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Background:
Systematic Review

Consistent Condom and Lubricant Use and Associated Factors Amongst Men Who Have Sex with Men in Sub-Saharan Africa: A Systematic Review

by
Ratif Abdulai
1,
Edith Phalane
1,
Kyeremeh Atuahene
2 and
Refilwe Nancy Phaswana-Mafuya
1,*
1
South African Medical Research Council/University of Johannesburg (SAMRC/UJ) Pan African Center for Epidemics Research (PACER) Extramural Unit, Johannesburg 2006, South Africa
2
Department of Research, Monitoring and Evaluation, Ghana AIDS Commission, Accra CT5169, Ghana
*
Author to whom correspondence should be addressed.
Sexes 2024, 5(4), 796-813; https://doi.org/10.3390/sexes5040051
Submission received: 22 September 2024 / Revised: 17 December 2024 / Accepted: 20 December 2024 / Published: 23 December 2024
(This article belongs to the Section Sexual Behavior and Attitudes)
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Abstract

:
Men who have sex with men (MSM) in sub-Saharan Africa (SSA) are disproportionately affected by the human immunodeficiency virus (HIV) compared to adult men in the general population. Unprotected anal sexual intercourse is a high-risk behavior for HIV infection. This makes the correct and consistent use of condoms with condom-compatible lubricants crucial in reducing further HIV acquisition amongst the MSM population in SSA. However, consolidated data on the scope of the consistency of condom use with lubricants among MSM in SSA is lacking. In this regard, it was necessary to consolidate existing evidence on consistent condom usage with lubricants, as well as associated context-specific factors among the MSM population in SSA. A systematic review was conceptualized and registered with the International Prospective Register of Systematic Reviews (registration number: CRD42023437904). It was compiled following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) principles and guidelines between July 2023 and June 2024. We searched PubMed, Scopus, ScienceDirect, Google Scholar, and governmental and non-governmental institutions to find published and gray literature relevant to the review objectives from 2005 to June 2024. Studies conducted in SSA, published in English, focusing on MSM aged ≥15 years and also reported condom and lubricant use were considered for this review. Following the removal of duplicates and ineligible articles, 40 studies out of 202 reviewed were selected for the study. The most common study designs were cross-sectional surveys (n = 32) followed by prospective cohorts (n = 4), integrated bio-behavioral surveillance surveys (n = 3), and intervention studies (n = 1). Of the 40 eligible studies included in this review, half (n = 20) reported consistent use of condoms but without lubricants, three reported consistent use of condoms with lubricants but did not specify the lubricant type, six reported consistent condom use with water-based condom-compatible lubricants, and 11 reported only condom use but not consistent usage. Factors linked to consistent condom use with lubricants among MSM from various studies included higher educational level, knowing one’s HIV status, accessibility challenges, and older age. Having a high level of self-worth and HIV risk-reduction counseling was also associated with a consistency of condom use amongst MSM who engaged in receptive anal sex. This review indicates that only a few studies reported consistent condom use with lubricants and water-based compatible lubricants.

1. Introduction

The risk of human immunodeficiency virus (HIV) transmission during unprotected anal sexual activity is about 18 times higher than during unprotected vaginal sex [1,2,3], but a higher percentage of this risk can be lessened by the consistent and correct use of condoms with lubricants [4].
Condoms are part of biomedical HIV prevention methods that serve as a barrier, preventing the exchange of sexual fluid between two intimate partners [5]. A lubricant is a liquid or gel that reduces friction during sexual intercourse [6,7]. According to the Centers for Disease Control and Preventions, “consistent and correct use of condoms with lubricants means utilizing a new condom for each act of oral, anal, and vaginal sex during the whole sex act, and removing the condom immediately after ejaculation to prevent spillage” [4].
Compared to the general population, men who have sex with men (MSM) have a lower rate of consistency of condom use with lubricants. Men who have sex with men in most sub-Saharan African countries are stigmatized and discriminated against [7,8,9,10]. Again, the customary, cultural, and legally unfriendly environments of the MSM population in most countries in sub-Saharan Africa (SSA) make it difficult for them to have access to some of the basic HIV prevention needs and services, such as condoms and lubricants [11]. In times of unforeseen circumstances, such as in the case of the coronavirus disease (COVID-19) pandemic era, accessing these services becomes difficult for MSM and other key population groups [12,13]. During the COVID-19 outbreak, the MSM population in South Africa reported having inadequate access to condoms and lubricants due to the access being extremely skewed toward public sources [14]. In another study in Zambia, MSM reported difficulty acquiring condoms and lubricants at healthcare facilities, leading to an increase in condomless sex and inconsistent condom and lubricant use [15].
The scope of consistent condom usage with lubricants among the MSM population in SSA is not known. This requires attention, given the fact that unprotected anal sexual activity is a risk factor for HIV transmission and acquisition. Additionally, there is no consolidated data on the consistent use of condoms with lubricants and associated factors amongst the MSM population in SSA. In view of this, we carried out a systematic review to determine the scope of consistent condom use with lubricants and associated factors among the MSM population in SSA. Findings from this review will support and guide the development of a predictive model aimed at improving the consistency and correct use of condoms with lubricants among MSM in SSA.

2. Materials and Methods

2.1. Systematic Review Registration and Approach

This systematic review was registered with the International Prospective Register for Systematic Reviews (PROSPERO) (registration number: CRD42023437904). The review was put together according to the concepts and criteria of the preferred reporting items for systematic reviews and meta-analysis (PRISMA) [16]. It is also part of a doctoral study by RA and has received research and ethics clearance from the Research and Ethics Committee of the University of Johannesburg (REC-2742-2024).

2.2. Inclusion and Exclusion Criteria of the Studies

Inclusion and exclusion criteria were utilized to ensure the consistent exclusion of papers that did not address the research objective. The eligibility criteria further ensured that the selected and included studies had the relevant data required to address the research objectives. The eligibility criteria are highlighted in Table 1 below.

2.3. Study Outcomes and Variables

The primary outcome is consistent condom use with lubricants during sexual intercourse, measured as the number of participants with one or more sexual partner(s) in the past six months or more (sexually active participants) who reported always using condoms and lubricants during every sexual intercourse, given as a percentage. The secondary outcome is the associated factors of consistent condom with lubricant use among MSM. For the secondary outcome, we considered only the adjusted estimates for the Odds Ratio. The primary outcomes, “reported always using a condom”, “used a condom every time”, or “consistently used a condom”, were considered synonymous with condom use consistency during sexual intercourse.

2.4. Search Strategy and Process

The reviewer (Ratif Abdulai, RA) developed the search strategy with the guidance of the supervisors, using key terms and phrases (“men who have sex with men”, “MSM”, “homosexual men”, “bisexual men”, “gay men”, “HIV prevention”, “consistent condom usage”, “consistent lubricant use”, “condomless sex”, “correct condom use”, “sub-Saharan Africa”, “factors associated with condom use”, “factors associated with consistent condom use with lubricants”) and in consultation with the University of Johannesburg’s Librarian. For each key term or phrase, a Medical Subject Heading (MeSH) term was developed and combined with Boolean operators: “AND”, “OR”, and “NOT” during the title search. We searched through electronic databases and data sources such as PubMed, Google Scholar, Science Direct, Scopus, and governmental and non-governmental organizations to identify published and gray literature relevant to the research objectives. To maximize the search for relevant papers, we reviewed the reference lists of all the included studies and systematic reviews conducted on condom and lubricant use among MSM in SSA.

2.5. Study Screening and Data Abstraction

All the identified studies were exported to Covidence (a screening and data extraction tool) to manage the data and remove duplicate citations. References were also managed using Mendeley. The reviewer (RA) conducted a comprehensive screening of the abstracts and full-text articles guided by the eligibility criteria to draw conclusions on which studies to include in the systematic review. In cases where full-text articles were not freely available, a request to retrieve the full-text was sent to the University of Johannesburg Library services. The University librarian provided training on database search and Covidence software (https://www.covidence.org/) and helped retrieve eligible articles that were not freely available in full text. Discrepancies at the abstract screening stage were resolved between the two co-supervisors (EP and KA), while discrepancies at the full-text screening stage were resolved by the principal supervisor (RNPM). After retrieving and reading the full-text studies that met the inclusion criteria, a standard data extraction tool was used to abstract the data: the first author’s last name and year; the study setting and country; the study objective; the sample size; the study design and data collection tool; the use of condoms; the consistent use of condoms and the consistent use of condoms with lubricants; and the factors associated with consistent condom use with lubricants. Data on condom use among MSM was categorized into condom use, consistent condom use with lubricants, and consistency of condom use with condom-compatible lubricants.

2.6. Risk of Bias Assessment

Kappa statistics were utilized to assess the degree of agreement regarding the consistency in screening the studies and data extraction. A risk of bias assessment in the included studies was performed using a nine-item quality evaluation checklist with nine scores for prevalence studies [17]. Due to its ease of use, high inter-rater agreement, and almost perfect agreement between individual items, this tool is frequently used in systematic reviews to evaluate the risk of bias in cross-sectional studies [17]. It examines the risk of bias in studies on a binary scale. The nine items included were as follows: (1) the study’s target population was a close representation of the general population in terms of pertinent variables such as age, sex, and occupation; (2) the sampling frame was a true or close representation of the target population; (3) the sample was chosen randomly or through a census; (4) there was little chance of non-response bias; (5) data were collected directly from the subjects rather than through the use of a proxy; (6) the study employed an acceptable case definition; (7) the study instrument, which measured the variable of interest (consistent condom use or condom use at the most recent intercourse), was proven to be valid and reliable; (8) the same technique for data collection was utilized for all the individuals; and (9) the numerator and denominator for consistent condom use were appropriate.

2.7. A Summary of the Systematic Review Selection Process

A total number of 1724 articles were found through the initial search of multiple databases: PubMed (707), Scopus (215), Google Scholar (698), ScienceDirect (100), and four (4) from citation searching. After removing duplicates and ineligible articles through title/abstract screening, 202 studies were further assessed for full-text review, with 40 articles retained for the final systematic review. The reasons for removing certain studies during the full-text assessment were studies that did not target condom use among MSM in SSA, full-text not accessible even upon request from corresponding authors, and the wrong study population; see Figure 1.

3. Results

This section summarizes the study characteristics of the articles included in the review on consistent condom and lubricant use and associated factors among the MSM population in SSA. This study also reviewed factors associated with consistent condom use with lubricants among MSM in certain types of sexual engagements. This is important since sexual behaviors, such as condomless regular versus casual sex as well as receptive versus insertive anal sex, are important risk factors for HIV transmission [18,19]. Compared to regular sex partners, casual partners have a higher number of sex partners [19]. Condomless sex in both receptive and insertive sexual engagements is also a significant risk factor for HIV transmission [20]. Other studies have also documented that the risk of HIV transmission from receptive anal sex is about 20 times higher than from insertive anal sex.

3.1. Characteristics of the Included Studies

Table 2 presents the characteristics of the studies included in this review. A total of 40 articles were included in the final analysis after removing duplicates and ineligible studies. The studies reviewed used different methodologies, including a cross-sectional survey (32), prospective cohort (4), integrated bio-behavioral surveillance survey (IBBS) (3), and one (1) intervention study. Figure 2 shows the regional distribution of the studies that were included in this review: West Africa (14), East Africa (17), Central Africa (2), and Southern Africa (7). Six (6) studies each were reported from Nigeria and Kenya; five (5) were from Tanzania; South Africa (5), Togo (3), and two (2) from each of the following countries: Cote d′Ivoire, Cameroon, Malawi, Mali, and Rwanda. One (1) each from Uganda, Swaziland, Zimbabwe, and Benin. The sample size of the included studies ranges between 85 and 1342 participants. The studies only reported MSM aged ≥15 years old, with a total sample size of 22,556 participants.

3.2. Consistent Condom and Lubricant Use Amongst Men Who Have Sex with Men

Table 3 summarizes the findings of consistent condom use with/without lubricants. Out of the 40 eligible studies included in this review, 29 of them reported consistent condom use. Only 9 out of the 29 studies reported consistent condom use with lubricants [28,29,33,42,44,47,49,53,59], with just six (6) studies reporting consistent condom use with water-based condom-compatible lubricants (CCLs) [28,33,44,49,53,59].
Consistent condom use varied according to the participants’ sexual behavior. For MSM who had sexual relations exclusively with only male partners, consistent condom usage ranged between 9% and 48.1% [22,27,49,50,60]. Consistent condom use with only female partners amongst bisexual men also ranged between 39% and 43% [22,49,50,53,56]. For MSM who reported having sexual relationships with both partners (all male and female partners), the prevalence of consistent condom use ranged from 34% to 52 [22,60].
The prevalence of consistent condom use with lubricants was generally low, with estimates ranging from about 1.3% to 67% [28,29,33,42,44,47,49,53,59] compared to consistent condom use without lubricants (7% to 65%) [22,24,26,27,30,32,34,38,39,40,41,43,45,50,51,54,55,56,57,60]. Amongst MSM who engaged in insertive anal sex with casual partners, the prevalence of consistent condom use with lubricants ranged from 29% to 35%, and 12.4% to 29.1% amongst those who had receptive anal sex with regular partners [33,42,49,59]. Consistent condom use with water-based CCLs among regular sex partners ranged from 1.3% to 31% and 11% to 21.7% in casual sex partners [49,59].

3.3. Factors Associated with Consistent Condom with Lubricant Use

Positively Associated Factors of Consistent Condom Use with LubricantsReferences
Amongst the eligible studies included in the review (40), less than half (18) reported the various factors that are associated with consistent condom and lubricant use.[21,24,33,34,38,39,40,42,43,44,45,47,48,51,52,53,56,59].
Socio-demographic factors such as older age and higher levels of education were positively associated with consistent condom use with lubricants.[33,34]
A high level of self-worth, having a main female partner, having had an HIV test, and having a casual sex partner are behavioral factors associated with consistent condom use.[38,43,45,56,59]
For structural factors, risk-reduction counseling services at the time of PrEP initiation and follow-ups, as well as the widespread availability of condoms to MSM through national programs, were positively associated with consistent condom with lubricant use.[53]
Knowing one’s HIV status, being infected with HIV, and using the internet more frequently were also reported to be positively associated with consistent condom use with lubricants.[42,53]
For knowledge and awareness, factors that were positively associated with consistent condom use with lubricants were having appropriate knowledge of condom and lubricant use and having a comprehensive understanding of HIV/AIDs.[42,53]
Negatively associated factors of condom and lubricant useReferences
Of the 18 studies that reported the factors, eight studies reported factors that negatively affected consistent condom use with lubricants.[34,40,43,44,47,48,51]
Factors that negatively affect the consistency of condom and lubricant use include sex under the influence of alcohol and drugs, unplanned sexual intercourse, the attractiveness of the partner, perceived condom quality, and difficulties with using condoms (such as breakage).

Financial incentives, socio-economic vulnerabilities, access challenges, lack of knowledge and misinformation about condom use, decreased pleasure and interference with sexual performance, self-perception of low HIV risk, history of physical abuse due to MSM status, and partner’s opposition to using condoms.		[34,40,43,44,47,48,51]

4. Discussion

4.1. Main Findings

The consistency of condom use with lubricants is very effective in the fight against the spread of new HIV infections and other sexually transmitted infections. This review sought to critically appraise the correct and consistent use of condoms with lubricants and associated factors amongst MSM in SSA.
Firstly, the prevalence of consistent condom use ranges between 48% and 75%, based on the reviewed articles. The lowest and the highest prevalences of consistent condom use from the included studies were taken to form the range. The findings of this review are similar to those found in Vancouver, Canada, and China, where only 56% and 44.9% of MSM, respectively, reported consistent condom use [61,62]. Conversely, a much higher consistent condom use prevalence was reported in Asia. Studies conducted in Indonesia and Thailand also reported 84% and 77% prevalence of consistent condom use amongst MSM, respectively [63,64]. An explanation for the high prevalence of consistent condom use in other countries may be a result of the enactment of laws and flexible regulations in these countries that protect the rights and freedoms of MSM, thus allowing them to have full access to HIV prevention interventions, which is not the case in most SSA countries. In most SSA countries, homosexuality is penalized by lifelong imprisonment, stigmatization and discrimination of homosexuals, and customary and culturally unfriendly environments [65]. This may have made it difficult for MSM to open up about their sexuality or have access to HIV preventive intervention services.
This review revealed that MSM who engaged in insertive anal sex with casual partners were more likely to use condoms with lubricants consistently (29–35%) compared to receptive anal sex with regular partners (12.4–29.1%). The reason most insertive sex partners use condoms with lubricants consistently compared to receptive partners during anal sex may be due to the difficulties they might experience during anal penetration, which puts them at a greater risk of HIV acquisition and transmission due to skin tear [66,67]. Casual partners used condoms with lubricants more consistently than regular partners because they could not possibly trust their sex partners completely. Hence, they needed to protect themselves from acquiring any sexually transmitted infections. The above findings agree with studies conducted in Spain and some European countries [68,69].
Again, this review revealed that the prevalence of consistent condom use with water-based CCLs amongst regular sex partners ranges from 1.3% to 31% and 11% to 21.7% in casual sex partners. This is consistent with the findings of a study conducted by Romijnders et al. (2016), which reported a 30% prevalence of consistent condom use with condom-compatible lubricants [39].
Factors such as a higher level of education, extensive risk-reduction counseling during PrEP initiation and follow-up visits, and high perceived self-worth were positively associated with the consistency of condom use with lubricants among MSM. These agree with studies conducted in Sweden and China, which reported that well-educated MSM may be more aware of HIV/AIDS-related information, have access to quality educational materials, and have thorough HIV-related knowledge, which increases their self-worth [70,71,72]. Knowing one’s HIV status and having knowledge of HIV/STI reduction activities also corroborate the findings of studies conducted in Nigeria and China [72,73], which documented that consistent condom use was linked to the knowledge of HIV/STDs and the partner’s HIV status. The above positively associated factors indicate that those few MSM might have been well-informed about their sexual behavior and, therefore, had ample knowledge of the risks involved in their activities and needed to avoid behaviors that could jeopardize their health and that of their partners or clients.
Additionally, the results of this review also indicate that consistent condom use is positively associated with older age among MSM; however, regional outcomes on this factor have been inconsistent. Studies conducted in Cameroon, Swaziland, and Nigeria found no correlation between age and condomless anal sex among MSM [72,73,74]. In contrast, a study conducted by Lane and colleagues reported that MSM aged 25 years and above were more likely to have protected anal sexual intercourse [75]. The reason behind consistent condom use among older MSM could be attributed to their improved negotiation skills and/or easier access to counseling services that emphasize the value of consistent condom use as a preventive measure against HIV infection.
On the other hand, factors that negatively influenced consistent condom use with lubricants, such as interference with pleasure during sexual intercourse, also support the findings of studies conducted by Ajayi et al. (2010) and Crosby et al. (2016) [73,76]. Sex under the influence of alcohol and drugs also agrees with the findings of studies conducted in Cambodia, SSA, and Brazil [77,78,79]. The use of alcohol and other drugs may have impaired their judgment, thus, forgetting about the risks involved in unprotected anal intercourse.
Financial incentives and socio-economic vulnerability were found to be negatively associated with the consistent use of condoms with lubricants. This is corroborated by a study conducted by Allen and Thomas-Purcell (2012) [80]. Poor socio-economic difficulties may have negatively influenced their decision to give in to unprotected anal sex to gain financial incentives from paying male sex customers. This might also be due to their inability to afford quality condoms and lubricants during anal sex as a result of financial constraints [81,82]. Malala and Wojcicki reported that sex workers or those engaged in transactional sex activities are more likely to compromise on safe or protected sex for higher financial incentives [83]. This is confirmed by another study conducted in Asia by Beattie and Colleagues (2012), which documented that MSM whose livelihood depends on sex work are more likely to give in to unprotected sex when they are offered more income [84]. Another study conducted in India also emphasized that transactional sex workers who used condoms consistently experienced income losses of up to 79% [85].
Access to condoms and lubricants was a significant challenge. This is supported by studies conducted in the United Kingdom, South Africa, and Zambia [14,15,47]. Limited access to condoms was common, especially during the COVID-19 pandemic period, as was found by similar studies conducted by Mukwenha et al. (2020) and Mishra et al. (2021), which reported that MSM and other key population groups access condoms and lubricants from key population-centered NGOs, which were not considered essential services during the COVID-19 lockdown period in various countries [86,87]. Studies conducted in Tunisia and Egypt reported that 85.3% and 70.5% of MSM, respectively, had difficulties accessing condoms and lubricants [88].
Practical difficulties with using condoms, such as pains with using condoms for receptive partners, condom breakage, and slippage, were also found to be negatively associated with consistent condom with lubricant use. This is consistent with a study conducted in the United States, where most receptive partners reported pains, condom breakage, anal discomfort, and bleeding [89]. These occurrences may have been due to inadequate knowledge of the correct use of condoms or not using lubricants or condom-compatible lubricants during anal sexual intercourse.

4.2. Challenges Identified

There were certain biases reported in the review of the included studies, which caused data to be unrepresentative in some of the studies. The majority of the studies examined in this review used a cross-sectional study design, which is prone to biases that come with sensitive information being self-reported. Differential loss to follow-up in some of the studies may have confounded the analyses of condom and lubricant use over time in studies that employed a prospective cohort study design. Also, individuals may have likely acquired the “correct” responses to inquiries regarding sexual risk behaviors without genuinely changing their conduct. Additionally, the snowball sampling technique used in all the cross-sectional study designs is selection bias, especially in countries where homosexuality is penalized. In studies that utilized this method, reaching this hidden population was difficult, so it relied on MSM community leaders.

4.3. Strengths and Limitations of the Study

This review adhered to a comprehensive review process, gaining an in-depth understanding of the scope of consistent condom usage with lubricants and associated challenges amongst the MSM population in SSA. This review was first registered with PROSPERO to avoid duplication. In addition to the registration, the PRISMA guidelines were employed to generate consistent results and enhance the study’s reproducibility. The comprehensive literature search was conducted in SSA across different journal databases and governmental and non-governmental organizations. The Covidence software aided the exclusion of all duplicate citations and ineligible studies, which was very reliable and easy. Two reviewers screened the articles, and the third reviewer resolved discrepancies at the full-text screening stage.
Only research articles published in English and conducted in SSA were considered for this review. We excluded studies published before 2005 because we were interested in more recent data on the research topic. Articles published in other languages and those not accessible as full text, which could have been relevant to the review, were excluded. However, the researcher requested articles that were not open access from the corresponding authors, but some never responded.

5. Conclusions

This review indicates that consistent condom use with/without lubricants is low amongst the MSM population in SSA and, therefore, poses a significant threat to HIV control and prevention in SSA. The variation seen in the consistency of condom use with lubricants amongst the MSM population with different sexual behaviors suggests that context-specific factors undoubtedly influence consistent usage. Both positively and negatively associated factors influenced consistent condom use with lubricants. Factors that hindered the consistent use of condoms with lubricants can be addressed through the provision of comprehensive information and education and the development of intervention strategies and models to improve correct and consistent usage. Future studies should focus on the consistency of correct condom use with condom-compatible lubricants instead of just consistent use.

Recommendations

Based on the findings of this review, it will be prudent to develop a predictive model to improve the consistency and correct use of condoms with lubricants amongst MSM and other KP groups in SSA. It is also essential to enact flexible rules across the sub-region so that MSM and other key population groups can have the confidence and courage to access HIV prevention interventions in any healthcare facility without being stigmatized or discriminated against. We also observed that none of the studies included reported data on the consistency of the correct use of condoms and lubricants or condoms with lubricants. This is a huge setback as the correct use of condoms and lubricants or condoms with lubricants is very vital in terms of transmission and acquisition of all STIs. If condoms with lubricants are not used correctly, then the purpose for which these interventions exist can never be achieved. In the future, information on the correct use of condoms with lubricants must be incorporated into research data collection tools to provide data on the prevalence and associated factors of the correct use of condoms with lubricants. Education on how to correctly use condoms must also be improved.

Author Contributions

R.A., R.N.P.-M. and E.P. conceptualized. R.A., data curation. R.A., project administration. R.N.P.-M. and E.P. supervised the research. R.A., R.N.P.-M., K.A. and E.P. reviewed the data. R.A. conducted the literature search and wrote the first draft of the manuscript. All authors have read and agreed to the published version of the manuscript.

Funding

The work reported herein is made possible through funding by the SAMRC project Code #57035 (SAMRC File Reference No.: HDID8528/KR/202) through its Division of Research Capacity Development under the Mid-Career Scientist Programme using funding received from the South African National Treasury. The first author, Ratif Abdulai, is also supported by the GES 4.0 Scholarship. This work is conducted under the auspices of the SAMRC/UJ PACER. The content hereof is the authors’ sole responsibility and does not necessarily represent the official views of the SAMRC or UJ.

Data Availability Statement

Not applicable.

Acknowledgments

We sincerely appreciate the support and contributions of PACER, SAMRC/UJ, and the GAC staff. We acknowledge the contribution of the Global Excellence Stature, Fourth Industrial Revolution (GES 4.0) Scholarship.

Conflicts of Interest

The authors declare no conflicts of interest.

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Figure 1. PRISMA diagram for the review selection process.
Figure 1. PRISMA diagram for the review selection process.
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Figure 2. Regional distribution of the studies included in the review.
Figure 2. Regional distribution of the studies included in the review.
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Table 1. Indicates the inclusion and exclusion criteria using the PICO framework.
Table 1. Indicates the inclusion and exclusion criteria using the PICO framework.
ItemInclusionExclusion
PopulationMen who have sex with men (aged 15 years and older).Studies that did not focus on MSM.
InterventionCondom and lubricant use aimed at preventing the transmission and acquisition of new HIV infections amongst MSM in SSA.Studies that did not report data on condom and lubricant use amongst MSM in SSA.
ComparisonMSM who used condoms or used condoms with lubricants consistently or inconsistently.Studies on MSM that did not report data on condom and lubricant use were excluded.
OutcomeFor the primary outcomes, this study considered data on condom use, condom use with lubricants, consistent condom use with lubricants, and consistency of the correct use of condoms with condom-compatible lubricants.
The secondary outcome measures were (i) factors that are positively associated with consistency of condom use with lubricants or condom-compatible lubricants and (ii) factors that hinder consistent condom use with/without lubricants.		This review exempted studies that did not report on any of these outcomes.
Table 2. Summary of the characteristics of the eligible studies.
Table 2. Summary of the characteristics of the eligible studies.
First Author, YearStudy Setting/CountryStudySample Size and AgeStudy Design/Data Collecting Tool
1. Munyaneza et al. (2024) [21]RwandaTo measure the level of awareness and readiness of Rwanda’s MSM to pre-exposure prophylaxis (PrEP).521 participants were enrolled in the study.Cross-sectional survey design using RDS.
2. Davis et al. (2024) [22]Harare and Bulawayo, ZimbabweTo describe MSM in bisexual relationships and associated factors.1143 participants were involved in the study.Cross-sectional survey design using RDS.
3. Mwaniki et al. (2023) [23]Nairobi, KenyaTo estimate the prevalence of HIV and its determining factors among student MSM.248 MSM were involved in the study.Cross-sectional survey design using RDS.
4. Manguro et al. (2022) [24]KenyaTo measure the changes in sexual behavior among MSM on oral PrEP.822 MSM were recruited into the study.Cross-sectional survey design using RDS.
5. Smith et al. (2021) [25]Nairobi, KenyaTo determine the gender identity of men and transgender persons who have sex with other men and to investigate its linkage with sexual health outcomes, risky behaviors, and adherence to HIV preventive measures.612 MSM participated in the study.Cross-sectional survey design using RDS.
6. Mutisya et al. (2020) [26]Nairobi, KenyaIdentify the factors motivating key populations to participate in future vaccine trials.200 MSM were recruited into the study.Cross-sectional survey design using RDS/structured questionnaire.
7. Moran et al. (2020) [27]Cote d’IvoireTo understand the relationship between social cohesiveness and HIV in infection cisgender MSM and transgender women.1301 MSM and transgender women were recruited into the study.Cross-sectional survey design using RDS.
8. Mmbaga et al. (2020) [28]Dar Es Salaam,
Tanzania		To investigate the extent and role of early anal sexual activity in risk of HIV infection in a large group of MSM.753 MSM participated in the study.Cross-sectional survey design using RDS.
9. Hessou et al. (2020) [29]BeninTo identify relevant factors that affect HIV incidence in the MSM population.518 MSM were recruited into the study.Prospective cohort study design.
10. Twahirwa Rwema et al. (2020) [30]Kigali, RwandaTo describe the prevalence of HIV and care cascade among MSM and transgender women.736 participants took part in the study.Cross-sectional survey design using RDS.
11. Alexander Ishungisa et al. (2020) [31]Dar es Salaam, TanzaniaTo provide data on the HIV prevalence and associated sexual behavior risk factors among MSM.777 MSM participated in the study.Cross-sectional survey design using RDS.
12. Robbins et al. (2020) [32]NigeriaTo investigate the relationship between oral sex practices and HIV among MSM and transgender women.1342 MSM and transgender women participated in the study.Cross-sectional survey design using RDS.
13. Crowell et al. (2019) [33]Abuja and
Lagos, Nigeria.		To assess the availability and acceptance of condoms and condom-compatible water-based lubricants among MSM and TGW.2090 MSM and transgender women were recruited into the study.Prospective cohort study.
14. Ruiseñor-Escudero et al. (2019) [34]The study was conducted in Lome and Kara, Togo.To determine the relationship between the consistent use of condoms and socio-economic, biological, and behavioral factors among MSM.683 MSM participated in the study: 354 (51.8%) from Lome and 329 (48.2%) from Kara.Cross-sectional survey design using RDS.
15. Hakim et al. (2018) [35]Bamako, Mali.To characterize the HIV care cascade, identify HIV status predictors, and estimate the percentage of recent infections among MSM and TGW.552 participants took part in the study: 387 MSM and 165 transgender women.Cross-sectional survey design using RDS.
16. Lahuerta et al. (2018) [36]Bamako, Mali.To establish the prevalence of HIV and its related risk factors among men who have sex with men.552 MSM participants were enrolled in the study.Integrated bio-behavioral survey design using RDS.
17. Teclessou et al. (2017) [37]TogoTo examine sexual behaviors and determine the prevalence of HIV among MSM.496 MSM were involved in the study.Cross-sectional survey design using RDS (interviewer-administered questionnaires).
18. Bakai et al. (2016) [38]TogoTo describe the use of condoms and its associated determinants among Togo’s MSM population.724 MSM were recruited into the study.A cross-sectional survey design using RDS.
19. Romijnders et al. (2016) [39]This study was conducted at two locations in Tanzania: Dar es Salaam and Tanga.To investigate the factors associated with condom and lubricant use among MSM.300 MSM participated in the study: 100 came from Tanga and 200 from Dar es Salaam.Cross-sectional survey design using RDS.
20. Musinguzi et al. (2015) [40]The study was conducted in 11 districts in Uganda.To investigate condom use barriers among MSM.33 MSM participated in the study.Cross-sectional descriptive study/semi-structured interviews.
21. Holland et al. (2015) [41]Yaoundé and Douala, CameroonTo evaluate the uptake of HIV services and develop better HIV preventive and treatment methods among MSM.511 MSM were recruited: 239 in Yaoundé and 272 in Douala.Integrated Biological and Behavioral Surveillance Survey.
22. Wirtz et al. (2015) [42]Blantyre, MalawiTo mitigate HIV prevention barriers associated with high HIV risks among MSM.103 MSM were enrolled in the cohort study.Prospective cohort study.
23. Siegler et al. (2014) [43]Cape Town and Port Elizabeth, South Africa.To examine condom bargaining strategies in relationships and to investigate consistent condom use among MSM.34 participants were recruited for the study.Cross-sectional survey design using RDS. Semi-structured interviews.
24. Aho et al. (2014) [44]Abidjan, Cote d′IvoireTo investigate risk behaviors and vulnerabilities of MSM in Abidjan, Cote d’Ivoire.601 MSM were enrolled in the study.A bio-behavioral survey/in-depth interview.
25. McKinnon et al. (2014) [45]Nairobi, KenyaTo determine HIV risk factors among the MSM population.507 MSM sex workers were enrolled in the study.Prospective cohort study design.
26. Sheehy et al. (2014) [46]NigeriaTo examine the characteristics and the associations of MSMW.557 MSM were recruited into the study.Cross-sectional survey design using RDS.
27. Ayoola et al. (2013) [47]Lagos State, NigeriaTo investigate the link between sexual practices and condom and lubricant use among MSM.A total of 321 respondents were recruited for the study.A descriptive cross-sectional study design using RDS/self-administered questionnaire.
28. Park et al. (2013) [48]The study was conducted in Douala and Yaoundé, Cameroon.To examine the prevalence and associated factors of HIV and syphilis infection among MSM.511 MSM participated in the study; 272 were recruited from Douala and 239 from Yaoundé.Cross-sectional surveillance study design using RDS/self-administered structured questionnaire.
29. Baral et al. (2013) [49]SwazilandTo identify and characterize the critical correlations of prevalent infections among MSM.324 MSM who reported sex with another man in the last 12 months were recruited.Cross-sectional survey design using RDS/structured survey instruments administered by trained staff.
30. Wirtz et al. (2013) [50]Blantyre, MalawiTo determine the prevalence of HIV, characterize associations, and examine the barriers and the uptake of HIV preventive services.338 MSM were enrolled in the study.Cross-sectional survey design using RDS.
31. Nyoni and Ross (2013) [51]Dar es Salaam,
Tanzania		To study demographics and HIV-related attitudes and behaviors, such as condom use.271 MSM were recruited into the study.Cross-sectional survey design using RDS.
32. Vu et al. (2013) [52]Abuja, Ibadan, and Lagos, NigeriaTo explore sexual risk behaviors and associations with unprotected anal sex among MSM.712 MSM were recruited into the study; Abuja (n = 194), Ibadan (n = 210), and Lagos (n = 308).Cross-sectional survey design using RDS.
33. Strömdahl et al. (2012) [53]Abuja, NigeriaTo determine the associated factors of consistent condom use among MSM in Nigeria.297 MSM were recruited into the study.Cross-sectional study with peer referral and venue-based sampling.
34. Wagenaar et al. (2012) [54]South AfricaTo investigate the underlying causes of low HIV/AIDS knowledge among MSM in South Africa.439 MSM from South Africa were recruited into the study.An online cross-sectional survey using a US-validated HIV knowledge scale (HIV-KQ-18).
35. Geibel and Luchters, (2011) [55]Nairobi and Mombasa, KenyaTo investigate the impact of same-sex sexual activity on HIV prevention, initiatives, and policy.500 study participants were recruited from Nairobi and 425 from Mombasa.Intervention study.
36. Baral et al. (2011) [56]Peri-urban townships of Cape Town, South Africa.To determine the prevalence of HIV infection and associations among MSM in Cape Town.200 MSM were recruited for the study from January to February 2009.A cross-sectional survey was conducted using a venue-based sampling approach with peer referral at each venue.
37. Dahoma et al. (2011) [57]Unguja and Zanzibar, TanzaniaTo examine the relationship between HIV prevalence and risk behaviors among MSM.The study recruited a total of 509 MSM.Cross-sectional survey design using RDS.
38. Rispel et al. (2011) [58]Johannesburg and Durban, South Africa.To estimate the HIV prevalence and risk behaviors among MSM.285 MSM were recruited into the study: Johannesburg (n = 204) and Durban (n = 81).Cross-sectional survey design using RDS.
39. Beyrer et al. (2010) [59]Southern African (Malawi, Namibia, and Botswana)To investigate the linkage between bisexual relationships and HIV in South Africa’s MSM population.533 study participants were enrolled in the study: Namibia (216), Malawi (200), and Botswana (117).Cross-sectional survey design using RDS.
40. Sanders et al. (2007) [60]Mombasa, KenyaTo determine the risk factors for HIV-1 infection prevalence among MSM.285 MSM were recruited for the study.Cross-sectional survey design using RDS.
Table 3. Consistent condom and lubricant use amongst men who have sex with men in sub-Saharan Africa.
Table 3. Consistent condom and lubricant use amongst men who have sex with men in sub-Saharan Africa.
First Author, YearCondom UseConsistent Condom Use with or Without Lubricants
1. Davis et al. (2024) [22]Condom use in the past six months was reported by 48% of MSM.Consistent condom use during the past six months with main male partners was reported by 52% (183/351) of MSM who had both male and female partners and 47% (371/792) by those who reported only male partners.

More than one-third (42%) of all the participants reported consistent condom use with their partners.
2. Manguro et al. (2022) [24]65% of the respondents reported condom use at PrEP initiation, which increased to 91% during month three.Out of the 822 MSM who were recruited into the study, 65% (531) reported having used condoms consistently during PrEP initiation.

The proportion of MSM who used condoms consistently rose to 80% and 91% during follow-up after the first and second months of PrEP initiation, respectively.
3. Mutisya et al. (2020) [26]Condom use in the last month was reported by 84% of MSM who participated in the study.Of the number of MSM who reported using condoms, only 64% of them consistently used condoms.
4. Moran et al. (2020) [27]Condom use at last intercourse with a casual male partner was reported to be 28.4%, non-casual male partners (61%), regular male partners (55.6%), and non-regular male partners (31%).
For female partners, condom use during anal sex was 46%.		Only 9.0% (93/1010) of participants reported always using condoms with male partners in the last 30 days.
About 7.2% reported always using condoms with all male partners.
5. Mmbaga et al. (2020) [28]Condom use at last sexual intercourse was reported by 48% of the recruited participants.More than two-thirds (78%) used condoms with water-based lubricants during the last anal sex.
6. Hessou et al. (2020) [29]Almost all the participants reported using condoms at least once in the last six months prior to the study.Amongst those who reported using condoms consistently (43%), 35% used them with lubricants, which then increased to 47% at 30 months during follow-up.
7. Twahirwa Rwema et al. (2020) [30]Less than half of the study participants reported having used condoms during their last sexual activity.Consistent condom use was reported by 12.8% (94/736) of the participants recruited for the study.
8. Robbins et al. (2020) [32]Among men living with HIV, 96% reported condomless oral sex, compared to 93% not living with HIV in the last 12 months.Just 4% reported consistently using a condom during oral sex among the HIV positives, while only 7% reported using a condom consistently with those without HIV in the last 12 months.
9. Crowell et al. (2019) [33]Out of the total number of participants who reported both receptive and insertive anal sex (3122), only a third of them (33.5%) reported condom use in the last 12 months before their enrollment in the study.Out of those (1530) who reported receptive anal sex at enrollment, 469 (30.7%) reported using condoms always.
Participants who used condoms consistently during insertive anal sex was 36.3% (578/1592).
About one-third (29.2%) of those who reported always using condoms during receptive anal sex did so consistently with lubricants, with 21.7% of them using water-based lubricants.

Less than a third (25.4%) of those who had insertive anal sex used condoms consistently with water-based CCLs but later increased to 56.2% after nine months of follow-up.
10. Ruiseñor-Escudero et al. (2019) [34]More than half (54.8%) (374/683) of MSM reported always using condoms for anal sex with a male partner.Men who have sex with men in Kara had lower odds of consistent condom use [(aOR) = 0.29, 95% CI = 0.19–0.44] compared with those in Lome.
11. Bakai et al. (2016) [38]Condom use differed from one sex practice to another. Insertive anal sex (78.4%), receptive anal sex (81.2%).Consistent condom use varied according to their sexual behavior.
78.4% reported consistent condom use during insertive anal sex, and 81.2% during receptive anal sex.
12. Romijnders et al. (2016) [39]Two-thirds of the participants (300) reported using condoms during both insertive and receptive anal sexual intercourse.Out of those who used condoms (66.7%) during anal sex, about 48.1% and 33.3% always used condoms during insertive sex with partners and receptive anal sex, respectively.
13. Musinguzi et al. (2015) [40]More than one-third of the respondents (38.8%) reported non-use of condoms at last sexual intercourse.More than half (61.2%) of the participants responded to consistent condom use.
14. Holland et al. (2015) [41]More than one-third of the participants (40.5%) reported inconsistent condom use during the last year: 41% from Douala and 40% from Yaoundé.Of the number of MSM (511) who took part in the study, 59.5% reported always using condoms with casual partners in the last 12 months.
15. Wirtz et al. (2015) [42]Condom use during last intercourse with the main male partner increased from 63% (60/96) to 77% (57/74) in the 3rd follow-up.

During the 3rd follow-up, condom use with a casual male partner increased significantly from 70.7% (53/73) to 86.3% (63/73).		Almost a third (29%; 28/97) of the participants reported consistent condom usage with lubricants during insertive sex.
This rose to 74% (71/96; p < 0.001) after the 3rd follow-up.
16. Siegler et al. (2014) [43]A little above half (55.9%) of the respondents reported having used condoms during intercourse.62% of the participants reported using condoms consistently.
17. Aho et al. (2014) [44]More than half (63.2%) of the study participants reported condom use at last sexual intercourse.Consistent condom use was reported by one-third (34.8%) of the MSM.

Only a small percentage of the participants (9.9%) consistently used condoms with water-based lubricants.
18. McKinnon et al. (2014) [45]More than half (59%) of men reported using a condom during their last sex act, with no differences based on HIV status.Approximately one-third (31%) of MSM reported using condoms consistently during insertive anal sex and 34% in receptive anal sex; condom use was marginally higher among HIV-negative participants.
19. Ayoola et al. (2013) [47]Almost two-thirds (62.5%) of the respondents reported using a condom during the last sexual encounter.Consistent condom use was practiced by 40.5% of respondents during the last ten sexual encounters.

Out of the percentage of MSM (40.5%) who reported consistent condom use, 67.9% of them used lubricants consistently with condoms.
20. Baral et al. (2013) [49]More than half (61.4%) of 308 participants who reported condom use reported always using condoms during sex.Consistent condom use by the various groups of MSM are as follows:
condom utilization with main male partners in the past 12 months (48.1%), casual male partners (46.1%), regular female partners (38.2), and casual female partners (44.4%).

Out of all those who reported consistent condom use, only 12.6% used condoms with lubricants consistently with male partners, 24.7% with female partners, and only 1.3% used condoms with water-based CCLs consistently with all sexual partners.
21. Wirtz et al. (2013) [50]More than half of the participants (66.3%) reported condom use with casual male partners, and 59.6% amongst main male partners.

For main female partners, condom use was reported by 50.3% and 58.2% amongst casual female partners.		Consistent condom usage with main male partners was reported by 35.7% of the participants and 44.2% of casual male partners.

Always using a condom with main female partners at last sexual intercourse was also reported by 39.1% of MSM.
22. Nyoni and Ross (2013) [51]Only about half of the participants reported using condoms during sex.Less than half (43%) of casual partners reported using condoms during intercourse, while 49% reported using them with their last regular partner.
23. Strömdahl et al. (2012) [53]Almost all the study participants (97.6%) reported using condoms one way or the other.More than half (53%) of participants reported consistently using condoms with male partners and 43% (n = 95/219) with female companions in the past six months.

Only 11% (n = 16/144) reported always using condoms with water-based condom-compatible lubricant with both male and female partners.
24. Wagenaar et al. (2012) [54]Out of the 338 people who reported having anal sex in the last 12 months, less than half of them 165/338 (48.8%) used condoms.Consistent condom use among the study participants was almost negligible (1.6%).
25. Geibel and Luchters, (2011) [55]About three-fourths of the participants (75%) who were recruited from Nairobi reported condom use at last sex with a male partner, 58% from Mombasa before the study, and 68% during follow-up.About half (56%) of the participants from Nairobi reported consistent condom use with a male partner, 30% from Mombasa before the study, and 50% during follow-up.
26. Baral et al. (2011) [56]Condom use was reported by 92% (184/200) of all the participants.Out of the number of participants who reported using condoms, only 6.5% (n = 12/184) of them reported using condoms consistently with all sexual partners. A little above half (52.4%) reported always wearing condoms with male sex partners and 39.5% with female sex partners.
27. Dahoma et al. (2011) [57]Condom use with non-paying insertive anal sex partners in the past month was reported by 75.6% (385/509) and 42% (214/509) of non-paying receptive anal sex partners.

Condom use with males who paid for insertive anal sex in the past month was reported by 58.9% (300/509) of MSM and nearly 65% (332/509) by receptive anal sex partners.		Only 14.5% (51/385) of MSM used condoms consistently among non-paying insertive anal sex partners in the past month and 9.2% (21/214) amongst non-paying receptive anal sex partners.

Amongst those who paid for insertive anal sexual intercourse, only 16.3% (49/300) used condoms consistently, while only 15% (50/332) used condoms consistently during paid receptive anal sex.
28. Beyrer et al. (2010) [59]Almost all the participants (99%) reported using condoms in the last six months.Consistent condom use was reported by 16.7% of the participants in bisexual relationships, 22% by casual partners, and 17.4% by regular partners.

More than half (63.7%) of those who reported using condoms used them with lubricants. And out of those who used condoms with lubricants, 38% used water-based lubricants.
29. Sanders et al. (2007) [60]Only 18% (51/279) of MSM reported condom use during anal sex. Amongst regular sex partners, 27.8% reported condom use and casual partners (39%).For regular partners, 27.8% used condoms consistently amongst MSME and MSMW; casual partners were MSME (42.6%) and MSMW (37.2%).
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Abdulai, R.; Phalane, E.; Atuahene, K.; Phaswana-Mafuya, R.N. Consistent Condom and Lubricant Use and Associated Factors Amongst Men Who Have Sex with Men in Sub-Saharan Africa: A Systematic Review. Sexes 2024, 5, 796-813. https://doi.org/10.3390/sexes5040051

AMA Style

Abdulai R, Phalane E, Atuahene K, Phaswana-Mafuya RN. Consistent Condom and Lubricant Use and Associated Factors Amongst Men Who Have Sex with Men in Sub-Saharan Africa: A Systematic Review. Sexes. 2024; 5(4):796-813. https://doi.org/10.3390/sexes5040051

Chicago/Turabian Style

Abdulai, Ratif, Edith Phalane, Kyeremeh Atuahene, and Refilwe Nancy Phaswana-Mafuya. 2024. "Consistent Condom and Lubricant Use and Associated Factors Amongst Men Who Have Sex with Men in Sub-Saharan Africa: A Systematic Review" Sexes 5, no. 4: 796-813. https://doi.org/10.3390/sexes5040051

APA Style

Abdulai, R., Phalane, E., Atuahene, K., & Phaswana-Mafuya, R. N. (2024). Consistent Condom and Lubricant Use and Associated Factors Amongst Men Who Have Sex with Men in Sub-Saharan Africa: A Systematic Review. Sexes, 5(4), 796-813. https://doi.org/10.3390/sexes5040051

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