Consistency of condom use
The percentage of male and female respondents who used a condom every time they had sex with any non-spouse or non-cohabiting partner over the past 12 months. For more detail on similar indicators measuring consistency of condom use with commercial partners and among youth, see Family Health International (FHI, 2000).
This indicator is calculated as:
(Number of male and female respondents who used a condom every time they had sex with any non-spouse or non-cohabiting partner during the last 12 months / Total number male and female respondents who had sex with at least one non-spouse or non-cohabiting partner during the past 12 months) x 100
Respondents who report sex with non-spouse or non-cohabiting partners are asked about condom use with the most recent partner of the type, and are further asked about consistency of condom use with all non-regular partners in the past year. Those who report having always used condoms make up the numerator. The indicator should be disaggregated by sex, age groups, and membership in most-at-risk subgroups (e.g., men who have sex with men, injecting drug users).
Behavioral surveillance surveys (BSS) and Biological and behavioral surveillance surveys (BBSS) (FHI, 2000).
Condom use is an important measure of protection against HIV and other sexually transmitted infections (STIs), especially among people with multiple sexual partners. The maximum protective effect of condoms is achieved when their use is consistent rather than occasional (WHO et al., 2006). This indicator can be used to assess progress towards preventing exposure to HIV through reducing unprotected sex with non-regular partners, in addition to the extent to which condoms are used by people who are likely to have higher-risk sex and change partners regularly (PEPFAR, 2009). Maintaining a high threshold for this indicator is important where the prevalence of HIV and/or other STIs is high, since the protective value of occasional condom use diminishes as the likelihood of sex with an infected partner increases. This is a core indicator in the ‘Second Generation HIV Surveillance’ system, which focuses on the groups in which HIV infection is most likely to be concentrated and emphasizes using behavioral data to understand population trends in HIV infection, while advocating for more extensive use of behavioral data in planning and evaluating an appropriate response to HIV (FHI, 2000).
This indicator may refer to many different acts of sex with different partners and is subject to recall bias. Respondents may give the answer they think is socially desirable, and where strong media and HIV prevention campaigns have been ongoing, may overreport consistent use. Also respondents who use condoms most of the time may report that they are consistent uses. The indicator sets the standard high for consistent (always) use and may result in very low levels for periods of time.
Women’s knowledge about, access to and ability to negotiate use of condoms (both male and female condoms) may be limited by cultural gender norms affecting women’s mobility, exposure to media and HIV prevention information, access to health care services, resources to purchase condoms, and unbalanced power dynamics within sexual relationships. Women may be less informed about prevention of STI/HIV transmission in general and condom use in specific, and may be reluctant to seek out information that could make them look sexually active (if unmarried) or promiscuous. Health care workers may not discuss HIV prevention including use of male or female condoms with women clients and, where rates of female literacy are low, women may not benefit from media and communication strategies that rely on printed materials. The UNAIDS (2010) agenda for women, girls, and gender equality calls for national AIDS authorities and ministries of health to incorporate gender equality into HIV prevention and policies, which includes gender equality education, male and female condom distribution, better negotiation of safe and consensual relations, and increased access to sexual and reproductive health services and supplies.
Family Health International, 2000, Behavioral surveillance surveys (BSS/BBSS): Guidelines for repeated behavioral surveys in populations at risk for HIV. Arlington, VA, http://www.who.int/hiv/strategic/en/bss_fhi2000.pdf
PEPFAR, 2009, The President’s Emergency Plan for AIDS Relief: Next Generation Indicators Reference Guide, Washington, DC: USAID/PEPFAR. https://www.k4health.org/toolkits/igwg-gender/president%E2%80%99s-emergency-plan-aids-relief-next-generation-indicators-reference
UNAIDS, 2010, Agenda for Accelerated Country Action for Women, Girls, Gender Equality and HIV, Geneva, UNAIDS. http://www.unfpa.org/webdav/site/global/shared/documents/publications/2010/agenda_for_accelerated_country_action_en.pdf
WHO, UNAIDS, The Global Fund, CDC, USAID, UNICEF, MEASURE Evaluation, US Dept. of State: OGAC, 2006, Monitoring and Evaluation Toolkit: HIV/AIDS, Tuberculosis, and Malaria, Geneva: WHO.