Is cost a structural barrier preventing men who have sex with men accessing condoms? A systematic review.

A systematic review was undertaken to determine whether cost is a structural barrier preventing men who have sex with men (MSM) accessing condoms. Studies were examined from a range of countries where condoms have been distributed free to particular populations and also those where condoms were available at a cost to the individual. The study inclusion criteria were: published between January 1990 and September 2014 inclusive; published in any language, discussed cost as a barrier to condom use, discussed cost barriers to MSM accessing condoms and included a measure of outcome. Articles were systematically extracted from MEDLINE, Embase, PyschINFO and Informat using the five search terms; Male Homosexuality, Access, Cost, Cost and Cost analysis, Condoms. Sixty-four articles were initially identified and 11 included in the final review. The included studies used cost-utility analysis, qualitative, cross-sectional, cohort or randomised control trial design. Large-scale free distribution programmes and smaller targeted programmes showed positive correlations in reducing the burden of disease from HIV and other sexually transmitted infections through eliminating the issue of cost. Decreasing the cost of condoms, and providing them for no cost, appears to increase their utilisation amongst MSM and possibly reduce the burden from HIV and other sexually transmitted infections. Inequality and stigma remain important barriers to MSM accessing and using condoms particularly in the developing world.