Condoms

13 March 2024—A new report, HIV Prevention: From Crisis to Opportunity shows that HIV infections continue to decline in countries that are part of the Global HIV Prevention Coalition (GPC) faster than in the rest of the world.

Eleven GPC focus countries have reduced their annual number of new HIV infections by at least 66% since 2010. By comparison, the average reduction in new HIV infections since 2010 globally is 38%. The GPC is a coalition of 38 countries working together to accelerate declines in new HIV infections to achieve the target of having 95% of the people who are at risk of HIV accessing effective combination prevention options.

The GPC countries that have prioritised primary prevention and treatment and that have focused on reaching people most at risk have secured the strongest consistent declines in new HIV infections.

Globally, progress in HIV prevention has been highly uneven and a majority of the world’s countries are not currently on track to achieve the 2025 targets. Indeed, several countries are experiencing prevention crises with low access to services and face record rising new HIV infections.

“The findings of this report offer crucial lessons for action,” said Angeli Achrekar, Deputy Executive Director Programme, UNAIDS. “The report shows that sustained political leadership, investment in effective HIV prevention programmes, and an enabling policy environment are crucial to end AIDS as a public health threat by 2030.”

Declines in new HIV infections have been boosted by the cumulative impact of combination HIV prevention options and increased access to antiretroviral treatment which has also increased viral suppression in people living with HIV. People who are on treatment and are virally supressed cannot transmit HIV.

“It’s remarkable to see what has been achieved in the AIDS response in the past 20 years. But the progress to date has not been equitable and is not yet sustainable, and we must never confuse progress with being sure of success,” said Mitchell Warren, GPC co-chair and Executive Director, AVAC. “Our progress is fragile, and what we’ve achieved today could slip away even more quickly than it was achieved if we let complacency take hold.”

Key populations and adolescent girls and young women are still at high risk of new infections

HIV incidence remains unacceptably high among populations where gaps in HIV prevention investments persist. This includes key populations in all regions globally and adolescent girls and young women in parts of sub-Saharan Africa.

Around 3100 young women and girls aged 15-24 became newly infected with HIV every week in sub-Saharan Africa in 2022 and HIV incidence declined less rapidly than it has among young men. Only 43% of the sub-national areas in which there is elevated HIV incidence among young women are being reached with dedicated prevention programmes for young women.

Although GPC countries have shown solid gains in reducing new HIV infections, challenges remain worldwide in reaching key populations most at risk of new HIV infections including men who have sex with men, sex workers and people who inject drugs. Every week, more than 11 000 new HIV infections occur among key populations and their sexual partners globally.

Only 44% of sex workers, 28% of gay men and other men who have sex with men, and 37% of people who inject drugs accessed two or more HIV prevention services in the previous three months according to median values reported by GPC countries ––against a target of 90%.

HIV prevention is being obstructed by shortfalls in prevention financing, and by punitive laws. Social stigma, violence, discrimination and social exclusion are barriers to key populations’ access to health-care services and information, exacerbating their risk of acquiring HIV. Law reform is a crucial enabler of prevention programmes. Protecting the human rights of everyone is vital for protecting the health of everyone.

Investments in both condom and voluntary medical male circumcision programmes, which are both effective in preventing HIV, have fallen in some of the countries with the largest HIV epidemics. In addition, breakthrough HIV prevention options such as pre-exposure prophylaxis (PrEP), medicine to prevent HIV, are still only available to a small fraction of the people who need them.

There are unprecedented opportunities for HIV prevention in 2024. There is a growing array of prevention options including existing tools and new long-acting prevention technologies, as well as country examples of how to implement prevention at scale and increase choices available to communities.

HIV Prevention programmes need to be at scale, efficient and equitable. The actions that are needed for success and sustainability are known, have been shown to work, and have been agreed: collaborate, follow science, tackle inequalities, protect everyone’s rights, let communities lead, and invest in what is needed. Sliding back on resourcing or inclusion would hurt everyone. Solidarity will benefit everyone. Communities, countries and international partners can prevent new infections – together.

UNAIDS

The Joint United Nations Programme on HIV/AIDS (UNAIDS) leads and inspires the world to achieve its shared vision of zero new HIV infections, zero discrimination and zero AIDS-related deaths. UNAIDS unites the efforts of 11 UN organizations—UNHCR, UNICEF, WFP, UNDP, UNFPA, UNODC, UN Women, ILO, UNESCO, WHO and the World Bank—and works closely with global and national partners towards ending the AIDS epidemic by 2030 as part of the Sustainable Development Goals. Learn more at unaids.org and connect with us on Facebook, Twitter, Instagram and YouTube.

On the eve of World AIDS Day, the Russian language social media network OK.RU hosted a live broadcast, Telling the Truth, as part of an education project that has been run by UNAIDS and the United Nations Educational, Scientific and Cultural Organization since 2015. The show was organized in collaboration with a popular magazine, Domashniy Ochag, and was devoted to the use of condoms and the link to the HIV epidemic in eastern Europe and central Asia. 

During the broadcast, which was watched by more than 1 million people, experts and celebrities discussed the most common myths, misconceptions, difficulties and fears connected to condom use.

Before the broadcast, an online survey of 1050 people aged 18 to 60 years was conducted on what Russian Internet users think about protection against sexually transmitted infections and what they consider to be safer sex. The study found that 87% of respondents had had sex without a condom, with older respondents reporting higher rates of sex without a condom.

“HIV has already reached the general population in this region. Almost 70% of all new HIV infections have been linked to heterosexual sex in recent years. At-risk people include single women aged more than 35 years and men and women who no longer worry about contraception and therefore do not use a condom,” said Natalya Ladnaya, Senior Researcher at the Central Research Institute of Epidemiology, Rospotrebnadzor. 

Among the reasons for unprotected sex, the respondents most often named “awkwardness of discussing it with a partner”, which was reported by 41% of the respondents. In addition, “trust in a partner” (35%), “discomfort during intercourse” (20%), “fear of spoiling romance” (31%) and “fear of being misunderstood by a partner” (19%) were listed among the reasons for not using a condom.

Appearing on the broadcast was Masha Godlevskaya, who has been living with HIV for 22 years. She works as a peer consultant for the EVA Association, which provides HIV services. She explained that many women who go to the EVA Association for a consultation are embarrassed to carry condoms because of the stereotype that having a condom available means that they are available and ready for sex.

“Both women and men are victims of this story,” said Ms Godlevskaya. “If a man insists on having sex without a condom, the woman should be ready to say: “I don’t want to. I don’t want to offend you, but no sex without a condom.””

“We help women believe in themselves, work with a psychologist, fight back against their abusers, build new relationships where they can discuss everything frankly. I want our women to be able to defend their bodies, their rights, and be able to take their lives into their own hands,” she added.

Vera Brezhneva, UNAIDS Goodwill Ambassador for Eastern Europe and Central Asia, noted that many women vulnerable to HIV were born in the time of the Soviet Union, when there was no promotion of safer sex. “I didn’t know about HIV at all. Most of us at that time were afraid of pregnancy only. We believed in love as if love protects you from everything. We were not told that a condom is not protection against men or women but protection against infections.”

Ms Godlevskaya shared her story of becoming infected with HIV. “I was 16 years old. He was my first love, and, as it seemed to me then, the last one. It was a serious relationship, there was trust and we knew nothing about the need to use a condom.”

Marina Travkova, a family psychologist and sex therapist, noted that adolescents are vulnerable to HIV and other sexually transmitted infections. “They need help. There is nowhere to get reliable information. I am in favour of compulsory sex education in high school and for condoms to be available in school toilets. I always remind my sons before they go out: wallet, phone, brain, condom,” she said.

For a significant part of the population, especially young people, the cost of condoms is too high, noted Ms Ladnaya. “We are discussing these issues with partners, and we hope that there will be government programmes to support the production of condoms. There are nongovernmental organizations that provide condoms for free, but I believe that they should be available at every step,” she said.

Discussing the perception that sex with a condom is worse than sex without one, the reason that people often do not use condoms, the panellists noted that comfort might be related to the quality and size of a condom, as well as insufficient knowledge of how to use a condom and lubricant correctly.

Grisha Tumanov, a journalist and blogger and author of the Man, Where Are You Going? podcast, commented on a viewer’s question: “Is a condom needed if it’s love, which presupposes mutual trust.” He noted that, “We don't have a culture of speaking on sensitive topics, what you expect from relationships, including sexual relationships. And love does not absolve one of responsibility. This does not happen in adulthood. You are responsible for each other.”

When used correctly and consistently, male and female condoms and lubricant offer very high protection against HIV, sexually transmitted infections and unintended pregnancy. Condom use has had an enormous impact on the global AIDS pandemic: model simulations show that increased condom use since 1990 has averted an estimated 117 million new HIV infections, close to half (47%) of them in sub-Saharan Africa and more than one third (37%) in Asia and the Pacific. 

If condom use rates are increased to reach 95% coverage of higher-risk sex acts by 2025 and all other prevention interventions remain at 2019 coverage levels, about one third of the required reductions in new HIV infections will be achieved. Consistent condom use, although possible, has proved difficult to achieve among all populations. Women in many countries, for example, need greater agency and support to negotiate consistent condom use. Where available, some people also choose other HIV prevention methods. Condoms alone, therefore, are not sufficient to control HIV epidemics. Full achievement of the 2025 prevention target of reducing annual new HIV infections to under 370 000 requires increased investment in combination HIV prevention to ensure access to and use of condoms as well as the full range of other prevention choices for 95% of people at risk of HIV infection.

The defunding of condom social marketing programmes and decline in sales of socially marketed condoms in sub-Saharan Africa is emblematic of a decreased focus on condom demand generation, reduced emphasis on condoms in family planning services and weak stewardship of condom programmes since 2010, leaving the world far off the 90% target for condom use.

A new generation of sexually active young people has not been exposed to the intense condom promotion that was in place a decade ago. Condom use at last higher risk sex reported by young women (aged 15 to 24 years) declined in five countries in western and central Africa and three countries in eastern and southern Africa. Condom use at higher risk sex among men (aged 15 to 49 years) also declined in five out of nine countries (compared to the previous survey). The use of condoms across all of western and central Africa and eastern and southern Africa remains far too low.

It is a morning like any other at the Thai Red Cross AIDS Research Centre, a civil society organization operating under the umbrella of the Thai Red Cross Society. In a building in the heart of Bangkok, nurses, doctors, counsellors and peer educators are busy with their daily work, providing HIV services for the 200 people who attend the Thai Red Cross Anonymous Clinic every day for medical check-ups, HIV tests and HIV prevention services, including condoms and pre-exposure prophylaxis (PrEP).

When he was 35 years old, Praphan Phanuphak―the Director of the centre, which he co-founded in 1989―discovered the first case of HIV in Thailand. “It happened by accident. A patient was referred to me to investigate why he had a recurrent fungal skin infection,” he recalled. “In February 1985, this patient was admitted with pneumocystis pneumonia. During that month, another man was referred to the hospital with generalized cryptococcus infection. Both were diagnosed with HIV. Since then, I have devoted my life to treating people living with HIV and developing solutions to expand access to HIV services in the country.”

Mr Praphan remembers that in the early days of HIV the response in Thailand faced several challenges. At the time, Thai law required hospitals to report the names of people diagnosed with HIV to the Ministry of Public Health, which contributed to increasing stigma and discrimination against people living with HIV. In response, the Thai Red Cross established the Thai Red Cross Anonymous Clinic, Asia’s first anonymous clinic, and advocated with the Thai Government to remove the reporting law. The Anonymous Clinic remains the most renowned centre providing voluntary HIV testing in the country.

“Until the beginning of 2000, antiretroviral medicines were not available through public health facilities in Thailand, and many people living with HIV could not afford to buy them,” said Mr Praphan. He said that in 1996 the Thai Red Cross AIDS Research Centre was the first to provide free antiretroviral medicines as part of its clinical trials through the HIV Netherlands–Australia–Thailand Research Collaboration.

“After years of despair, a time of hope finally came. For that, I want to thank Her Royal Highness Princess Soamsawali, who stood by our side by setting up a fund for the prevention of mother-to-child transmission of HIV in 1996, several years before the Thai Government started its successful prevention programme,” said Mr Praphan.

The AIDS response in Thailand has changed dramatically over the years. In 2006, Thailand integrated its HIV services, including antiretroviral therapy, into its universal health coverage scheme. Since 2014 Thailand has provided antiretroviral therapy for all regardless of their CD4 level. Everyone can access treatment for free, and people living with HIV are offered treatment immediately after diagnosis.

However, many people are starting antiretroviral therapy late. “We have the medicines, but many people are not being diagnosed fast enough,” warned Mr Praphan. Despite tremendous progress, the HIV epidemic is not yet over in Thailand. HIV remains concentrated among key populations: almost 50% of new HIV infections in 2018 were among gay men and other men who have sex with men. Low uptake of HIV testing among key populations is related to the acceptability of services and stigma and discrimination, which hinder access to HIV diagnosis, prevention and care.

“From our experience, helping key populations to reach their peers and bring them to HIV drop-in centres, where they can be tested, is the best way to detect and diagnose people living with HIV early enough,” said Mr Praphan, who successfully advocated to amend Thai law to allow certified lay providers from key populations to provide a number of HIV services.

The Thai Red Cross AIDS Research Centre’s approach focuses on undertaking pilot projects to generate evidence to inform national planners and policymakers. That evidence provides a foundation for national acceptance and the roll-out of innovation on a national scale.

Taking the lead in reaching out to key populations, the centre has been offering PrEP to people at substantial risk of HIV since 2014 through projects such as the Princess PrEP Programme. In October 2019, Thailand introduced PrEP under its universal health coverage benefits package as a pilot phase in efforts to scale up PrEP nationwide.

Mr Praphan believes that policymakers and programme implementers should understand that, “We cannot continue to do business as usual. In Asia and the Pacific, several countries are still either sceptical or conservative in terms of promoting the necessary approaches to change the course of the HIV epidemic.” He thinks that the region cannot achieve the 90–90–90 targets by 2020 at the current pace. “We need to think out of the box and look at what other countries are doing that can be taken as a model. This is how we can move faster on our way towards ending AIDS as a public health threat.”

Condoms, if easily available and used consistently and correctly, are one of the most effective and inexpensive methods available to reduce the sexual transmission of HIV and other sexually transmitted infections and to prevent unintended pregnancy. Despite this, condoms are still not sufficiently available to those who need them in many countries with a high burden of HIV.

The estimated condom need in 47 countries in sub-Saharan Africa in 2015 was 6 billion male condoms; however, only an estimated 2.7 billion condoms were distributed.

HIV and other sexually transmitted infections and unintended pregnancies continue to pose a high health burden for millions of people, especially young women and key populations.

Data presented during a session of the 2018 International AIDS Conference, held in Amsterdam, Netherlands, from 23 to 27 July, entitled Condoms 2.0: Reinvigorating Effective Condom Programming in the Era of Epidemic Control, shows that condom promotion has averted an estimated 50 million new HIV infections since the onset of the HIV epidemic. Condom use at last higher-risk sex has increased over the past three decades in most countries across the world and is as high as 80–90% in some countries. Furthermore, in all countries for which data are available, a steady decrease in new adult HIV infections between 2000 and 2016 is associated with steady increases and high levels (more than 60%) of condom use by both men and women at last sex with a non-regular partner and condom use by men at last paid sex.

However, 30 years into the response to HIV and despite the increased use of condoms over the past three decades, condom availability and use gaps remain, in particular in sub-Saharan Africa, where the gap between availably and need is estimated to be more than 3 billion condoms. The estimated condom need in 47 countries in sub-Saharan Africa in 2015 was 6 billion male condoms; however, only an estimated 2.7 billion condoms were distributed.

The participants highlighted the many barriers and inequities hindering access to, and the use of, condoms that continue to exist, including poor access, age restrictions, gender norms, religious norms, stigma, insufficient supply and, in some places, laws that make it an offence to carry condoms. Many countries also prohibit condom promotion and distribution in schools and other venues where adolescents socialize. According to the participants, of the 100 countries that reported having a national plan or strategy related to condoms in 2017, only 26 reported that the plan included condom promotion in secondary schools.

International funding for condom procurement in sub-Saharan Africa has decreased in recent years, and domestic funding has not sufficiently increased, the participants noted. In several countries condom programming, in particular condom promotion and demand creation, has stalled due to a lack of funding and decreased investment.

During the session, the participants stressed the need for a new generation of comprehensive, data-driven and people-centred condom programmes as part of the delivery of combination HIV prevention and sexual and reproductive health services for people at higher risk of HIV and other sexually transmitted infections and unintended pregnancies.

These new programmes should aim at strengthening demand for and supply of condoms and lubricants and address the barriers and inequities that hinder the demand for and the provision, access and use of condoms by young people, key populations and other people at higher risk of HIV. Furthermore, condom promotion and distribution strategies and approaches need to be informed by data, tailored to the context and needs of different communities.

Lastly, the participants agreed on the need to set up effective multistakeholder condom programming coordination and oversight platforms and ensure the full involvement of beneficiaries and communities in planning, service delivery and monitoring.