the smaller condoms.

Studies in Ghana, Kenya and Mali compared larger condoms (55 mm lay-flat width) with standard condoms (52 mm). Each of 272 men from all three countries tested one condom of each width. More than half the men chose the standard condom as the one they "liked better" and/or as the one they would use in the future, while almost equal proportions of men chose each of the two sizes as "more comfortable to wear." In Mali, however, about two-thirds indicated a preference for the larger condoms for at least one of each of the three measures of acceptability above. (Joanis)

Given the acceptability parameters included in these studies, there was no clear indication that, based purely on user preferences, people would choose a condom width that is not currently widely available to them over a standard condom. The impact of condom width on breakage and slippage is reviewed in Chapter 3.

Thickness. FHI has also carried out studies to evaluate acceptability of thicker condoms. Theoretically, these would be stronger, but they also could allow less sensation. Sixty-five current condom users per country were recruited in Mali, Sri Lanka and the Dominican Republic. At the time of the studies, most men were using pre-lubricated latex condoms with a standard thickness of .066 mm, compared to the condom being tested of .086 mm. (Cordero 1990)

Participants were not told that the study condoms were thicker, but they were told that these condoms were stronger. Thus, although the results suggest a fairly consistent preference for the "stronger" condom, they should be interpreted with some caution.

In all three sites, about two-thirds of the men chose the stronger condom with respect to their "general preference." At least three-fourths of the men in each site reported that they would "prefer to purchase" the stronger condom for future use. Slightly more men also preferred the stronger condom based on "comfort" and "sensation."

In contrast, the Consumer Reports study found that more than a third of the respondents preferred extra-thin condoms. Consistent with these findings, more than two out of five condom users included in the U.S. national survey reported that they prefer thinner condoms. (Grady)

Data evaluating the role of thickness in condom acceptability are insufficient to suggest a clear relationship. As discussed below, the combination of innovative condom shapes and thickness may lead to more acceptable condoms.

Formulation. In a six-country evaluation of how well men liked condoms of two different latex formulations, FHI found that the formulation rarely affected acceptability. Made by the same manufacturer, the condoms were pre-lubricated latex of similar thickness (and therefore, theoretically of similar sensitivity) -- one standard formulation, which was more elastic, and one so-called "extra-strong" formulation, which was less elastic. (For breakage results, see Chapter 4.) About 100 men were recruited in each of six sites (Dominican Republic, Jamaica, Kenya, Mali, Mexico and Sri Lanka) to use five of each type of condom. Neither participants nor interviewers were told what type of condoms were used in the study.

In Jamaica, Sri Lanka and Kenya, slightly more men favored the standard formulation in terms of which they "liked better," which were "easier to put on," and/or which were "more comfortable." In Jamaica, there was not a strong preference with respect to future use. (Figueroa) In Sri Lanka and Kenya, however, about two-thirds preferred the standard condom for future use. (Abeywickrema; Ndumbu) In both Mexico and the Dominican Republic, men gave the two condoms very similar ratings. (Alvarado; Cordero 1991) Only in Mali did the men find the stronger condoms to be more acceptable. (Sidibe) More than two-thirds liked the stronger condoms better and/or found them more comfortable. Just over half of the Malian men also indicated that the "extra-strong" condoms would be their choice for future use.

Shape/Texture. Some research suggests that the shape and fit of a condom might affect acceptability. In a prospective study, participants compared a standard latex condom with an experimental latex condom that fit loosely over the tip of the penis. This condom design is intended to facilitate friction during intercourse between the inside of the condom and the most sensitive area of the penis (the glans), functioning like a vaginal liner rather than a condom sheath. The study findings suggest that despite being thicker, the experimental condom was at least as pleasurable and comfortable as the standard condom. (Trussell 1992a)

Other human trials of loose fitting non-latex condoms suggest that this type of design modification may lead to enhanced sensitivity and acceptability. (Bernstein) About 40 percent of the respondents in the U.S. national survey identified a condom reservoir tip as a preferable feature in a condom. (Grady) More research is needed to determine if other variations in condom shape could lead to improved acceptability.

Only limited data exist on textured or ribbed condoms. About 25 percent of the Consumer Reports respondents indicated that they preferred textured condoms, while a similar proportion responded that they would not use them. Except for condom color, ribbing was the least frequently mentioned characteristic looked for by condom users in the U.S. survey. (Grady)

Materials. Limited published research has compared acceptability of latex to synthetic condoms. A randomized, controlled efficacy study with 800 couples and more than 3,500 condoms compared standard latex and polyurethane condoms (both packaged with a silicone-based lubricant). Differences in participant complaints (e.g. irritation, itching) about the two types of condoms were minimal. Male participants did report more frequent penile constriction with use of the latex than the polyurethane condom. The participants found the two condoms similar in terms of recommending or choosing for future use, lubrication, fit, appearance, sensitivity and odor. They rated the latex condom as easier to put on than the polyurethane condom. (A Nelson 1997)

In a similar study among 360 couples who used more than 2,000 condoms, the polyurethane condom was slightly thinner than in the study described above. Participants reported more difficulty unrolling the polyurethane condom and more problems with penile constriction with the latex condoms. Both men and women perceived that the polyurethane condom broke and stretched out of shape more often, and the latex condom allowed less stimulation. Polyurethane condoms received better ratings for sensitivity, odor and overall lubricant preference, while latex condoms were given higher ratings for fit and dependability. (A Nelson 1996)

In a study among 49 couples who tested 478 latex and non-latex condoms, participant responses to several indicators of acceptability suggest that the two types of condoms were similar in terms of acceptability. (Trussell 1992b) Ratings for fit, appearance, overall sensitivity or pleasure experienced were generally in the same direction as those discussed above, but they were not significantly different for the two condoms.

These studies suggest that synthetic condoms have some distinct advantages and disadvantages, and can achieve at least equal footing with latex condoms in terms of acceptability.

Some respondents to the Consumer Reports questionnaire preferred natural skin condoms while others did not. Regardless of acceptability, skin condoms (made from lamb cecum, part of the intestine) provide less protection against STDs and hence are not a good choice for those needing disease protection. For more information on both synthetic and skin condoms, see Chapter 7.

Conclusion

Improving the acceptability of condoms is a multi-faceted process. Surveys indicate many reasons why people do not use condoms, ranging from diminished sexual pleasure to fear of a partner's reaction. In the AIDS era, many types of efforts are being used to change sexual behaviors, with increased condom use a primary strategy for reducing the spread of all STDs. Increasing condom use will require more government and cultural approval, increased availability of condoms, more information, increased skill on negotiating condom use, more promotion, and better and more focused counseling.

Changes in product attributes do not appear to play an important role at this point in getting people to use condoms initially. However, changes might make people more willing to keep using condoms once they start. Limited research suggests that use of additional lubricants could increase acceptability among some groups. With some exceptions, variations in width, thickness and latex formulation generally appear to have limited impact on acceptability. Changes in shape appear to offer some promise for increased acceptance of condom use among certain groups. Limited research comparing latex to synthetic condoms suggests comparable acceptability with potential for future advances.

by Alan B. Spruyt and William R. Finger

References

1. Abeywickrema D, Steiner M, Piedrahita C, et al. Analysis of Actual Use Breakage Rates of Standard and Extra-strong Condoms: Sri Lanka. Durham, NC: Family Health International, 1993.
2. Ahmed G, Liner EC, Williamson NE, et al. Characteristics of condom use and associated problems: experience in Bangladesh. Contraception 1990;42:523-33.
3. AIDSCAP, Making Prevention Work - Global Lessons from AIDS control and prevention (AIDSCAP) project 1991-1997. Unpublished paper. Family Health International, 1997.
4. Alvarado G, Piedrahita C, Holschneider S, et al. Analysis of Actual Use Breakage Rates of Standard and Extra-strong Condoms: Mexico. Durham, NC: Family Health International, 1991.
5. Andrada A, Ravelo N, Spruyt A, et al. Acceptability and Functionality of Standard and Smaller Latex Condoms during Human Use: Philippines. Durham, NC: Family Health International, 1993.
6. Bernstein GS, Frezieres R, Walsh T, et al. Stretching the barriers: the changing methodology for non-latex condom research. 1994. Presented at the 121st Annual Meeting of the American Public Health Association, San Francisco, CA, October 24-28, 1993.
7. Brown CB, Brown JE, Ayowa OB. Vaginal inflammation in Africa (letter). N Engl J Med 1992;327:572.
8. Can you rely on condoms? Consumer Reports March 1989:135-41.
9. Cordero M, Tounkara M, Abeywickrema D, et al. Acceptability of a Stronger Condom in Three Developing Countries. Durham, NC: Family Health International, 1990.
10. Cordero M, Piedrahita C, Holschneider S, et al. Analysis of Actual Use Breakage Rates of Standard and Extra-strong Condoms: Dominican Republic. Durham, NC: Family Health International, 1991.
11. Douglas JM, Rogers J, Rhodes F, et al. Contraceptive practices before and after an intervention promoting condom use to prevent HIV infection and other sexually transmitted diseases among women - selected US sites, 1993-1995. MMWR 1997;46:373-77.
12. Figueroa P, Martinez K, Joanis C, et al. Analysis of Actual Use Breakage Rates of Standard and Extra-strong Condoms: Jamaica. Durham, NC: Family Health International, 1992.
13. Finger WR. Barrier methods require consistent use. Network 1996;16(3):6-9.
14. Folmar S, Nurul Alam SM, Raihan Sharif, AHM. Condom Use in Bangladesh: Final Report. Durham, NC: Family Health International, 1992.
15. Grady WR, Klepinger DH, Billy JOG, et al. Condom characteristics: the perceptions and preferences of men in the United States. Fam Plann Perspect 1993;25:67-73.
16. Hulton L, Falkingham J. Male contraceptive knowledge and practice: what do we know? Reprod Health Matters 1996;7:90-100.
17. Joanis C, Brookshire T, Piedrahita C, et al. Evaluation of Two Condom Designs: A Comparison of Standard and Larger Condoms in Ghana, Kenya, and Mali. Durham, NC: Family Health International, 1990.
18. Kelly JA, Murphy DA, Washington CD, et al. The effects of HIV/AIDS intervention groups for high-risk women in urban clinics. Am J Public Health 1994;84:1918-22.
19. Kusseling FS, Shapiro MF, Greenberg JM, et al. Understanding why heterosexual adults do not practice safer sex: a comparison of two samples. AIDS Educ Prev 1996;8:247-57.
20. Lin L, Shzhong W, Jian G et al. Improving condom use in Sichuan, China: findings from a qualitative study. Reprod Health Matters 1996;7:101-6.
21. Liskin L, Wharton C, Blackburn R, et al. Condoms - now more than ever. Popul Rep 1990;H(8).
22. Ndumbu F, Steiner M, Piedrahita C, et al. Analysis of Actual Use Breakage Rates of Standard and Extra-strong Condoms: Kenya. Durham, NC: Family Health International, 1991.
23. Nelson A, Bernstein GS, Frezieres R, et al. Study of the efficacy, acceptability and safety of a non-latex (polyurethane) male condom - final report, NIH contract NO1-HD-1-3109. Unpublished paper. National Institutes of Health, 1997.
24. Nelson A, Frezieres R, Walsh T, et al. Controlled, randomized evaluation of a commercially available polyurethane and latex condom (Avanti versus Ramses Sensitol) - final report, NIH contract NO1-HD-1-3109. Unpublished paper. National Institutes of Health, 1996.
25. Nelson KE, Celentano DD, Eiumtrakol S, et al. Changes in sexual behavior and a decline in HIV infection among young men in Thailand. N Engl J Med 1996; 335:297-303.
26. Neupane S, Abeywickrema D, Martinez K, et al. Acceptability and Actual Use Breakage and Slippage Rates of Standard and Smaller Latex Condoms: Nepal and Sri Lanka. Durham, NC: Family Health International, 1992.
27. Oakley D, Bogue E-L. Quality of condom use as reported by female clients of a family planning clinic. Am J Public Health 1995;85:1526-30.
28. Padian NS, O'Brien TR, Chang Y, et al. Prevention of heterosexual transmission of human immunodeficiency virus through couple counseling. J Acq Immune Defic Syndr 1993;6:1043-48.
29. Pinkerton SD, Abramson PR. Condoms and the prevention of AIDS. American Scientist 1997; 85:364-73.
30. Population Services International. Annual Report 1995/96. Washington, D.C.: Population Services International, 1996.
31. Potter LS, Williamson NE, Clarke K, et al. Acceptability of spermicidally-lubricated condoms in five developing countries and related policy issues. IV International Conference on AIDS, Stockholm, Sweden, June 12-16, 1988.
32. Richters J, Donovan B, Gerofi J. How often do condoms break or slip off in use? Int J STD AIDS 1993;4:90-94.
33. Rojanapithayakorn W, Hanenberg R. The 100 percent condom program in Thailand. AIDS 1996;10:1-7.
34. Runganga A, Pitts M, McMaster J. The use of herbal and other agents to enhance sexual experience. Soc Sci Med 1992;35:1037-42.
35. Rwabukwali CB, Schumann DA, McGrath JW, et al. Culture, sexual behavior, and attitudes toward condom use among Baganda women. In: Feldman DA, ed. Global AIDS Policy. (Westport, CT: Bergin & Gorvey, 1994) 70-89.
36. Sidibe M, Steiner M, Joanis C, et al. Analysis of Actual Use Breakage Rates of Standard and Extra-strong Condoms: Mali. Durham, NC: Family Health International, 1991.
37. Spruyt A, Fox L, Figueroa P, et. al. Dual method use among family planning clients: Kingston, Jamaica, 1996. Presented at the 124th Annual Meeting of the American Public Health Association, New York, NY, November 17-21, 1996.
38. Steiner M, Piedrahita C, Glover L, et al. The impact of lubricants on latex condoms during vaginal intercourse. Int J STD AIDS 1994;5:29-36.
39. Thapa S. Social Marketing of Condoms in India: Final Report. Durham, NC: Family Health International, 1992.
40. Trussell J, Warner DL, Hatcher RA. Condom slippage and breakage rates. Fam Plann Perspect 1992a;24:20-3.
41. Trussell J, Warner D, Hatcher R. Condom performance during vaginal intercourse: comparison of Trojan-Enz and Tactylon condoms. Contraception 1992b;45:11-19.
42. United Nations. World Contraceptive Use 1994. Department for Economic and Social Information and Policy Analysis, Population Division, United Nations, 1994.
43. Williamson NE, Joanis C. Acceptability of barrier methods for prevention of unwanted pregnancy and infection. In: Mauck CK, Cordero M, Gabelnick HL, et al. eds. Barrier Contraceptives: Current Status and Future Prospects. (New York: Wiley-Liss, 1994) 53-67.

Return to table of contents