Revisiting the use of condoms in Brazil

Dourado, Inês; MacCarthy, Sarah; Reddy, Manasa; Calazans, Gabriela; Gruskin, Sofia

doi:10.1590/1809-4503201500050006

ABSTRACT

Introduction:

It is known that a single prevention strategy is not enough to control multiple HIV epidemics around the world and in Brazil. However, it is not only necessary to recognize the importance of condoms as part of the policy of HIV/AIDS prevention but also discuss its limits. In this article, we aim to investigate the use of condoms in Brazil, draw critical reflections, and understand how they can once again be highlighted in Brazil's prevention strategy going forward.

Methods:

A narrative review of literature was conducted using keywords in PubMed. Reports from national surveys that guide the epidemiological and behavioral surveillance of the Brazilian Ministry of Health were also included.

Results:

A total of 40 articles and 3 reports were included in the review and 11 intervention studies to promote the condom use; the main findings were as follows: 1) Despite the increase in national studies on sexual behavior, little attention is given to the role of condom use; 2) There are few studies examining the factors associated with condom use among key populations such as men who have sex with men (MSM), female sex workers (FSW), drug users (DU), and transvestites and transexuals (TT), while substantial studies focus on adolescents and women; 3) Evidence suggests that a combination of interventions is more effective.

Discussion:

new prevention technologies must not lose sight of the critical importance of condoms, and efforts to reintroduce them should focus on the role of pleasure in addition to their potential to minimize the risk of HIV.

Keywords:
Condoms; HIV; Acquired Immunodeficiency Syndrome; Disease Prevention; Prevalence; Brazil

[1] Corresponding author: Inês Dourado. Instituto de Saúde Coletiva, Universidade Federal da Bahia. Rua Basílio da Gama, s/n, Campus do Canela, CEP 40110-140, Salvador, BA, Brazil. E-mail: ines.dourado@gmail.com

Descriptor	Pubmed Search Term
Brazil	Brazil OR Brasil
condom use (male or female)	"Condoms/supply and distribution"[Mesh] OR "Condoms/trends"[Mesh] OR "Condoms/utilization"[Mesh] OR condom [tiab]
condom use (female)	"Condoms, Female/supply and distribution"[Mesh] OR "Condoms, Female/ trends"[Mesh] OR "Condoms, Female/utilization"[Mesh]
HIV/AIDS	"HIV Infections"[Mesh] OR HIV OR aids OR Acquired Immunodeficiency Syndrome
Sex workers	"sex worker" [MeSH] OR "sex worker" OR prostitute*
Drug users	("substance-related disorders"[MeSH Terms] OR "injection drug use")
Men who have sex with men	("men who have sex with men" OR "males who have sex with males" OR MSM OR homosexual* OR bisexuality OR homosexuality male)
Transgender individuals	("transsexualism"[MeSH Terms] OR "transsexualism"[All Fields] OR "transgender"[All Fields])
Adolescents	("adolescent"[MeSH Terms] OR "adolescent"[All Fields] OR "youth"[All Fields] OR "young men" OR "young women")

Number Reference	Study design/methodology*	Study range±	Goals	Study population**	Measures used for condom use	Condom use	Associated factors identified	Year of Study realization
1 Berquó et al., 2008¹⁷	CS	n = 2,578 (1998); n = 3,960 (2005); Brazil	To analyze the levels, trends, and sociodemographic differentials of condom use	GP (16 - 65a)	Frequency of condom use	Increased condom use, 12 months and at the last sexual intercourse. Young people (16 - 24 years) are more protected, especially with casual partners	There was no regional difference in consistent condom use. In stable relationships, Pentecostals reveal the least protection on sex; schooling was proven an important differential factor as to condom use in 1998	1998; 2005
2 Bertoni et al., 2011¹¹	CS	n = 295; RJ/RJ	To analyze trends and sociodemographic differentials of condom use	DU	Frequency of condom use	40% never used condoms; 60% did not use under the influence of substances	Being under the influence of drugs	2006-7
3 Calazans et al., 2005²³	CS	n = 681; SP/SP	To investigate condom use among teenagers	Teens	No condom use among young people in the last sexual intercourse with fixed or casual partners	Overall level of condom use at the last sexual intercourse 60% in stable relationships: 49%; in casual relationships: 80%	Condom use more common in casual relationships (p = 0.0001); cohabitation is associated with nonuse with casual and fixed partners. Female, less educated, not working, and family per capita income higher than the minimum wage are associated with not using condoms with fixed partners. Alcohol use in life, first intercourse between 9 and 16 years, poor knowledge about the treatment of AIDS, and mourning for violent causes associated with lower use among casual partners	2003
4 Cerqueira-Santos et al., 2008²⁴	CS	n = 1,013; POA/LOL	To investigate the relationship between the use of condoms and other contraceptive methods and religiosity/spirituality among young people of low socioeconomic status.	Teens	Frequency of use to prevent HIV/AIDS and as contraception	> 80% of the sample reported using condoms	Boys reported more frequently the use of condoms for both contraceptive purposes and prevention HIV/AIDS transmission of (p < 0.001); older age at first sexual intercourse was a positive predictor of condom use; no significant differences were found for groups of different religions	2005
5 Dal Pogetto et al., 2012²⁵	CS	n = 102; SP/SP	To describe sociodemographic characteristics, gynecological history, and behavioral aspects of prostitutes and to verify associations with STD	F-SW	Condom use (yes, no)	99% used condoms with clients; 26.3% used condoms with a stable partner	26.3% reported condom use with fixed partners, compared with 99% using it in commercial sex	2008-9
6 Damascena et al., 2011²⁶	CS	n = 2,523; 10 Brazilian cities	To investigate factors associated with the prevalence of HIV	F-SW	-	-	Not using a condom in negotiation with clients as an important risk factor for HIV	2009-10
7 Darden 2003²⁶	CS	n = 2,000; SP/SP, RJ/RJ, BH/MG Porto Alegre/RS	To introduce a type of condom in Brazil and to research condom use	M-Straight; Homo M; M-Bi	-	58% reported always or usually using condoms in a study that compared those who identified themselves as homosexuals or bisexuals (85%)	-	2000
8 de Azevedo et al., 2007²⁷	CS	n = 252; Campinas/SP	To assess sexual behavior, risk for HIV infection, and serum prevalence of HIV	DU-crack	Condom use (always, occasionally, or never)	Injecting cocaine users: 25% always, 75% occasionally, and 0% never; crack users: 13% always, 61% sometimes, and 25% never	-	2006
9 Doreto et al., 2007²⁹	CS	n = 90; Ribeirão Preto/SP	To analyze the knowledge of teens about STDs and transmission, condom use, and health care	Teens F-	Condom use (always, sometimes, or never)	35.2% of the sample reported always using condoms; 25.9% reported never using it, and 38.9% reported using it sometimes	Drop in condom use by comparing the first versus the most recent sexual intercourse (71.1% to 37.1%)	2005
10 Driemeier et al., 2012³⁰	CS	n = 329; Campo Grande/MS	To assess vulnerability to AIDS among individuals who attend community centers for seniors	Id	Condom use in the last year; condom use with a partner with multiple partners	14% of the sample reported using condoms	-	2009
11 Fernandes et al., 2000³¹	CS	n = 249; Campinas/SP	To assess knowledge, attitudes, and practices of women for the prevention of STDs in primary health care	F	Frequency of condom use	10% reported condom use and 7.6% consistent use	-	1996-7
12 Ferreira et al., 2006³²	CS	n = 709; Six Brazilian cities	To describe the profile of MSM-DUs and compare with other male DUs	MSM-DU	Condom use in the previous 6 months (always/sometimes/never); unspecified sexual practice	36.4% reported always using condoms	34.9% of MSM-DU reported always using condoms versus 25.2% of DU (OR = 1.6; 95%CI 1.0 - 2.6; p = 0.075)	2000-1
13 Fialho et al., 2008³³	CS	n = 300; SALT/BA	To assess the prevalence of STDs and blood-borne infections among adolescents deprived of freedom	Teens-Depr.Fred	Condom use (always, sometimes, and never)	27% never used	Those who reported using condoms were significantly less likely to report a previous STD (OR = 0.06, 95%CI 0.01 - 0.61; p < 0.01)	2004-5
14 Filipe et al., 2005³⁴	CS	n = 250; SP/SP	To describe the risk perception and behavior of HIV-+ve men who had sex with women before knowing they had HIV	M-HIV +	Consistent condom use	Condom with women before diagnosis: 22.6% among heterosexual men; 34.7% among bisexual men	Consistent use reported by 23% of heterosexuals and 35% of bisexual men (p < 0.05)	2001-2002
15 Greco et al., 2007³⁵	CS	n = 1,025; BH/MG	To describe bisexual men's behavior and sexual identity, condom use, frequency of sexual intercourse, and types of partners and to determine inconsistent condom use rates according to the partner's sex	M-Bi	Inconsistent rate of condom use during active and receptive anal sex	35% of inconsistent condom use for active anal sex with a fixed male partner; around 60% reported condom use with stable partner; between 68 and 86% reported condom use with casual partners; 55% of inconsistent condom use in receptive anal sex with fixed male partner	Active anal sex associated with lower rates of inconsistent condom use	1994-2005
16 Harrison et al., 1999³⁶	CHS	n = 753 followed up for 1.5 years; RJ/RJ	To evaluate the incidence of HIV in a cohort of adult MSM	MSM	Rate of use in receptive anal sex	59.6% and 43.6% among serum positive and serum negative, respectively, who practiced unprotected receptive anal sex	-	1995-7
17 Juarez & Le Grand, 2005³⁸	CS	-; Recife/PE	To study condom use among boys at first intercourse	M-Teens living in slums	Age at first intercourse and factors associated with not using condoms	-	Highest SSE was positively associated with condom use among male adolescents	-
18 Kerr et al., 2012⁹	CS	n = 3,859; 10 Brazilian cities	Conducting national survey of behavioral surveillance of HIV among adult MSM in Brazil	MSM	Unspecified type of sexual practice. Condom use with all partners, condom use with casual or commercial partners in the previous 6 months; and condom use at the last sexual intercourse with a man or woman	Proportion of protected sex with all partners ranged from 30.1% in Manaus to 55.3% in Santos; Proportion of protected sex between casual partners ranged from 50.0% in Curitiba to 77.7% in Campo Grande	-	2009
19 Lazzarotto et al., 2008³⁷	CS	n = 510; Vale dos Sinos/RS	To evaluate the knowledge about HIV/AIDS in community groups	Elderly	Knowledge about condoms and condom use	86.3% did not use condoms, but it is unclear if this was because of sexual inactivity	-	2005
20 Martins et al., 2006³⁸	CS	n = 1,594; SP/SP	To compare knowledge about STD/AIDS and to identify factors associated with adequate knowledge and consistent use of male condoms in teenagers from public and private schools	Teens	Condom use (always, most often, occasionally, and never)	Consistent condom use was 60% in private schools and 57.1% in public schools	Consistent condom use associated with male gender and lower socioeconomic status; consistent use was higher in private schools (p < 0.05)	-
21 Miranda et al., 2004³⁹	CS	n = 122; Cariacica/ES	To identify the sociodemographic and health conditions of inmates in a women prison	F-Depr.Fred	Frequency of condom use in life	Women: reported never or rarely having used condoms, either as contraception or for STD prevention, 78.5% of women	-	1997
22 Nicolau et al., 2012⁴⁰	CS	n = 155; Fortaleza/EC	To evaluate the knowledge, attitude, and practice of female prisoners as to the use of male and female condoms	F-Depr.Fred	Percentage of knowledge, attitude, and practices in condom use	Women: 18.7 and 1.3% reported using male and female condoms, respectively, in all sexual relations	-	2010
23 Nunes et al., 2007⁴¹	CS	n = 125; SAL/BA	To investigate sociodemographic and behavioral characteristics and infection rates among crack users in poor communities	F-DU	Condom use in the previous 30 days	58% DU did not use condoms in the last 30 days preceding the interview and 52% reported not keeping condoms at home in the same period	-	2001-2
24 Paiva et al., 2008⁴²	CS	n = 670; SP/SP	To analyze age and condom use at first intercourse among Brazilian adolescents at two periods: 1998 and 2005	Teens	Condom use at first intercourse	Condom use at first sex with stable partners in 1998: 48.5% in 2005: 67.7%; condom use at first intercourse with casual partners in 1998: 47.2% and 2005: 62.6%	Gender, skin color, and schooling	1998, 2005
25 Paiva et al., 2011⁴³	CS and FG	n = 250; SP/SP	To investigate the disclosure of positive HIV status to sexual partners among men hetero and bisexual attended in centers for the treatment of HIV/AIDS	M-HIV +	Use of condoms (always, often, sometimes, or never) and anal and vaginal sex rates	Straight and bisexual: 83.1% reported always using condoms with partners in vaginal sex, 42% reported always using condoms with partners in anal sex. For all partners, 42.2% reported always using in anal sex; 3.1% sometimes, 9.4% never, and 45.3% reported no anal intercourse; in vaginal sex: 83.1% always, 9.7% sometimes, 7.1% never. Among the ones who did not show their HIV status for the partner, 1.9% and 7.7% never used condoms in anal and vaginal sex, respectively, compared with 12.3% and 7.0% of those who revealed their HIV status	Unprotected sex with HIV-positive partners more often. 83.1% reported always using condoms with their main partner for vaginal sex and 42% for anal sex
26, 27 Pascom et al., 2010, 2011^18,19	CS	n = 8,000; Brazil	To present results of a national study on knowledge, attitudes and practices (PCAP-2008)	GP (16 - 64a)	Use at first intercourse for young people aged 15-24 years; the last relationship (any kind of partnership and casual partner); regular use (use in all relations in the previous 12 months)	Almost 61% of the sexually active Brazilian population aged 15 to 24 years reported having used a condom at first intercourse. 59% at the last sex with casual partners; one-fourth of them reported regular use regardless of the partner, being 19.4% with fixed partners and 45.7% with casual partners	59% reported condom use at the last sex with casual partners	2008
28 Peres et al., 2002⁴⁴	CS	n = 275; SP/SP	To investigate knowledge, attitudes, and practices related to AIDS among adolescent male prisoners and to develop an AIDS prevention intervention	Teens-Depr.Fred	Consistency of use; condom use in life; and use at the last intercourse before prison	Male adolescents: 9% consistent use; 35% used at the last sex before prison	Predictors of condom use included have a condom and the statement "I would use condoms with my girlfriend"	1998
29 Pinto et al., 2005⁴⁵	CS	n = 145; SP/SP	To analyze the epidemiology of STDs among women who have sex with women in São Paulo	WSW	Condom use in the last 3 months	Among women who have sex with women: 54.5% used condoms when sharing sex toys	-	2002-3
30 Rocha et al., 2007⁴⁶	CS	n = 960; Pelotas/RS	To evaluate the prevalence of contraceptive use among adolescents	Teens	Use of contraception, including condoms	88% reported using no contraceptive. Male condom method was the most used (63.2%)	Low education of adolescents associated with increased risk of nonuse; more frequent use of condoms among boys whose mothers had 9 or more years of schooling, and those reporting sexual partners in the last year	2002
31 Rocha et al., 2013²¹	CS	n = 3,449; 10 Brazilian cities	To investigate factors associated with unprotected sex among MSM	MSM	Factors associated with unprotected sex	47% of unprotected anal sex story	Association between unprotected receptive anal sex in the 6 months before the study: living with a male partner; using illicit drugs; having stable partners or having stable and casual trading partners; sex only with male partners; reporting that no or few friends encouraged condom use; homosexual/gay/MSM identity; and being considered at high or moderate risk for HIV infection	2009-10
32 Silva et al., 2002⁴⁷	IS	n = 25; Campinas/SP	To develop a STD/AIDS prevention program among professional soccer players	Teens	Consistent condom use with casual partners compared with fixed partners	73% of young athletes consistently used condoms with casual partners	-	1998/ 1999
33,34 Szwarcwald et al., 2005, 2007^8,20	CS	1997-2002: n = 30,970; 2007; n = 35,432; Brazil	To assess sexual behavior of young Brazilian boys aged 17 - 20 years	Conscripts; (17 - 20 years)	Using condoms during sexual intercourse	-	Decreased regular use of condoms in relations with fixed and casual partners compared with the study of 1999 - 2002	1997-2002 E 2007
35 Taquette et al., 2005⁴⁹	CS	n = 251; RJ/RJ	To evaluate social and behavioral characteristics in adolescents with sexually transmitted diseases compared with those who have sexually transmitted diseases and to identify risk factors related to STD	Teens F-	Use of condoms (always, often, sometimes, or never)	80.3% of girls with STDs reported not using condoms during sexual intercourse compared with 59% of those without STD	Those who reported not using condoms were more likely to report having an STD (p < 0.05)	2001-3
36 Trevisol et al., 2005⁵⁰	CS	n = 90; Imbituba/SC	To examine the prevalence of HIV and potential risk factors among sex workers	F-SW	Use of condoms (always, often, sometimes, or never)	Always: 16.7%; sometimes: 77.8%; never: 5.6%	Not using condoms correlated with HIV infection	2003-4
37 Tun et al., 2008⁵¹	CS	n = 658; Campinas/SP	To compare population estimates of risky sexual behavior and HIV prevalence among male sex workers who have sex with men and nonsex workers	MSM; M-SW	Condom use in active and receptive anal intercourse and vaginal sex	5.0% reported condom use with active anal sex; with receptive anal intercourse, 4.6% reported using a condom, 30% among those who reported unprotected anal sex with at least one partner in the last 2 months (CI: 26 - 35%); 7% among those who reported unprotected anal sex with ≥ 2 partners in the last 2 months (CI: 4 - 10%); 20.5% of condom use in active anal sex; in receptive anal sex: 22.4%; and vaginal sex: 22.7%	Male sex workers were more likely to practice receptive anal sex and unprotected active anal sex with ≥ 2 male partners and have unprotected vaginal sex with women	2005-6
38 Viana et al., 2007⁵²	CS	n = 600; BH/MG	To assess the factors associated with safe sex among sexually active public school students	Teens	Consistent condom use with casual and fixed partner	51-54% reported always using condoms with regular or fixed partners; 57-61% reported always using condoms with casual partners	Being a male, attended by health professionals in school activities, and mother's education > 8 years was positively associated with consistent condom use with casual or fixed partner. Secondary education (versus fundamental) and older age were inversely associated with consistent condom use with casual and fixed partners, respectively	2000
39 Villarinho et al., 2002⁵³	CS and equalizer	n = 279; Santos/SP	To describe the vulnerability of sexual transmission of HIV/AIDS among truck drivers	M-Straight truck	Consistency of condom use by sex and type of partner: fixed, frequent, or casual	Condom use reported with key partners (6.0%) (regardless of the type of intercourse).With regular partners: 56.6% in vaginal sex, 45.0% in anal sex and 6.4% in oral sex; with casual partners: 67% in vaginal sex, 54% in anal sex and 46% in oral sex	-	1998
Intervention assessment				M-Straight truck			-	1998
40 Diaz et al., 2005²⁸	CS	n = 763; RJ/RJ; n = 819; BH/MG; n = 714, SAL/BA	To compare opinions and sexual practices among students in schools with and without sex education programs	Teens	Current condom use	Between 41.0% and 57.0% of sexually active adolescents reported condom use	Education on sexual physiology, contraception, sexuality, and gender roles. Adjusted OR of condom use among sex education groups compared with controls: RJ: OR = 1.07; 95%CI 0.64 - 1.77; BH: OR = 0.83; 95%CI 0.51 - 1.36; SSA: OR = 1.08; 95%CI 0.51 - 2.28	1997

Fatores	General Population	MSM	Sex workers	Drug users	Teens	Women	Indians	Seniors	Conscripts
Associated with increased condom use
Male	X	X
Younger ages	X	X	X
Higher education	X
Multiple partners in the recent past	X	X	X	X
Single	X	X
With casual partners (vs. fixed or regular partners)	X
Mother's education > 8 years	X
Having or buying condoms	X	X
Already took condoms for free	X
Associated with decreased condom use
Married or in a stable relationship	X	X
Initiation of sexual activity before 14 years	X	X
Not informed about HIV/AIDS	X
Negative attitudes toward condom	X
Not knowing someone with AIDS and not engaging in gay NGOs	X
Being MSM	X
Contradictory results
Years of schooling	X
Religion	X
Socioeconomic status	X
Other factors relevant to the groups, but no quantification of the effect on condom use
Incorrect beliefs about the use of condoms and STDs	X	X
Condom use as contraceptive	X
Gender relations	X	X
Situations of violence	X