There are many ways of preventing the sexual transmission of HIV between men and their partners. These include abstinence, mutual fidelity, sex that does not involve vaginal or anal penetration, and condom use. However, most prevention messages are simplistic and not tailored to the complex, and often hidden, realities of men's relationships with women or other men. National AIDS campaigns have promoted abstinence outside marriage and fidelity within it with some success. However, abstinence for young men is difficult and a menu of risk reduction options therefore needs to be offered.
The consistent use of male or female condoms in vaginal or anal sex also protects against HIV and STIs. Condoms, however, are underused for a variety of reasons. In casual or commercial sex, men's condom use is more common than in marriage, but still often inconsistent. In a study in Zimbabwe, for instance, men interviewed had sex with prostitutes an average of seven times a month, but only used condoms in about half of those encounters.
Difficulty in finding or paying for male condoms may be part of the explanation. Embarrassment, lack of experience or the wrong size of condom can lead to young men failing in their first attempt to use one and becoming more reluctant to use them in future. Difficulties in achieving or maintaining erection, as can happen with older men or those who have taken alcohol or other substances, contribute as well.
Resistance to condom use, inside or outside long-term relationships, may also be rooted in men's attitudes about sex. In many cultures, it is believed that men's need for sex is uncontrollable. Research from Mexico and Brazil finds that some men believe they cannot turn down any opportunity to have sex, even if they do not have a condom with them.
Loss of sensation, or the belief that sensation will be lost, is another problem. In a study in 14 countries, the most common reason men reported for not using condoms was reduced sexual pleasure. Much of the sensation can be restored by applying a small amount of a suitable lubricant to the inside of the condom; however, such lubricants are generally unavailable in most communities.
Studies in many countries have confirmed that the female condom is an alternative which some men and women find more comfortable than the male version. Like the male condom, the female version can also be used for anal intercourse. Female condoms are, however, much more expensive and difficult to acquire, and because they remain visible during intercourse they still require male consent.
Despite these difficulties, many targeted condom promotion campaigns for men have shown success. A campaign among migrant mine workers in South Africa led to an increase in condom use both with sex workers and with the men's wives from 18% to 26% over the course of two years. In Thailand, the government carried out a campaign promoting "100% condom use" in brothels. As a result, condom use increased in most urban sex-work settings. At the same time, the Thai government embarked on an ambitious effort to change male attitudes towards women; the campaign to increase respect for women and diminish brothel visits started bearing fruit in a surprisingly short time. In Côte d'Ivoire and other African countries, efforts to promote condom use through social marketing have proved remarkably successful in encouraging the uptake and use of condoms on a regular basis.
A risk-free and condom-free alternative to intercourse is sex without penetration
When condoms are not used, the prevalence of unsafe sex before and outside marriage plus the lack of HIV testing means that millions of couples around the world do not know whether they are practising safer sex or not. Except when the goal is contraception, introducing condom use into a regular relationship can be difficult. One problem is the difficulty of acknowledging premarital or casual sex and discussing the possibility of infection. For couples who wish to have children, the challenge is compounded by the fact that condoms interfere with procreation. A great deal of HIV transmission occurs as a result.
This article was provided by UNAIDS. It is a part of the publication Men and AIDS -- A Gendered Approach, 2000 World AIDS Campaign. Visit UNAIDS' website to find out more about their activities, publications and services.