Effectiveness of community-based condom distribution interventions to prevent HIV in the United States: A systematic review and meta-analysis

Background: Despite significant public health implications, the extent to which community-based condom distribution interventions (CDI) prevent HIV infection in the United States is not well understood. Methods: We systematically reviewed research evidence applying Cochrane Collaboration methods. We used a comprehensive search strategy to search multiple bibliographic databases for relevant randomized controlled trials (RCTs) and non-RCTs published from 1986–2017. We focused on CDI that made condoms widely available or accessible in community settings. Eligible outcomes were HIV infection (primary), sexually transmitted infections, condom use, and multiple sexual partnership. Two reviewers independently screened citations to assess their eligibility, extracted study data, and assessed risk of bias. We calculated risk ratios (RR) with 95% confidence intervals (CI) and pooled them using random-effects models. We assessed evidence quality using GRADE. Results: We reviewed 5,110 unique records. Nine studies (including one RCT) met eligibility criteria. Studies were conducted in 10 US states between 1989 and 2011. All studies were at high risk of bias. Interventions were categorized into three groups: “Ongoing” (unlimited access to condoms), “Ongoing-plus” (unlimited access to condoms, with co-interventions), and “Coupon-based” (coupons redeemed for condoms). No studies reported incident HIV. Ongoing CDI (four non-RCTs) modestly reduced condomless sex (RR 0.88, 95% CI 0.78 to 0.99). Ongoing-plus CDI (two non-RCTs) significantly reduced multiple sexual partnership (RR 0.37, 95% CI 0.16 to 0.87). Of two coupon-based studies, one (non-RCT) showed reduction in condomless sex in female participants (Odds Ratio 0.67, 95% CI 0.47 to 0.96), while the other one (RCT) showed no effect on STI incidence (RR 0.91, 95% CI 0.63 to 1.31). Evidence quality was “very low” for all outcomes. Conclusions: CDI may reduce some risky sexual behaviors, but the evidence for any reduction is limited and of low-quality. Lack of biological outcomes precludes assessing the link between CDI and HIV incidence.