The Open AIDS Journal




ISSN: 1874-6136 ― Volume 14, 2020
SYSTEMATIC REVIEW

Errors in Condom Use in the Setting of HIV Transmission: A Systematic Review



Alwazzeh Marwan Jabr1, Mariantonietta Di Stefano2, Pantaleo Greco3, Teresa Santantonio2, Jose Ramon Fiore1, 2, *
1 Department of Internal Medicine, Unit of Infectious Diseases, King Fahad Hospital of the University, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
2 Department of Clinical and Experimental Medicine, Clinic of Infectious Diseases, University of Foggia, Foggia, Italy
3 Department of Morphology, Surgery and Experimental Medicine, Section of Obstetrics and Gynaecology, University of Ferrara, Ferrara, Italy

Abstract

Background:

The efficacy of condom use in declining HIV transmission may be compromised by their incorrect usage. Much focus has been paid on the regularity of condom usage but consumer mistakes and challenges must be considered. Breakage, slipping, leakage, incomplete use and other problems during the sexual event may compromise the protective role of the condom.

Objective:

To evaluate through a systematic review of published data, the type, and incidence of error and problems in condom use, and their possible role in reducing the preventive action of condoms.

Methods:

A systematic literature search for peer-reviewed articles published between January 2000 and January 2019, issued in English in peer-reviewed journals, and reporting the occurrence of condom errors/problems among HIV high-risk populations.

Results:

Twenty studies representing nine countries met the inclusion criteria. The most predominant mistakes associated with condom use included condom breakage, slippage, delayed condom application, early removal, issues related to erection loss and difficulties with fit and feel were reported, failure to squeeze out air, use of expired condoms, reuse of condom, and wearing the condom outside out were other issues noticed.

Conclusions:

Condom use problems and mistakes are prevalent across the globe. Educational efforts are needed to empower HIV the at-risk population with confidence and knowledge to improve correct condom use and increase preventive activity

Keywords: Breakage, Condom, Errors, HIV, Mistakes, Slippage.


Article Information


Identifiers and Pagination:

Year: 2020
Volume: 14
First Page: 16
Last Page: 26
Publisher Id: TOAIDJ-14-16
DOI: 10.2174/1874613602014010016

Article History:

Received Date: 21/10/2019
Revision Received Date: 14/01/2020
Acceptance Date: 21/01/2020
Electronic publication date: 20/03/2020
Collection year: 2020

© 2020 Jabr et al.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: https://creativecommons.org/licenses/by/4.0/legalcode. This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


* Address correspondence to this author at the Department of Clinical and Experimental Medicine, Clinic of Infectious Diseases, OO.RR Viale Pinto n.1 71121 Foggia Italy; Tel: +39 3284732048; Email: jose.fiore@unifg.it





1. BACKGROUND

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 [1Malekinejad M, Parriott A, Blodgett JC, et al. Effectiveness of community-based condom distribution interventions to prevent HIV in the United States: A systematic review and meta-analysis. PLoS One 2017; 12(8.) Available from: http://www.embase.com/search/results? subaction=viewrecord&from=export&id=L617642247%0Ahttp://dx.doi.org/10.1371/journal.pone.0180718
[http://dx.doi.org/10.1371/journal.pone.0180718] [PMID: 28771484]
]. 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 WHO. Global Health Observatory data: HIV/AIDS [Internet]. WHO. World Health Organization; 2018 [cited 2019 Jan 25]. Available from: https://www.who.int/gho/hiv/en/]. 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 [3Centers for Disease Control and Prevention. HIV Surveillance Report 2014. Glob Heal Sci Pract 2015; 2(1): 1-28. Available from: http://www.jstor.org/stable/2138017?origin=crossref%5Cnhttp://www.nsf.gov/pubs/1997/nsf97153/chap_4.htm%5Cnhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=17652268%5Cnhttp://www.cdc.gov/hiv/library/reports/surv]. 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 [1Malekinejad M, Parriott A, Blodgett JC, et al. Effectiveness of community-based condom distribution interventions to prevent HIV in the United States: A systematic review and meta-analysis. PLoS One 2017; 12(8.) Available from: http://www.embase.com/search/results? subaction=viewrecord&from=export&id=L617642247%0Ahttp://dx.doi.org/10.1371/journal.pone.0180718
[http://dx.doi.org/10.1371/journal.pone.0180718] [PMID: 28771484]
, 4Fladseth K, Gafos M, Newell ML, McGrath N. The impact of gender norms on condom use among HIV-positive adults in KwaZulu-Natal, South Africa. PLoS One 2015; 10(4) e0122671 http://www.embase.com/search/results?subaction=viewrecord&from=export&id=L604108659%0Ahttp://dx.doi.org/10.1371/journal.pone.0122671%0Ahttp://vu.on.worldcat.org/atoztitles/link?sid=EMBASE&issn=19326203&id=doi:10.1371%2Fjournal.pone.0122671&atitle=The+impa
[http://dx.doi.org/10.1371/journal.pone.0122671] [PMID: 25853870]
, 5Lau JTF, Zhou H, Su XY, et al. Condoms used but sex not well protected. AIDS Behav 2014; 18(10): 1934-44.
[http://dx.doi.org/10.1007/s10461-013-0690-y] [PMID: 24452496]
].

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 [6Bradley H, Hall HI, Wolitski RJ, et al. Vital Signs: HIV diagnosis, care, and treatment among persons living with HIV--United States, 2011. MMWR Morb Mortal Wkly Rep 2014; 63(47): 1113-7.http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6347a5.htm?s_cid=mm6347a5_w
[PMID: 25426654]
]. Likewise, a significant number of HIV-negative people have no idea of the status of their sexual partners [7Mendelsohn JB, Calzavara L, Daftary A, et al. A scoping review and thematic analysis of social and behavioural research among HIV-serodiscordant couples in high-income settings. BMC Public Health 2015; 15(1): 241.
[http://dx.doi.org/10.1186/s12889-015-1488-9] [PMID: 25885027]
]. 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 [8Rendina HJ, Parsons JT. Factors associated with perceived accuracy of the Undetectable = Untransmittable slogan among men who have sex with men: Implications for messaging scale-up and implementation. J Int AIDS Soc 2018; 21(1): 1-10.
[http://dx.doi.org/10.1002/jia2.25055] [PMID: 29334178]
]. 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 [7Mendelsohn JB, Calzavara L, Daftary A, et al. A scoping review and thematic analysis of social and behavioural research among HIV-serodiscordant couples in high-income settings. BMC Public Health 2015; 15(1): 241.
[http://dx.doi.org/10.1186/s12889-015-1488-9] [PMID: 25885027]
, 9Sweeney SM, Vanable PA. The Association of HIV-Related Stigma to HIV Medication Adherence: A Systematic Review and Synthesis of the Literature. AIDS Behav 2016; 20(1): 29-50.
[http://dx.doi.org/10.1007/s10461-015-1164-1] [PMID: 26303196]
-12Grulich A, Bavinton B, Jin F, Prestage G, Zablotska I, Grinsztejn B, et al. HIV Transmission in Male Serodiscordant Couples in Australia, Thailand and Brazil | CROI Conference. In: P-W3: Risk Factors for Transmission in MSM. 2015 [cited 2019 Jan 25]. Available from: http://www.croiconference.org/sessions/hiv-transmission-male-serodiscordant-couples-australia-thailand-and-brazil]. 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) [13Smith DK, Herbst JH, Zhang X, Rose CE. Condom Effectiveness for HIV Prevention by Consistency of Use Among Men Who Have Sex With Men in the United States. JAIDS J Acquir Immune Defic Syndr 2015 Mar; 1 [[cited 2019 Jan 25]];68(3): 337-44. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25469526
[http://dx.doi.org/10.1097/QAI.0000000000000461]
, 14Kennedy CE, Medley AM, Sweat MD, O’Reilly KR. Behavioural interventions for HIV positive prevention in developing countries: a systematic review and meta-analysis. Bull World Health Organ 2010; 88(8): 615-23.http://www.who.int/bulletin/volumes/88/8/09-068213.pdf [Internet].
[http://dx.doi.org/10.2471/BLT.09.068213] [PMID: 20680127]
]. 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 [7Mendelsohn JB, Calzavara L, Daftary A, et al. A scoping review and thematic analysis of social and behavioural research among HIV-serodiscordant couples in high-income settings. BMC Public Health 2015; 15(1): 241.
[http://dx.doi.org/10.1186/s12889-015-1488-9] [PMID: 25885027]
]. 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 [1Malekinejad M, Parriott A, Blodgett JC, et al. Effectiveness of community-based condom distribution interventions to prevent HIV in the United States: A systematic review and meta-analysis. PLoS One 2017; 12(8.) Available from: http://www.embase.com/search/results? subaction=viewrecord&from=export&id=L617642247%0Ahttp://dx.doi.org/10.1371/journal.pone.0180718
[http://dx.doi.org/10.1371/journal.pone.0180718] [PMID: 28771484]
].

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 [15United Nations Population Fund. UNFPA, WHO and UNAIDS: Position statement on condoms and the prevention of HIV, other sexually transmitted infections and unintended pregnancy. Bull World Health Organ 2015 Aug; 1 [[cited 2019 Jan 25]];90(8): 613-22. Available from: http://www.who.int/bulletin/volumes/90/8/11-094268.pdf]. 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 WHO. Global Health Observatory data: HIV/AIDS [Internet]. WHO. World Health Organization; 2018 [cited 2019 Jan 25]. Available from: https://www.who.int/gho/hiv/en/]. 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 [15United Nations Population Fund. UNFPA, WHO and UNAIDS: Position statement on condoms and the prevention of HIV, other sexually transmitted infections and unintended pregnancy. Bull World Health Organ 2015 Aug; 1 [[cited 2019 Jan 25]];90(8): 613-22. Available from: http://www.who.int/bulletin/volumes/90/8/11-094268.pdf]. 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 [16Moreno R, Nababan HY, Ota E, Wariki WM, Ezoe S, Gilmour S, et al. Structural and community-level interventions for increasing condom use to prevent the transmission of HIV and other sexually transmitted infections. Cochrane Database Syst Rev 2014 Jul; 29 [[cited 2019 Jan 25]];(7): CD003363. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25072817
[http://dx.doi.org/10.1002/14651858.CD003363.pub3]
], Charania et al. used the term to imply institutions and establishments that host non-geographically demarcated sub-groups, like “the MSM community” [17Charania MR, Crepaz N, Guenther-Gray C, et al. Efficacy of structural-level condom distribution interventions: a meta-analysis of U.S. and international studies, 1998-2007. AIDS Behav 2011; 15(7): 1283-97.
[http://dx.doi.org/10.1007/s10461-010-9812-y] [PMID: 20886277]
]. 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 [16Moreno R, Nababan HY, Ota E, Wariki WM, Ezoe S, Gilmour S, et al. Structural and community-level interventions for increasing condom use to prevent the transmission of HIV and other sexually transmitted infections. Cochrane Database Syst Rev 2014 Jul; 29 [[cited 2019 Jan 25]];(7): CD003363. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25072817
[http://dx.doi.org/10.1002/14651858.CD003363.pub3]
, 17Charania MR, Crepaz N, Guenther-Gray C, et al. Efficacy of structural-level condom distribution interventions: a meta-analysis of U.S. and international studies, 1998-2007. AIDS Behav 2011; 15(7): 1283-97.
[http://dx.doi.org/10.1007/s10461-010-9812-y] [PMID: 20886277]
]. 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.

1.1. The Rationale of the Study

Regrettably, there are few investigations that have paid attention to the assessment of the correlates and prevalence of errors and problems that individuals may encounter when wearing condoms [18Sanders SA, Yarber WL, Kaufman EL, Crosby RA, Graham CA, Milhausen RR. Condom use errors and problems: a global view. Sex Health 2012; 9(1): 81-95.
[http://dx.doi.org/10.1071/SH11095] [PMID: 22348636]
]. In this context, errors imply those practices that result in the wrong use of the condom, such as removing during the sexual act or exposing the condom to sharp appliances, while problems are those occurrences that are not straightforwardly within the control of the user, but may reduce the efficacy of its purpose. The issues may include challenges with fit and feel, slippage, breakage and erection difficulties [18Sanders SA, Yarber WL, Kaufman EL, Crosby RA, Graham CA, Milhausen RR. Condom use errors and problems: a global view. Sex Health 2012; 9(1): 81-95.
[http://dx.doi.org/10.1071/SH11095] [PMID: 22348636]
]. Notably, neglecting to justify condom use errors and problems can result in false inferences with respect to condom efficacy or appraisal of deterrence initiatives. Besides, the suggested mistakes and problems may not only reduce the effectiveness of condoms in the mitigation of new HIV infections but may also dampen its uptake by causing frustrations or if users experience less pleasurable sex life due to them.

2. OBJECTIVE

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.

3. METHODOLOGY

3.1. Search Strategy

Hand and automatic searches were conducted to guarantee the inclusion of all the appropriate studies. The automatic query was performed in three online databases, namely: PubMed, EMBASE, and PsychINFO for English papers published between January 2000 and January 2019. The search was limited to the aforementioned time frame since a previously published systematic review had covered articles published between 1995-2012. The search was done using a combination of diverse Boolean phrases, including: [“human immunodeficiency virus” or “HIV”, “acquired immunodeficiency syndrome” or “AIDS”] and [“condom failure rates” or “incomplete use” or “condom errors”] and [“homosexual” or “sexual” or “coital” or “heterosexual” or “anal” or “intercourse” or “oral”]. Due to indexing gaps, a hand search of key journals, including AIDS and Behavior, AIDS, and AIDS Education, that often issue research on Sexually Transmitted Infections (STI) and HIV was carried out to locate extra intervention studies (Appendix. 1).

Figure 1
Prisma flow diagram


3.2. Study Selection

Articles were selected if 1) reported on the occurrence of condom errors/problems among HIV high-risk populations (MSM, serodiscordant couples, female sex workers) irrespective of study design, 2) if they were published between January 2000 and January 2019, and 3) it is issued in English, and the full text is available in a peer-reviewed journal. Out of the n=2,025 relevant studies, n=515 duplicate citations were removed. Abstracts of the n=1,510 articles were further screened leading to the elimination of another n=1357. Of the remaining n=153 studies, n=133 did not meet the inclusion criteria. Therefore, only n=20 investigations met the inclusion criteria and they were selected for appraisal in the systematic review (Fig. 1).

Two authors [AMJ & MDS] independently extracted data from the selected articles using standardized forms. For every investigation, the reviewers extracted the following data: citation, research framework, methods, study setting, outcomes, results, and limitations. The two reviewers then matched the extracted information and resolved differences through discussion and consensus. The methodological quality of all the selected papers was assessed using the Critical Appraisal Skills Programme (CASP), and all of the studies that met the systematic review’s inclusion criteria were presented in a tabular format (Table 1). The extracted data were synthesized thematically by first assembling the outcomes as per their quality, classifying the results based on the similarity in meaning, and lastly, subjecting the groupings to generate a single detailed set of synthesized results. Eventually, the findings were documented and reported in accordance with the PRISMA guidelines.

4. RESULTS

4.1. Characteristics of the Studies

Twenty studies conducted in nine countries fulfilled the inclusion criteria, and they documented outcomes for the use of condoms for either anal or vaginal penetration or both. Of the twenty articles, two were systematic reviews [18Sanders SA, Yarber WL, Kaufman EL, Crosby RA, Graham CA, Milhausen RR. Condom use errors and problems: a global view. Sex Health 2012; 9(1): 81-95.
[http://dx.doi.org/10.1071/SH11095] [PMID: 22348636]
, 19Giannou FK, Tsiara CG, Nikolopoulos GK, Talias M, Benetou V, Kantzanou M, et al. Condom effectiveness in reducing heterosexual HIV transmission: a systematic review and meta-analysis of studies on HIV serodiscordant couples. Expert Rev Pharmacoecon Outcomes Res 2016 Jul; 3 [[cited 2019 Jan 29]];16(4): 489-99. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26488070
[http://dx.doi.org/10.1586/14737167.2016.1102635]
], seven employed surveys [20Kim M, McKenney J, Khosropour CM, Prater AB, Rosenberg ES, Siegler AJ, et al. Factors Associated With Condom Breakage During Anal Intercourse: A Cross-Sectional Study of Men Who Have Sex With Men Recruited in an Online Survey. JMIR public Heal Surveill 2016 [[cited 2019 Jan 25]];2(1)e7 Available from: http://www.ncbi.nlm.nih.gov/pubmed/27227161
[http://dx.doi.org/10.2196/publichealth.5298]
-26Crosby R, DiClemente RJ, Wingood GM, et al. Correct condom application among African-American adolescent females: the relationship to perceived self-efficacy and the association to confirmed STDs. J Adolesc Health 2001; 29(3): 194-9.
[http://dx.doi.org/10.1016/S1054-139X(01)00273-7] [PMID: 11524218]
], ten were cross-sectional [19Giannou FK, Tsiara CG, Nikolopoulos GK, Talias M, Benetou V, Kantzanou M, et al. Condom effectiveness in reducing heterosexual HIV transmission: a systematic review and meta-analysis of studies on HIV serodiscordant couples. Expert Rev Pharmacoecon Outcomes Res 2016 Jul; 3 [[cited 2019 Jan 29]];16(4): 489-99. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26488070
[http://dx.doi.org/10.1586/14737167.2016.1102635]
, 27Hernández-Romieu AC, Siegler AJ, Sullivan PS, Crosby R, Rosenberg ES. How often do condoms fail? A cross-sectional study exploring incomplete use of condoms, condom failures and other condom problems among black and white MSM in southern U.S.A. Sex Transm Infect 2014; 90(8): 602-7.
[http://dx.doi.org/10.1136/sextrans-2014-051581] [PMID: 25080511]
-36Crosby R, Mena L, Yarber W, Graham C, Sanders S, Milhausen R. Condom Use Errors and Problems: A Comparative Study of HIV- Positive Versus HIV-Negative Young Black MSM. Sex Transm Dis 2016; 15(5): 477-91.], and one was a simulation-based study that used structural-modeling [36Crosby R, Mena L, Yarber W, Graham C, Sanders S, Milhausen R. Condom Use Errors and Problems: A Comparative Study of HIV- Positive Versus HIV-Negative Young Black MSM. Sex Transm Dis 2016; 15(5): 477-91.]. Most of the studies took place in the United States (n=8), and one each in Canada, Scotland, China, South India, Cambodia, Italy, Croatia and Australia. Excluding the systematic reviews, 44% (n=8/18) involved men having sex with men, 11% (n=2/18) involved heterosexual men, 5.6% (1/18) on discordant couples, another two involved female sex workers and asylum seekers, while 16.7% (n=3/18) were heterosexual male and females.

Generally, two kinds of incidence approximate are considered, namely: 1) the fraction of respondents reporting an error(s) or problem(s) during condom use within a certain follow-up period, or 2) percentage of occurrences for which a problem or a failure transpired. Even though diverse terms were employed across the reviewed articles, the errors and mistakes were categorized into four major themes, namely: 1) problems associated with condom failure, slippage, or breakage, 2) incomplete use (including failing to wear the condom from the start to the end of intercourse, comprising of removal before the end of the act, or late application), 3) other mistakes, such as failure to check the expiry date, exposure of the condom to sharp objects, failure to squeeze out the air at the tip, wearing it inside out, re-use of the condom, and poor storage. Finally, 4) are the challenges with condom-related erection problems, including the fit/feel of condom, and erection loss during intercourse or while rolling on.

4.2. Condom Failure: Slippage or Breakage during Intercourse

Condom breakage frequencies varied from 3% to 37% among the respondents across n=10 studies [20Kim M, McKenney J, Khosropour CM, Prater AB, Rosenberg ES, Siegler AJ, et al. Factors Associated With Condom Breakage During Anal Intercourse: A Cross-Sectional Study of Men Who Have Sex With Men Recruited in an Online Survey. JMIR public Heal Surveill 2016 [[cited 2019 Jan 25]];2(1)e7 Available from: http://www.ncbi.nlm.nih.gov/pubmed/27227161
[http://dx.doi.org/10.2196/publichealth.5298]
, 22Baćak V, Štulhofer A. Condom use errors and problems in a national sample of young Croatian adults. Arch Sex Behav 2012; 41(4): 995-1003.
[http://dx.doi.org/10.1007/s10508-011-9838-x] [PMID: 21882054]
-25D’Anna LH, Margolis AD, Warner L, Korosteleva OA, O’Donnell L, Rietmeijer CA, et al. Condom use problems during anal sex among men who have sex with men (MSM): Findings from the Safe in the City Study. AIDS Care - Psychol Socio-Medical Asp AIDS/HIV 2012; 24(8): 1028-38. , 27Hernández-Romieu AC, Siegler AJ, Sullivan PS, Crosby R, Rosenberg ES. How often do condoms fail? A cross-sectional study exploring incomplete use of condoms, condom failures and other condom problems among black and white MSM in southern U.S.A. Sex Transm Infect 2014; 90(8): 602-7.
[http://dx.doi.org/10.1136/sextrans-2014-051581] [PMID: 25080511]
, 29Crosby RA, DiClemente RJ, Yarber WL, Snow G, Troutman A. Young African American men having sex with multiple partners are more likely to use condoms incorrectly: a clinic-based study. Am J Men Health 2008; 2(4): 340-3.
[http://dx.doi.org/10.1177/1557988308321320] [PMID: 19477797]
-39Crosby RA, Charnigo RJ, Salazar LF, et al. Enhancing condom use among Black male youths: a randomized controlled trial. Am J Public Health 2014; 104(11): 2219-25.
[http://dx.doi.org/10.2105/AJPH.2014.302131] [PMID: 25211749]
]. Eight of the studies that reported breakage showed that the prevalence rates of slippage ranged between 2.1% and 28%. Some of these investigations detailed the exact time of the slippage during the sexual encounter (either when applying or when rolling out of the penis), while a number did not discuss the timing. Nonetheless, guesstimates for slippage at condom application and during withdrawal vacillated between 9% and 16% [27Hernández-Romieu AC, Siegler AJ, Sullivan PS, Crosby R, Rosenberg ES. How often do condoms fail? A cross-sectional study exploring incomplete use of condoms, condom failures and other condom problems among black and white MSM in southern U.S.A. Sex Transm Infect 2014; 90(8): 602-7.
[http://dx.doi.org/10.1136/sextrans-2014-051581] [PMID: 25080511]
, 29Crosby RA, DiClemente RJ, Yarber WL, Snow G, Troutman A. Young African American men having sex with multiple partners are more likely to use condoms incorrectly: a clinic-based study. Am J Men Health 2008; 2(4): 340-3.
[http://dx.doi.org/10.1177/1557988308321320] [PMID: 19477797]
]. Two studies identified ethnic/racial differences in terms of slippage rates. Black respondents posted a slippage frequency of condom twice as high than in their White counterparts. Leakage was also noted in one study [39Crosby RA, Charnigo RJ, Salazar LF, et al. Enhancing condom use among Black male youths: a randomized controlled trial. Am J Public Health 2014; 104(11): 2219-25.
[http://dx.doi.org/10.2105/AJPH.2014.302131] [PMID: 25211749]
].

Table 1
Summary of the reviewed articles


4.3. Incomplete Use

Ten of the studies reported cases of incomplete condom use, including failure to wear the during the whole act, early removal, or late application. In two of the studies, the type of inconsistency was not indicated or the faults were pooled in reporting [39Crosby RA, Charnigo RJ, Salazar LF, et al. Enhancing condom use among Black male youths: a randomized controlled trial. Am J Public Health 2014; 104(11): 2219-25.
[http://dx.doi.org/10.2105/AJPH.2014.302131] [PMID: 25211749]
-41Reis RK, Melo ES, Gir E. Factors associated with inconsistent condom use among people living with HIV/Aids. Rev Bras Enferm 2016 Feb; [[cited 2019 Jan 26]];69(1): 47-53. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26871214] and in two articles involving MSM, cases of unprotected anal sex were attributed to new HIV infections among the participants [35Goodall L, Clutterbuck D, Flowers P. Towards condom skills: a cross-sectional study of the association between condom proficiency, condom problems and STI risk amongst MSM. BMC Public Health 2012; 12(1): 747.
[http://dx.doi.org/10.1186/1471-2458-12-747] [PMID: 22950519]
, 37Remis R, Alary M, Liu J, Kaul R, Palmer R. HIV Transmission among Men Who Have Sex with Men due to Condom Failure. PLoS One 2008; 43(1): 206-10.
[PMID: 25211493]
], while one about female sex workers found a 2.6% rate of complete disregard for condom among their clients [5Lau JTF, Zhou H, Su XY, et al. Condoms used but sex not well protected. AIDS Behav 2014; 18(10): 1934-44.
[http://dx.doi.org/10.1007/s10461-013-0690-y] [PMID: 24452496]
]. In four investigations, combined regularity of delayed condom application and early removal was shown to vary between 12.3%-38% and 14%-36%, respectively [5Lau JTF, Zhou H, Su XY, et al. Condoms used but sex not well protected. AIDS Behav 2014; 18(10): 1934-44.
[http://dx.doi.org/10.1007/s10461-013-0690-y] [PMID: 24452496]
, 27Hernández-Romieu AC, Siegler AJ, Sullivan PS, Crosby R, Rosenberg ES. How often do condoms fail? A cross-sectional study exploring incomplete use of condoms, condom failures and other condom problems among black and white MSM in southern U.S.A. Sex Transm Infect 2014; 90(8): 602-7.
[http://dx.doi.org/10.1136/sextrans-2014-051581] [PMID: 25080511]
, 32Crosby R, Sanders S, Yarber WL, Graham CA. Condom-use errors and problems: a neglected aspect of studies assessing condom effectiveness. Am J Prev Med 2003; 24(4): 367-70.
[http://dx.doi.org/10.1016/S0749-3797(03)00015-1] [PMID: 12726876]
, 39Crosby RA, Charnigo RJ, Salazar LF, et al. Enhancing condom use among Black male youths: a randomized controlled trial. Am J Public Health 2014; 104(11): 2219-25.
[http://dx.doi.org/10.2105/AJPH.2014.302131] [PMID: 25211749]
] investigation, only the occurrence rate of delayed use at 34% was reported [22Baćak V, Štulhofer A. Condom use errors and problems in a national sample of young Croatian adults. Arch Sex Behav 2012; 41(4): 995-1003.
[http://dx.doi.org/10.1007/s10508-011-9838-x] [PMID: 21882054]
]. Similarly, two other studies recounted disparities of inconsistent condom application with respect to the number of partners or the type of relationship the respondents shared with their sexual partners. Crosby et al. found that 36% and 53.1% of respondents with ≤ 2 and ≥ 3 intimate partners recalled incomplete condom use in the past 60 days [29Crosby RA, DiClemente RJ, Yarber WL, Snow G, Troutman A. Young African American men having sex with multiple partners are more likely to use condoms incorrectly: a clinic-based study. Am J Men Health 2008; 2(4): 340-3.
[http://dx.doi.org/10.1177/1557988308321320] [PMID: 19477797]
], while in another study, the rates of inconsistency differed dependent on the type of sexual partners as follows: 21.9%, 24.1%, 27.0%, 29.7%, 35.8% and 44.9% for intimate partners who were male clients, female customers, male sex workers, female sex workers, boyfriends and girlfriends, respectively [30Zoboli F, Martinelli D, Di Stefano M, et al. Correlation between knowledge on transmission and prevention of HIV/STI and proficiency in condom use among male migrants from Africa and Middle East evaluated by a Condom Use Skills score using a wooden penile model. BMC Res Notes 2017; 10(1): 216.
[http://dx.doi.org/10.1186/s13104-017-2520-1] [PMID: 28629409]
].

4.4. Problems with “Fit” and Feel and Condom-Related Erection Difficulties

From the appraised investigations, condom-associated challenges can arise at application or during the act. Loss of penal erection can transpire during intercourse or when putting on the condom. Nonetheless, only a single study reported both cases at 15%, and 10%, respectively [32Crosby R, Sanders S, Yarber WL, Graham CA. Condom-use errors and problems: a neglected aspect of studies assessing condom effectiveness. Am J Prev Med 2003; 24(4): 367-70.
[http://dx.doi.org/10.1016/S0749-3797(03)00015-1] [PMID: 12726876]
], the findings of a systematic analysis included in the present review reported a range between 14.3%-28.1% and 9.9%-20.2% at application and during sex, respectively [18Sanders SA, Yarber WL, Kaufman EL, Crosby RA, Graham CA, Milhausen RR. Condom use errors and problems: a global view. Sex Health 2012; 9(1): 81-95.
[http://dx.doi.org/10.1071/SH11095] [PMID: 22348636]
]. Two other investigations did not specify whether the erection problem occurred at application or during the act but reported combined frequencies of 17% and 21%, respectively [22Baćak V, Štulhofer A. Condom use errors and problems in a national sample of young Croatian adults. Arch Sex Behav 2012; 41(4): 995-1003.
[http://dx.doi.org/10.1007/s10508-011-9838-x] [PMID: 21882054]
, 31Crosby RA, Milhausen RR, Sanders SA, Graham CA, Yarber WL. Condom use errors and problems: a study of high-risk young Black men residing in three Southern US cities. Int J STD AIDS 2014; 25(13): 943-8.
[http://dx.doi.org/10.1177/0956462414526707] [PMID: 24648319]
]. One other study reported erection loss as a common cause of breakage without outlining either the proportion of respondents who suffered or the period of occurrence [23Crosby RA, Yarber WL, Sanders SA, et al. Men with broken condoms: who and why? Sex Transm Infect 2007; 83(1): 71-5.
[http://dx.doi.org/10.1136/sti.2006.021154] [PMID: 16870644]
]. One study reported erection problems to be twice likely to affect respondents with ≥3 intimate partners than those with a single sexual associate [22Baćak V, Štulhofer A. Condom use errors and problems in a national sample of young Croatian adults. Arch Sex Behav 2012; 41(4): 995-1003.
[http://dx.doi.org/10.1007/s10508-011-9838-x] [PMID: 21882054]
]. Three studies reported difficulties with “fit” and feel with the prevalence of 23% and 54%, respectively [27Hernández-Romieu AC, Siegler AJ, Sullivan PS, Crosby R, Rosenberg ES. How often do condoms fail? A cross-sectional study exploring incomplete use of condoms, condom failures and other condom problems among black and white MSM in southern U.S.A. Sex Transm Infect 2014; 90(8): 602-7.
[http://dx.doi.org/10.1136/sextrans-2014-051581] [PMID: 25080511]
, 31Crosby RA, Milhausen RR, Sanders SA, Graham CA, Yarber WL. Condom use errors and problems: a study of high-risk young Black men residing in three Southern US cities. Int J STD AIDS 2014; 25(13): 943-8.
[http://dx.doi.org/10.1177/0956462414526707] [PMID: 24648319]
], and a range of 7.0% - 29.9% in the systematic review [18Sanders SA, Yarber WL, Kaufman EL, Crosby RA, Graham CA, Milhausen RR. Condom use errors and problems: a global view. Sex Health 2012; 9(1): 81-95.
[http://dx.doi.org/10.1071/SH11095] [PMID: 22348636]
].

4.5. Other Condom-Associated Errors

As portrayed in the table, eight classifications of additional errors associated with condom use were reported in the included articles. Three papers approximated the frequency of not squeezing out the air from the repository tip, recounted by 2.05% -50% of the respondents [23Crosby RA, Yarber WL, Sanders SA, et al. Men with broken condoms: who and why? Sex Transm Infect 2007; 83(1): 71-5.
[http://dx.doi.org/10.1136/sti.2006.021154] [PMID: 16870644]
, 34Lau JT, Yu X, Mak WW, et al. Prevalence of inconsistent condom use and associated factors among HIV discordant couples in a rural county in China. AIDS Behav 2013; 17(5): 1888-94.
[http://dx.doi.org/10.1007/s10461-012-0269-z] [PMID: 22802078]
, 39Crosby RA, Charnigo RJ, Salazar LF, et al. Enhancing condom use among Black male youths: a randomized controlled trial. Am J Public Health 2014; 104(11): 2219-25.
[http://dx.doi.org/10.2105/AJPH.2014.302131] [PMID: 25211749]
], while 2.64% -11% of the participants in three investigations exposed the condom to sharp objects like jewelry [23Crosby RA, Yarber WL, Sanders SA, et al. Men with broken condoms: who and why? Sex Transm Infect 2007; 83(1): 71-5.
[http://dx.doi.org/10.1136/sti.2006.021154] [PMID: 16870644]
, 32Crosby R, Sanders S, Yarber WL, Graham CA. Condom-use errors and problems: a neglected aspect of studies assessing condom effectiveness. Am J Prev Med 2003; 24(4): 367-70.
[http://dx.doi.org/10.1016/S0749-3797(03)00015-1] [PMID: 12726876]
, 39Crosby RA, Charnigo RJ, Salazar LF, et al. Enhancing condom use among Black male youths: a randomized controlled trial. Am J Public Health 2014; 104(11): 2219-25.
[http://dx.doi.org/10.2105/AJPH.2014.302131] [PMID: 25211749]
],. One of the studies highlighted other mistakes, including 37% of participants knowingly using the expired condoms, 19.7% re-used the condom later, 29.5% wore the condom inside out and 79% failed to check for probable damages [31Crosby RA, Milhausen RR, Sanders SA, Graham CA, Yarber WL. Condom use errors and problems: a study of high-risk young Black men residing in three Southern US cities. Int J STD AIDS 2014; 25(13): 943-8.
[http://dx.doi.org/10.1177/0956462414526707] [PMID: 24648319]
].

5. DISCUSSION

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 [18Sanders SA, Yarber WL, Kaufman EL, Crosby RA, Graham CA, Milhausen RR. Condom use errors and problems: a global view. Sex Health 2012; 9(1): 81-95.
[http://dx.doi.org/10.1071/SH11095] [PMID: 22348636]
]. 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 [18Sanders SA, Yarber WL, Kaufman EL, Crosby RA, Graham CA, Milhausen RR. Condom use errors and problems: a global view. Sex Health 2012; 9(1): 81-95.
[http://dx.doi.org/10.1071/SH11095] [PMID: 22348636]
]. 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 [23Crosby RA, Yarber WL, Sanders SA, et al. Men with broken condoms: who and why? Sex Transm Infect 2007; 83(1): 71-5.
[http://dx.doi.org/10.1136/sti.2006.021154] [PMID: 16870644]
, 42Spruyt A, Steiner MJ, Joanis C, et al. Identifying condom users at risk for breakage and slippage: findings from three international sites. Am J Public Health 1998; 88(2): 239-44.
[http://dx.doi.org/10.2105/AJPH.88.2.239] [PMID: 9491014]
, 43Yarber WL, Graham CA, Sanders SA, Crosby RA. Correlates of condom breakage and slippage among university undergraduates. Int J STD AIDS 2004; 15(7): 467-72.
[http://dx.doi.org/10.1258/0956462041211207] [PMID: 15228732]
]. 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 [24Hall KM, Brieger DG, De Silva SH, et al. Errors and Predictors of Confidence in Condom Use amongst Young Australians Attending a Music Festival. J Sex Transm Dis 2016; 20166054870
[http://dx.doi.org/10.1155/2016/6054870] [PMID: 27957381]
]. 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 [20Kim M, McKenney J, Khosropour CM, Prater AB, Rosenberg ES, Siegler AJ, et al. Factors Associated With Condom Breakage During Anal Intercourse: A Cross-Sectional Study of Men Who Have Sex With Men Recruited in an Online Survey. JMIR public Heal Surveill 2016 [[cited 2019 Jan 25]];2(1)e7 Available from: http://www.ncbi.nlm.nih.gov/pubmed/27227161
[http://dx.doi.org/10.2196/publichealth.5298]
].

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 [25D’Anna LH, Margolis AD, Warner L, Korosteleva OA, O’Donnell L, Rietmeijer CA, et al. Condom use problems during anal sex among men who have sex with men (MSM): Findings from the Safe in the City Study. AIDS Care - Psychol Socio-Medical Asp AIDS/HIV 2012; 24(8): 1028-38.]. 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 [22Baćak V, Štulhofer A. Condom use errors and problems in a national sample of young Croatian adults. Arch Sex Behav 2012; 41(4): 995-1003.
[http://dx.doi.org/10.1007/s10508-011-9838-x] [PMID: 21882054]
, 31Crosby RA, Milhausen RR, Sanders SA, Graham CA, Yarber WL. Condom use errors and problems: a study of high-risk young Black men residing in three Southern US cities. Int J STD AIDS 2014; 25(13): 943-8.
[http://dx.doi.org/10.1177/0956462414526707] [PMID: 24648319]
]., and discomfort due to “fit” and feel issues are some of the antecedents for removal before the end of the act [27Hernández-Romieu AC, Siegler AJ, Sullivan PS, Crosby R, Rosenberg ES. How often do condoms fail? A cross-sectional study exploring incomplete use of condoms, condom failures and other condom problems among black and white MSM in southern U.S.A. Sex Transm Infect 2014; 90(8): 602-7.
[http://dx.doi.org/10.1136/sextrans-2014-051581] [PMID: 25080511]
, 31Crosby RA, Milhausen RR, Sanders SA, Graham CA, Yarber WL. Condom use errors and problems: a study of high-risk young Black men residing in three Southern US cities. Int J STD AIDS 2014; 25(13): 943-8.
[http://dx.doi.org/10.1177/0956462414526707] [PMID: 24648319]
]. Empirical evidence strongly suggests that protected sex remains the major public health intervention in curbing the rise of new HIV infections [31Crosby RA, Milhausen RR, Sanders SA, Graham CA, Yarber WL. Condom use errors and problems: a study of high-risk young Black men residing in three Southern US cities. Int J STD AIDS 2014; 25(13): 943-8.
[http://dx.doi.org/10.1177/0956462414526707] [PMID: 24648319]
], particularly among young Black MSM [36Crosby R, Mena L, Yarber W, Graham C, Sanders S, Milhausen R. Condom Use Errors and Problems: A Comparative Study of HIV- Positive Versus HIV-Negative Young Black MSM. Sex Transm Dis 2016; 15(5): 477-91.]. 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 [27Hernández-Romieu AC, Siegler AJ, Sullivan PS, Crosby R, Rosenberg ES. How often do condoms fail? A cross-sectional study exploring incomplete use of condoms, condom failures and other condom problems among black and white MSM in southern U.S.A. Sex Transm Infect 2014; 90(8): 602-7.
[http://dx.doi.org/10.1136/sextrans-2014-051581] [PMID: 25080511]
, 39Crosby RA, Charnigo RJ, Salazar LF, et al. Enhancing condom use among Black male youths: a randomized controlled trial. Am J Public Health 2014; 104(11): 2219-25.
[http://dx.doi.org/10.2105/AJPH.2014.302131] [PMID: 25211749]
]. 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 [43Yarber WL, Graham CA, Sanders SA, Crosby RA. Correlates of condom breakage and slippage among university undergraduates. Int J STD AIDS 2004; 15(7): 467-72.
[http://dx.doi.org/10.1258/0956462041211207] [PMID: 15228732]
, 44Vermund SH, Tique JA, Cassell HM, Pask ME, Ciampa PJ, Audet CM. Translation of biomedical prevention strategies for HIV: prospects and pitfalls. J Acquir Immune Defic Syndr 2013; 63(Suppl. 1): S12-25.
[http://dx.doi.org/10.1097/QAI.0b013e31829202a2] [PMID: 23673881]
]. 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.

6. LIMITATIONS

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 [45Mutchler MG, McDavitt B, Ghani MA, Nogg K, Winder TJA, Soto JK. Getting PrEPared for HIV prevention navigation: Young Black gay men talk about HIV prevention in the biomedical era. AIDS Patient Care STDS 2015; 29(9): 490-502.
[http://dx.doi.org/10.1089/apc.2015.0002] [PMID: 26121564]
, 46Ali MS, Tesfaye Tegegne E, Kassa Tesemma M, Tesfaye Tegegne K. GC. Aids Res Treat 2019; 20197134908
[PMID: 31007955]
]. 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.

CONCLUSION

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.

CONSENT FOR PUBLICATION

Not applicable.

STANDARD FOR REPORTING

PRISMA guidelines and methodology were followed.

FUNDING

None

CONFLICT OF INTEREST

The author declares no conflict of interest, financial or otherwise.

APPENDIX 1
Search Strategy Used in PubMed Database


ACKNOWLEDGEMENTS

Declared none.

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