Revisiting the use of condoms in Brazil

Inês Dourado Sarah MacCarthy Manasa Reddy Gabriela Calazans Sofia Gruskin About the authors

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

RESUMO

Introdução:

No âmbito da atual política de prevenção do HIV/AIDS é necessário reconhecer a importância do preservativo masculino e discutir seus limites. Esse artigo objetivou investigar o uso do preservativo masculino no Brasil e elaborar reflexões críticas sobre o papel do mesmo no novo contexto da prevenção do HIV/AIDS.

Métodos:

Revisão narrativa sobre o uso do preservativo masculino no Brasil em diferentes grupos populacionais e fatores associados ao uso, por meio de buscas realizadas entre março e abril de 2013, utilizando-se descritores em inglês categorizados na base PubMed. Incluíram-se também documentos provenientes de inquéritos nacionais que orientam a vigilância epidemiológica e comportamental do Ministério da Saúde.

Resultados:

Incluí-se 40 artigos e 3 relatórios para caracterizar a produção de conhecimentos e outros 11 estudos de intervenção para promoção do uso de preservativos. Observou-se que: 1) apesar do aumento de estudos nacionais, estes apresentam baixa regularidade; 2) há poucos estudos sobre fatores associados ao uso de preservativo entre os grupos nos quais a epidemia se concentra, como homens que fazem sexo com homens (HSH), trabalhadoras sexuais (TS), usuários de drogas (UD) e travestis e transexuais (TT), e concentração entre adolescentes e mulheres; 3) combinação de intervenções mostrou-se mais efetiva do que uma só.

Discussão:

A reflexão e discussão do uso do preservativo no âmbito das novas tecnologias de prevenção devem não só enfatizar a importância do mesmo, mas também considerar o papel do prazer e do sexo nas intervenções combinadas, além do potencial de redução do risco de infecção por HIV.

Palavras-chave:
Preservativos; HIV; Síndrome de Imunodeficiência Adquirida; Prevenção de doenças; Prevalência; Brasil

INTRODUCTION

The male condom has played a key role in the fight against HIV/AIDS around the world and in Brazil1. Paiva V VG, França Junior I, Lopes F. Uso de preservativos: pesquisa nacional MS/IBOPE, Brasil 2003. Disponível em http://www.usp.br/nepaidsabia/images/ BIBLIOTECA/_MIGRAR/artigo_preservativo.pdf (Acessado em 20 de dezembro de 2013).
http://www.usp.br/nepaidsabia/images/ BI...
. Early in the epidemics, these used to be distributed at certain moments of the year such as Carnival and the "World Day Against AIDS" or through research projects. In 1994, the wide and systematic distribution started, in addition to the purchase of the most male condoms and lubricant gels by the Brazilian National Health System2. Brasil. Ministério da Saúde. Departamento de DST, AIDS e Hepatites Virais. Por que usar a camisinha. Disponível em http://www.aids.gov.br/pagina/porque-usar (Acessado em 12 de dezembro de 2013).
http://www.aids.gov.br/pagina/porque-usa...
3. Brasil. Ministério da Saúde. Departamento de DST, AIDS e Hepatites Virais. Insumos de prevenção. Disponível em http://www.aids.gov.br/pagina/insumos-deprevencao (Acessado em 12 de dezembro de 2013).
http://www.aids.gov.br/pagina/insumos-de...
, coordinated by the National STD/AIDS Program, currently Department of STD/AIDS/HIV and Viral Hepatitis (DDAHV) of the Ministry of Health.

Over the past 35 years, the field of HIV prevention has undergone several transformations. Today, it is argued that effective HIV prevention requires a combination of behavioral, biomedical, and structural intervention strategies. It is known that a single prevention strategy is not enough to control multiple HIV epidemics around the world and in Brazil. To the global extent, there are high expectations on the so-called "new prevention technologies" or "biomedical prevention technologies" (circumcision, microbicides, postexposure prophylaxis - PEP, and preexposure prophylaxis - PrEP), in addition to behavioral strategies (such as sero-positioning, sero-adaptation, and other forms of agreement between sexual partners)4. Padian NS, Buve A, Balkus J, Serwadda D, Cates W, Jr. Biomedical interventions to prevent HIV infection: evidence, challenges, and way forward. Lancet 2008; 372(9638): 585-99. 7. Celum C, Hallett TB, Baeten JM. HIV-1 prevention with ART and PrEP: mathematical modeling insights into resistance, effectiveness, and public health impact. J Infect Dis 2013; 208(2): 189-91..

At the same time, the country is experiencing an increasing HIV prevalence among young people, especially men who have sex with men (MSM)8. Szwarcwald CL, Andrade CL, Pascom AR, Fazito E, Pereira GF, Penha IT. HIV-related risky practices among Brazilian young men, 2007. Cad Saude Publica 2011; 27 Suppl 1: S19-26.; high prevalence of HIV

is also noted in some population groups in vulnerable contexts (MSM, sex workers - SW, drug users - DU, and transvestites and transsexuals - TT)9. Kerr LR, Mota RS, Kendall C, Pinho AD, Mello MB, Guimaraes MD, et al. HIV among MSM in Brazil. AIDS 2012; 26: 000-00 1212 . Brasil. Ministério da Justiça. Perfil dos usuários de crack e/ou similares no Brasil. Brasília: Secretaria Nacional de Políticas sobre Drogas; 2013, currently referred to as key populations1313 . World Health Organization (WHO). Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations. Geneva: World Health Organization; 2014., in addition to downward trend in the consistent use of condoms1414 . Brasil. Pesquisa de Conhecimentos, Atitudes e Práticas na População Brasileira de 15 a 64 anos, 2008. Brasília: Ministério da Saúde; 2011.. It is, thus, necessary to recognize the importance of condoms as part of the HIV/AIDS prevention policy and to discuss its limits.

This article aimed to investigate the use of condoms in Brazil and to make critical reflections on their role in the new context of HIV/AIDS prevention.

METHODS

We conducted a literature review1515 . Cordeiro AM, Oliveira GMd, Rentería JM, Guimarães CA. Revisão sistemática: uma revisão narrativa. Rev Col Bras Cir 2007; 34: 428-31. 1616 . Rother E. Revisão sistemática X revisão narrativa. Acta Paulista de Enfermagem 2007; 20(2): 2. aiming at the use of condoms in Brazil as a strategy for HIV/AIDS prevention in different population groups, the factors associated with its use, and the actions taken to promote the use of male condoms. To draw up a more organized search of documents, guaranteeing sensitivity (including the largest number of documents) and specificity (excluding documents not related to the study purposes), we used descriptors in English previously defined and categorized in PubMed database (MeSH Terms) and keywords used by authors in publications identified in the exploratory readings on the theme (Chart 1). Titles and abstracts were read when addressing condom use as the main outcome variable. Searches were carried out between March and April 2013, and articles with full-text available were kept in the sample, all of them published between 2000 and 2013.

Chart 1
Words and keywords related to use of male condom in Brazil at Pubmed, 2000 - 2013.

We also included documents from national surveys that guide the epidemiological and behavioral surveillance of the DDAHV, and included condom use as one of the main outcomes, such as in the "Sexual Behavior and Perceptions of the Brazilian Population on HIV/AIDS" survey conducted in 1998 and 2005, in a representative sample of the population aged 16 - 65 years, by the Brazilian Center for Analysis and Planning (CEBRAP)1717 . Berquó E, Barbosa RM, Lima LP; Grupo de Estudos em População, Sexualidade e AIDS. [Trends in condom use: Brazil 1998 and 2005]. Rev Saude Publica 2008; 42 Suppl 1: 34-44.; and in on the knowledge, attitudes, and practices related to STD and AIDS (PCAP), household survey undertaken in 2004 and 2008 among a representative sample of the population aged 15-64 years1414 . Brasil. Pesquisa de Conhecimentos, Atitudes e Práticas na População Brasileira de 15 a 64 anos, 2008. Brasília: Ministério da Saúde; 2011. 1818 . Pascom ARP, Ferraz DAS, Arruda MR, Brito I. Conhecimento e práticas sexuais de risco associados ao HIV na população brasileira de 15 a 64 anos, 2008. Tempus Actas em Saúde Coletiva. 2010; 4(2): 101-12. 1919 . Pascom AR, Szwarcwald CL. Sex inequalities in HIV-related practices in the Brazilian population aged 15 to 64 years old, 2008. Cadernos de saude publica 2011; 27 Suppl 1: S27-35., surveys among conscripts of the Brazilian Army8. Szwarcwald CL, Andrade CL, Pascom AR, Fazito E, Pereira GF, Penha IT. HIV-related risky practices among Brazilian young men, 2007. Cad Saude Publica 2011; 27 Suppl 1: S19-26. 2020 . Szwarcwald CL, de Carvalho MF, Barbosa Junior A, Barreira D, Speranza FA, de Castilho EA. Temporal trends of HIVrelated risk behavior among Brazilian military conscripts, 1997-2002. Clinics (Sao Paulo) 2005; 60(5): 367-74., and behavioral surveillance surveys among key populations9. Kerr LR, Mota RS, Kendall C, Pinho AD, Mello MB, Guimaraes MD, et al. HIV among MSM in Brazil. AIDS 2012; 26: 000-00 1212 . Brasil. Ministério da Justiça. Perfil dos usuários de crack e/ou similares no Brasil. Brasília: Secretaria Nacional de Políticas sobre Drogas; 2013 2121 . Rocha GM, Kerr LR, de Brito AM, Dourado I, Guimaraes MD. Unprotected receptive anal intercourse among men who have sex with men in Brazil. AIDS and Behav 2013;17(4):1288-95. 2222 . Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de DST, AIDS e Hepatites virais. Taxas de prevalência de HIV e sífilis e conhecimento, atitudes e práticas de risco relacionadas às infecções sexualmente transmissíveis no grupo das mulheres profissionais do sexo, no Brasil (RDS-PS)- Anexo VIII. Brasília: Ministério da Saúde; 2009..

Information about the characteristics of the scientific literature on the use of male condoms was organized in Table 1. Factors associated with condom use were organized by population group and sexual practice inTable 2. Tables 3 and 4 summed up data on the effects of combined and single interventions to promote condom use. Exclusion criteria were:

  1. studies that did not report the proportion of condom use (even if changes in attitudes and knowledge had been reported) and

  2. if no intervention component had been performed in Brazil.

RESULTS

A total of 40 papers8. Szwarcwald CL, Andrade CL, Pascom AR, Fazito E, Pereira GF, Penha IT. HIV-related risky practices among Brazilian young men, 2007. Cad Saude Publica 2011; 27 Suppl 1: S19-26. 9. Kerr LR, Mota RS, Kendall C, Pinho AD, Mello MB, Guimaraes MD, et al. HIV among MSM in Brazil. AIDS 2012; 26: 000-00 1111 . Bertoni N, Singer M, Silva CM, Clair S, Malta M, Bastos FI. Knowledge of AIDS and HIV transmission among drug users in Rio de Janeiro, Brazil. Harm Reduct J 2011; 8: 5. 1717 . Berquó E, Barbosa RM, Lima LP; Grupo de Estudos em População, Sexualidade e AIDS. [Trends in condom use: Brazil 1998 and 2005]. Rev Saude Publica 2008; 42 Suppl 1: 34-44. 2121 . Rocha GM, Kerr LR, de Brito AM, Dourado I, Guimaraes MD. Unprotected receptive anal intercourse among men who have sex with men in Brazil. AIDS and Behav 2013;17(4):1288-95. 2323 . Calazans G, Araujo TW, Venturi G, Franca Junior I. Factors associated with condom use among youth aged 15-24 years in Brazil in 2003. AIDS 2005; 19 Suppl 4: S42-50. 5454 . Villarinho L, Bezerra I, Lacerda R, Latorre Md Mdo R, Paiva V, Stall R, et al. [Vulnerability to HIV and AIDS of short route truck drivers, Brazil]. Rev Saude Publica 2002; 36(4 Suppl): 61-7. (Table 1) and 3 DDAHV reports were included in this article to describe the production of knowledge about the use of condoms in Brazil and associated factors. The reports were not included in Table 1, but condom use information from the PCAP report1414 . Brasil. Pesquisa de Conhecimentos, Atitudes e Práticas na População Brasileira de 15 a 64 anos, 2008. Brasília: Ministério da Saúde; 2011., the national study of crack users1212 . Brasil. Ministério da Justiça. Perfil dos usuários de crack e/ou similares no Brasil. Brasília: Secretaria Nacional de Políticas sobre Drogas; 2013, and the RDS-TS study2222 . Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de DST, AIDS e Hepatites virais. Taxas de prevalência de HIV e sífilis e conhecimento, atitudes e práticas de risco relacionadas às infecções sexualmente transmissíveis no grupo das mulheres profissionais do sexo, no Brasil (RDS-PS)- Anexo VIII. Brasília: Ministério da Saúde; 2009. were described. Studies addressing the type of intervention to encourage condom use were also identified: combined interventions- five studies2929 . Diaz M, Mello MB, Sousa MH, Cabral F, Castro e Silva R, Campos M, et al. Outcomes of three different models for sex education and citizenship programs concerning knowledge, attitudes, and behavior of Brazilian adolescents. Cad Saude Publica 2005; 21(2): 589-97. 5555 . Lippman SA, Donini A, Diaz J, Chinaglia M, Reingold A, Kerrigan D. Social-environmental factors and protective sexual behavior among sex workers: the Encontros intervention in Brazil. Am J Public Health 2010; 100 Suppl 1: S216-23. 5858 . Pechansky F, Bassani DG, Diemen L, Kessler F, Leukefeld CG, Surratt HL, et al. Using thought mapping and structured stories to decrease HIV risk behaviors among cocaine injectors and crack smokers in the South of Brazil. Rev Bras Psiquiatr 2007; 29(3): 233-40. (Table 3) and only one intervention- eight studies5353 . Viana FJ, Faundes A, de Mello MB, de Sousa MH. Factors associated with safe sex among public school students in Minas Gerais, Brazil. Cad Saude Publica 2007; 23(1): 43-51. 5757 . Sampaio M, Brites C, Stall R, Hudes ES, Hearst N. Reducing AIDS Risk Among Men Who Have Sex with Men in Salvador, Brazil. AIDS Behav 2002; 6(2): :173-81. 5959 . Andrade HH, Mello MB, Sousa MH, Makuch MY, Bertoni N, Faundes A. Changes in sexual behavior following a sex education program in Brazilian public schools. Cad Saude Publica 2009; 25(5): 1168-76. 6464 . Colosio R, Fernandes MI, Bergamaschi DP, Scarcelli IR, Lopes IC, Hearst N. [HIV prevention using the operative group approach among men who have sex with men in Sao Paulo, Brazil]. Cad Saude Publica 2007; 23(4): 949-59. (Table 4).

Table 1
Features of the production of knowledge related to male condom use in Brazil, 2000 - 2013.
Table 2
Factors associated with condom use by different population groups.
Table 3
Effect of two interventions to promote condom use.
Table 4
Effect of one intervention to promote condom use.

FEATURES OF THE PRODUCTION OF KNOWLEDGE ABOUT THE USE OF CONDOMS

A critical reading of the production of knowledge about condom use in Brazil over the past 13 years leads us to the following summarization:

  1. National studies showed substantial variation with respect to the measures taken to promote the condom use in the characterization of the different types of sexual partners (casual, occasional, fixed, stable, etc.); investigation of sexual practices (vaginal, anal, receptive, active, etc.); and intervals (last relationship, sexual practice in 3, 6, or 12 months before the survey, etc.). Some measures are investigated in specific groups only, which makes it difficult to compare with the results of different studies.

  2. Studies on factors associated with condom use among population groups in which the epidemics is concentrated in Brazil, such as MSM, DU, and TT, date back to 2009.

  3. There is a concentration of studies among adolescents.

  4. Effective interventions to encourage the use of condoms indicated that, combination of interventions was more effective than the concentration in a specific practice; there is a need, however, for further studies to understand and produce evidence on how to effectively handle these interventions to increase the use and adherence to condom (Tables 3and 4).

  5. National surveys investigating the general population (CEBRAP and PCAP) were carried out in 1998, 2004, 2005, and 2008; conscripts surveys took place from 1997 - 2000, 2002, and the last one in 2007. Studies on specific populations (MSM, SW, and DU) were a survey for each population between 2008 and 2009. In the last 4 years, there were virtually no studies on the use of condoms promoted and/or financed by DDAHV.

WHAT IS KNOWN ABOUT THE USE OF CONDOMS AND ASSOCIATED FACTORS?

Condom use rates differ substantially between the national surveys. Those conducted by CEBRAP indicated: an increase of 19.1% (1998) to 33.1% (2005) in the proportion of the use in sex encounters with steady partners in the 12 months preceding the interview; lower condom use rate among individuals with higher education in contrast to the use rate among those with secondary education; association between sexual debut of those aged between 15 and 16 years and decreased use of condoms, especially among those who initiated sex before 14 years of age; and increased use of condoms in sexual debut among those aged 16 - 19 years, comparing with the data collected in 1998 and 20051717 . Berquó E, Barbosa RM, Lima LP; Grupo de Estudos em População, Sexualidade e AIDS. [Trends in condom use: Brazil 1998 and 2005]. Rev Saude Publica 2008; 42 Suppl 1: 34-44..

Data from PCAP showed a downward trend in condom use at the last sexual intercourse in the 12 months before the survey comparing the years of the study (38.4% versus 36.8%), despite the fact that knowledge about the use of condoms has remained high in 2004 and 2008; higher proportions of use among young people; and an increased use among them at first intercourse, when comparing the different versions of PCAP (53.2% versus 60.9%)1414 . Brasil. Pesquisa de Conhecimentos, Atitudes e Práticas na População Brasileira de 15 a 64 anos, 2008. Brasília: Ministério da Saúde; 2011..

These studies highlight a diverse set of factors associated with the use of condoms among different groups. With regard to the general population, data from PCAP indicated associations between regular condom use (in all sexual relations in the 12 months before the survey) and: being a man; aged 15 - 24 years; having received condoms for free; and not living with a partner1414 . Brasil. Pesquisa de Conhecimentos, Atitudes e Práticas na População Brasileira de 15 a 64 anos, 2008. Brasília: Ministério da Saúde; 2011. 1818 . Pascom ARP, Ferraz DAS, Arruda MR, Brito I. Conhecimento e práticas sexuais de risco associados ao HIV na população brasileira de 15 a 64 anos, 2008. Tempus Actas em Saúde Coletiva. 2010; 4(2): 101-12. 1919 . Pascom AR, Szwarcwald CL. Sex inequalities in HIV-related practices in the Brazilian population aged 15 to 64 years old, 2008. Cadernos de saude publica 2011; 27 Suppl 1: S27-35.. Importantly, studies show a greater difficulty in keeping condom use in the context of relationships considered stable by the parties involved2323 . Calazans G, Araujo TW, Venturi G, Franca Junior I. Factors associated with condom use among youth aged 15-24 years in Brazil in 2003. AIDS 2005; 19 Suppl 4: S42-50. 6565 . Jimenez AL, Gotlieb SL, Hardy E, Zaneveld LJ. [Prevention of sexually transmitted diseases in women: association with socioeconomic and demographic variables]. Cad Saude Publica 2001; 17(1): 55-62. 6666 . Hearst N, Chen S. Condom promotion for AIDS prevention in the developing world: is it working? Studies in family planning. 2004; 35(1): 39-47..

There is controversy, however, regarding the associations between condom use and socioeconomic status (SES). While Martins et al.4040 . Martins LB, da Costa-Paiva LH, Osis MJ, de Sousa MH, Pinto-Neto AM, Tadini V. [Factors associated with condom use and knowledge about STD/AIDS among teenagers in public and private schools in Sao Paulo, Brazil]. Cad Saude Publica 2006; 22(2): 315-23. found an association between condom use with lower SES, Juarez et al.3838 . Juarez F, LeGrand T. Factors influencing boys' age at first intercourse and condom use in the Shantytowns of Recife, Brazil. Stud Fam Plann 2005; 36(1): 57-70. indicated that higher SES was positively associated with condom use among male adolescents. With regard to religion, Berquó et al.1717 . Berquó E, Barbosa RM, Lima LP; Grupo de Estudos em População, Sexualidade e AIDS. [Trends in condom use: Brazil 1998 and 2005]. Rev Saude Publica 2008; 42 Suppl 1: 34-44. found greater adherence to condom use among Brazilians who reported no religion, while Viana et al.5353 . Viana FJ, Faundes A, de Mello MB, de Sousa MH. Factors associated with safe sex among public school students in Minas Gerais, Brazil. Cad Saude Publica 2007; 23(1): 43-51. reported greater adherence, although not significantly higher, among Catholic students compared with students who identified themselves as evangelicals or linked to other or no religion (Table 2).

When considering the groups in which the epidemics is concentrated, MSM use condoms more often when compared with heterosexuals1414 . Brasil. Pesquisa de Conhecimentos, Atitudes e Práticas na População Brasileira de 15 a 64 anos, 2008. Brasília: Ministério da Saúde; 2011.. Recently, monitoring and surveillance studies in key populations, with sampling technique directed by the participant [the respondent-driven sampling (RDS)], were used to obtain more detailed information about HIV/AIDS among MSM, with 47% of them reporting unprotected anal sex, and associations between unprotected receptive anal sex in the 6 months before the study and: living with a male partner; using illicit drugs; having stable partners or having stable and casual trading partners; having sex only with male partners; no or few friends encouraging condom use; homosexual/gay/MSM identity; and being considered at high or moderate risk for HIV infection2121 . Rocha GM, Kerr LR, de Brito AM, Dourado I, Guimaraes MD. Unprotected receptive anal intercourse among men who have sex with men in Brazil. AIDS and Behav 2013;17(4):1288-95..

In the report of FSW study with RDS, the proportion of regular use (in all sexual relations) of condoms with steady partners in the practice of vaginal and anal sex was 21.4% and 29.4%, respectively. The use with clients in during vaginal and anal sex was 69.7% and 64%, respectively2222 . Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de DST, AIDS e Hepatites virais. Taxas de prevalência de HIV e sífilis e conhecimento, atitudes e práticas de risco relacionadas às infecções sexualmente transmissíveis no grupo das mulheres profissionais do sexo, no Brasil (RDS-PS)- Anexo VIII. Brasília: Ministério da Saúde; 2009..

Studies about SW are concentrated in women, and few identify factors associated with condom use. Most of them describe the proportion of use in different situations or refer to not using condoms as a risk factor for HIV infection. The RDS study indicated nonuse of condoms when negotiating with clients as an important risk factor for HIV2525 . Dal Pogetto MR, Marcelino LD, Carvalhaes MA, Rall VL, Silva MG, Parada CM. Characteristics of a population of sex workers and their association with the presence of sexually transmitted diseases. Rev Esc Enfermagem USP 2012; 46(4): 877-83.,2626 . Damacena GN, Szwarcwald CL, de Souza Junior PR, Dourado I. Risk factors associated with HIV prevalence among female sex workers in 10 Brazilian cities. J Acquir Immune Defic Syndr 2011; 57 Suppl 3: S144-52.,5151 . Trevisol FS, Silva MV. HIV frequency among female sex workers in Imbituba, Santa Catarina, Brazil. Braz J Infect Dis 2005; 9(6): 500-5..

With respect to drug users, about 40% of them reported never using condoms, with an increase to 60% when under influence of psychoactive substances1111 . Bertoni N, Singer M, Silva CM, Clair S, Malta M, Bastos FI. Knowledge of AIDS and HIV transmission among drug users in Rio de Janeiro, Brazil. Harm Reduct J 2011; 8: 5.. But, there are no recent publications on injecting drug users (IDUs) - at least indexed studies. The most recent survey funded by the National Secretariat of Policies for Drugs (SENAD) of the Ministry of Justice among crack and/or similar drug users in 26 Brazilian capitals and the Federal District was conducted between 2011 and 2013. In this study, more than one-third (39.5%) of crack/similar drug users in Brazil reported not having used a condom in vaginal intercourses in the previous month before the interview1212 . Brasil. Ministério da Justiça. Perfil dos usuários de crack e/ou similares no Brasil. Brasília: Secretaria Nacional de Políticas sobre Drogas; 2013.

Finally, considering the studies conducted with adolescents, there is an increase in the rate of condom use when comparing 1998 with 20054444 . Paiva V, Calazans G, Venturi G, Dias R; Grupo de Estudos em População, Sexualidade e AIDS. [Age and condom use at first sexual intercourse of Brazilian adolescents]. Rev Saude Publica 2008; 42 Suppl 1: 45-53.. and more frequent reports of condom use during sex intercourse with casual partners (80%) when compared with steady partners (40%)2323 . Calazans G, Araujo TW, Venturi G, Franca Junior I. Factors associated with condom use among youth aged 15-24 years in Brazil in 2003. AIDS 2005; 19 Suppl 4: S42-50.. The most recent article on young conscripts of the Brazilian Army in 2007 indicated regular condom use with steady and casual partners around 40% and 50% in 1999, 2000, 2002, and 2007, respectively. Some concerns have arisen owing to the decrease in regular use of condoms in sexual relations with steady and casual partners between 2002 (48.5%) and 2007 (43.1%), especially among those with lower educational levels; the increase in the composite risk behavior (average number of partners in the previous year, weighted by the proportion of nonuse of condoms in accordance with the type of relationships participants maintain); and the lower proportion of condom use among young MSM8. Szwarcwald CL, Andrade CL, Pascom AR, Fazito E, Pereira GF, Penha IT. HIV-related risky practices among Brazilian young men, 2007. Cad Saude Publica 2011; 27 Suppl 1: S19-26..

KEY FINDINGS FROM INTERVENTION STUDIES: WHAT WORKS TO PROMOTE CONDOM USE?

We identified proposals of intervention that have been proven effective to encourage condom use (Tables 3 and 4)2929 . Diaz M, Mello MB, Sousa MH, Cabral F, Castro e Silva R, Campos M, et al. Outcomes of three different models for sex education and citizenship programs concerning knowledge, attitudes, and behavior of Brazilian adolescents. Cad Saude Publica 2005; 21(2): 589-97. 5353 . Viana FJ, Faundes A, de Mello MB, de Sousa MH. Factors associated with safe sex among public school students in Minas Gerais, Brazil. Cad Saude Publica 2007; 23(1): 43-51. 5555 . Lippman SA, Donini A, Diaz J, Chinaglia M, Reingold A, Kerrigan D. Social-environmental factors and protective sexual behavior among sex workers: the Encontros intervention in Brazil. Am J Public Health 2010; 100 Suppl 1: S216-23. 5858 . Pechansky F, Bassani DG, Diemen L, Kessler F, Leukefeld CG, Surratt HL, et al. Using thought mapping and structured stories to decrease HIV risk behaviors among cocaine injectors and crack smokers in the South of Brazil. Rev Bras Psiquiatr 2007; 29(3): 233-40. 6060 . Magnani RJ, Gaffikin L, de Aquino EM, Seiber EE, Almeida MC, Lipovsek V. Impact of an integrated adolescent reproductive health program in Brazil. Stud Fam Plann 2001; 32(3): 230-43. 6464 . Colosio R, Fernandes MI, Bergamaschi DP, Scarcelli IR, Lopes IC, Hearst N. [HIV prevention using the operative group approach among men who have sex with men in Sao Paulo, Brazil]. Cad Saude Publica 2007; 23(4): 949-59.. These include a combination of interventions to improve the adherence to condoms and to support groups to discuss their use and negotiation. A combination of interventions was more effective than focusing on a specific practice (Table 3). Participating in support groups that discuss strategies to promote the use of condom and mobilize the negotiation has been signalized as an important factor to increase the acceptability and confidence of women in bringing condom into their relationships. However, there is little evidence of how effective these interventions are to increase the adherence to condom.

DISCUSSION

Before presenting the main considerations on the literature reviewed, we emphasize that our intention was not to exhaust the production of knowledge about condom use in Brazil. There are also limitations, such as the time frame in the selection of articles, the selection criteria chosen, and the limited number of intervention studies found.

Examination of articles identified here allows highlighting three key points about the use of condoms as part of HIV/AIDS prevention policy for the reflection about and the improvement of HIV prevention in Brazil:

  1. Whatever be the prevention model of STD/HIV/AIDS that Brazil adopts in the near future, a greater regularity in national studies to evaluate prevention indicators including the use of condoms is necessary. Moreover, a joint effort between the government, the academy, and civil society to ensure the regularity needed in the development of these studies, aiming at the establishment of a monitoring policy for these indicators, and the standardization of measures adopted in studies to ensure comparability are also required. As pointed out earlier, in a systematic review of studies that have estimated the prevalence of HIV in FSW, DU, and MSM in Brazil, commissioned by the former PN in 20086767 . Mello MB, Malta M, Pascom AR, Linhares Y. Revisão sistemática de estudos com HSH, UDI e TS no Brasil:1998-2008. Brasília: Departamento Nacional de DST/AIDS. Ministério da Saúde; 2008. 6868 . Malta M, Magnanini MM, Mello MB, Pascom AR, Linhares Y, Bastos FI. HIV prevalence among female sex workers, drug users and men who have sex with men in Brazil: a systematic review and meta-analysis. BMC Public Health 2010; 10: 317., the nonstandardization of male condom use indicators among different studies made it difficult to effectively compare them. In addition, in these documents and according to the UNAIDS report's recommendations on the UNGASS indicators6969 . United Nations Programme on HIV/AIDS (UNAIDS). Monitoring the Declaration of Commitment on HIV/ AIDS: guidelines on construction of core indicators; 2008 reporting. UNAIDS. Geneva.2008., it is recommended that "further studies and, especially, national behavioral surveillance surveys among FSW, MSM and IDUs incorporate at least UNGASS indicators of use of male condoms in order to enable consistent monitoring of risky sexual behaviors in these populations and the effectiveness of prevention when adopting safer behaviors."

  2. In the same effort, it must be ensured that, from all studies conducted within the HIV/ AIDS prevention policy in Brazil, analyzes are carried out and published addressing factors associated with the use of condoms both in the general population and among the groups in which the epidemics is concentrated in Brazil.

  3. The prevention policy based on the promotion of use of condoms should be based on a combination of interventions, including participation in support groups to discuss strategies to promote use and mobilize negotiation. However, the development of studies contributing to understand and produce evidence on how to effectively operate these interventions to increase the use and adherence to condom is very important. We set forth below some additional points for consideration of new perspectives in the national policy of HIV prevention and promotion of condom use.

Other points to think about the future of HIV/AIDS prevention in Brazil should take into account that the data showing reduction or eventual stabilization in the use of condoms bring a variety of issues to the national prevention policy. Would it be possible to obtain a higher proportion of male condom use? The literature and the international media have been mentioning, since the late 1990s, the so-called "condom fatigue" or "prevention fatigue"7070 . Adam BD, Husbands W, Murray J, Maxwell J. AIDS optimism, condom fatigue, or self-esteem? Explaining unsafe sex among gay and bisexual men. J Sex Res 2005; 42(3): 238-48. 7272 . James SK. Condom Fatigue Or Prevention Fatigue? 2010. Disponível em http://ezinearticles.com/?CondomFatigue-Or-Prevention-Fatigue?&id=5196308 (Acessado em 12 de Janeiro de 2014).
http://ezinearticles.com/?CondomFatigue-...
and the lack of contact of the youngest with AIDS, the reduction of intervention programs, and changes in the way of finding partners (online networks) as explanatory causes of the increase of AIDS cases in cities and countries where the epidemics had previously declined or stabilized.

The emergence of new biotechnologies for prevention (circumcision, microbicides, PEP, and PrEP), in addition to behavioral strategies (such as soro-positioning, soro-adaptation, and other forms of agreement between sexual partners) calls into question whether the condom will be, for all and in all cases, the most appropriate method of prevention. Also important is the measurement of consistent or regular condom use, characterized by the use with all types of partners, fixed, casual, or occasional, in all sexual relations over the last 3, 6, and 12 months, which has been used in surveillance behavioral studies and is shown as the most appropriate method to refer to safe or appropriate prevention practices. However, people could report not using a condom in a particular sexual relationship, and not being exposed to the virus, once other methods of prevention have been adopted. There is a need for further studies to seek new ways to measure the adoption of a combination of prevention strategies, including condom use and assessment of how appropriate this method is.

The combination strategies of condom use motivation, that articulates reflections and the possibility of appropriation, by the subjects, of social conditions of prevention methods appears to be more effective. Thus, new approaches to recognize such social constraints associated with a measure of prevention that focuses on sexual practices should bring the issue of sex and pleasure to the scope of adherence to condoms, in the context of affective heterosexual or homosexual relationships, where the values assigned to trust, faithfulness, and love contrast with the risk of a disease being prevented, or in the context of heterosexual relationships in which there are expectations for reproduction, as highlighted in the study by Villela and Barbosa7373 . Villela WV, Barbosa RM. Prevenção da transmissão heterossexual do HIV entre mulheres: é possível pensar estratégias sem considerar suas demandas reprodutivas? Rev Bras Epidemiol 2015; n.esp HIV: 131-42. and by Everett et al.7474 . Everett SA, Warren CW, Santelli JS, Kann L, Collins JL, Kolbe LJ. Use of birth control pills, condoms, and withdrawal among U.S. high school students. J Adolesc Health 2000; 27(2): 112-8.; or in the context of homosexual relationships, in which attention is given to the contact with the partner's sperm and fluids, as sign of acceptance and intimacy, as highlighted in the article by Terto Jr7575 . Terto Jr. V. Diferentes prevenções geram diferentes escolhas? Reflexões para a prevenção de HIV/AIDS em homens que fazem sexo com homens e outras populações vulneráveis. Rev Bras Epidemiol 2015; n.esp HIV: 156-68.. It is mandatory to recognize various affective-normative explanations that imply barriers to the adoption of condoms as a regular method of prevention.

Regarding the difficulty in maintaining the use of condoms in the context of relationships considered stable by partners involved, some prevention strategies recently adopted, biomedical or behavioral, aim to overcome such challenge. That is the case with " treatment as prevention"7676 . Dabis F. Test and treat all as soon as possible. Lancet Glob Health 2014; 2(1): e2-e3., in which serodiscordant couples abandon condom use with a view to the protection conferred by antiretroviral treatment or even of sero-adaptation strategies7777 . McConnell JJ, Bragg L, Shiboski S, Grant RM. Sexual seroadaptation: lessons for prevention and sex research from a cohort of HIV-positive men who have sex with men. PloS One 2010; 5(1): e8831. that have been adopted by the international gay communities as an alternative to reduce the risk of infection. It all leads us to believe that one should consider the limitations of expanding the proportion of people who use condoms regularly. For some people and some relationship contexts, it is possible that other prevention strategies prove more appropriate and, thus, more effective.

ACKNOWLEDGEMENTS

The authors thank the Department of Preventive Medicine, Medical School of Universidade de São Paulo (FMUSP) (Alexandre Grangeiro), Institute for Health of The State of São Paulo (SES/SP) (Project CTA Mais) and the National Department of STD, AIDS and Viral Hepatitis of the Ministry of Health, along with the Center for Training in STD and AIDS of SES/SP, Medical School of Santa Casa de São Paulo and Fiocruz-Brasília (Dulce Ferraz). Sarah MacCarthy participated in this study supported by the Project "HIV and Other Infectious Consequences of Substance Abuse" (T32DA13911-12), by Lifespan/Tufts/Brown Center for AIDS Research (P30AI042853) and National Institute for Allergy and Infectious Diseases (NIAID/EUA).

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  • Financial support: none.

Publication Dates

  • Publication in this collection
    Sept 2015

History

  • Received
    30 Jan 2014
  • Reviewed
    07 Jan 2015
  • Accepted
    27 Jan 2015
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