Effects of free condoms on HIV and STI in MSM

The effects of free condom distribution on HIV and

other sexually transmitted infections in men who
have sex with men

Reinier J.M. Bom,1 Kalja van der Linden,1 Amy Matser,2,3 Nicolas Poulin,4 Maarten F. Schim
van der Loeff,3,5 Bouko H.W. Bakker,6 and Theodoor F. van Boven1
1 Condomerie, Amsterdam, the Netherlands; 2 Department of Research, Cluster of Infectious Diseases, Public Health Ser-
vice of Amsterdam (GGD Amsterdam), Amsterdam, the Netherlands; 3 Julius Center for Health Sciences & Primary Care,
University Medical Center Utrecht (UMCU), Utrecht University (UU), Utrecht, the Netherlands; 4 Centre de Statistique
de Strasbourg (CeStatS), Institut de Recherche Mathématique Avancée (IRMA, UMR 7501), Université de Strasbourg &
Centre National de la Recherche Scientifique (CNRS), Strasbourg, France; 5 Center for Infection and Immunology Am-
sterdam (CINIMA), Academic Medical Center (AMC), Amsterdam, University of Amsterdam (UvA), the Netherlands;
6 Rutgers, Utrecht, the Netherlands.

Contact: condoms@condomerie.com

HIV and other sexually transmitted infections remain a burden on men who have sex with men
in the era of effective combination antiretroviral therapy. New prevention efforts are therefore
needed. One of these approaches is the current country-wide free condom distribution at gay
bars with darkrooms and gay saunas in the Netherlands. This study assessed the effects of free
condom distribution on incidence and burden of disease of HIV and other sexually transmitted
infections.
A model was constructed to calculate the impact of free condom distribution on HIV, hep-
atitis C, chlamydia, gonorrhoea, and syphilis among men who have sex with men visiting these
venues. Outcomes included new infections averted and disability-adjusted life years averted.
Scenario studies were performed to predict the effects of a further increase of condom use,
condom effectiveness and coverage. Lastly, cost-effectiveness and sensitivity analyses were per-
formed.
Condom use at public sex venues increased after the intervention. Our model showed de-
creases in annual incidence risk, ranging from 5.73% for gonorrhoea to 7.62% for HIV. The
annual number of new infections averted was largest for chlamydia and gonorrhoea (261 and
394 infections, respectively), but 42 new HIV infections were averted as well. Over 98% of
the decrease in burden of disease was due to HIV. In scenarios where condom use and condom
effectiveness were further increased, this reduction became more extensive. The intervention
was cost-effective and cost-saving (for every e1 spent on condom distribution, e5.51 was saved)
and remained this in all sensitivity analyses.
Free condoms at public sex venues can reduce the transmission of HIV and other sexually
transmitted infections. Condom distribution is an affordable and easily implemented interven-
tion that can reduce the burden of disease in men who have sex with men substantially.

INTRODUCTION of condoms especially designed for anal inter-

Promoting condom use has been part of HIV
prevention strategies since the beginning of the
epidemic among men who have sex with men
(MSM).1 As the effectiveness of condoms in
reducing HIV transmission became apparent
during the 1980s, their use was actively pro-
moted, which lead to a steady increase in con-
dom uptake.2 By the end of the decade, brands
course were marketed to MSM. As the use
of condoms and other safe sex practices be-
came common, the incidence of HIV dropped
sharply.3 This lower incidence was maintained
throughout the 1990s, until the introduction
of effective combination antiretroviral therapy
(cART) in 1996. New antiretroviral therapies
greatly improved the quality of life and life ex-

Bom et al, PrePrint, March 2018 1

Effects of free condoms on HIV and STI in MSM
pectancy of those living with HIV, but also
led to decreased sexual risk perception among
MSM.4-8 As a consequence, sexual risk be-
haviour, such as unprotected anal intercourse
(UAI), has increased among MSM, and preval-
ences of various sexually transmitted infections
(STIs) have risen; 9,10 also the incidence of HIV
increased.3
Gay bars with darkrooms and gay saunas
(collectively known as public sex venues or
PSVs) are known to attract both seropositive
and seronegative MSM. UAI with anonymous
partners is not uncommon at PSVs.11 There-
fore, these locations are major risk locations for
serodiscordant mixing and possible transmis-
sion of HIV and other STIs. Availability and
promotion of free condoms could increase con-
dom uptake, and therefore, decrease transmis-
sion. In response to decreasing use of condoms
and increasing sexual risk behaviour, a collab-
oration of various PSVs in Amsterdam, sexual
health promotion institute Schorer, and public
health service GGD Amsterdam started to pro-
mote safe sex in PSVs. Free condom distribu-
tion is an integral part. At first, condoms and
lubricants were paid for by PSVs and offered
for free to their patrons, which showed to be
a financial burden for many PSVs, and there-
fore, has been an obstacle for upscaling and
structural implementation. These initial prob-
lems were resolved as condom distribution was
expanded into the CLub GUN (Condoms &
Lubricant Gay United Netherlands) project by
AIDS Fonds (Dutch AIDS fund) and Condo-
merie (retail, wholesale and knowledge centre
of condoms and lubricants) through offering
subsidised condoms and lubricants.12 Based on
the Amsterdam experience, the intervention
was implemented nationwide and is currently
being supported by sexual health promotion in-
stitute SOA AIDS Nederland and local public
health services. At the start of 2014, 32 PSVs
in 11 different cities throughout the Nether-
lands were participating in CLub GUN and
were offering free condoms and lubricants to
their patrons. A pilot study was conducted on
the feasibility of free condom distribution at
PSVs in Amsterdam and Rotterdam between
2006 and 2008.11 Availability of free condoms
was greatly appreciated and most patrons re-
ported a positive influence on condom use.
Bom et al, PrePrint, March 2018
About half of the patrons started to make use
of free condoms within the first weeks and 14%
of them reported they would not have used a
condom, if condoms had not been freely avail-
able at PSVs.
Although free condoms and lubricants are
now available at most PSVs throughout the
Netherlands and similar initiatives are seen
internationally,13,14 the effects of these kinds of
interventions on the transmission of HIV and
other STIs were never investigated. There-
fore it is unknown to what extent free con-
dom distribution can reduce the burden of
these infections in MSM. To assess this, we de-
veloped a model to calculate the incidence of
HIV before and after free condom distribution
at PSVs. In addition, we performed a cost-
utility analysis to estimate the number of new
infections averted (NIA) and the reduction in
burden of disease among MSM by calculating
disability-adjusted life years (DALYs) averted.
Next to HIV, annual incidence risk, NIA and
DALY were calculated for hepatitis C (HCV),
chlamydia, gonorrhoea and syphilis. Scenario
studies were performed to assess the effects of
increasing condom use, condom effectiveness
and coverage. Lastly, cost-effectiveness and
sensitivity analyses were performed.
METHODS
Data collection and parameters
To investigate possible effects of free con-
dom distribution at PSVs, we used data
from three main sources. The first data
collection we used came from the study
“Gezonde keuzes makkelijk maken (Making
healthy choices easy)”, the pilot study on free
condom and lubricant distribution, conducted
by Schorer and GGD Amsterdam.11 In this
study, 375 patrons from PSVs in Amsterdam
and Rotterdam were interviewed before the in-
tervention, and 1010 men were interviewed af-
terwards, between December 2006 and May
2008. The second data source we used was
the “MSM network study” conducted among
2492 MSM at the STI outpatient clinic of GGD
Amsterdam between July 2008 and August
2009.15,16 The third one was the nationally rep-
resentative study “LHBT Survey 2013”, con-
ducted among 883 MSM in June and July 2013
2
Effects of free condoms on HIV and STI in MSM

Table 1. Key parameters used in the model.

Parameter Point estimate Uncertainty Source
Condom use in PSVs after intervention 87.8% 83.8%, 91.0% [11]
Percentage of MSM that used a condom that were 49.4% 43.9%, 54.8% [11]
influenced through the availability of free
condoms at PSVs
Percentage of MSM that used a free condom from the 14.2% 9.4%, 20.3% [11]
condom distribution, and that reported they
would not have used a condom if condoms were
not freely available at PSVs
Percentage of relationships with casual partners that 59.6% 56.5%, 62.7% [16]
involved anal intercourse formed at PSVs among
men frequenting PSVs
Number of active MSM in the Netherlands 300,000 estimate [18]
Percentage of active MSM, who met a casual partner 17.1% 15.5%, 18.9% [17]
at a PSV in the last year
Number of condoms distributed in 2013 371,952 exact [19]
Condom wastage 15% estimate
Mean annual number of casual partners among men 21.8 1-200 [17]
frequenting PSVs
Mean number of sexual acts per casual partner 2.20 1-50 [16]
Percentage insertive anal intercourse per sexual act 63.3% 59.2%, 67.2% [16]
Market share of CLub GUN condoms at the CLub 79.3% 73.8%, 84.0%
GUN locations
Condom effectiveness 70% estimate [20,21]
Prevalence among casual partners met at a PSV
HIV 36.2% 29.9%, 42.8% [16]
HCV 0.46% 0.05%, 2.11% [16]
Chlamydia 10.0% 6.6%, 14.5% [16]
Gonorrhoea 5.9% 3.4%, 9.7% [16]
Syphilis 1.8% 0.6%, 4.3% [16]
Prevalence among casual partners met in general
HIV 22.8% 19.9%, 26.0% [16]
HCV 0.40% 0.11%, 1.08% [16]
Chlamydia 9.6% 7.6%, 11.8% [16]
Gonorrhoea 6.1% 4.5%, 8.0% [16]
Syphilis 2.0% 1.2%, 3.2% [16]
Per-act infectivity
HIV 1.025% estimate [22]
HCV 0.5% estimate [23]
Chlamydia 17% estimate [24]
Gonorrhoea 50% estimate [25]
Syphilis 30% estimate [26]

PSV = public sex venues; MSM = men who have sex with men; HCV = hepatitis C.
Uncertainty is given as 95%CI (beta distribution), except when given otherwise.

by Rutgers.17 As the current study made use
of previously published datasets, no ethical ap-
proval was required. Statements on ethical ap-
proval were provided in the subsequent public-
ations, if applicable. All key parameters are
presented in Table 1, and a detailed descrip-
tion of extraction of parameters can be found
in Supplementary data 1.
Incidence
Annual incidence risk before and after the in-
troduction of free condoms at PSVs were cal-

Bom et al, PrePrint, March 2018 3

Effects of free condoms on HIV and STI in MSM

Table 2. Annual incidences and number of cases of HIV, hepatitis C, chlamydia,

gonorrhoea, and syphilis at public sex venues.
HIV HCV Chlamydia Gonorrhoea Syphilis
Annual incidence risk before 3.43% 0.0235% 16.4% 27.4% 5.87%
intervention
Annual incidence risk after 3.17% 0.0218% 15.4% 25.8% 5.49%
intervention
Decrease in annual incidence risk 7.62% 7.14% 6.32% 5.73% 6.46%
Incident cases before intervention 550 2.13 4128 6875 1473
Incident cases after intervention 508 1.98 3867 6481 1378
New infections averted 41.9 0.152 260.7 393.8 95.1

HCV = hepatitis C.

culated for HIV, HCV, chlamydia, gonorrhoea,
and syphilis. A detailed description of these
calculations can be found in Supplementary
data 2. To estimate number of incident cases,
we multiplied number of susceptible men by
annual incidence risk. For HIV, only HIV-
negative men were assumed susceptible for in-
fection. For HCV only HIV-positive MSM
were assumed susceptible.27 All men were as-
sumed susceptible for chlamydia, gonorrhoea
and syphilis. NIAs were calculated by sub-
tracting the number of incident cases after the
intervention from those before.
Burden of disease
DALYs of the various STIs were calcu-
lated using uniform age weights and without
discounting.28,29 Generalised courses of infec-
tion of HIV, HCV, chlamydia, gonorrhoea, and
syphilis in Dutch MSM in presence of treat-
ment were constructed and included in the
models. These included the different stages of
infection a patient passes through, the experi-
enced disability within the various stages and
their durations. Parameter estimates of these
generalised courses of infection within this risk
group were collected from literature. A de-
tailed description of these generalised courses
of infection and parameter estimates can be
found in Supplementary data 3.
Condom use, condom effectiveness, and
coverage
Scenario studies were performed to examine Sensitivity analyses
the effects of increasing condom use, effective- A sensitivity analysis was performed by in-
ness and coverage. We evaluated a scenario in creasing and decreasing all parameters by 25%.
which condom use at PSVs increased to 100%,
and a scenario in which condom use at PSVs
increased to 100% and at a maximum efficacy
of 100% for CLub GUN condoms. In addition,
a scenario was evaluated in which the interven-
tion covered 100% of the susceptible MSM in
the Netherlands.
Cost-effectiveness analyses
To assess the cost-effectiveness of the interven-
tion, we calculated the total costs of the in-
tervention. These included purchase, storage,
distribution of condoms and lubricants used,
plus additional costs such as salary and promo-
tion costs. From these data we calculated costs
per DALY, by dividing the total costs by the
total number of DALYs averted. World Health
Organization (WHO) criteria were used to as-
sess cost-effectiveness.30 To assess whether the
intervention is cost-saving, we calculated the
potential annual costs per averted HIV infec-
tion. Costs of bacterial infections and HCV
were excluded. No data were found on which
proportion of bacterial infections will remain
untreated and therefore the total costs cannot
be calculated. In addition, the treatment of
HCV infections is currently advancing fast and
therefore the costs are subjected to change. We
determined the threshold value for each para-
meter at which it was no longer cost-effective
or cost-saving. Lastly, we calculated at what
price per condom and lubricant the interven-
tion was still cost-saving, highly cost-effective
and cost-effective.

Bom et al, PrePrint, March 2018 4

Effects of free condoms on HIV and STI in MSM
Table 3. Annual disability-adjusted life years lost due to HIV, hepatitis C,
chlamydia, gonorrhoea, and syphilis at public sex venues.
DALYs lost before
intervention
n (%)
HIV 5778.7 (98.32)
HCV 24.7 (0.42)
Chlamydia 33.5 (0.57)
Gonorrhoea 28.3 (0.48)
Syphilis 12.1 (0.21)
Total 5877.3
DALY = disability adjusted life year; HCV = hepatitis C.
RESULTS
Incidence of HIV, HCV, chlamydia,
gonorrhoea, and syphilis
We deduced that the annual incidence risks be-
fore intervention ranged from 0.0235% for HCV
to 27.4% for gonorrhoea (Table 2 ). Implement-
ation of free condom distribution had largest
effect on the less infectious viral infections; the
annual incidence risk of HIV decreased with
7.62%, and that of HCV with 7.14%. Whereas
the decrease found among the more infectious
bacterial infections was lower, the highest NIAs
were found within this group (n=394 for gonor-
rhoea and n=261 for chlamydia).
Burden of disease
The estimated annual number of DALYs aver-
ted by the intervention was 447. The in-
tervention had largest impact on HIV; 98.6%
of DALYs averted were through prevention of
HIV infections, while 0.4% and 1.0% were from
preventing HCV and the three bacterial infec-
tions combined (Table 3 ).
Effects of increased condom use,
condom effectiveness, and coverage
Scenario studies were performed to examine
the impact of increasing number of protected
sexual acts at PSVs, increasing effectiveness of
CLub GUN condoms, and increasing coverage
of PSVs. An increase in number of protected
acts to 100% would result in a maximum of
126 HIV infections and 1340 DALYs averted.
If condom effectiveness was increased to 100%
(with initial levels of condom use), 302 HIV
infections and 3219 DALYs would be averted.
If 100% of acts at PSVs were protected and
Bom et al, PrePrint, March 2018
DALYs lost after DALYs averted
intervention
n (%) n (%)
5338.4 (98.30) 440.28 (98.59)
22.9 (0.42) 1.76 (0.39)
31.4 (0.58) 2.12 (0.47)
26.7 (0.49) 1.62 (0.36)
11.3 (0.21) 0.78 (0.17)
5430.8 446.57
condom effectiveness was 100%, the interven-
tion would avert 425 HIV infections and 4535
DALYs; thus decreasing the burden of disease
in the pre-intervention situation by 77.2%. The
effects of upscaling condom use or effectiveness
on disease burden of other STIs was minimal,
compared with HIV, as the other STIs com-
prise between 1.7% and 2.3% of DALYs in all
scenarios (Figure 1 ). The largest decrease in
DALYs can be seen for HIV, 77.3% at 100%
condom use and 100% condom effectiveness.
This decrease was a bit less for the other infec-
tions, ranging from 66.1% for syphilis to 71.1%
for HCV; Figure 2 ).
As the current intervention is estimated to
cover 48.8% of the target population, an in-
crease in coverage to 100% would add 104.9%
to all NIAs and DALYs averted. In the scenario
where both coverage and condom use were in-
creased to 100%, the total number of condoms
distributed increased with 133.4% to 868,071
condoms per year, which in combination with
lubricant, would result in the maximal costs of
the condom distribution project of e124,638
per year.
Cost-effectiveness analyses and
sensitivity analyses
In 2013, 371,952 condoms and 390,974 lub-
ricants were distributed. As the total costs
per distributed condom or sachet of lubricant
were e0.07, the total costs of the CLub GUN
project were e53,405. As an estimated 447
DALYs were averted, costs per DALY averted
was e119.59. The intervention was highly cost-
effective, as gross domestic product (GDP)
per capita (upper bound of costs per averted
5
Effects of free condoms on HIV and STI in MSM

Figure 1. Graph of the relation between the number of disability-adjusted life years lost
(left axis), the number of incident HIV infections (right axis) and condom use at public
sex venues. Red lines indicate HIV, while blue lines indicate the cumulative effect on all other sexually
transmitted infections (hepatitis C, chlamydia, gonorrhoea, and syphilis). Solid lines indicate the current
condom effectiveness (70%), while dotted lines indicate a condom effectiveness of 100%. Condom use at
PSV before and after the intervention are indicated by the vertical grey lines.

DALY for highly cost-effective interventions)
was e35,864.31 It was estimated that 68% of
HIV-infected MSM in the Netherlands were in
care in 2013, of whom 85% are on cART.32 An-
nual costs per HIV-infected MSM of consulta-
tions in an HIV treatment centre were e758,
and e11,256 for those on cART.33 Therefore
the estimated average annual costs per HIV
infection, including those undiagnosed, were
e7026. The intervention averted 41.9 HIV in-
fections, which would have cost e294,216 annu-
ally for consultations at HIV treatment centres
and cART. This means that for every e1 spent,
e5.51 was saved. Net costs saved would be
e240,811: HIV treatment costs averted minus
the costs of the intervention.
A sensitivity analysis was performed for all
key parameters, which were increased and de-
creased by 25% (Table 1 ). In the sensitivity
analysis, the intervention remained cost-saving
for all parameter settings (Figure 3 ).
For some parameters (‘Condom use some-
times’, ‘Insertive acts’, and ‘Market share’ ),
the model remained cost-saving for every value
between 0% and 100%, while for other para-
meters the model remained cost-saving up to
extreme values (Supplementary table 1 ). This
effect was even greater, when analysing cost-
effectiveness.
When increasing the total costs per con-
dom or sachet of lubricant, the model remained
cost-saving up to e0.39 per distributed item,
5.5 times the original costs. In addition, the
model remained highly cost-effective or cost-
effective up to e20.99 or e62.98 per item, 300
or 900 times the original costs respectively.
DISCUSSION
Distribution of free condoms at PSVs in the
Netherlands has a substantial impact on the
transmission of HIV. We estimated that the
annual incidence risk of HIV among PSV pat-
rons decreased with 7.62% due to the interven-

Bom et al, PrePrint, March 2018 6

Effects of free condoms on HIV and STI in MSM

Figure 2. Graph of the relation between the number of disability-adjusted life years lost
and condom use at public sex venues. The blue line indicates hepatitis C, the green line indicates
chlamydia, the orange line indicates gonorrhoea, and the purple line indicates syphilis. Solid lines indic-
ate the current condom effectiveness (70%), while dotted lines indicate a condom effectiveness of 100%.
The condom use at PSV before and after the intervention are indicated by the vertical grey lines.

tion, which corresponds to 42 new infections
and 447 DALYs averted annually. Similar pat-
terns were seen for the other infections, but
due to the lower prevalence of HCV and the
lower severity of the bacterial infections, the
reduction of these infections contributed only
minimal to the reduction of burden of disease.
This impact could potentially be even larger,
as more beneficial results could be obtained by
increasing condom uptake and especially con-
dom effectiveness, as these factors have a large
impact on modelled annual incidence risk of
STIs. In addition, the current intervention is
cost-saving, due to low costs of condoms and
lubricants. For every e1 spent on condom dis-
tribution, e5.51 was saved, which leads to an
estimated e240,811 that is saved annually on
HIV-related medical expenses. This amount
will increase even further when also the bac-
terial infections and HCV are considered. Al-
though no data is available on the actual costs
saved, we are able to show the order of mag-
nitude: in the Netherlands in 2011, 134 million
euros of the national healthcare budget were
spent on HIV and AIDS, while 56 million euros
and 33 million euros were spent on STIs and
viral hepatitis, respectively.34
Other recent studies also showed the im-
portance of condom use in HIV prevention:
an increase in condom use showed an equal
or greater effect on HIV transmission than an
increase in HIV testing, linkage to care, and
cART uptake combined.35,36 In agreement with
our results, Sadler et al. found condom distri-
bution projects can be cost-effective and cost-
saving, especially in settings with high HIV
prevalences such as MSM.37 In these settings,
they predicted that even a 2% increase in con-
dom use would be cost-effective. This confirms
that availability of free condoms at PSVs has
a beneficial effect on transmission of HIV and
other STIs, and on the financial burden this
brings to society.
Although the current HIV prevention de-
bate focuses much more on topics such as treat-
ment as prevention and pre-exposure prophy-

Bom et al, PrePrint, March 2018 7

Effects of free condoms on HIV and STI in MSM
Figure 3. Tornado plot of the sensitivity analysis. All parameters were increased (dark green) or
decreased (light green) with 25%. On the top axis the total annual costs saved can be seen, while on the
bottom axis the annual number of new HIV infections averted is depicted. All parameters are described
Table 1.
laxis, condoms are the mainstay of STI preven-
tion and should not be neglected. While phar-
maceutical interventions will only effect HIV
incidence, condoms work on all STIs, includ-
ing those who still have to emerge. According
to Sullivan et al., the most successful interven-
tions combine efforts to increase condom use
with other efforts such as increasing testing and
treatment, as these interventions decrease STI
prevalence and infectivity in the population.1
Therefore, it is of great importance that the
current CLub GUN project is integrated into
HIV and STI prevention programs. Through
collaboration with sexual health promotion in-
stitutes, information is available at PSVs on
safe sex, testing, and treatment. Local pub-
lic health services can provide general hygiene
controls at PSVs, as well as easy access to test-
ing facilities. For example, GGD Amsterdam
is currently conducting STI testing at PSVs.38
Most behavioural data in this study came
from post-intervention measurements, as pre-
intervention data were limited, and no clin-
ical data on changes in annual incidence risk
of the various infections during the interven-
Bom et al, PrePrint, March 2018
tion were collected. Therefore, the impact of
the intervention could only be modelled and
may deviate from the actual impact. Clinical
data were derived from data collected at the
STI outpatient clinic in Amsterdam. Both spe-
cific clientele as well as location of the clinic
may result in an overestimation of prevalence
of HIV and other STIs. Visitors of STI out-
patient clinics are expected to have a high
risk for having an STI, even after correct-
ing for having symptoms and partner notific-
ation, and prevalence of STIs in more urban-
ised areas, such as Amsterdam, are expected to
be higher than elsewhere in the Netherlands.39
However, prevalences of bacterial STIs used
in this study are similar to prevalences found
at PSVs (chlamydia: prevalence in this study
is 10.0% vs. 11.0% found in tested PSVs;
gonorrhoea: 5.9% vs. 6.6%; syphilis: 1.8%
vs. 1.1%), 16,38 and number of HIV infections
(n=508) are in line with trends found among
MSM in the Netherlands (700-750 newly iden-
tified cases annually).40 As the majority of par-
ticipating PSVs are located in Amsterdam and
other large cities, lower prevalences in rural
8
Effects of free condoms on HIV and STI in MSM
areas are of minor importance. Lastly, the
model is a simplified representation and might
not contain all factors responsible for transmis-
sion dynamics of the various infections. No in-
teractions between having an STI on susceptib-
ility for HIV were considered, neither were risk
reduction strategies like serosorting or seropos-
itioning. These factors might be worth invest-
igating in future models.
Nowadays HIV is considered a chronic in-
fection instead of a lethal one, but the burden
of HIV on MSM is still very high. The impact
of STIs on the health of MSM is still domin-
ated by HIV, and with an estimated preval-
ence of 36% among PSV patrons, these health
concerns are still very real. Efforts to min-
imise the burden of disease due to HIV in
MSM should therefore be continued unrelent-
ingly. Our model shows that free condoms at
PSVs can reduce the transmission of HIV sub-
stantially, as well as that of other STIs. A con-
dom distribution program can be an affordable
and an easily incorporated intervention to alle-
viate this burden. Future research should focus
on how condom use and especially how condom
effectiveness can be increased further, as these
factors have a large impact on transmission of
STIs. Most importantly, condom distribution
projects should be made sustainable and incor-
porated into larger public health projects that
focus on testing and treatment to maximise the
effects of the intervention.
CONCLUSIONS
Free condom distribution at public sex venues
can reduce the transmission of HIV among men
who have sex with men substantially. In addi-
tion, similar effects were seen for hepatitis C,
chlamydia, gonorrhoea, and syphilis. Condom
distribution is therefore an affordable and eas-
ily implemented intervention that can reduce
the burden of disease in men who have sex
with men. However, this kind of intervention
is most effective when combined with other ef-
forts such as increased testing and treatment,
as these interventions decrease the prevalence
and infectivity of the various infections in the
population. Future research should focus on
how condom use and condom effectiveness can
be increased further and how condom distri-
Bom et al, PrePrint, March 2018
bution projects can be incorporated into larger
public health projects that focus on testing and
treatment.
LIST OF ABBREVIATIONS
MSM: men who have sex with men
cART: combination antiretroviral therapy
UAI: unprotected anal intercourse
STI: sexually transmitted infection
PSV: public sex venue
CLub GUN : Condoms & Lubricant Gay United
Netherlands
NIA: new infections averted
DALY: disability-adjusted life year
HCV: hepatitis C
WHO: World Health Organization
GDP: gross domestic product
DECLARATIONS
Ethics approval and consent to
participate
The research involved secondary data ana-
lysis. No specific ethics committee approval
was therefore necessary for this study.
Consent for publication
Not applicable
Availability of data and material
All data is publically available from sources
specified in the text.
Competing interests
Some of the authors (RJMB, KvdL and TFvB)
are affiliated with a commercial organisation.
No profit was made by this organisation of the
condom distribution project, nor will it in the
future. No brands of condoms or lubricants are
given, and any brand could potentially be used
as long as it meets the regulations of the local
authorities and the specific requirements of the
target group.
Funding
No funding was received for this study.
Authors’ contributions
RJMB: conceptualization, methodology, soft-
ware, formal analysis, investigation, resources,
9
Effects of free condoms on HIV and STI in MSM

writing original draft, visualization, project ad-
ministration; KvdL: conceptualization, invest-
igation, resources, data curation, writing re-
view & editing, visualization, supervision, pro-
ject administration, funding acquisition; AM:
methodology, software, validation, formal ana-
lysis, investigation, resources, data curation,
writing review & editing; NP: methodology,
software, validation, formal analysis, resources,
writing review & editing; MFSvdL: methodo-
logy, validation, investigation, resources, data
curation, writing review & editing; BHWB:
validation, investigation, resources, data cur-
ation, writing review & editing; TFvB: con-
ceptualization, investigation, resources, data
curation, writing review & editing, visualiza-
tion, supervision, project administration, fund-
ing acquisition.
All authors had full access to all of the data
(including statistical reports and tables) in the
study and can take responsibility for the integ-
rity of the data and the accuracy of the data
analysis. The lead author affirms that this ma-
nuscript is an honest, accurate, and transpar-
ent account of the study being reported; that
no important aspects of the study have been
omitted; and that any discrepancies from the
study as planned have been explained.
ACKNOWLEDGEMENTS
We would like to thank Ronald Berends,
Daniela Bezemer, Kai Jonas, Richard Kel-
doulis, Arjan Kröner, Bart-Jan Mulder, Mar-
tijn van Rooijen, Elizabeth Russell, and Joost
Vanhommerig for all their technical expertise,
advice, and efforts.

REFERENCES

1. Sullivan PS, Carballo-Diéguez A, Coates T, Goodreau SM, McGowan I, Sanders EJ, et al.
Successes and challenges of HIV prevention in men who have sex with men.
Lancet. 2012, 380:388-399.
2. King E. Safety in Numbers: Safer Sex and Gay Men. Routledge; 1993.
3. Jansen IA, Geskus RB, Davidovich U, Jurriaans S, Coutinho RA, Prins M, et al. Ongoing
HIV-1 transmission among men who have sex with men in Amsterdam: a 25-
year prospective cohort study. AIDS. 2011, 25:493-501.
4. Van de Ven P, Prestage G, Crawford J, Grulich A, Kippax S. Sexual risk behaviour
increases and is associated with HIV optimism among HIV-negative and HIV-
positive gay men in Sydney over the 4 year period to February 2000. AIDS.
2000, 14:2951-2953.
5. Elford J, Bolding G, Davis M, Sherr L, Hart G. Trends in sexual behaviour among
London homosexual men 1998-2003: implications for HIV prevention and
sexual health promotion. Sex Transm Infect. 2004, 80:451-454.
6. Hart GJ, Williamson LM. Increase in HIV sexual risk behaviour in homosexual
men in Scotland, 1996-2002: prevention failure? Sex Transm Infect. 2005, 81:367-
372.
7. Kalichman SC, Eaton L, Cain D, Cherry C, Fuhrel A, Kaufman M, et al. Changes in
HIV treatment beliefs and sexual risk behaviors among gay and bisexual men,
1997-2005. Health Psychol. 2007, 26:650-656.
8. Sullivan PS, Drake AJ, Sanchez TH. Prevalence of treatment optimism-related
risk behavior and associated factors among men who have sex with men in 11
states, 2000-2001. AIDS Behav. 2007, 11:123-129.
9. Stolte IG, Dukers NH, Geskus RB, Coutinho RA, de Wit JB. Homosexual men change
to risky sex when perceiving less threat of HIV/AIDS since availability of
highly active antiretroviral therapy: a longitudinal study. AIDS. 2004, 18:303-
309.

Bom et al, PrePrint, March 2018 10

Effects of free condoms on HIV and STI in MSM

10. Bezemer D, de Wolf F, Boerlijst MC, van Sighem A, Hollingsworth TD, Prins M, et al.
A resurgent HIV-1 epidemic among men who have sex with men in the era of
potent antiretroviral therapy. AIDS. 2008, 31:1071-1077.
11. Osté JP, Bakker BHW, Cremer SW. Gezonde keuzes makkelijk maken: Onderzoek naar
gratis condoomverstrekking in sekslocaties. Amsterdam: Schorer & GGD Amsterdam;
2008.
12. Club GUN. https://condomerie.com/condomologie/condomerie-informatie/clubgun
(2017). Accessed 17 Oct 2017.
13. Sherriff N, Gugglberger L. A European seal of approval for ‘gay’ businesses: find-
ings from an HIV-prevention pilot project. Perspect Public Health. 2014, 134:150-
159.
14. Condom Distribution Programs. https://effectiveinterventions.cdc.gov/en/HighImpact
Prevention/StructuralInterventions/CondomDistribution/HealthDepartmentPrograms.
aspx (2017). Accessed 17 Oct 2017.
15. Bom RJ, Matser A, Bruisten SM, van Rooijen MS, Heijman T, Morré SA, et al. Multi-
locus sequence typing of Chlamydia trachomatis among men who have sex with
men reveals cocirculating strains not associated with specific subpopulations.
J Infect Dis. 2013, 208:969-977.
16. Matser A, Heijman T, Geskus R, de Vries H, Kretzschmar M, Speksnijder A, et al. Per-
ceived HIV status is a key determinant of unprotected anal intercourse within
partnerships of men who have sex with men in Amsterdam. AIDS Behav. 2014,
18:2442-2456.
17. Goenee M, Picavet C. Beschermingsgedrag van mannen die seks hebben met
mannen. In: De Graaf H, Bakker BHW, Wijsen C, editors. Een wereld van verschil:
seksuele gezondheid van LHBT’s in Nederland 2013. Eburon; 2014. p. 85-104.
18. Schorer. Factsheet: HIV en SOA bij MSM (juni 2011). Amsterdam: Schorer; 2011.
19. Condomerie. Jaarverslag 2013. Amsterdam: Condomerie; 2013.
20. Pickles M, Foss AM, Vickerman P, Deering K, Verma S, Demers E, et al. Interim
modelling analysis to validate reported increases in condom use and assess
HIV infections averted among female sex workers and clients in southern India
following a targeted HIV prevention programme. Sex Transm Infect. 2010, 86:i33-
i43.
21. Smith DK, Herbst JH, Zhang X, Rose CE. Condom Effectiveness for HIV Preven-
tion by Consistency of Use among Men Who Have Sex with Men (MSM) in
the U.S. J Acquir Immune Defic Syndr. 2015, 68:337-344.
22. Jin F, Jansson J, Law M, Prestage GP, Zablotska I, Imrie JC, et al. Per-contact probab-
ility of HIV transmission in homosexual men in Sydney in the era of HAART.
AIDS. 2010, 24:907-913.
23. De Carli G, Puro V, Ippolito G. Risk of hepatitis C virus transmission following
percutaneous exposure in healthcare workers. Infection. 2003, 31:22-27.
24. Xiridou M, Vriend HJ, Lugner AK, Wallinga J, Fennema JS, Prins JM, et al. Modelling
the impact of chlamydia screening on the transmission of HIV among men
who have sex with men. BMC Infect Dis. 2013, 13:436.
25. Morin BR, Medina-Rios L, Camacho ET, Castillo-Chavez C. Static behavioral effects
on gonorrhea transmission dynamics in a MSM population. J Theor Biol. 2010,
267:35-40.

Bom et al, PrePrint, March 2018 11

Effects of free condoms on HIV and STI in MSM

26. Holmes KK, Sparling PF, Stamm WE, Piot P, Wasserheit JN, Corey L, et, al. Sexually
transmitted diseases. 4th ed. New York: McGraw-Hill; 2008.
27. Urbanus AT, van de Laar TJ, Stolte IG, Schinkel J, Heijman T, Coutinho RA, et al.
Hepatitis C virus infections among HIV-infected men who have sex with men:
an expanding epidemic. AIDS. 2009, 23:F1-F7.
28. Murray CJ, Ezzati M, Flaxman AD, Lim S, Lozano R, Michaud C, et al. GBD 2010:
design, definitions, and metrics. Lancet. 2012, 380:2063-2066.
29. Murray CJ, Vos T, Lozano R, Naghavi M, Flaxman AD, Michaud C, et al. Disability-
adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990-
2010: a systematic analysis for the Global Burden of Disease Study 2010.
Lancet. 2012, 380:2197-2223.
30. Walker DG, Hutubessy R, Beutels P. WHO Guide for standardisation of economic
evaluations of immunization programmes. Vaccine. 2010, 28:2356-2359.
31. International Monetary Fund. World Economic Outlook Database. International Monet-
ary Fund; 2014.
32. SOA AIDS Nederland. Onder Controle. Strategie voor de aanpak van soa’s en hiv onder
MSM in Nederland 2013-2018. SOA AIDS Nederland; 2013.
33. Vriend HJ, Lugnér AK, Xiridou M, Schim van der Loeff MF, Prins M, de Vries HJ, et al.
Sexually transmitted infections screening at HIV treatment centers for MSM
can be cost-effective. AIDS. 2013, 27:2281-2290.
34. Kosten Seksueel Overdraagbare Aandoeningen. https://www.volksgezondheidenzorg.
info/onderwerp/soa/kosten/kosten (2017). Accessed 17 Oct 2017.
35. Phillips AN, Cambiano V, Nakagawa F, Brown AE, Lampe F, Rodger A, et al. Increased
HIV incidence in men who have sex with men despite high levels of ART-
induced viral suppression: analysis of an extensively documented epidemic.
PLoS One. 2013, 8:e55312.
36. Lou J, Blevins M, Ruan Y, Vermund SH, Tang S, Webb GF, et al. Modeling the impact
on HIV incidence of combination prevention strategies among men who have
sex with men in Beijing, China. PLoS One. 2014, 9:e90985.
37. Sadler S, Tosh J, Pennington R, Rawdin A, Squires H, Romero C, et al. A cost-
effectiveness analysis of condom distribution programmes for the prevention
of sexually transmitted infections in England. J Epidemiol Community Health.
2017, 71:897-904.
38. Van Rooijen MS, van Leeuwen AP. Jaarverslag 2011 soa-polikliniek GGD Amsterdam.
GGD Amsterdam; 2012.
39. Conti S, Presanis AM, van Veen MG, Xiridou M, Donoghoe MC, Rinder Stengaard A,
et al. Modeling of the HIV infection epidemic in the Netherlands: A multi-
parameter evidence synthesis approach. Ann Appl Stat. 2011, 5:2359-2384.
40. Van Sighem A, Gras L, Kesselring A, Smit C, Engelhard E, Stolte I, et al. Monitoring Re-
port 2013. Human Immunodeficiency Virus (HIV) Infection in the Netherlands. Stichting
HIV Monitoring, 2013.

Bom et al, PrePrint, March 2018 12

Effects of free condoms on HIV and STI in MSM

The effects of free condom distribution on HIV and

other sexually transmitted infections in men who
have sex with men

SUPPLEMENTARY DATA 1

Calculations on condom use, number of MSM, condoms and

casual partners, and prevalence and incidence

Condom use
I. Condom use at PSVs after intervention:1
N ever : 4.1%
Sometimes : 16.2%
Always : 79.7%

Assumption: The MSM reporting “Sometimes” are assumed to use condoms 50% of the time.
This is analysed in the sensitivity analyses as the parameter ‘Condom use sometimes’ .

II. Condom use in PSVs after intervention:

87.8%, 95%CI [83.8%, 91.0%]
based on I.
= 79.7% + 50% × 16.2%
= fpost

III. Source of condom:1

F ree condom, P SV (condom distribution) : 39.0%
F ree condom, P SV (not condom distribution) : 4.7%
F ree condom, elsewhere : 9.7%
Bought condom, P SV : 29.3%
Bought condom, elsewhere : 5.8%
Sex partner provided condom : 11.3%

Assumption: MSM reporting having used a free condom available at the PSV, are assumed to be
influenced in their use through the availability of free condoms at the location. Those reporting
bringing a free condom or buying a condom, are assumed not to be influenced. Condoms
provided by the sex partner are excluded, as the source of these is unclear and assumed to be
similar that of the index partner.

IV. Percentage of MSM that used a condom that were influenced through the availability of
free condoms at PSVs:
49.4%, 95%CI [43.9%, 54.8%]
based on III.
= (39.0% + 4.7%)/(100% − 11.3%)
= ‘Influenced through free condoms’

Bom et al, PrePrint, March 2018 13

 Effects of free condoms on HIV and STI in MSM

V. Percentage of MSM that used a free condom from the condom distribution, and that
reported they would not have used a condom if condoms were not freely available at
PSVs:1
14.2%, 95%CI [9.4%, 20.3%]
= ‘Condom not used otherwise’

VI. Percentage of use unaffected by availability of free condoms:

93.0%
based on IV. & V.
= 49.4% × (100% − 14.2%) + (100% − 49.4%)

VII. Condom use in PSVs before intervention:

81.6%
based on II. & VI.
= 87.8% × 93.0%
= fpre

VIII. Percentage of relationships with casual partners that involved anal intercourse formed at
PSVs among men frequenting PSVs:2
59.6%, 95%CI [56.5%, 62.7%]
=δ
= ‘Partner PSV’

Number of MSM, condoms and casual partners

IX. Number of active MSM in the Netherlands:3
300,000, estimate

X. Percentage of active MSM, who met a casual partner at a PSV in the last year:4
17.1%, 95%CI [15.5%, 18.9%]

XI. Number of MSM eligible for inclusion in the intervention:

51,415
based on IX. & X.
= 300,000 × 17.1%

XII. Number of condoms distributed in 2013:5

371,952, exact

XIII. Condom wastage:

15%, estimate
= ‘Condom wastage’

Bom et al, PrePrint, March 2018 14

 Effects of free condoms on HIV and STI in MSM

XIV. Actual number of condoms used:

316,159
based on XII. & XIII.
= 371,952 × (100% − 15%)

XV. Mean annual number of casual partners among men frequenting PSVs:4
21.8, [1–200]
= ‘Number partners’

XVI. Mean number of sexual acts per casual partner:2

2.20, [1–50]
= ‘Number acts per partner’

XVII. Mean annual number of sexual acts with casual partner:

48.0
based on XV. & XVI.
= 21.8 × 2.20
=n

XVIII. Mean annual number of sexual acts at PSVs with casual partner:
28.6
based on VIII. & XVII.
= 59.6% × 48.0

XIX. Mean annual number of protected sexual acts at PSVs with casual partner:
25.1
based on II. & XVIII.
= 87.8% × 28.6

XX. Percentage insertive anal intercourse per sexual act:2

63.3%, 95%CI [59.2%, 67.2%]
= ‘Insertive acts’

XXI. Market share of CLub GU N condoms at the CLub GU N locations:

79.3%, 95%CI [73.8%, 84.0%]
= ‘Market share’

XXII. Mean annual number of CLub GU N condoms used per PSV patron:
12.6
based on XIX., XX. & XXI.
= 25.1 × 63.3% × 79.3%

XXIII. Number of MSM included in the intervention:

25,098
based on XIV. & XXII.
= 316,159/12.6

Bom et al, PrePrint, March 2018 15

 Effects of free condoms on HIV and STI in MSM

XXIV. Coverage:
48.8%
based on XI. & XXIII.
= 25,098/51,415

Prevalence and incidence

XXV. Condom effectiveness:6,7

70%, estimate
=ε
= ‘Condom effectiveness’

XXVI. Prevalence among casual partners met at a PSV:2

HIV : 36.2%, 95%CI [29.9%, 42.8%]
= phivpsv
= ‘Prevalence HIV PSV’
HCV : 0.46%, 95%CI [0.05%, 2.11%]
= phcvpsv
Chlamydia : 10.0%, 95%CI [6.6%, 14.5%]
= pchlampsv
Gonorrhoea : 5.9%, 95%CI [3.4%, 9.7%]
= pgonopsv
Syphilis : 1.8%, 95%CI [0.6%, 4.3%]
= psyphpsv

XXVII. Prevalence among casual partners met in general:2

HIV : 22.8%, 95%CI [19.9%, 26.0%]
= phivgen
HCV : 0.40%, 95%CI [0.11%, 1.08%]
= phcvgen
Chlamydia : 9.6%, 95%CI [7.6%, 11.8%]
= pchlamgen
Gonorrhoea : 6.1%, 95%CI [4.5%, 8.0%]
= pgonogen
Syphilis : 2.0%, 95%CI [1.2%, 3.2%]
= psyphgen

XXVIII. Per-act infectivity:8-12

HIV : 1.025%, estimate
= λhiv
= ‘Infectivity HIV’
HCV : 0.5%, estimate
= λhcv
Chlamydia : 17%, estimate
= λchlam
Gonorrhoea : 50%, estimate
= λgono
Syphilis : 30%, estimate
= λsyph

Bom et al, PrePrint, March 2018 16

 Effects of free condoms on HIV and STI in MSM

XXIX. Formula annual incidence risk:

based on II., VII., XVII., XXV., XXVI., XXVII. & XXVIII.
see Supplementary Data 2

 
I = 1 − (1 − (1 − ε) p1 λ)nδf1 × (1 − p1 λ)nδ(1−f1 ) δ
 
+ 1 − (1 − (1 − ε) p2 λ)n(1−δ)f2 × (1 − p2 λ)n(1−δ)(1−f2 ) (1 − δ)

REFERENCES

1. Osté JP, Bakker BHW, Cremer SW. Gezonde keuzes makkelijk maken: Onderzoek naar
gratis condoomverstrekking in sekslocaties. Amsterdam: Schorer & GGD Amsterdam;
2008.
2. Matser A, Heijman T, Geskus R, de Vries H, Kretzschmar M, Speksnijder A, et al. Per-
ceived HIV status is a key determinant of unprotected anal intercourse within
partnerships of men who have sex with men in Amsterdam. AIDS Behav. 2014,
18:2442-2456.
3. Schorer. Factsheet: HIV en SOA bij MSM (juni 2011). Amsterdam: Schorer; 2011.
4. Goenee M, Picavet C. Beschermingsgedrag van mannen die seks hebben met
mannen. In: De Graaf H, Bakker BHW, Wijsen C, editors. Een wereld van verschil:
seksuele gezondheid van LHBT’s in Nederland 2013. Eburon; 2014. p. 85-104.
5. Condomerie: Jaarverslag 2013. Amsterdam: Condomerie; 2013.
6. Pickles M, Foss AM, Vickerman P, Deering K, Verma S, Demers E, et al. Interim
modelling analysis to validate reported increases in condom use and assess
HIV infections averted among female sex workers and clients in southern India
following a targeted HIV prevention programme. Sex Transm Infect. 2010, 86:i33-
i43.
7. Smith DK, Herbst JH, Zhang X, Rose CE. Condom Effectiveness for HIV Preven-
tion by Consistency of Use among Men Who Have Sex with Men (MSM) in
the U.S. J Acquir Immune Defic Syndr. 2015, 68:337-344.
8. Jin F, Jansson J, Law M, Prestage GP, Zablotska I, Imrie JC, et al. Per-contact probab-
ility of HIV transmission in homosexual men in Sydney in the era of HAART.
AIDS. 2010, 24:907-913.
9. De Carli G, Puro V, Ippolito G. Risk of hepatitis C virus transmission following
percutaneous exposure in healthcare workers. Infection. 2003, 31:22-27.
10. Xiridou M, Vriend HJ, Lugner AK, Wallinga J, Fennema JS, Prins JM, et al. Modelling
the impact of chlamydia screening on the transmission of HIV among men
who have sex with men. BMC Infect Dis. 2013, 13:436.
11. Morin BR, Medina-Rios L, Camacho ET, Castillo-Chavez C. Static behavioral effects
on gonorrhea transmission dynamics in a MSM population. J Theor Biol. 2010,
267:35-40.
12. Holmes KK, Sparling PF, Stamm WE, Piot P, Wasserheit JN, Corey L, et, al. Sexually
transmitted diseases. 4th ed. New York: McGraw-Hill; 2008.

Bom et al, PrePrint, March 2018 17

Effects of free condoms on HIV and STI in MSM

The effects of free condom distribution on HIV and

other sexually transmitted infections in men who
have sex with men

SUPPLEMENTARY DATA 2

Calculations on annual incidence risk

The annual incidence risk I of the various STIs (i.e. HIV, HCV, chlamydia, gonorrhoea, and
syphilis) before (pre) and after (post) the introduction of free condoms at PSVs is the probability
to be infected during the year. Let Iy be the event of being infected during the year. Hence

I = IP (Iy )
 
= 1 − IP Iy (1)

 
where, for any event I, I is the complement of I. Hence, IP Iy is the probability of not being
infected during the year. Let n be the annual number of sexual acts with casual partners, and
Ii , represents being infected during the ith sexual act. Using this notations we derive:

n
!
  [
IP Iy = IP Ii
i=1
n
Y  
= IP Ii
i=1
Y   Y  
= IP Ii IP Ii
i∈{PAI} i∈{UAI}
Y    Y   
= 1 − IP Ii 1 − IP Ii (2)
i∈{PAI} i∈{UAI}

We need to introduce some more notations. Let p be the prevalence of infection, ε the condom
effectiveness, λ the per-act infectivity and f the proportion of protected sexual acts (PAI or
protected anal intercourse). When unprotected (UAI or unprotected anal intercourse), infection
occurs when the partner is infected and the act is infective. Hence, during an unprotected act,

IP (Ii ) = p × λ (3)

During sexual contact with a condom, infection occurs when the condom is ineffective, the act
is infectious and the partner is infected, so that for such an act:

IP (Ii ) = (1 − ε) pλ (4)

The number of protected acts per year is n × f and the number of unprotected acts is n (1 − f ).
If we consider sexual acts to occur independently, using (3) and (4), (2) can be rewritten:
 
IP Iy = (1 − (1 − ε) pλ)nf × (1 − pλ)n(1−f ) (5)

Bom et al, PrePrint, March 2018 18

Effects of free condoms on HIV and STI in MSM

Considering (1) and (5) we obtain:

I = 1 − (1 − (1 − ε) pλ)nf × (1 − pλ)n(1−f ) (6)

Sexual acts can take place either at PSVs or not. Consider a ratio δ of sexual acts taking place
at PSVs. Let D be the event that sexual contact occurs at PSVs. Conditioning by D, and using
the law of total probability we obtain:

I = IP (Iy )
   
= IP (Iy |D) IP (D) + IP Iy |D IP D (7)

The definition of δ gives directly

 
IP (D) = δ and IP D = 1 − δ (8)

If n1 is the number of sexual acts at PSVs and n2 the number of sexual acts outside PSVs, than

n1 = nδ and n2 = n (1 − δ) (9)

Using formula (6), (8), and (9), we derive

 
I = 1 − (1 − (1 − ε) p1 λ)nδf1 × (1 − p1 λ)nδ(1−f1 ) δ (10)
 
+ 1 − (1 − (1 − ε) p2 λ)n(1−δ)f2 × (1 − p2 λ)n(1−δ)(1−f2 ) (1 − δ)

where p1 is the prevalence of infection and f1 the proportion of protected sexual acts at PSVs,
and p2 the prevalence of infection, and f2 the proportion of protected sexual acts outside PSVs.

Bom et al, PrePrint, March 2018 19

Effects of free condoms on HIV and STI in MSM

The effects of free condom distribution on HIV and

other sexually transmitted infections in men who
have sex with men

SUPPLEMENTARY DATA 3

Calculations on burden of disease

DALYs of the various STIs were calculated using uniform age weights, and without discounting,
using the following formula:1,2

DALY = Y LD + Y LL
= IcDwLd + IcLl

Where Y LD is years lived with disability, Y LL is years of life lost, Ic is the annual number of
incident cases, Dw is the disability weight of the disease stage, Ld is the duration of the disease
stage in years, and Ll are the years lost due to premature death caused by infection. The life
expectancy of healthy males in the Netherlands was 79.5 years.3 Generalised courses of infection
of HIV, HCV, chlamydia, gonorrhoea, and syphilis in Dutch MSM in presence of treatment were
constructed and included in the models. Parameter estimates of these generalised courses of
infection are shown in T able 1.

For HIV, the course of infection was divided into a pre-AIDS and AIDS stage, leading to a
premature death, and we assumed that HIV was acquired at age 37.9 years (T able 1).6,19

HIV:

DALYhiv = Ichiv Dwpreaids Ldpreaids

+Ichiv Dwaids Ldaids
+Ichiv Llhiv

The course of infection with HCV was assumed as follows: the infection starts with an acute
stage, followed by a chronic stage, which leads first to compensated liver cirrhosis, then to decom-
pensated liver cirrhosis, and ultimately to premature death. HIV-positive individuals acquired
the infection at age 42.6 years, and acute infection could be cleared spontaneously (at rate γ),
or become chronic.20 The acute and chronic stage were symptomatic (s) or asymptomatic.12,21
Sexually transmitted HCV is only found among HIV-infected MSM, who have a reduced life
expectancy compared to healthy males, reducing the number of years lost due to HCV.6 HCV
disease progression is enhanced by HIV, which was accounted for by using age-specific paramet-
ers from an older age group (T able 1).12,21

Bom et al, PrePrint, March 2018 20

Effects of free condoms on HIV and STI in MSM

HCV:

DALYhcv = sachcv Ichcv Dwachcv Ldachcv

+ (1 − γachcv ) schrhcv Ichcv Dwchrhcv Ldchrhcv
+ (1 − γachcv ) Ichcv Dwcomlivhcv Ldcomlivhcv
+ (1 − γachcv ) Ichcv Dwdeclivhcv Lddeclivhcv
+ (1 − γachcv ) Ichcv Llhcv

For chlamydia and gonorrhoea, we assumed infection could be symptomatic or asymptomatic,

and all cases recovered due to either spontaneous clearance or treatment (T able 1).

Chlamydia:

DALYchlam = schlam Icchlam Dwchlam Ldchlam

Gonorrhoea:

DALYgono = sgono Icgono Dwgono Ldgono

Syphilis’ course of infection is composed of alternating symptomatic (primary, secondary and

tertiary syphilis) and asymptomatic stages (latent syphilis). Among MSM with syphilis at the
STI clinic, 18.8% were diagnosed with primary syphilis, 33.7% with secondary syphilis, and
47.5%with latent syphilis.17 No progression towards tertiary syphilis was seen. Latent syphilis
is asymptomatic, but can relapse (at rate r) to secondary syphilis. Recovery occurred in 18.8%
of primary cases, 41.5% of secondary cases, and in 100% of MSM with latent syphilis due to
treatment (T able 1).

Syphilis:

DALYsyph = Icsyph Dwprimsyph Ldprimsyph

+ (1 − γprimsyph ) Icsyph Dwsecsyph Ldsecsyph
+ (1 − γprimsyph − γsecsyph ) rsecsyph Icsyph Dwsecsyph Ldsecsyph

Bom et al, PrePrint, March 2018 21

Effects of free condoms on HIV and STI in MSM

Table 1. Parameters used in the DALY calculations.

Infection Stage Parameter Value ref.
HIV Pre-AIDS Disability weight for pre-AIDS (Dwpreaids ) 0.221 [ 4]
Duration of pre-AIDS in years (Ldpreaids ) 10 [ 5]
AIDS Disability weight for AIDS (Dwaids ) 0.053 [ 4]
Duration of AIDS in years (Ldaids ) 24.6 [ 6]
Death Years lost due to premature death due to AIDS 7 [ 6]
(Llhiv )
HCV Acute HCV Proportion symptomatic acute HCV infections 0.48 [ 7]
infection (sachcv )
Disability weight for acute HCV infection 0.210 [ 8]
(Dwachcv )
Duration of acute HCV infection in years 0.5 [ 9]
(Ldachcv )
Recovery rate for acute HCV (γachcv ) 0.15 [10]
Chronic HCV Proportion symptomatic chronic HCV infections 0.25 [11]
infection (schrhcv )
Disability weight for chronic HCV infection 0.360 [ 8]
(Dwchrhcv )
Duration of chronic HCV infection in years 12.5 [12]
(Ldchrhcv )
Compensated Disability weight for compensated liver cirrhosis 0.310 [ 8]
liver cirrhosis (Dwcomlivhcv )
Duration of compensated liver cirrhosis in years 6 [12]
(Ldcomlivhcv )
Decompensated Disability weight for decompensated liver cirrhosis 0.840 [ 8]
liver cirrhosis (Dwdeclivhcv )
Duration of decompensated liver cirrhosis in years 2 [12]
(Lddeclivhcv )
Death Years lost due to premature death due to 8.9 [12]
decompensated liver cirrhosis (Llhcv )
Chlamydia Proportion symptomatic chlamydia infections 0.31 [13]
(schlam )
Disability weight for chlamydia (Dwchlam ) 0.067 [14]
Duration of chlamydia in years (Ldchlam ) 0.39 [14]
Gonorrhoea Proportion symptomatic gonorrhoea infections 0.51 [13]
(sgono )
Disability weight for gonorrhoea (Dwgono ) 0.067 [14]
Duration of gonorrhoea in years (Ldgono ) 0.12 [14]
Syphilis Primary Disability weight for primary syphilis 0.015 [15]
syphilis (Dwprimsyph )
Duration of primary syphilis in years (Ldprimsyph ) 0.1 [16]
Recovery rate for primary syphilis (γprimsyph ) 0.188 [17]
Secondary Disability weight for secondary syphilis 0.048 [15]
syphilis (Dwsecsyph )
Duration of secondary syphilis in years (Ldsecsyph ) 0.15 [16]
Recovery rate for secondary syphilis (γsecsyph ) 0.337 [17]
Latent syphilis Relapse rate for latent syphilis (rsecsyph ) 0.25 [18]

DALY = disability adjusted life year; HCV = hepatitis C.

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Effects of free condoms on HIV and STI in MSM

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Effects of free condoms on HIV and STI in MSM

The effects of free condom distribution on HIV and

other sexually transmitted infections in men who
have sex with men

SUPPLEMENTARY TABLE 1

Threshold values of the key parameters at which free condom distribution at

PSVs remains cost-saving, highly cost-effective or cost-effective.
Point Cost-saving Highly cost- Cost-
estimate effective effective
‘Condom use sometimes’ 50% ≥0% ≥0% ≥0%
‘Influenced through free condoms’ 49.4% >8.9% >0.16% >0.055%
‘Condom not used otherwise’ 14.2% >2.6% >0.047% >0.016%
‘Partner PSV’ 59.6% >10.4% >0.19% >0.063%
‘Condom wastage’ 15% <84.6% <99.72% <99.906%
‘Number partners’ 21.8 <885 <13884 <104103
‘Number acts per partner’ 2.2 <89 <1399 <10489
‘Insertive acts’ 63.3% ≤100% ≤100% ≤100%
‘Market share’ 79.3% ≥0% ≥0% ≥0%
‘Condom effectiveness’ 70% >13.4% >0.25% >0.083%
‘Prevalence HIV PSV’ 36.2% 4.2%–95.3% ≥0% ≥0%
‘Infectivity HIV’ 1.025% >0.180% ≥0% ≥0%

PSV = public sex venue.

All parameters are described in detail in Supplementary data 1.

Bom et al, PrePrint, March 2018 25