Not everyone needs counseling, however, and counseling may not be able to help everyone. Some people prefer to obtain information and condoms privately, often from friends or relatives. Some people, regardless of their interpersonal skills, cannot hope to change their partner's sexual behavior (82). Certainly, access to condoms should never be limited because counseling is not available. The mass media can provide much information about how to use condoms, where to obtain them, and, through dramatic depictions, even how to discuss condoms with one's sex partner.

Counseling is most important for those at greatest risk—for example, clients receiving treatment for STIs. Counseling can help people initiate and sustain condom use. Rehearsing with a client each step of condom use, from buying the condom to disposing of it, can help make using condoms part of the client's routine. In very high-risk situations, continued counseling may be important. In Kigali, Rwanda, couples in which one partner was infected with HIV were tested and counseled every three months. The program led to increased condom use and lower rates of infection than among other couples (22).

Teaching condom skills. While condom use may seem a simple matter, in fact skill is needed (8, 386, 439, 499). Many men do not know how to use condoms. The result can be embarrassment, loss of erection, or condom breakage, and thus even giving up on condoms entirely. Young people, particularly, need to be confident about their ability to use condoms before they need them. Both counseling and sex education programs can inform young people and train them in the negotiation and communication skills needed for consistent and effective use (47).

Counseling can help women learn how to ask for—even to insist on—the use of condoms (12, 463, 602). Strengthening women's self-esteem and determination to use condoms reinforces training in negotiation (255, 287, 464). Counselors and clients working together can plan responses appropriate to the client's personal circumstances and culture, including a preparation of appropriate responses to men's objections to condoms (575).

Programs often have approached condom counseling by focusing on building women's skills in negotiating and communicating with men. Programs also need to focus directly on changing men's behavior toward condoms, since they have more power in most relationships and, in any case, are the ones who use condoms (238). Counseling couples together or both the man and the woman separately often can be important (12, 137, 239). Counseling can take many forms, including peer counseling, small-group counseling (439), reaching out to community groups, and particularly reaching high-risk groups.

Peer counseling. Peer attitudes have a powerful effect on a person's behavior, including their sexual behavior (7, 15, 50, 121, 534). Programs increasingly are involving peers to counsel healthy behavior and provide information about STIs and condoms (11, 12, 287).