A prospective study on condom slippage and breakage among female brothel-based sex workers in Singapore

Actions taken by female sex workers (FSWs) after condom failure in semi urban Blantyre, Malawi

Background

Little is known about actions taken by female sex workers (FSWs) after male condom failure during male–female sexual intercourse. The objective of this study was to investigate the actions taken by FSWs after condom failure among FSWs in semi-urban, Blantyre in Malawi.

Methods

A cross sectional, qualitative study was conducted among FSWs in Blantyre, Malawi between May and July 2019. Snowballing technique was used to recruit study participants in four purposively selected study sites. Focus group discussions and in-depth interviews were conducted by trained research assistants among 40 FSWs. Data were analyzed using thematic content analysis.

Results

Study participants reported having taken different actions after condom failure. Out of 18 FSWs who experienced condom failure, 10 reported to have stopped sex immediately and changed the condom and then resumed afterwards. They reported to have douched, urinated, and/or squatted to prevent pregnancy, sexually transmitted infections (STIs) and HIV acquisition. Five study participants reported to have asked for extra pay from the client; 10 FSWs didn’t seek medical care. They thought the actions taken were enough for HIV and pregnancy prevention. Out of the 18 FSWs, only 3 stopped sexual intercourse completely and sought medical care which included post-exposure prophylaxis for HIV, STI treatment, and emergency contraceptives. Another 3 reported that they did not stop the sexual intercourse but only squatted and/or douched after sexual intercourse. The remaining 2 FSWs reported not to have stopped sexual intercourse and no any other actions were taken after the condom failure.

Conclusion

We report some inadequate behaviors among FSWs after condom failure. Health programs should develop interventions and support the performance of safer sex and actions after condom failure among FSWs to prevent STIs including HIV, and unplanned pregnancies. Interpersonal, structural and policy factors hindering FSWs’ access to perform effective interventions need to be addressed.

Assessing the perceived benefits of a new condom wrapper/integrated applicator: an exploratory study

Errors and problems associated with male condom use are very prevalent and increase the likelihood of inconsistent and incomplete use, thereby compromising condom effectiveness. The aim of this study was to assess the perceived benefits of a new condom wrapper/integrated applicator designed to reduce barriers to condom use and lessen the likelihood of user errors and problems. After viewing videos depicting features of the wrapper/applicator, participants (N = 547; 62.9% male, M age = 29.2) completed online questionnaires. Most participants reported that the product would make condom application easier and quicker, make them more confident that condoms had been applied correctly and make sex more pleasurable and playful. The majority of participants who had recent experience of condom use errors/problems reported that the use of the product would likely prevent these issues from occurring. Reduced chance of condom damage, the design features of the wrapper and not having to touch the condom itself during application were perceived as particular benefits of the product. The findings suggest that the product might reduce the likelihood of a range of condom user errors and problems and enhance pleasure during condom-protected sex. Future larger-scale studies that involve participants physically testing the condom wrapper/applicator are warranted.

Intentional and Unintentional Condom Breakage and Slippage in the Sexual Interactions of Female and Male Sex Workers and Clients in Mombasa, Kenya

We examined why male condoms broke or slipped off during commercial sex and the actions taken in response among 75 female and male sex workers and male clients recruited from 18 bars/nightclubs in Mombasa, Kenya. Most participants (61/75, 81%) had experienced at least one breakage or slippage during commercial sex. Many breakages were attributed to the direct actions of clients. Breakages and slippages fell into two main groups: those that were intentionally caused by clients and unintentional ones caused by inebriation, forceful thrusting during sex and incorrect or non-lubricant use. Participant responses included: stopping sex and replacing the damaged condoms, doing nothing, getting tested for HIV, using post-exposure prophylaxis and washing. Some sex workers also employed strategies to prevent the occurrence of condom breakages. Innovative client-oriented HIV prevention and risk-reduction interventions are therefore urgently needed. Additionally, sex workers should be equipped with skills to recognize and manage breakages.

Actions of female sex workers who experience male condom failure during penetrative sexual encounters with clients in Cape Town: Implications for HIV prevention strategies

Background

Condom failure has always been found to coexist with condom usage, especially among sex workers.

Objective

To describe the actions of female sex workers when they are faced with situations of condom failure.

Methods

Using the survey design, the participants were selected through the snowball sampling method. Their responses were obtained using a structured questionnaire. A total of 100 questionnaires were analysed.

Results

With respect to the immediate actions of sex workers after condom failure, 36% of the respondents continued with the sexual encounter after noticing that the condom was broken. Another 36% stopped immediately when they noticed that the condom had failed, but replaced the condom; 13% of the participants stopped the sexual encounter completely; 3% applied vaginal spermicidal foam; and 5% of the respondents stopped immediately and took a douche when they had the chance. For the actions within the next 24 hours of experiencing condom failure with a client, 53% of the participants did nothing; 4% sought counsel from a professional; 3% of the respondents took alcohol or drugs to forget the incident, 25% went to the clinic for assistance and 8% offered other responses.

Conclusion

While continuing the sexual encounter without replacing the condom, taking alcohol and drugs or doing nothing could increase the risk of contracting HIV; however, actions like stopping the sexual encounter completely and visiting a clinic or a professional could make a difference between staying HIV negative or seroconverting. There is a need for targeted intervention to address issues of inappropriate behaviours after experiencing condom failure.

Perspectives on condom breakage: a qualitative study of female sex workers in Bangalore, India

A qualitative study was conducted to obtain a detailed understanding of two key determinants of condom breakage - 'rough sex' and poor condom fit - identified in a recent telephone survey of female sex workers, in Bangalore, India. Transcripts from six focus-group discussions involving 35 female sex workers who reported condom breakage during the telephone survey were analysed. Rough sex in different forms, from over-exuberance to violence, was often described by sex workers as a result of clients' inebriation and use of sexual stimulants, which, they report, cause tumescence, excessive thrusting and sex that lasts longer than usual, thereby increasing the risk of condom breakage. Condom breakage in this setting is the result of a complex set of social situations involving client behaviours and power dynamics that has the potential to put the health and personal lives of sex workers at risk. These findings and their implications for programme development are discussed.

Use of emergency contraceptive pills among female sex workers in Swaziland

OBJECTIVES

Female sex workers (FSW) often have unprotected sex. Emergency contraceptive pills (ECP) are an important back-up method to prevent unwanted pregnancy among FSW. We examine ECP use among FSW in Swaziland.

METHODS

Using data from a 2011 respondent-driven sampling survey of 325 Swazi FSW, we explored the association between individual characteristics and ever having used ECP.

RESULTS

In weighted analyses, 27.5% of FSW had ever used ECP. Most (77.8%) had ever been pregnant, among whom 48.7% had had an unwanted pregnancy and 11.7% had had an abortion. Nearly half (47.5%) had experienced condom failure in the past month. Significant independent correlates of ECP use were younger age, higher education, higher income, having two or more children, and never having been married.

CONCLUSIONS

FSW who are older or of lower socioeconomic status may not have adequate access to ECP. By better addressing these women's family planning needs, the dual goals of preventing unwanted pregnancy and preventing vertical transmission of HIV can be achieved.

Analysis of duration of risk behaviour for key populations: a literature review

Background

The objective of this paper is to review literature in order to calculate regional estimates of the average duration of time individuals maintain a specific high-risk behaviour.

Methods

The review targeted the key populations of female sex workers (FSW), male clients of female sex workers (MCFSW), people who inject drugs (injecting drug users (IDU)) and high-risk men who have sex with men (MSM). To be included in the review the study had to provide information on (1) the time a person spent at risk until death or cessation of the risk behaviour, (2) the percentage of the sample who initiated the risk behaviour in less than a year or (3) the mean or median duration of the behaviour from a representative sample.

Results

49 papers were found for the FSW population describing the period of time FSW stay in sex work to be between 2.9 years (Asia) and 12 years (Latin America). Eight papers were found for MCFSW showing the duration of the risk behaviour in this category varying from 4.6 years in Africa to 32 years in Asia. 86 papers were reviewed for the population of IDU showing that the average time a person injects illegal drugs varies from 5.6 years (Africa) to 21 years (South America). No information was found for duration of high-risk behaviour among MSM; instead, the definitions found in the literature for high- and low-risk behaviour among MSM were described.

Conclusions

There is high variability of estimates of duration of high-risk behaviours at regional level. More research is needed to inform models and prevention programmes on the average duration of time individuals maintain a specific high-risk behaviour.

Condom use errors and problems: a global view

Background Significantly more research attention has been devoted to the consistency of condom use, with far fewer studies investigating condom use errors and problems. The purpose of this review was to present the frequency of various condom use errors and problems reported worldwide. Methods: A systematic literature search was conducted for peer-reviewed articles, published in English-language journals between 1995 and 2011. Results: Fifty articles representing 14 countries met criteria for inclusion. The most common errors included not using condoms throughout sex, not leaving space at the tip, not squeezing air from the tip, putting the condom on upside down, not using water-based lubricants and incorrect withdrawal. Frequent problems included breakage, slippage, leakage, condom-associated erection problems, and difficulties with fit and feel. Prevalence estimates showed great variation across studies. Prevalence varied as a function of the population studied and the period assessed. Conclusion: Condom use errors and problems are common worldwide, occurring across a wide spectrum of populations. Although breakage and slippage were most commonly investigated, the prevalence of other condom use errors and problems found in this review were substantially higher. As a framework for understanding the role of condom errors and problems in inadequate protection, we put forward a new model: the Condom Use Experience model. This model can be used to generate testable hypotheses for future research. Addressing condom use errors and problems in research and interventions is crucial to closing the gap between the perfect use and typical use of condoms.

HIV and sexual risk behavior among commercial sex workers in the Netherlands

In 2002-2005, a cross-sectional study to assess the potential for HIV transmission was carried out among 557 female and male-to-female transgender commercial sex workers (CSW) in three cities in the Netherlands. Female CSW (F-CSW), drug-using female CSW (DU), and transgender sex workers were recruited in street-based and establishment-based sites. An anonymous questionnaire was administrated by interviewers and a saliva sample was collected for HIV antibody testing. The overall HIV prevalence was 5.7% (31/547; 10 samples were excluded because of "intermediate" test results). HIV was more prevalent among transgender (18.8%, 13/69) and DU (13.6%, 12/88) sex workers than among F-CSW (1.5%, 6/390). Of the HIV positive CSW, 74% were unaware of their infection. Consistent condom use with clients was 81%. Regular condom failure with clients was reported by 39%. In multivariate analyses, transgender sex workers (OR = 22.9), drug-using CSW who ever injected drugs (OR = 31.1), African (OR = 19.0), and South European ethnicity (OR = 7.2) were independently associated with HIV. Condom failure (PRR = 2.0), anal sex (PRR = 2.1), and drug use (PRR = 3.8) were associated with inconsistent condom use with clients. There is a potential risk for further spread of HIV, through clients and (private) partners of sex workers, to the general population. Targeted health promotion activities are indicated for transgender sex workers and drug-using female CSW; active HIV testing must be continued.

Do participant characteristics influence the effectiveness of behavioral interventions? Promoting condom use to women

OBJECTIVES

This study assessed whether participant baseline characteristics modified the effects of a skill-based intervention promoting condom use.

STUDY

The randomized, controlled trial enrolled 427 women from a sexually transmitted disease clinic in Birmingham, Alabama. The main outcome measures: consistent (100%) and problem-free (correct, no breakage or slippage) condom use were verified by sexual diary self-report and contraceptive product counts.

RESULTS

The enhanced intervention group had a 60% higher consistent condom use rate compared to the basic group (risk ratio [RR], 1.6; 95% confidence interval [CI], 1.4-1.8). There was no statistically significant difference between groups in relationship to problem-free, consistent use (RR, 1.0; 95% CI, 0.9-1.1). A binomial regression analysis identified the following factors as significant modifiers of intervention effectiveness on consistent condom use: intention to use condoms next time, early-age sexual debut, marital status combined with place of intercourse, and substance use before sex.

CONCLUSIONS

The results suggest that participant baseline characteristics can be modifiers of intervention effectiveness.

Female Condom and Male Condom Failure Among Women at High Risk of Sexually Transmitted Diseases

OBJECTIVE

The objective of this study was to study the frequency and determinants of breakage and slippage during female and male condom use.

GOAL

The goal of this study was to determine condom breakage and slippage rate.

STUDY

We conducted a 6-month prospective follow-up study of women attending 2 sexually transmitted disease clinics. Breakage and slippage rates were computed. Logistic regression was used to evaluate baseline characteristics and time-dependent behaviors.

RESULTS

A total of 869 women used condoms in 20,148 acts of intercourse. Breakage was less common for female condoms (0.1%; 95% confidence interval [CI], 0.05-0.21) than for male condoms (3.1%; 95% CI, 2.80-3.42). Slippage was more common for female condoms (5.6%; 95% CI, 5.10-6.13) than for male condoms (1.1%; 95% CI, 0.90-1.28). Rates significantly decreased with use and increased with number of previous failures. From first use to >15 uses, combined failure rate fell from 20% to 1.2% for female condoms (P < 0.0001) and 9% to 2.3% for male condoms (P < 0.01).

CONCLUSIONS

Both condoms may provide good protection against sexually transmitted diseases. Experience determines success with either condom.