Since the first description of the human immunodeficiency virus (HIV) more than 35-years ago, its high transmission rate continues to pose serious public health concerns around the globe [1]. Statistics from the World Health Organization (WHO) estimates that the virus has infected more than 70 million people since the first case was discovered in 1981 50% of whom have succumbed to the infection [2]. The WHO further projected that by the conclusion of 2017, between 31-43.9 million worldwide were HIV positive, with the highest rates (24.9 million) occurring in sub-Saharan Africa. In the United States (US), 93% of the 44,000 new cases of HIV reported in 2014 were mainly transmitted through sexual means [3]. As per the Center for Disease Control and Prevention (CDC) publication, a significant proportion of the incidences were detected among individuals who failed to apply condoms completely, or used incorrectly, and/or inconsistently [1, 4, 5].

Even though beyond 80% of the 1.2 million HIV positive Americans know their HIV status and 40% are receiving antiretroviral therapy (ART), the rest (approximately 20%) are unaware that they are infected and may spread it to others [6]. Likewise, a significant number of HIV-negative people have no idea of the status of their sexual partners [7]. Besides, other empirical findings suggest that the adoption of ART is known to help in the deterrence of HIV transmission by suppressing viral load in the victim’s blood, implying that undetectable viral load is ‘untransmittable’ during sex [8]. Nonetheless, a significant number of HIV patients do not observe the optimal degree of medication compliance that is needed to curb viral multiplication; therefore, they may still pass on the virus to their partners [7, 9-12]. Irrespective of an individual's level of compliance to ART or his or her HIV status awareness, it is projected that the right and constant use of condoms decreases the odds of spreading HIV via sexual means by 70% in both heterosexual couples and men having sex with men (MSM) [13, 14]. As such, behavioral strategies that ensure the availability of condoms have been the backbone of HIV mitigation attempts at the community, local, state and national levels in most countries. Regularly, Condom Distribution Initiatives (CDI), which are frequently employed in combination with other strategies, like health promotion activities and awareness creation, intent on ensuring condoms are extensively accepted, availed, and/or accessed by people at increased risk of acquiring HIV [7]. Malekinejad et al. posit that the application of many interventions alongside CDI enables public health efforts to straightforwardly and incidentally heighten the impact of CDI by revealing the socio-economic, attitudes, knowledge, and behavioral factors that shape condom use [1].

Nonetheless, the efficacy of condom applications in declining incidences of HIV, especially in high-risk populations, is compromised by lack and incorrect usage of the condom by the consumers [15]. For instance, the WHO outlined that the male condom has a specific failure rate of 15%, and 2% when used correctly as a birth control measure [2]. Extrapolated over the global population, this four-fold disparity poses significant consequences for the world's growth in population and, subsequently, health resources. The difference between incorrect and precise use has comparable relevance for the mitigation of Sexually Transmitted Infections (STIs) and HIV, implying that thousands of new infections can be prevented by enhanced user efficiency. The incongruity between perfect and typical rates of letdowns is ascribable to the amalgamation of both erroneous and unreliable use [15]. Considerably, much focus has been paid on the regularity of condom usage, and few studies have highlighted the specifics of consumer mistakes and challenges. Besides, there is a wealth of literature on the evaluation of distribution interventions instead of mistakes incurred during use. For instance, two recently published systematic analyses investigated the influence of condom use on HIV prevention in communities, but they diverged on the description of “community.” While Moreno et al. considered “community” to represent a geographical setting, like a district or city [16], Charania et al. used the term to imply institutions and establishments that host non-geographically demarcated sub-groups, like “the MSM community” [17]. In both studies, “community” is utilized incorrectly and, as a pragmatic issue, it is best for scientific reviews to encompass investigations employing the two perspectives [16, 17]. Moreover, while the former included randomized controlled trials (RCTs) from all over the world except the U.S, the latter incorporated many US-based non-RCTs and RCTs. Also, none proved if CDI decreased the occurrence rate of HIV, but both articles found a positive correlation between CDI and behavioral outcomes.

The aim of the systematic review is to investigate the occurrence and the associated impacts of errors in condom use among populations at high risk of HIV infection.

As illustrated in Table 1, the systematic review encompassed the synthesis of findings of 20 peer-reviewed articles published between January 2000 and January 2019, reporting on the occurrence of condom use errors and problems among HIV high-risk populations. The temporal restriction allowed for comparison of the occurrence of condom use errors and challenges identified in the previously issued integrative review that included 50 papers issued between 1995-2012 [18]. The outcomes of the current systematic review illustrated that errors in condom use are common occurrences across the globe. Besides, although most of the selected investigations involve men having sex with men, the inclusion of diverse high-risk populations, including female sex workers, refugees, young heterosexual Black and Caucasian men, HIV discordant couples, college students, and sexually active female adolescents, indicate that condom-use mistakes and problems are placing millions of individuals at increased risk of acquiring or transmitting HIV. The predominant blunders encompass failure to eradicate the air at the tip of the condom before use, erection loss during application and while having coitus, experiencing discomfort due to “fit” and feel issues, complete disregard of condom use, inconsistent application (delayed application or removal before the end of the act), wearing the condom inside out, and most commonly, slippage and breakage errors.

From the synthesis of findings, the second largest proportion of the investigations were those exploring the occurrences of breakage and slippage faults? Undoubtedly, these investigations are essential provided that ruptures and slippage are the main types of failures in condom use. As stated by one study, the errors mentioned above place the sexual partner at extremely high risk of acquiring HIV through direct contact with fluids or a penis [18]. For instance, incident approximates of late application of condoms after unprotected anal or vaginal sex are frequently extensive compared to those for slippage or breakage. Therefore, this inaccuracy may embody a more probable risk of exposure than in rupture or slip-up.

In addition, grounded on correlates of condom errors in the explored studies, it is likely that users experience slippage and breakage frequently due to the simultaneous occurrence of other errors, or risky behaviors. For instance, the wrong way of handling or rolling on the condom on to the penis by opening the packet using a sharp object has been associated with the rupture of the condom [23, 42, 43]. These studies found that slippage/breakage was common among users with multiple sexual partners, those experiencing erection loss, failure to read and follow the instruction manual, and lack of confidence to use it owing to previous experience. In this regard, breakage may also be correlated with age, such that younger individuals like students, who are considered less experienced are likely to encounter breakage than older adults [24]. In addition, individuals with a high school level of education and below, particularly among racial minorities are more likely to encounter condom breakage. This is probably owing to the failure to observe the necessary information or they have not received adequate knowledge on the best approach of avoiding errors [20].

Condom slippage or breakage can remarkably demoralize a user's drive to employ a protective condom. Equally, the absence of self-efficacy and incentive to wear condoms may result in conducts, which might elevate the probability of condom slippage or breakage. In one of the investigations, the likelihood of incurring breakage/slippage is greater among people with many other mistakes. Thus, incomplete protection by the condom causes leakage, breakage/slippage, alongside other mistakes that can result in increased vulnerability to HIV and STIs. Another study also shows that condom failure also ensues following cases of erratic or complete disregard of condoms irrespective of the sexual event [25]. Thus, impactful interventions may be accomplished by conducting an extensive assessment of the incidences of other errors and challenges that precipitate the occurrence of breakage or slippage. One such error is that of incomplete use, which was reported by most of the selected studies in the present review.

Late application or early condom withdrawal before the conclusion of the penetrative intercourse has often been explored, and empirical evidence suggests that it is regularly reported. Nonetheless, irrespective of their pervasiveness, the exact length of time users takes before putting on a condom in the delayed application is unexplained. With regards to early condom withdrawal, it is evident that problems associated with loss of erection [22, 31]., and discomfort due to “fit” and feel issues are some of the antecedents for removal before the end of the act [27, 31]. Empirical evidence strongly suggests that protected sex remains the major public health intervention in curbing the rise of new HIV infections [31], particularly among young Black MSM [36]. This review concurs noting that young men may encounter difficulties with condoms that result in loss of erection, and are frequently reported among participants having multiple sexual partners and amidst people who engage in sex while under the influence of alcohol. Erection loss due to condom use remains an under-investigated subject; however, from the presented outcomes it is a strong predictor of slippage/breakage and incomplete use [27, 39]. It is also an essential determinant of perceptions towards prospective use of a condom.Even though the current systematic review recommends the correct use of condoms to prevent the transmission of HIV infections, innovative approaches, such as pre-exposure prophylaxis (PrEP) and treatment as prevention (TasP), have been identified to be more successful than condoms [43, 44]. Therefore, the aforementioned HIV preventive techniques are suggested as alternatives of condoms. We should consider, anyway, that HIV effective treatment or prophilaxys are not available in all countries and especially in low resources ones that are, as a matter of fact, the more interested in HIV transmission. In addition, we should consider that transmission of other sexually transmitted infections still need a correct use of condom to be prevented.

Although the study’s results are supported by the existing literature, heightening the findings’ validity, they still have some limitations. First, an overwhelming majority of the appraised investigations were conducted in industrialized economies, mostly in the United States. In fact, excluding two papers issued in Cambodia and South India focusing on the risk factors for incomplete use and errors when using condoms, all the other eighteen studies were carried out in the U.S, Canada, China, and European countries. Besides, the two papers mentioned above did not identify the specific types of intimate partners or sexual activity associated with condom use errors. Yet, the burden of HIV/AIDS has been acknowledged to be more widespread in developing rather than in resource-rich countries [45, 46]. Therefore, additional studies that focus on participants from a broader array of countries, especially from evolving economies, are necessary. The upshots of such analyses will influence the formulation and implementation of strategies to foster the production of consistent condoms and subsequently, reduce HIV transmissions. Another major limitation of the systematic review is that a large share of the appraised articles relied on self-reports, which are likely to suffer from recall bias. Specifically, the majority of the articles did not mention the self-reporting tools employed in collecting the participants’ data. Hitherto, the selection of self-report instruments with sufficient measurement qualities for the evaluation of condom use errors is necessary, given that the diversity of measures associated with condom use mistakes and problems are related to multidimensional constructs. Lastly, the selection of English articles only has potentially introduced language bias in the current systematic review. Therefore, further studies should focus on using other data collection techniques alongside self-reports, as well as consideration of non-English publications to avoid language bias in future systematic reviews.

Nonetheless, it is clear from the synthesized findings that condom errors, particularly slippage/breakage and incomplete use, are common among adults, youth, and sexually active adolescents. The review recommends the heightening of condom use promotion initiatives that highlight both the correct and consistent application of the condom. In this case, both patients and clients should plan ahead before intercourse, and during the act, the user should ensure the condom is not expired, create room for safe opening by pushing the condom to one corner, and avoid the use of sharp item, like fingernails, razor, or teeth, in opening the condom package. Similarly, users should learn how to correctly wear the condom, including applying it before making any contact with the partner's vaginal, oral, or anal regions. After ejaculation, the user ought to hold the base of the condom when removing to avoid leakage or slips, and in case of any form of failure during intercourse, the act should be stopped, and it is necessary to apply a new one.