Multiple condom use and decreased condom breakage and slippage in Thailand

J Acquir Immune Defic Syndr Hum Retrovirol. 1997 Feb 1;14(2):169-73. doi: 10.1097/00042560-199702010-00011.


There is compelling evidence that male condoms effectively prevent transmission of sexual pathogens, including HIV-1. Condom breakage and slippage reduce this effect. We measured rates of condom slippage and breakage during heterosexual commercial sex in northern Thailand. Of 7,594 condoms examined in 4,734 client visits (5,040 sex acts), breakage was noted in 1.8% of single condom use (49.3% of acts), as compared with 0.2% with two condoms (49% of sex acts), and no breaks with more than two condoms (1.2% of sex acts). These breakage rates declined from 5.9% in a similar 1992 study in which 2.8% of sex acts were with more than one condom used at a time. Slippage occurred in only 0.1% of sex acts. Case-control analysis indicated that multiple clients, younger aged clients, sex after midnight, and high intensity (rough) sex were associated with condom breaks. The decline in breakage may be attributable to greater expertise in condom use by sex workers and clients, in response to the successful Thai national "100% Condom Campaign." Use of more than one condom during sex has been initiated by sex workers and their clients, a community response to condom promotion messages and fears of HIV infection. These data demonstrate the potential of condom use for high efficacy in reducing exposure to HIV-1 and other STDs. If condom use in commercial sex remains high, HIV incidence may decline among Thai men.

PIP: During August-October 1995, in northern Thailand, laboratory personnel examined 7594 condoms from 4734 client visits and 5040 sexual acts to evaluate mechanisms of condom breakage and slippage among 68 female commercial sex workers (CSWs) (mean age, 25 years) in 7 brothels in Lamphun City in Lamphun Province in order to verify condom use self-reports among the CSWs and to identify targets for interventions to reduce condom failure. Sexually transmitted disease (STD) episodes in the last year among the CSWs were gonorrhea (45.6%), pelvic inflammatory disease (29.4%), genital ulcer (29.3%), syphilis (13.2%), nongonococcal cervicitis (13.2%), and genital warts (8.8%). A condom was not used during 0.6% (30) of the sexual acts. 99.4% (5010) of the sexual acts involved use of at least one condom. There were only 5 condom slippage events--a condom slippage rate of 0.1%. This rate did not vary with the number of condoms used per sexual act. On the other hand, the condom breakage rate decreased as the number of condoms used per sexual act increased (1 condom = 1.8%; 2 condoms = 0.2%; 3-4 condoms = 0). Single condom use was more likely to yield breakage than multiple condom use (odds ratio [OR] = 11.4). The condom breakage rate 1 year after initiation of the 100% Condom Campaign (1992) was 5.9% compared to 1% in 1995. Condom breaks occurred just below the reservoir (40.2%), at reservoir tips (31.7%), along the shaft (18.3%), and at the base (9.8%). Multiple condom use increased from 2.8% to 50.4% during 1992-95. Factors independently associated with condom breaks included high-intensity (rough) sex (OR = 8.49; p 0.0001), more than one sexual act with the same client on the night of the breakage (OR = 2.72; p = 0.02), and sexual service after midnight (OR = 2.58; p = 0.03). These findings suggest that multiple condom use significantly contributed to the decline in condom breakage among multiple users. Another strong possible factor was greater skill in condom use by CSWs and by clients in response to the 100% Condom Campaign. Multiple condom use may reduce exposure to HIV-1 and other STDs.

Publication types

  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Adult
  • Case-Control Studies
  • Condoms / standards*
  • Contraception Behavior*
  • Female
  • HIV Infections / prevention & control*
  • HIV-1*
  • Humans
  • Male
  • Multivariate Analysis
  • Sex Work*
  • Sexual Behavior
  • Sexually Transmitted Diseases / prevention & control*
  • Thailand