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. Author manuscript; available in PMC: 2018 Apr 1.
Published in final edited form as: Cult Health Sex. 2016 Oct 14;19(4):501–514. doi: 10.1080/13691058.2016.1239134

Breakage Is the Norm: Use of Condoms and Lubrication in Anal Sex among Black South African Men Who Have Sex with Men

Matthew Lee a, Theo Sandfort a,*, Kate Collier a, Tim Lane b, Vasu Reddy c
PMCID: PMC5340618  NIHMSID: NIHMS817532  PMID: 27737625

Abstract

This paper explores condom use and lubrication practices among Black men who have sex with men in South African townships. Results are from 81 in-depth individual interviews conducted among a purposive sample from four townships surrounding Pretoria as part of a larger qualitative study. Awareness that condoms should be used to have safer anal sex was ubiquitous. Fewer men reported that lubricants should be used to facilitate anal intercourse. Partner pressure and partner distrust were the most common barriers cited for not using condoms and lubricants. Knowledge about condom-lubricant compatibility was rare. Condom problems were a norm, with widespread expectations of condom failure. Men’s subjectivities – their perceptions of and preferences for specific brands, types, and flavours of condoms and lubricants – influenced engagement with such safer sex technologies. However, what was available in these settings was often neither what men needed nor preferred. Findings show the need to enhance access to appropriate and comprehensive: safer sex supplies, health services, and health education, and underline the importance of efforts to develop targeted programmes relevant to experiences of men who have sex with men in the South African context.

Keywords: men who have sex with men, sexual experiences, condoms, lubricants, South Africa

Introduction

This paper is one of the first to explore use of male condoms in combination with lubricants during anal sex among Black men who have sex with men living in Africa. Globally, across high-, medium-, and low-income countries, men who have sex with men continue to be disproportionally affected by HIV and other sexually transmitted infections (STIs) (Beyrer et al. 2013; Meng et al. 2015). According to the World Health Organization (WHO) (2011), water- and silicone-based lubricants are central to correct condom use during anal sex, and consistent condom use can reduce HIV transmission by 64% and STI transmission by 42% among men who have sex with men. As such, it remains crucial to understand what can be done with these longstanding and still relevant prevention methods in the face of the global HIV and STI pandemics. While promising innovations to be used in conjunction with condoms are emerging, including pre-exposure prophylaxis (PrEP) and microbicidal lubricants, these may not be available, affordable, or accessible for some time; particularly on larger scales and in low- and middle-income countries.

Most work on condom use and lubrication practices has been conducted in high-income countries. For example, recent research demonstrates that in the USA, Black men who have sex with men are using condoms and lubricants at the same rates as their white counterparts, but experience higher rates of condom use problems (including breakage, slippage, incomplete use, and lack of sexual pleasure for both insertive and receptive partners), and also more frequently use non-condom compatible lubricants (Hernández-Romieu et al. 2014; Mustanski, Ryan, and Garofalo 2014; Halkitis, Kapadia, and Ompad 2015).

Some recent work has been conducted in Asian countries that examined associations between consistent lubricant use, condom use, and other factors among men who have sex with men in Bangkok, Thailand (Thienkrua et al. 2016) and willingness to use lubricants and recent lubricant and condom use among men who have sex with men in Tianjin, China (Zhang et al. 2016). Both of these studies demonstrated very high rates of recent lubricant use, similar to those found in the USA, and higher than those reported among men who have sex with men in Indonesia and Lima, Peru (Carballo-Diéguez et al. 2000; Morineau et al. 2011; Clark et al. 2013; Thienkrua et al. 2016; Zhang et al. 2016).

Although some work in Africa has sought to understand the attitudes and practices of men who have sex with men surrounding condom use (Larmarange et al. 2010; Nyoni and Ross 2013), and sometimes with mention of lubricants (Moen et al. 2013; Musinguzi et al. 2015), only one study looked at condoms and lubricants with equal attention. In this study amongst men who have sex with men in Abuja, Nigeria, more than half of the sample reported always using condoms with male partners in the past 6 months and an even greater majority reported always using lubricants with male partners (Strömdahl et al. 2012). None of this work has been conducted in South Africa, despite having the greatest incidence and prevalence of HIV in the world (UN Joint Programme on HIV/AIDS, 2014). As such, still little is known in South Africa about whether and how men who have sex with men actually use safer sex technologies such as condoms and lubricants.

While extensive research has been conducted on vaginal practices in Southern Africa, including investigating rural South African women’s use of lubricant-based vaginal gels (Gafos et al. 2010), and even a recent study assessing heterosexual penile-anal intercourse in South Africa, Uganda and Zimbabwe (Duby et al. 2016a; Duby et al. 2016b), there is a long history of men who have sex with men in South Africa being ignored in research and in national HIV/AIDS interventions (Reddy, Sandfort, and Rispel 2009; Republic of South Africa 2012). According to the South African Global AIDS Response Progress Report, there is currently ‘no data’ on both ‘percentage of men who have sex with men reached with HIV prevention programmes’ and ‘percentage of men reporting the use of condom the last time they had sex with a male partner’ (Republic of South Africa 2012, 56). However, there is evidence that this is changing. For example, the South African 2012-2016 National Strategic Plan for STIs, HIV and TB does recognise men who have sex with men as a key population most likely to be exposed to or transmit HIV and says ‘concerted efforts are needed to reach this target group’ (South African National AIDS Council 2011, 47). Additionally, recent research demonstrates that HIV/AIDS has changed the ways in which South African men construct and experience hegemonic masculinity and engage in safer sex (Mfecane 2012). As part of the 2012-2016 Plan, the South African National Department of Health sponsors free condoms on a national scale and seeks to distribute 1 billion male condoms during this period. These condoms, colloquially referred to as ‘government condoms’, are branded under the name, ‘Choice’. Understanding men who have sex with men’s experiences with the condoms and lubricants available to them will facilitate more effective HIV and STI prevention efforts.

Methods

Data for this study were collected as part of a larger qualitative project to describe the social organisation of same-sex sexual practices of Black men who have sex with men in four townships within Tshwane Municipality (the greater metropolitan area that includes Pretoria) in South Africa, and to identify structural and psychosocial factors that affect how these practices are experienced. These four townships are: Atteridgeville, Mamelodi, Soshanguve, and Hammanskraal. Atteridgeville and Mamelodi both share borders with the Pretoria city limits, while Soshanguve is 36 km north west and Hammanskraal is the furthest—49 km due north of Pretoria and the central business district there. This ethnography included in-depth interviews with both members from the target population (see table 1 for inclusion criteria) and key informants, as well as participant observations in local taverns and clubs.

Table 1.

Inclusion criteria

  • Between 20-44 years old

  • Had oral, anal or masturbatory sex with at least one man in the preceding year (regardless of involvement with women)

  • Black

  • Living in one of the four selected townships – Atteridgeville, Mamelodi, Soshanguve, Hammanskraal

  • Agreed to being audiotaped during the interview

  • Fluent in English, Northern Sotho (Sepedi), or Tswana (Setswana)

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Procedure

Potential participants were identified by the study’s Community Advisory Board, outreach workers, interviewers, and snowball referrals. Purposive selection of participants to interview was then used to ensure a diverse sample in terms of age, sexual orientation, self-identification, and gender presentation. Using a semi-structured guide with suggested opportunities for further probing, interviews were conducted in private settings at the offices of collaborating agencies or in other safe spaces, and lasted approximately 90 minutes. Local interviewers were selected on the basis of holding non-judgmental attitudes towards same-sex sexuality, and trained in the conduct of qualitative interviews about sexuality-related issues. Most interviews were conducted in English. Participants sometimes switched to using local languages, as is common in South Africa. All interviews were audio-recorded, transcribed and, if necessary, translated into English. Data for this particular study about men’s experiences with condoms and lubricants were generated using a selection of survey items from the full study questionnaire. Observations were conducted at 16 commercial sites where men who have sex men were known to congregate and mingle with other men including township bars, clubs, and shebeens. Shebeens are the previously illegal (under apartheid) drinking houses particular to South Africa, where people gather, meet, and usually drink alcohol and dance. None of the commercial sites in these townships are exclusively patronised by men who have sex with men. All study procedures were approved by the Ethical Committee of the Human Sciences Research Council in South Africa (Protocol # REC 5/19/11/08) and the Institutional Review Board of the New York State Psychiatric Institute (Protocol #5836). Participants signed informed consent before the start of each interview.

Analysis

Qualitative data were coded in two steps. (1) Concept-driven codes, based on the study’s main research questions and the interview guide, were applied independently by three coders using ATLAS.ti software. Relevant to the present study were quotations with the code ‘Unsafe and safer sex practises’. (2) For purposes of this paper, a second round of data-driven coding was undertaken in which codes (table 2) were deduced from the data, discussed, and agreed upon by all. Query reports for secondary codes were generated through ATLAS.ti. Significant themes reported here were identified through a process of consensus among raters.

Table 2.

Second-round codes

  • Perceptions of own risks and risk practices

  • Any mention of use and kinds of condoms

  • Any mention of use and kinds of lubricants

  • Perceived facilitators to condom use

  • Perceived barriers to condom use

  • Stories of condom use errors and failures

  • Experiences of unprotected anal intercourse

  • Perceptions of risks and risk practices of friends and general men who have sex with men

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Findings

The final sample consisted of 81 men, 20 to 39 years old (mean = 25.16 years) – with 20 interviews being conducted in Atteridgeville, Mamelodi, and Soshanguve each, and 21 in Hammanskraal. Most participants identified as gay and fewer as bisexual, straight, or did not adopt a specific sexual identity label. The sample also included biologically male participants who self-identified as ‘drag queen’, women, or transgender. Although we use the terms ‘men,’ ‘men who have sex with men,’ and ‘Black men who have sex with men’ to refer to the participants as a group, given the nuance and diversity of the gender identities and sexualities in the sample, these are imperfect descriptors. We do not seek to perpetuate “men who have sex with men” and “Black men who have sex with men” as static labels that capture all intersections of gender performance, sexual identity, sexual positioning, social and sexual networks, socioeconomic status and race. Other research has described the problematising assumptions and labeling implicit in using these categories across spaces and cultures (Young and Meyer 2005; Garcia et al. 2016; Mantell et al. 2016), including within South Africa (de Voux et al. 2016).

Not all participants exclusively engaged in sex with men; several also reported sexual contact with women. Over half of the sample identified as ‘bottoms’ (preferring the receptive role), fewer identified as ‘top’ (preferring the insertive role) or ‘versatile’ (preferring both), and a few men reported ‘unknown’ or did not state a preference due to either never having had anal sex before or not engaging in anal sex anymore. Quotes are presented here using the participant’s assigned pseudonym, as well as their age and township.

Relevance of Condoms and Lubricants

Awareness that condoms should be used to have safer anal sex was ubiquitous in this sample. When asked about the best way for men who have sex with men to protect themselves against transmission, almost all men said that condoms are the ‘best’ way – ‘Using condoms, it is condoms only’. Fewer reported that lubricants must be used with condoms to ensure safety. Alternative strategies such as thigh sex’, ‘masturbation’, or ‘just abstain’ were also mentioned as methods to stay safer.

When asked how they felt about using condoms when having anal sex, most men said ‘fine’ and ‘okay,’ or ‘safe’ and ‘protected’. Some responded with catchphrases such as ‘No glove, no game’, while others stressed not feeling differently during use. For example, Paseka (23, Soshanguve) explained – ‘I do not feel any difference because I usually use the ultra-thin ones’. A few men described experiencing heightened pleasure from using condoms because they are pre-lubricated or make them feel safer during sex. As Fenyang (28, Atteridgeville) described – ‘It’s great because ahem…I am not only protecting myself but protecting the next person’. Lastly, participants also said condoms were either ‘boring’ or ‘difficult’, and framed using them as an obligation. According to Masingita (26, Atteridgeville) – ‘Ja, I feel like I don’t want to use a condom but for my safety I have to’.

The relevance of using lubricants for safer sex was not as ubiquitous in this sample. Although almost all participants reported having ever used a condom (except those who never had anal sex); fewer men reported having ever used a substance to lubricate anal intercourse. For those who have used lubricants, knowledge about condom-lube compatibility was low. Less than half of these men knew that water- and silicone-based lubes are recommended. Several men explicitly stated having never heard this before.

The most common reason cited for using lubricants was to ease discomfort and reduce pain, particularly upon initial penetration of the sphincter, especially if a partner’s penis was bigger than accustomed. Descriptions of lubricant use were mostly framed using language of dryness and wetness. As Montsgo (28, Mamelodi) described—‘One gets dry down there when you are having sex, so the lubricants make it a bit more wet’.

Others also described lubricating to avoid condom problems. For example Paki (20) explained – ‘Because condoms, it can at any time you know, burst, so it’s easy to use a lube for it not to burst’. Paolosi (22, Mamelodi) explained – ‘What I have realised is that when you use a condom without lubricants, the condom tends to burst. So I always use lubricants’.

Condom Problems as the Expectation and Non-Commercial Lubricant Use

Despite men saying that condoms were the ‘only’ and ‘best’ way to have safer sex, condom failures were common. Expectations of breakage were widespread, with every interview describing condoms ‘bursting’, ‘tearing’, and ‘cracking’. Up to one third of the men spontaneously discussed condom failures that happened either personally or to friends without any prompting from the interviewer.

If lubricants were used, men were likely to use non-commercial lubricants, most of which are neither intended for internal use, nor condom-compatible, which facilitates condom failure. For purposes of this study, commercial lubricants are defined as ones designed for sex, sold in stores or online and are mostly silicone-based, water-based, or oil-based. Water-based and silicone-based lubricants are usually manufactured to be compatible for use with both latex and non-latex condoms, while oil-based lubricants break down latex and other condom materials. Most non-commercial sexual lubricants are usually oil-based and thus not compatible for use with condoms.

A quarter of the sample explicitly mentioned having ever used non-condom-compatible substances. The most mentioned non-commercial lubricants included body lotions (e.g. ‘Aqueous cream’, ‘Dawn’), soap, and saliva. Participants also described using food items to lubricate, including ‘yogurt’, ‘butter’, ‘fish oil’, and ‘chocolate spread’.

Additionally, two men described accessing condoms and lubricants through family or friends working in clinics and having used hospital-grade lubricants with mild pain-relief ingredients (‘remicaine/remicane’ and ‘amethocaine’) during anal sex. These lubricants are designed neither for sex, nor to be compatible with condoms, but rather for placing catheters and other procedures.

Some men mentioned only knowing not to use certain lubricants after experiencing that it causes condoms to break. Descriptions of such trial-and-error learning were common. Men described self-educating through both their own and their friends’ experiences because they lack appropriate education and services, particularly those relevant to anal sex. As Ayanda (21, Mamelodi) described:

No. I think it is because umm, they are not really as clued up on sex, on what goes on in sex. Because you know, sometimes people just say, okay, we will just use condoms and it does get dry so they do not really, really follow up on… Okay, if you get dry, what are the alternatives, we do not really inform ourselves. So most of them do not really know it because, like lack of information or sometimes a lack of interest. We just want to have sex. You do not care what goes on into it. So, we are not exposed to a lot of these things that make sex easier and safer.

In one case, Tsela (21, Hammanskral) explained self-educating by searching the Internet, however, the information he accessed only warned that anal sex is ‘very dangerous’ without sufficient explanation of how avoid STI/HIV transmission during both anal and oral sex:

I went to the website of health of gays. They are saying that anal sex is very dangerous. You may be affected by the disease through anal sex and again through oral sex.

Do you know how that happens?

No.

Facilitators to Condom and Lubricant Use

Men reported a number of facilitators to using condoms and lubricants consistently. Analyses show that there were three major facilitators to condom and lubricant use: 1) access to free condoms, 2) partner dynamics, namely partner distrust, and 3) increased acceptability to openly carry condoms and lubricants.

Free Condoms

Some men reported that free condoms such as ‘government condoms’, when available, facilitate use. Those without resources to purchase the brands of condoms that they preferred to use often described using Choice as a last resort.

Partner Dynamics

Two types of partner dynamics were reported by participants as facilitators for engaging in safer sex: 1) not trusting a partner and 2) not succumbing to partner pressure.

Partner distrust was a common factor that reinforced motivation to use condoms with both casual and regular partners. As Lefu (31, Atteridgeville) explained –

The only time I haven’t used a condom is once and I was in the middle of a relationship. We were doing like four years and it just happened (…) and I was like it shouldn’t happen again. I don’t care if we’re together for ten years. I don’t know what he does when I’m not here, I love him, I trust him to a certain point, but a man is a man and he’ll always be a man.

In one exceptional case, Zithembe (32, Mamelodi), was able to advocate for himself despite pressure from his boyfriend –

Because there was this one time. We were about to have sex, we were like hot and stuff, my boyfriend he almost penetrated me without using a condom, and when I asked he said he forgot and I said, ‘no, you must get one because this is our lives so I’m not sure who you are sleeping with when I’m not around so we have [to] use protection’ so anything was possible.

Increased Acceptability

According to several men, safer sex was now facilitated by a recent shift towards greater acceptability in carrying condoms and lubricants when going out to bars, taverns, and shebeens to meet other men. As Ayanda (21, Mamelodi) described –

Actually, nowadays I find that a lot of people engaging in sexual encounters, they usually carry condoms with them, like all the time. Back then, it was kind of awkward like if you carry a condom, it means that you wanted to have sex with men. But now, they just carry it, they do not care, we do not care, we just carry condoms.

Similarly, Lefu (31, Atteridgeville) observed—‘When I go clubbing, there are people who go clubbing and in their back pocket there’s a tube of lubricant and two condoms’.

Barriers to Condom and Lubricant Use

Despite these facilitators, men reported a number of barriers to using condoms and lubricants consistently and correctly, including: 1) sexual initiation, 2) issues with accessibility and availability, 3) being in the heat of the moment, 4) alcohol and drug use, 5) partner dynamics, namely partner distrust again, and 6) group sex. Most men in the sample had ever had unprotected anal intercourse, while even more described conditions that impeded condom use, resulting in condom failure.

Sexual Initiation

Several men explained that neither condoms nor lubricants were used the first time they had anal sex. This is because opportunities for sex often presented unexpectedly or because men were unaccustomed to using either condoms or lubricants. For example, Butholezwe (19, Hammanskraal), attempted to use a condom during sexual initiation but described it was difficult ‘for the first time’ because ‘there was a pain that I felt, I don’t know whether it was the pain of the penis or the pain of the condom but it was very difficult’. And when asked about the first time he had sex with another man, Ayanda (21, Mamelodi) described the experience as ‘very interesting’:

Beautiful, I am not going to lie, it was very beautiful. It was like something new and different and ja. It was very beautiful.

Did you know about safer sex?

Yes I did know about it but that did not happen.

Lastly, Moeketsi (23, Soshanguve) described that he did not use a condom the first time he had sex with a man, and as such decided to seek testing – ‘because I slept with somebody and didn’t use a condom so I needed to go and check’. This experience of testing due to anxiety-inducing incidents was common for these men (Sandfort et al. 2015).

Accessibility and Availability

Difficulty accessing condoms and/or lubricants was a key barrier, particularly the brands and types that men preferred or needed to use. Almost all men described ‘going to town’ (Pretoria central) to acquire safer sex supplies, which can involve travelling up to 50 km for those living in the farthest township (Hammanskraal). Such lengthy trips for ‘monthly toiletries’ were infrequent. Furthermore, the brands and textures of the condoms and lubricants available in town were not always what was desired, preferred, or needed by men or their partners.

Additionally, men described perceiving the lack of condoms with the right size and fit as making correct and consistent condom use particularly difficult. As Thina (25, Soshanguve) explained— ‘The problem is with my boyfriend, condoms don’t fit him because they are too small, especially Choice condoms, government condoms’. And as Fenyang (28, Atteridgeville) described –

Difficult, okay…It was not difficult. But it was …ah…can I not answer this. Oh God. Okay I met this guy from, from, from Nigeria, it’s long time. Ahem…not that the condom couldn’t fit him but it was hard to put it, it took us forever and…Ja it was a bit difficult…The thing is ahem…it was, it was a challenge for us to use it because ah…we had to stretch it like…He was way too big.

Lastly, data from the ethnographic observations conducted in the commercial sites revealed that condoms were neither free nor visible in these settings. The participant observers reported from all four townships that condoms were not found at the entrances, toilets, or at the counters of these establishments. Additionally, in the few taverns where condoms were available, condoms were only being sold and no free ‘government’ condoms were available.

Heat of the Moment

Several men described instances when they noticed condom failure upon penetration, during sex, or at withdrawal but decided to think about it later because they were in ‘the heat of the moment’. As Thabiso (22, Mamelodi) explained, ‘Well I have had instances where the condom would break. And we would just continue, you know’? Such events took place under the influence of alcohol and drugs, but also while sober.

Alcohol and Drugs

Most participants insisted that for them personally alcohol or drugs did not interfere with safer sex, but said it definitely was an issue for other men who have sex with men. Despite these statements, many still described personally forgoing condoms or using non-condom-compatible lubricants while intoxicated. Masopha (29, Mamelodi) described being drunk and using a body lotion to lubricate, even though he knew ‘it is bad on the condom’, because ‘there are times when I need it and desperate times call for desperate measures’.

Partner Dynamics

Whereas partner distrust and partner pressure were described by some men as facilitators for engaging in safer sex, they were also the two most commonly cited barriers for not using condoms and lubricants. As such, these multiple distinct dynamics can function in both ways.

For partner pressure, men described having competing opinions and interests with partners regarding condom and lubricant use can result in non-use. For example, Paseka (23, Soshanguve), explained that he only has free condoms and that there is a chance he ‘may engage in unprotected sex’ if ‘maybe somebody doesn’t like using government condoms’. Additionally, although Mosegi (22, Mamelodi) prefers to use lubricants to avoid pain, he also explained that sometimes he does not use any because –

You find that you want to use the lubrications for me [as the receptive partner] but I think for them [insertive partners] it is difficult because it is too slippery inside. Ja, some do not like that because then they do not enjoy it.

Instances of partner distrust serving as a barrier were evident in men’s descriptions of suspecting that a partner had removed a condom during sex or deliberately tampered with the condom to cause failure. Such experiences of partner sabotage took place despite men’s own intent to have safer sex. For example, Lerato (30, Mamelodi) described how a partner had once taken a condom off in the dark – ‘Sometimes these guys put on a condom and then they say switch off the light… I realised after. I was scared’.

Partner pressure was mostly experienced from regular partners, whereas partner distrust occurred with both regular and casual partners. With regular partners and boyfriends, these two dynamics worked synergistically as barriers. For example, several men described feeling obligated to forego condoms after being with a partner for some time, despite still feeling uneasy. Due to this, Mamello (23, Atteridgeville) explained his own belief that relationships are riskier than remaining single—

I think in a relationship you are more likely to get HIV because when you are in a relationship you end up in a situation where your boyfriends are skew, that you trust them or not when you want to take off a condom or not and they end up saying you do not trust them. So you take off the condom and then you have sex with them and that is how you get AIDS. But when you are having one-night stands or when you are promiscuous, you always care for about the decision so you are always thinking you should use a condom no matter what. Unlike when you are having somebody for the whole year it is when you stop using a condom.

Group Sex

A few men described group sex as a situation in which condom use was more difficult and using non-commercial lubricants was more likely. When Kefentse (26, Mamelodi) was asked, When you have group sex, do you use condoms when you change [partners] or at some point do you not use anymore?, he said —

Some you will never tell, like if it is dark, but for me what I learned I used to carry a condom and some lubrication if I have.

So if you do not have?

If it is not there we would use body lotions so that it is smooth. But I am not sure if some are using condoms or not because they might not have used a condom as we change partners in the dark.

And were you drinking there?

Yes, so that’s where you see the condom is not there and when you ask, the other person would say it doesn’t matter not to wear one. So some do not use it.

The Significance of Brands and Types

Specific features of brands and types of lubricants and condoms were both highly prevalent and relevant in men’s discourse. Men had strong preferences for specific textures (e.g. ribbed or studded condoms, water- or silicone-based lubricants), flavours (strawberry and cherry were most commonly cited), scents (‘I love the smell of Durex. It does not smell like condoms, it has got a fragrance’), and brands that they either use (e.g. ‘That is my name, I only buy my name’.) or do not use (e.g. ‘I hate the smell of the one from the government, so I prefer buying’.). Opinions were particularly strong in regards to the free government-distributed condoms. The majority of men voiced that Choice condoms are undesirable for failing at higher rates, smelling badly, not being ‘classy’, or being indicative of low-status. Lerato (30) explained that because ‘the government one burst on me (…) I’m now scared to use them and I feel they are not safer anymore, so I prefer to buy’.

Others did not experience problems using Choice condoms, but usually had no other options. Participants reported that using Choice condoms signals to friends and partners that they are currently poor or unemployed. Kabelo (39, Atteridgeville), expressed that even though he perceived government condoms as ‘safe’, he feels a social obligation to purchase condoms now that he is employed because otherwise people may perceive him as still unemployed –

I mostly use government condoms. I have never been in a chemist and bought condoms but right now I should buy them because I work. When I didn’t work, I didn’t see the need to buy condoms because there are condoms freely available and they are safe.

Additionally, Bandile (35, Atteridgeville) described only purchasing condoms and explained his refusal to use free government condoms as being related to class – ‘I just want to be classy. Maybe it’s because I can afford to’. Similarly, Letsego (34, Soshanguve) explained that the brands of condoms that someone has indicates their class— ‘Some use Choice, some Trust and so on. I first check what kind of class this person is’. Language surrounding ‘class’ and ‘status’ was often used to explain the low desirability of government condoms.

Discussion

This is one of the first studies to assess the experiences of Black men who have sex with men living in Africa with both condom and lubricant use. Our findings suggest that while knowledge that condoms should be used to prevent STI and HIV transmission is widespread, condom failure is a common expectation and knowledge that condom-compatible commercial lubricants can help facilitate safer and less painful anal sex is rare. In addition to the numerous barriers and facilitators identified that increase the risk of unprotected anal intercourse and condom failures, the brands and types of condoms and lubricants matter to men. As such, despite traveling far distances and going through great efforts to obtain safer sex technologies, it is a barrier when people can not access what they prefer to use in regards to texture, smell, feel, size, fit, and brand. Additionally, despite personal intent to use condoms, correct use remains dependent on partners, with partner distrust acting as both a barrier and a facilitator to having safer sex. Furthermore, our data demonstrate that using certain brands of condoms and lubricants can communicate tacit information about men’s employment and financial standing, and even their ‘class’ distinctions, to both their partners and the rest of their social networks.

These findings align with those obtained in other settings. A study of Black men who have sex with men in southern USA found a high prevalence of using oil-based lubricants and having problems with condom fit and feel (Hernández-Romieu et al. 2014). These results, along with context provided from our results, may begin to explain how black men who have sex with men continue to have greater rates of STI and HIV transmission, despite using condoms and lubricants at the same rates. Men who have sex with men in India reported similar difficulties using condoms, particularly due to limited availability, and to foregoing condoms with steady partners (Chakrapani et al. 2013). While the Indian men described trusting steady partners, it should be noted that our sample more frequently cited distrust of steady partners, and that partner dynamics served as both a barrier and a facilitator to condom and lubricant use. A study of young gay men in Hong Kong similarly found trust vs. mistrust and steady vs. casual partnership to be factors that worked both ways in terms of engaging in either condom use or having condomless anal sex (Yeo and Fung 2015). Lastly, a recent analysis of longitudinal data regarding gay and bisexual men in Western Canada acknowledge that group sex presents ‘a unique risk environment’, in which consistent condom use is increasingly difficult when men have multiple partners in one setting (Rich et al. 2016).

This study’s findings highlight significant structural barriers affecting men who have sex with men: limited access to appropriate and comprehensive safer sex supplies, sexual health services, and sexual education. Knowing more about the contexts in which men who have sex with men are using condoms and lubricants helps to better inform design, implementation, and dissemination of targeted health education and services that can address these structural conditions. For example, since many experiences of unprotected anal intercourse take place during sexual initiation, younger males should be better prepared for their first same-sex sexual experiences with early comprehensive and relevant sexual education. Furthermore, targeted education may prevent men from having to rely on trial-and-error approaches. For example, for men who engage in group sex, more innovative strategies may be required than just promoting condom use. The design of future education activities is likely to be more effective if it incorporates narrative learning and role-plays that demonstrate realistic scenarios in which men encounter and simulate responding to barriers to safer sex.

These workshops can also artificially structure the conditions that often lead to less safe practices. For example, our data demonstrate men are often putting condoms on themselves or on partners when they are drunk and in the dark. Demonstrations of proper condom application and removal should seek to incorporate these realities. One recommendation is for tutorials to have men practice proper application and removal of condoms on a model penis in dim lighting or while wearing alcohol simulation or impairment goggles. These devices use distorting lenses to simulate the effects of alcohol and marijuana on vision and depth perception, as well as balance and coordination.

Prevention efforts also need to address negotiating partner pressure, distrust, and sabotage. Some men described successfully advocating for themselves despite partner pressure, demonstrating feasibility for other men who have sex with men to do the same. Interventions that encourage shared decision-making for couples may improve consistent and correct condom and lubricant use (Muldoon et al. 2014).

Lastly, national programmes must reconsider the classic quality vs. quantity debate. Instead of supplying free, but less desirable, Choice condoms, it may be more effective to invest in diverse condom and lubricant types, brands, and flavours. While South Africa’s programme is now expanding to include coloured and scented condoms, they should also consider providing a variety of single-use packets of silicone- and water-based lubricants and differently sized condoms, as well as flavoured condoms which our results demonstrate matter to men and have implications for use during oral sex. Expanding the scope of these programmes not only benefits men who have sex with men, but all sexually active people. This must be considered as the current National Strategic Plan concludes and the next iteration is being designed and implemented.

Limitations to the study include that there was variability in probing due to having multiple interviewers. As such, not all topics were as intrinsically discussed in all interviews. However, the fact that every participant mentioned condom errors and condom failure, suggests that this is an issue of which many men who have sex with men are cognisant and prioritise. Additionally, asking participants about lubricant practices only in relation to condom use and not on its own may not have accurately captured or encouraged men to describe lubricant use while having condom-less anal sex. Nuance may have been lost on certain dimensions of lubricant use such as where and how men apply lubricants (e.g. onto the penis, onto the rim of the anus, into the rectum, etc.). Lastly, we did not seek to understand what impacts the promotion of wide-scale medical male circumcision may have on male condom and lubricant use, which should be considered for future study. Despite these limitations, our findings still offer important context to inform future research, practice, and programmes.

This study’s findings provide context on experiences that receive little research attention in Africa – those of black men who have sex with men who are actually using, misusing, and/or not using, safer sex technologies during anal sex. As mentioned, it is imperative to understand how existing prevention methods are being used in the face of the global STI and HIV pandemics. While innovative new condoms and condom applicators, microbicidal lubricants, and biomedical prevention methods such as pre-exposure prophylaxis for HIV are emerging, it remains crucial to understand what can be done on larger scales in low- and middle-income countries. National prevention efforts must be tailored and made relevant to the lives of men who have sex with men. While men are interested in using condoms and lubricants, identifiable social and structural factors prevent them from doing so consistently and correctly. Our results provide concrete targets to intensify efforts to reduce condom problems and encourage condom-compatible lubricant use in order to lessen the disproportionate burden of STIs, including HIV, among men who have sex with men.

Acknowledgments

This research was supported by a grant from the US National Institute of Mental Health [R01-MH083557; Principal Investigator: Theo Sandfort, Ph.D.]. The content is solely the responsibility of the authors and does not necessarily represent the official views of the US National Institute of Mental Health or the National Institutes of Health. The HIV Center for Clinical and Behavioral Studies is supported by a centre grant from the US National Institute of Mental Health [P30MH43520; Principal Investigator: Robert H. Remien, Ph.D.]. We wish to thank OUT Well-being, the communities that partnered with us in conducting this research, and the study participants for their contributions. We also thank study staff at all participating institutions for their work and dedication.

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