Our data illustrate that low condom use in eastern Africa can be attributed to the mixed messaging of HIV prevention campaigns, specifically ABC, which stigmatize male condoms by linking them with infidelity and mistrust. We have shown that distrust of one’s partner is a primary driver for condom use, leading people to use condoms with casual sexual partners, but not within partnerships where sexual exclusivity—or ‘being faithful’—is idealized.
Stigmatization of condoms in stable relationships
Condoms were not widely endorsed as a tool for family planning and were not a “normal” part of stable relationships. Women in our study cited an inability to protect themselves from the risk of their male partners’ extramarital sexual encounters—which were normalized as part of long-term relationships. Condom use relies on engagement by both partners. Patriarchal norms are a barrier to condom negotiation by women in long-term relationships are they are not typically the “decision makers” of their households [25]. Women in concurrent, casual relationships have higher rates of condom uptake, suggesting that the expectation of monogamy, however unrealistic, along with the traditional structure of male partners holding authority pose challenges to male condom uptake [26]. This tension highlights the need for effective HIV prevention tools that do not rely on abstinence or “being faithful.” Our data support the concept that low rates of condom use are inexorably tied to public health messaging about condoms as a less desirable mode of HIV prevention.
Stigmatization of condoms appears linked to the legacy of the ABC prevention model, whose messages persist. This model for HIV prevention is inherently hierarchical, where engagement at one level implies failure at the levels above it. Accordingly, abstinence is the best option for prevention, followed by being faithful, and finally by condom use. The ABC structure implies that, if someone is using condoms, they have failed to be abstinent and monogamous (Fig. 1). The hierarchy implied by the ABC model thereby creates a link between condom use and infidelity, thus stigmatizing the condom user.
The legacy of ABC’s impact on new HIV prevention strategies
Understanding barriers to condom utilization can inform and improve prevention strategies in HIV-endemic communities. Our data show that the legacy of the ABC model is deeply entrenched. Male condom use within relationships is unlikely to increase so long as they are stigmatized as a marker of infidelity and partner distrust. Prevention campaigns that do not account for this stigma are likely to face significant barriers to uptake. Newer tools in HIV prevention, such as PrEP, may encounter similar challenges to uptake in long-term relationships as they too acknowledge risk of outside sexual partners, though they differ from condoms in that one partner could take PrEP without the other’s knowledge. The invisibility of PrEP could facilitate uptake by women who consider themselves to be at high risk but cannot safely have conversations about risk reduction in their relationships [27, 28]. Public health campaigns could address stigma earlier in the promotion of HIV prevention tools, which could allow for increased uptake without replicating the decades-long history of stigma that the male condom carries.
Re-framing condom use
Though the prevention landscape has become more varied, male condom use remains an important tool in HIV prevention, family planning and STI prevention. We suggest that individual-centric messages may be culturally inappropriate for eastern Africa, where community, family, and religion may be valued above the individual [29]. An alternate message more aligned with prevailing social values may increase acceptability. Condoms’ unique position at the intersection of family planning and STI prevention could facilitate a change in messaging. For example, condoms could be ‘reframed’ to emphasize their utility as a method of family planning, or as a means of contributing positively towards the overall health of the community.
Reframing the conversation surrounding condom use to include family planning could empower women to negotiate condom use within relationships by de-centering mistrust [30]. Women in eastern Africa often believe that their husbands’ sexual behavior is their biggest source of HIV risk, and they lack control of their risk due to high incidence of extramarital sexual activity among married men [31, 32]. It is widely believed that women cannot realistically deny their husbands sex, and the stigma of male condom use within their partnerships leaves them vulnerable to HIV acquisition [10, 33]. While reframing condoms will not remove other barriers to uptake such as perceived decreased sexual pleasure, HIV prevention messages emphasizing condoms as family planning could allow women to more easily bring them into marriages, thus protecting both partners from HIV transmission.
Removing hierarchy from HIV prevention
We suggest that a non-hierarchical approach to HIV prevention may be an effective means to decrease HIV transmission. In an egalitarian model, multiple tools are valid and using one method does not signify failing at another: the goal is to pick one or more effective tools and use them (Fig. 2). “Combination prevention” strategies, like DREAMS’ packaged interventions, have successfully embraced this approach in health education campaigns throughout sub-Saharan Africa and achieved higher use of PrEP as HIV prevention, consistent male condom use, and lower rates of intimate partner violence [18, 34].
Study strengths and limitations
This exploratory analysis was born from commonalities observed in the qualitative data collected in two separate studies. As one study used focus groups centered on family planning and the other utilized interviews on HIV prevention, our analysis is limited by the different aims, lines of questioning and data collection settings. While focus groups and interviews generate different forms of qualitative data, both have been shown as appropriate to elicit perspectives on stigmatized topics [35, 36]. Despite these differences in study design and conduct, the presence of consistent discussion of condom stigmatization in two different countries suggests that these observed perceptions may be widespread. A future, more formal exploration of this topic would likely illustrate a wider array of themes and could elucidate promising strategies to combat this stigma.