Condoms

The UNAIDS Prevention gap report shows that HIV prevention efforts must be reinvigorated if the world is to stay on the Fast-Track to ending the AIDS epidemic by 2030. To achieve the global Fast-Track Target of reducing the number of new HIV infections to fewer than 500 000 by 2020, more political commitment and increased investment in HIV prevention, including condom promotion, are needed.

In 2015, an estimated 1.9 million [1.7 million–2.2 million] adults aged 15 years and over were newly infected with HIV—the vast majority through sexual transmission—and an estimated 500 million people acquired chlamydia, gonorrhoea, syphilis or trichomoniasis. Every year, more than 200 million women have unmet needs for contraception, leading to approximately 80 million unintended pregnancies. Condoms effectively prevent all of these. 

Male and female condoms are highly effective and the most widely available prevention tool, even in resource-poor settings, for people at risk of HIV infection, other sexually transmitted infections and unintended pregnancies. Condoms are inexpensive, cost-effective and easy to store and transport, their use does not require assistance of medical or health-care personnel and they can be utilized by anyone who is sexually active. A recent global modelling analysis estimated that condoms have averted up to 45 million new HIV infections since the onset of the HIV epidemic. For many young people worldwide, condoms remain the only realistic option to protect themselves.

The promotion of consistent use of condoms is a critical component of HIV combination prevention. Condom utilization complements all other HIV prevention methods, including a reduction in the number of sexual partners, voluntary medical male circumcision, pre-exposure prophylaxis (PrEP) and treatment as prevention for serodiscordant couples.

Despite increased use of condoms over the past two decades, studies show that reported use of condoms during a person’s most recent sexual encounter with a non-regular partner ranged from 80% in some countries to less than 30% in others. There is an urgent need for countries to strengthen demand for and supply of condoms and water-based lubricant. Countries agreed in the 2016 Political Declaration on Ending AIDS to increase the annual availability of condoms in low- and middle-income countries to 20 billion by 2020.

Many countries have not yet set ambitious condom distribution and use targets and condoms are suboptimally programmed, with gaps in demand creation and supply. Few condom programmes adequately address the barriers that hinder access and the use of condoms by young people, in particular adolescent girls and young women, gay men and other men who have sex with men and sex workers. In many countries, condoms are not easily available to young people in schools or anywhere outside health facilities. In some contexts, sex workers have unprotected sex with their clients, as carrying condoms is criminalized and used as evidence by the police to harass or prove involvement in sex work. Some programmes only provide a handful of condoms to each sex worker at each visit, but sex workers may have many more clients than condoms supplied. There is also insufficient access to lubricants—less than 25% of men who have sex with men in 165 countries have easy access to free lubricant, and many sex workers, too, desire but lack access to lubricants. Most countries do not plan for the provision of lubricants in their national strategic plans and condom programmes.

International funding for condom procurement in sub-Saharan Africa has stagnated in recent years, and domestic funding has not sufficiently increased. Funding for condom distribution and promotion has even declined. In 2015, there was an estimated gap of more than 3 billion condoms in sub-Saharan Africa against a total need of 6 billion.

To be successful, comprehensive condom programming must address components such as leadership and coordination, supply and commodity security, demand, access and promotion of utilization, and technical and logistic support. It is critical for governments to create an enabling environment among policy-makers and service providers so that users will be made aware of their risks, feel free to demand and access male and female condoms and have the knowledge to use them correctly and consistently. Young people and key populations are strong allies in the promotion of access to condoms. At the last International AIDS Conference in Durban, South Africa, for example, South African youth demonstrated for access to condoms and other sexual and reproductive health services and commodities such as sanitary pads.  

Effective condom promotion should be tailored for people at increased risk of HIV and other sexually transmitted infections and/or unintended pregnancy, including young people, sex workers and their clients, injecting drug users and gay men and other men who have sex with men. Many young women and girls, especially those in long-term relationships and sex workers, do not have the power to negotiate the use of condoms, as men are often resistant to their use. Condoms should also be made available in prisons and other closed settings and in humanitarian crisis situations.

There also needs to be a greater leverage of social networks, social media and new technologies to promote condom use and improved focusing. The UNFPA’s CONDOMIZE! campaign to destigmatize and promote condom use is being rolled out in nine countries, led by national governments, with two more national rollouts planned for 2016. The campaign actively involves young people as ambassadors, bloggers and peer educators. In the United States of America, condoms are increasingly promoted and freely distributed in schools in order to address health matters such as unintended teenage pregnancies, sexually transmitted infections and HIV. Cities such as New York and Washington, DC, have established targeted free condom distribution to reach key populations and people at higher risk. In France, condom distribution machines have been placed in schools and the South African Department of Education is in the process of revising its policies in order to allow condom promotion and distribution in schools.

In Zimbabwe, the government has supported large-scale condom distribution through social marketing and free distribution channels. In 2014, 104 million male condoms were distributed in Zimbabwe, one of the highest numbers in the world. Increases in condom use are credited as being one of the reasons that new HIV infections were halved for adults from 2009 to 2015. The South African government has funded a nationwide female condom distribution programme with over 300 distribution sites. In Brazil, public health officials have developed one of the largest condom distribution and promotion campaigns in the world. Despite some objections, the Brazilian government has remained steadfast in its commitment to sharing medically accurate information regarding the benefits of condom use.

Putting condoms on the Fast-Track and achieving 90% condom use by people at risk who are having sex with a non-regular partner would avert an additional 3.4 million new HIV infections by 2020 and would also have a significant impact on preventing other sexually transmitted infections and unintended pregnancies.  

UNAIDS and Anglo American, one of the world’s leading mining companies, have joined together to support ProTest HIV, a global initiative that encourages people to get tested for HIV.

The partnership was announced in Durban, South Africa, at the 21st International AIDS Conference. It promotes the importance of voluntary HIV testing, care and support for people living with HIV and broader HIV prevention programmes.  

Anglo American has been involved in the response to HIV for 30 years, during which it has worked to reduce the impact of the HIV on its employees, their families and the communities in which the company operates. The company’s HIV policy is based on a human rights framework and conforms to the internationally recognized best practices recommended by UNAIDS. Anglo American aims to ensure that all employees know their HIV status and offers free testing, counselling and antiretroviral therapy to all employees and their dependants.

Ahead of the conference, UNAIDS and Anglo American asked people to spread the word about the campaign by uploading a selfie using the hashtags #ProTESTHIV and #GenEndIt on to their social media channels, which will automatically drive traffic to the protesthiv.org website.

Ending AIDS by 2030 will only be achieved by working together. This partnership demonstrates the power of collective action in mobilizing people around the world.

UNAIDS Executive Director Michel Sidibé and the President of the Russian Olympic Committee and First Deputy Chairman of the Russian State Duma, Alexander Zhukov, signed an agreement on 23 March to join forces to accelerate the global goal of ending the AIDS epidemic. The memorandum of understanding was signed on the sidelines of the fifth Eastern Europe and Central Asia AIDS Conference, being held in Moscow, Russian Federation.

The memorandum of understanding commits UNAIDS and the Russian Olympic Committee to work together to raise HIV awareness among athletes and sports fans, promote access to HIV treatment and reduce the health, social and economic impact of the AIDS epidemic. The programme will also involve addressing stigma and discrimination affecting people living with HIV, including athletes.

UNAIDS and the Russian Olympic Committee will exchange and share know-how and will involve athletes, sports associations and nongovernmental organizations in HIV prevention and awareness efforts at the national and community levels. They will also cooperate in running media campaigns and other HIV-related programmes with athletes, coaches and other opinion leaders from the sports community in the Russian Federation and internationally, particularly in eastern Europe and central Asia.

UNAIDS has been working in partnership with the International Olympic Committee on AIDS awareness and HIV prevention since 2004.

GENEVA, 12 February 2016—Every day, more than one million people acquire a sexually transmitted infection (STI) and every year there are estimated to be around 80 million unintended pregnancies. Condoms are proven to be 98% effective in preventing STIs and HIV. In addition, male and female condoms prevent unintended pregnancies when used correctly and consistently.

Despite increased use of condoms over the past two decades, studies show that reported use of condoms during a person’s most recent sexual encounter with a non-regular partner ranged from 80% in some countries to less than 30% in others. There is an urgent need for countries to strengthen demand for and supply of condoms and water-based lubricant.

UNAIDS is calling for increased investments by donors and governments for the promotion and distribution of male and female condoms in order to ensure everyone has access to condoms to protect themselves and their partners from HIV, STIs and unintended pregnancies.

“Investing in condoms saves lives,” said UNAIDS Deputy Executive Director Luiz Loures. “It is unacceptable that so many people are becoming infected with HIV and sexually transmitted infections because they do not have access to something as easy to use, effective and low cost as condoms.”

Condoms are extremely cost-effective and have made a major contribution to preventing new HIV infections. An estimated 50 million HIV infections have been averted through condom use since the 1980s. Despite the low cost of condoms, international funding for condom procurement in sub-Saharan Africa has slowed in recent years. To achieve UNAIDS’ target of reducing new infections to fewer than 500 000 by 2020, more political commitment and increased investment in HIV prevention are needed.

Collaborative partnerships are needed to support national efforts to encourage the use of condoms. Action is also needed to increase domestic funding and private sector investment in condom distribution and promotion.

UNAIDS is working together with the United Nations Population Fund and other partners to support renewed investment in condom programming and to accelerate the scale-up of their  use in the countries where most new STIs are occurring. The new UNAIDS 2016–2021 Strategy has set an ambitious global target to increase the availability of condoms to 20 billion per year by 2020 in low- and middle-income countries and to achieve 90% condom use during the most recent sexual activity with a non-regular partner. 

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.

Israel is an indigenous community leader living in Veracruz, Panama City. He was diagnosed with HIV 7 years ago, when he was 24. At that time, Israel had no knowledge of HIV. “I thought I would die soon after and I wouldn't see my children grow up,” he said.

Israel looked for support and started to get involved with local civil society organizations advocating for improved sexual and reproductive health for young people and promoting the human rights of key populations. He became an active member of Genesis+ Panama, bringing to the organization the voice of indigenous people.

“Indigenous youth continue to encounter significant barriers in accessing comprehensive sexuality education and services in our language and according to our own practices and model of well-being,” Israel said. “This is a missed opportunity, since our communities can contribute to the HIV response and the development of our society.”

HIV among indigenous populations is an emerging public health concern, as data show that indigenous people are particularly vulnerable to HIV. The government reports that indigenous people have little knowledge of how HIV is transmitted, negative attitudes towards people living with HIV and low HIV testing rates. Reporting on indigenous people’s rights, the Economic Commission for Latin America and the Caribbean found that more indigenous girls initiate sexual activity before the age of 15 than their non-indigenous peers. The rate of teenage pregnancies is more than twice as high for indigenous girls. Another matter of concern is that violence against women, which has links to HIV infection, is prevalent among indigenous populations in Panama. 

Israel works hard to change the situation in his community. He organizes meetings with indigenous young people and teenagers, either at a home or the beach, to discuss health and other important topics. “I want to give my children and other young people access to information and tools to prevent HIV,” he said.

Israel also coordinates a football team of young indigenous women. Each weekend the team participates in local leagues. Before the games start, Israel and the other coaches provide the players with training related to HIV prevention. He said, “There are many young people at risk in my community and I feel that by leveraging the power of football we are creating opportunities to improve their well-being and strengthen social capital.”

Israel also dedicates his time to raising awareness about respect and solidarity towards key populations and people living with HIV. “In indigenous communities, myths still persist around HIV,” he said. “The fear of being excluded or rejected prevents people from taking an HIV test or going to health facilities.”

Reflecting on what he has learned since his diagnosis, Israel said, “HIV has not limited me. It opened my eyes to social justice and motivated me to become the person I am today.”

The many crises, wars and natural disasters around the globe are leaving women and adolescent girls facing a significantly heightened risk of unwanted pregnancy, maternal death, gender-based violence and HIV, says a new report from the United Nations Population Fund (UNFPA).

The State of world population 2015—Shelter from the storm: a transformative agenda for women and girls in a crisis-prone world is a “call to action” to meet the needs and ensure the rights of tens of millions of women and girls caught up in the turmoil of conflict and disaster. More than 100 million people are now in need of humanitarian assistance, more than at any time since the Second World War.

Although remarkable progress has been made in providing women and girls with humanitarian services in the past 10 years, not enough is yet being done to address their particular vulnerabilities, the report argues. It highlights how, for example, their risk of HIV infection is increased and how this heightened risk should inform programmes and assistance. Women and girls experiencing humanitarian crises often face sexual and gender-based violence, including rape, which is a risk factor for HIV transmission. Other factors experienced include trafficking, transactional sex and sex work.

Access to HIV prevention and life-saving treatment services can also be significantly reduced or disappear completely in times of crisis. The availability of medicines for the prevention of mother-to-child transmission of the virus is often severely disrupted. In addition, women and girls with disabilities face extra vulnerability to HIV in crisis situations, with even more limited access to services and information.

Shelter from the storm sets out concrete ways in which vulnerabilities can be addressed. It refers to an internationally agreed raft of essential reproductive health services and supplies that should be available from the start of any crisis. This basic package includes programmes to prevent sexual violence and manage the consequences of it, reduce HIV transmission, prevent maternal and newborn death and illness, and integrate sexual and reproductive health care into primary health care.   

Opportunities may emerge from crisis too, says the report. The example of HIV is cited, with well-run camps with sufficient resources enabling displaced people to have enhanced access to services.

There is also an emphasis on moving away from simply reacting to crises as they emerge and embracing a pre-emptive approach that promotes prevention, preparedness and resilience. The report argues that people who are healthy, educated and have their human rights protected are likely to have better prospects in the event of a disaster. 

Condoms are a critical component in a comprehensive and sustainable approach to the prevention of HIV and other sexually transmitted infections (STIs) and are effective for preventing unintended pregnancies. In 2013, an estimated 2.1 million people became newly infected with HIV^[i] and an estimated 500 million people acquired chlamydia, gonorrhoea, syphilis or trichomoniasis.^[ii] In addition, every year more than 200 million women have unmet needs for contraception,^[iii] leading to approximately 80 million unintended pregnancies.^[iv] These three public health priorities require a decisive response using all available tools, with condoms playing a central role.

Male and female condoms are the only devices that both reduce the transmission of HIV and other sexually transmitted infections (STIs) and prevent unintended pregnancy.

Laboratory studies show that condoms provide an impermeable barrier to particles the size of sperm and STI pathogens, including HIV.^[v] [vi] Condoms, when used consistently and correctly, are highly effective in preventing the sexual transmission of HIV. Research among serodiscordant couples (where one partner is living with HIV and the other is not) shows that consistent condom use significantly reduces the risk of HIV transmission both from men to women and women to men^{[vii] [viii] [ix]} Consistent and correct use of condoms also reduces the risk of acquiring other STIs and associated conditions, including genital warts and cervical cancer.^[x] With a failure rate of about 2% when used consistently and correctly, condoms are very effective at preventing unintended pregnancy.^{[xi] [xii]}

Condoms have played a decisive role in HIV, STI and pregnancy prevention efforts in many countries.

Condoms have helped to reduce HIV transmission and curtailed the broader spread of HIV in settings where the epidemic is concentrated in specific populations.^[xiii] Distribution of condoms has been shown to reduce rates of HIV and other STIs in sex workers^{[xiv] [xv] [xvi]} and men who have sex with men.^[xvii] In India^{[xviii] [xix]} and Thailand^[xx] increased condom distribution to sex workers and their clients in combination with other prevention interventions were associated with reductions of transmission of both HIV and other STIs. Zimbabwe^[xxi] and South Africa are two high-prevalence countries where increased condom use was found to contribute to reductions in HIV incidence.^[xxii]

A recent global modelling analysis estimated that condoms have averted around 50 million new HIV infections since the onset of the HIV epidemic.^[xxiii] For 2015, 27 billion condoms expected to be available globally through the private and public sector will provide up to an estimated 225 million couple years protection from unintended pregnancies.^{[xxiv] [xxv]}

Condoms remain a key component of high-impact HIV prevention programmes.

Recent years have seen major scientific advances in other areas of HIV prevention. Biomedical interventions including antiretroviral therapy (ART) for people living with HIV can substantially reduce HIV transmission. While the success of ART may alter the perception of risk associated with HIV, studies have shown that people living with HIV who are enrolled in treatment programmes and have access to condoms report higher condom use compared to those not enrolled.^[xxvi]

Condom use by people on HIV treatment and among serodiscordant couples is strongly recommended. ^[xxvii] Only when sustained viral suppression is confirmed and very closely monitored, and when the risk of other STIs and unintended pregnancy is low, it may be safe not to use condoms.^{[xxviii] [xxix] [xxx]}

Oral pre-exposure prophylaxis (PrEP)—where antiretroviral drugs are used by HIV-negative people to reduce their risk of acquiring HIV—is also effective in preventing HIV acquisition, but is not yet widely available and is currently only recommended as an additional tool for people at higher risk, such as people in sero-discordant relationships, men who have sex with men and female sex workers, in particular in circumstances in which consistent condom use is difficult to achieve.^[xxxi] Voluntary medical male circumcision (VMMC) can reduce the risk of HIV acquisition by 60% among men, but because protection is only partial, should be supplemented with condom use. ^[xxxii]

Hence, condom use remains complementary to all other HIV prevention methods, including ART and PrEP, in particular when other STIs and unintended pregnancy are of concern. The roll-out of large-scale HIV testing and treatment, VMMC and STI control programmes, and efforts to increase access to affordable contraception all offer opportunities for integrating condom promotion and distribution.

Quality-assured condoms must be readily available universally, either free or at low cost.

To ensure safety, efficacy and effective use, condoms must be manufactured according to the international standards, specifications and quality assurance procedures established by WHO, UNFPA and the International Organization for Standardization^{[xxxiii] [xxxiv]} and made available either free or at affordable cost. Condom use in resource-limited settings is more likely when people can access them at no cost or at subsidized prices.^{[xxxv] [xxxvi]}

Most countries with high HIV rates continue to heavily depend on donor support for condoms. In 2013, only about 10 condoms were made available to every man aged 15-64, and on average only one female condom per eight women in sub- Saharan Africa. HIV prevention programmes need to ensure that a sufficient number and variety of quality assured condoms are accessible to people who need them, when they need them. Adequate supplies of water based-lubricants also need to be provided to minimize condom usage failure, especially for anal sex, vaginal dryness and in the context of sex work.^[xxxvii]

Despite generally increasing trends in condom use over the past two decades, substantial variations and gaps remain. Reported condom use at last sex with non-regular partners ranges from 80% use by men in Namibia and Cambodia to less than 40% usage by men and women in other countries, including some highly affected by HIV. Similarly, among young people aged 15 to 24 years, condom use at last sex varies from more than 80% in some Latin American and European countries to less than 30% in some West African countries.^[xxxviii] This degree of variation highlights the need for countries to set ambitious national and subnational targets and that in many settings there are important opportunities for strengthening demand and supply of condoms.

Programmes promoting condoms must address stigma and gender-based and socio-cultural factors that hinder effective access and use of condoms.

Effective condom promotion should be tailored for people at increased risk of HIV and other STIs and/or unintended pregnancy, including young people, sex workers and their clients, injecting drug users and men who have sex with men. Many young women and girls, especially those in long-term relationships and sex workers, do not have the power and agency to negotiate the use of condoms, as men are often resistant to using condoms. Within relationships, the use of condoms may be taken to signal a lack of trust or intimacy.

However, few programmes adequately address the barriers that hinder access and use of condoms by young people,^[xxxix] key populations^[xl] and men and women in relationships. In some contexts, sex workers are forced to have unprotected sex by their clients.^{[xli] [xlii]} and carrying condoms is criminalized and used as evidence by police to harass or to prove involvement in sex work^{[xliii] [xliv]} These practices undermine HIV prevention efforts and governments should take actions to end these human rights violations.^[xlv] Condom programmes should ensure that condoms and lubricants are widely available and that young people and key populations have the knowledge, skills and empowerment to use them correctly and consistently.^[xlvi] Condoms should also be made available in prisons and closed settings,^{[xlvii] [xlviii]} and in humanitarian crises situations.^[xlix]

Adequate investment in and further scale up of condom promotion is required to sustain responses to HIV, other STIs, and unintended pregnancy.

Despite the low cost of condoms, international funding for condom procurement in sub-Saharan Africa has stagnated in recent years.^[l] Collective actions at all levels are needed to support the efforts of countries that depend on external assistance for condom procurement, promotion, and distribution and to increase domestic funding and private sector investment in condom distribution and promotion.^[li]

Although condoms are part of most national HIV, STI and reproductive health programmes, condoms have not been consistently distributed nor promoted proactively enough.^[lii] National condom distribution and sales can be strengthened by applying a total market approach that combines public sector distribution, social marketing and private sector sales.^{[liii] [liv]} Administrative barriers that prevent programmes and organizations from providing sufficient quantities of condoms for distribution need to be removed. In high-HIV prevalence locations condom promotion and distribution should become systematically integrated in community outreach and service delivery, and in broader health service provision.

^[i] UNAIDS. 2014. World AIDS Day Report 2014.

^[ii] WHO, Dept. of Reproductive Health and Research. Global incidence and prevalence of selected curable sexually transmitted infections.

^[iii] UNFPA/Guttmacher Institute. 2012. Adding It Up: Costs and Benefits of Contraceptive Services.

^[iv] Sedgh G et al. Intended and Unintended Pregnancies Worldwide in 2012 and Recent Trends. Studies in Family Planning, 2014, Vol 45. 3, 301–314, 2014.

^[v] Carey RF et al. Effectiveness of latex condoms as a barrier to human immunodeficiency virus-sized particles under conditions of simulated use. Sex Transm Dis 1992;19:230-4.

^[vi] WHO/UNAIDS. 2001. Information note on Effectiveness of Condoms in Preventing Sexually Transmitted Infections including HIV.

^[vii] Holmes K et al. Effectiveness of condoms in preventing sexually transmitted infections. Bulletin of the World Health Organization, 2004, 82 (6).

^[viii] Weller S et al. Condom effectiveness in reducing heterosexual HIV transmission. Cochrane Database Syst Rev. 2002;(1):CD003255.

^[ix] Smith DK et al. Condom effectiveness for HIV prevention by consistency of use among men who have sex with men in the United States. J Acquir Immune Defic Syndr. 2015 Mar 1;68(3):337-44.

^[x] Also see: http://www.cdc.gov/condomeffectiveness/brief.html

^[xi] Trussell J. Contraceptive efficacy, in: Hatcher RA et al., eds., Contraceptive Technology: Twentieth Revised Edition, New York: Ardent Media, 2011, pp. 779–863.

^[xii] Kost K et al. Estimates of contraceptive failure from the 2002 National Survey of Family Growth. Contraception, 2008; 77:10-21.

^[xiii] Hanenberg RS et al. Impact of Thailand's HIV-control programme as indicated by the decline of sexually transmitted diseases. Lancet, 1994, 23;344(8917): 243-5.

^[xiv] Ghys PD et al. Increase in condom use and decline in HIV and sexually transmitted diseases among female sex workers in Abidjan, Cote d’Ivoire, 1991–1998. AIDS, 2002, 16(2):251–258.

^[xv] Levine WC et al. Decline in sexually transmitted disease prevalence in female Bolivian sex workers: impact of an HIV prevention project. AIDS, 1998, 12(14):1899–1906.

^[xvi] Fontanet AL et al. Protection against sexually transmitted diseases by granting sex workers in Thailand the choice of using the male or female condom: results from a randomized controlled trial. AIDS, 1998, 12(14):1851–1859.

^[xvii] Smith D et al. Condom efficacy by consistency of use among MSM: US. 20th Conference on Retroviruses and Opportunistic Infections, Atlanta, abstract 32, 2013.

^[xviii] Boily M-C et al. Positive impact of a large-scale HIV prevention programme among female sex workers and clients in South India. AIDS, 2013, 27:1449–1460.

^[xix] Rachakulla HK et al. Condom use and prevalence of syphilis and HIV among female sex workers in Andhra Pradesh, India - following a large-scale HIV prevention intervention. BMC Public Health, 2011; 11 (Suppl 6): S1.

^[xx] UNAIDS. 2000. Evaluation of the 100% Condom Programme in Thailand, UNAIDS Case Study.

^[xxi] Halperin DT et al. A surprising prevention success: Why did the HIV epidemic decline in Zimbabwe? PLoS Med. 2011. 8;8(2).

^[xxii] Johnson LF et al. 2012. The effect of changes in condom usage and antiretroviral treatment coverage on human immunodeficiency virus incidence in South Africa: a model-based analysis, Journal of the Royal Society Interface. 2012, 7;9(72):1544-54.

^[xxiii] Stover J. 2014. Presentation. UNAIDS Global Condom Meeting, Geneva, November 2014.

^[xxiv] In line with standard assumptions, 120 condoms are required for 1 couple year of protection. Projected condom sales for 2015 cited based on: Global Industry Analysts. 2014. Global Condoms Market. May 2014.

^[xxv] Stover J et al. Empirically based conversion factors for calculating couple-years of protection. Eval Rev. 2000 Feb; 24(1):3-46.

^[xxvi] Kennedy C et al.  Is use of antiretroviral treatment (ART) associated with decreased condom use? A meta-analysis of studies from low- and middle-income countries (LMICs). July 2014 h International AIDS Conference. Melbourne, WEAC0104 - Oral Abstract Session.

^[xxvii] Liu H et al. Effectiveness of ART and condom use for prevention of sexual HIV transmission in sero-discordant couples: a systematic review and meta-analysis. PLoS One. 2014 4;9(11):e111175.

^[xxviii] Swiss AIDS Federation Advice Manual: Doing without condoms during potent ART. Swiss AIDS Federation, 2008.

^[xxix] Fakoya A et al. British HIV Association, BASHH and FSRH guidelines for the management of the sexual and reproductive health of people living with HIV infection. HIV Medicine, 2008, 9: 681-720, 2008.

^[xxx] Marks G et al. Time above 1500 copies: a viral load measure for assessing transmission risk of HIV-positive patients in care. AIDS 2015, 29:947–954.

^[xxxi] WHO. 2015. Technical update on Pre-exposure Prophylaxis (PrEP), February 2015. WHO/HIV/2015.4.

^[xxxii] WHO. 2007. New Data on Male Circumcision and HIV Prevention: Policy and Programme Implications. WHO/UNAIDS Technical Consultation on Male Circumcision and HIV Prevention: Research Implications for Policy and Programming Montreux, 6 – 8 March 2007 Conclusions and Recommendations.

^[xxxiii] WHO, UNFPA and Family Health International. 2013.  Male Latex Condom: Specification, Prequalification and Guidelines for Procurement, 2010 revised April 2013.

^[xxxiv] International Organisation for Standardisation. 2014. ISO 4074:2014 Natural rubber latex male condoms -- Requirements and test methods. http://www.iso.org/iso/catalogue_detail.htm?csnumber=59718.

^[xxxv] Charania MR et al. Efficacy of Structural-Level Condom Distribution Interventions: A Meta-Analysis of U.S. and International Studies, 1998–2007. AIDS Behav, 2011, 15:1283–1297.

^[xxxvi] Sweat MD et al. Effects of condom social marketing on condom use in developing countries: a systematic review and meta-analysis, 1990–2010. Bulletin of the World Health Organization 2012, 90:613- 622A. doi: 10.2471/BLT.11.094268.

^[xxxvii] Use and procurement of additional lubricants for male and female condoms: WHO/UNFPA/FHI360 Advisory note. 2012.

^[xxxviii]Source: Data from a database of Demographic and Health Surveys (DHS) available at statcompiler.com (verified January 2015).

^[xxxix] Dusabe J, et al.  “There are bugs in condoms”: Tanzanian close-to-community providers’ ability to offer effective adolescent reproductive health services. J Fam Plann Reprod Health Care 2015;41:e2.

^[xl] Key populations are defined groups who, due to specific higher-risk behaviours, are at increased risk of HIV irrespective of the epidemic type or local context. Also, they often have legal and social issues related to their behaviours that increase their vulnerability to HIV. These guidelines focus on five key populations: 1) men who have sex with men, 2) people who inject drugs, 3) people in prisons and other closed settings, 4) sex workers and 5) transgender people. In consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations. World Health Organization 2014.

^[xli] Global Commission on HIV and the Law. Risks, Rights & Health. 2012

^[xlii] UNAIDS. 2014. The Gap report.

^[xliii] Open Society Foundations. 2012. Criminalizing condoms. How policing practices put sex workers and HIV services at risk in Kenya, Namibia, Russia, South Africa, the United States and Zimbabwe. http://www.opensocietyfoundations.org/reports/criminalizing-condoms.

^[xliv] Bhattacharjya, M et al. The Right(s) Evidence – Sex Work, Violence and HIV in Asia: A Multi-Country Qualitative Study. Bangkok: UNFPA, UNDP and APNSW (CASAM). 2015.

^[xlv] WHO; UNFPA; UNAIDS; NSWP; World Bank. 2013. Implementing comprehensive HIV/STI programmes with sex workers: practical approaches from collaborative intervention. 2013.

^[xlvi] Vijayakumar G et al. A review of female-condom effectiveness: Patterns of use and impact on protected sex acts and STI incidence. International Journal of STD and AIDS, 2006, 17(10):652-659.

^[xlvii] UNODC/WHO/UNAIDS. 2006. HIV/AIDS Prevention, Care, Treatment and Support in Prison Settings A Framework for an Effective National Response.

^[xlviii] UNODC/ILO/UNDP/WHO/UNAIDS. 2012. Policy brief. HIV prevention, treatment and care in prisons and other closed settings: A comprehensive package of interventions.

^[xlix] Inter-Agency Standing Committee (IASC). 2003. Guidelines for HIV/AIDS interventions in emergency settings. Task Force on HIV/AIDS in Emergency Settings.

^[l] UNFPA. 2015. Contraceptives and condoms for family planning and STI/HIV prevention. External procurement support report 2013.

^[li] Foss AM et al. A systematic review of published evidence on intervention impact on condom use in sub-Saharan Africa and Asia. Sex Transm Infect 2007, 83:510–516.

^[lii] Fossgard IS et al. Condom availability in high risk places and condom use: a study at district level in Kenya, Tanzania and Zambia. BMC Public Health 2012, 12:1030.

^[liii] UNFPA-PSI.  2013. Total Market Approach Case Studies Botswana, Lesotho, Mali, South Africa, Swaziland, Uganda. http://www.unfpa.org/publications/unfpa-psi-total-market-approach-case-studies

^[liv] Barnes, J et al. 2015. Using Total Market Approaches in Condom Programs. Bethesda, MD: Strengthening Health Outcomes through the Private Sector Project, Abt Associates.