Many couples do not use condoms every time they have intercourse. In Bangladesh, for example, only about 60% of married men who said that they were using condoms for contraception used them at every act of intercourse (5). A 1990 analysis of US women found that only 46% of married women and 42% of never-married women who used condoms for contraception reported consistent use (403). Consistency of use may vary by the type of relationship, with more consistent use in high-risk relationships (350).

Uganda Ministry of Health	Kenya Ministry of Health
As posters from Uganda (left) and Kenya isllustrate, it is important to use condoms with every act of sexual intercourse and to use them correctly. If used consistently and correctly, condoms provide effective protection against HIV and other STIs.

Incorrect use of condoms also results in pregnancies and infections. In the same US study incorrect use accounted for about one-fourth of unwanted pregnancies (500). Breaks or tears can result from incorrect use such as unrolling the condom before putting it on, trying to put on the condom with the rolled rim held toward the body rather than away from it, snagging the condom with fingernails or rings, and reusing condoms (502). Other poor practices allow unprotected contact—starting intercourse and then withdrawing to put on the condom, or not holding the condom rim while withdrawing after ejaculation, allowing the condom to slip off and spill semen (383, 502).

Most studies report that condoms break less than 2% of the time during vaginal intercourse or withdrawal from the vagina, with a range among studies from less than 1% to 13%. Anal intercourse typically puts greater stress on the condom. Nevertheless, in three of four studies breakage rates for anal intercourse were 2.1% or less; the range in the four studies was 1.6% to 7.3% (135, 217, 530, 567).

Studies report that condoms slip off the penis completely in about 1% to 5% of acts of vaginal intercourse and slip down the penis without falling off in 3% to 13% (17, 198, 314, 374, 375, 458, 536). Rates of slippage during anal intercourse range from less than 2% to 21% (135, 217, 501, 567, 575).

A forgotten or misused condom does not always lead to pregnancy. A woman is fertile only a few days in each menstrual cycle; her chances of pregnancy from any one act of sexual intercourse on a random day have been estimated to average between 2% and 4% (526). In a survey, US women reported 443 condom breaks resulting in 19 pregnancies—one pregnancy for every 23 breaks, or 4.3 pregnancies per 100 condom breaks (240).

Not all kinds of condom breaks are equally risky, depending on the amount of exposure to semen and vaginal fluids (198). Breaks that occur while the condom is being put on are no risk as long as the user notices the break and substitutes a new condom. Studies report that 24% to 65% of breaks occur before intercourse (508, 510, 511, 536, 539).

Nor do most exposures to the risk of infection lead to actual infection. For example, the chances of becoming infected with HIV from a single unprotected sexual exposure have been estimated variously at less than 1 in 1,000 to greater than 1 in 10, depending on whether the transmission is male to female, female to male, or male to male, and whether the exposed person has genital ulcers (18, 29, 73, 340, 393).

Using condoms better. Condom breakage rates differ markedly among couples (5, 405, 580). One study found that married men broke condoms more often with their girlfriends than with their wives (263). Breakage is concentrated among a minority of users (503). In a study involving six volunteers testing new and aged condoms, one man accounted for almost half of all condom breaks (189). In a retrospective study of 41 Nevada, US, commercial sex workers, one woman accounted for more than 40% of all condom breaks (17).

Other studies, but not all, have found that inexperienced users break condoms more often than experienced users (17, 240, 263, 322, 405). In general, older married couples who have used condoms for some time and other couples who are strongly motivated to avoid pregnancy are the most effective users, as is true for most contraceptive methods (509).

Insufficient vaginal lubrication may contribute to condoms breaking—a problem that could often be remedied by longer sexual foreplay (298). Some men's preference for "dry sex," reported in parts of Africa, may contribute to breakage (465). Using lubricated condoms or appropriate lubricants with condoms can help reduce breakage.

Lubricants used with latex condoms must not contain oil, however. Mineral or vegetable oils in a lubricant substantially increase the risk of breakage because oils weaken latex in five minutes or less (573). These oils are found in common products such as petroleum jelly, skin lotion, and cooking oil. Many people use these products to lubricate condoms (510, 536).

Products that contain water rather than oil—for example, glycerin, egg white, and K-Y Jelly—do not damage latex. Neither do spermicidal jellies or foams, which double as lubricants and may provide extra protection but may cause irritation if used several times a day. Some of the safe lubricants are hard to find or expensive in some places, however. Programs can help by identifying inexpensive, easily obtained materials that people could safely use as lubricants.