Rationale: All studies have found that male latex condom users have a lower risk of STDs than nonusers (33, 57, 80, 110, 237). The overall risk reduction appears to be about 50%, but that figure is a gross estimate that includes consistent and correct users as well as inconsistent users. In Thailand, a condom-only campaign in brothels is associated with population-based reductions in gonorrhea and HIV rates (110).

Full-time latex condom users may reduce their risk to near-zero. A multicenter Italian study followed seronegative female sex partners of HIV-infected men for a median of 24 months. The HIV incidence rate was reduced by 90% in women whose partners always used condoms compared with women whose partners used them inconsistently or never; women whose partners were inconsistent condom users did not benefit (57).

In a multicountry European collaborative study, about half of 343 couples used condoms at every coital act, and no new HIV infections occurred among the consistent users. For the couples who used condoms inconsistently, new HIV infections occurred at the rate of 4.8 per 100 per year, even though 50% of the inconsistent users reported using condoms at least half the time (237). These two studies show that consistent condom use is highly effective protection against HIV transmission but that inconsistent use carries considerable risks of HIV infection (57, 237).

Rationale: Only one cross-sectional study of the female condom and STD re-occurrence has been done. Women with trichomoniasis were treated, enrolled, and followed for 45 days. Consistent users had no re-infections, while 14% of inconsistent users and nonusers were re-infected. The plastic membrane of the female condom is impermeable to HIV and other STD organisms, so the device may reduce the risk of HIV and other STDs in consistent users (67, 259).

Rationale: The reuse of male condoms cannot be recommended until further research is completed. Anecdotal reports suggest that reuse of male condoms is associated with higher breakage rates. The latex membranes are generally not strong enough to withstand repeated stretching, friction, and cleaning. In one large study, unrolling condoms before use increased the breakage and slippage rate (265).

Recommendation: Female condoms should not be reused.

Rationale: The reuse of female condoms is not currently recommended, pending further research. However, anecdotal reports from acceptability studies show that a minority of women use a female condom more than once. Reuse has not been associated with higher breakage rates; female condom breakage is rare in general. Research is currently underway to determine whether reuse reduces the structural strength of the device (increases breakage) and/or increases the risk of communicating STDs.

The female condom should be put into place any time before the penis touches the vagina in order to prevent exposure to pre-ejaculate and semen.

Rationale: Although viable sperm are generally absent from pre-ejaculatory fluid, HIV is present in the pre-ejaculate of HIV-positive men. Thus the pre-ejaculate may transmit disease, and the condom should be in place before genital contact occurs (125, 222).

There is no need to provide more than one size latex condoms.

Rationale: Some condom users complain of condoms being too small or too large, and some researchers have presumed that breakage could be minimized if condoms were made in different sizes. One study evaluated breakage rates and acceptability of larger (55 mm flat diameter) and smaller (49 mm) condoms against the industry standard condom (52 mm). In three countries, breakage rates were 5.5% and 7.4% for the standard and larger devices, respectively. In three other countries, breakage rates were under 5% and similar for the standard and smaller condoms; slippage rates were also similar. Further, condom size had a minimal impact on device acceptability. Certain individuals might benefit from different condom sizes, but the impact has not been demonstrated, and it is not justified for a program to invest in multiple condom sizes (79).

Clients who use condoms should be counseled on what locally available non-oil-based lubricants are appropriate with condom use.

Some substances that cause deterioration of latex condoms within an hour of exposure are mineral oil, baby oil, petroleum jelly, suntan oil, olive oil, peanut oil, corn oil, sunflower oil, palm oil, margarine, coconut oil, dairy butter, insect repellents, burn and hemorrhoidal ointments, rubbing alcohol, cod oil, and shark oil. Lubricants that contain these products should not be recommended for use with latex condoms.

Other products that weaken latex condoms are specific vaginal creams, vaginal spermicides, and sexual lubricants. Some of the brands that were identified as harmful to condoms are:

• Vaginal creams (Monistat, Estrace, Femstat, Vagisil, and Premarin),
• Vaginal spermicides (Rendell's Cone and Pharmatex Ovule), and
• Sexual lubricants (Elbow Grease, Hot Elbow Grease, and Shaft).

Studies have found that some condom users think products that wash off easily with water are water-based and therefore acceptable to use with condoms. However, several of the lotions that clients labeled as water-based contained mineral oil as a main ingredient (10, 114, 286).

Recommendation: Products that are considered water-based have not been shown to be harmful to condoms. Water-based lubricants may reduce the risk of condom failure.