Pre-Exposure Vaccination
Pre-exposure vaccination is one of the most effective methods
for preventing transmission of HPV, HAV, and HBV, all
of which can be sexually transmitted. HPV vaccination is
recommended routinely for males and females aged 11 or
12 years and can be administered beginning at age 9 years.
HPV vaccination is recommended through age 26 years for
those not previously vaccinated (11). Sharing clinical decisionmaking
about HPV vaccination is recommended for certain
adults aged 27–45 years who are not adequately vaccinated
in accordance with existing guidance (https://www.cdc.gov/
vaccines/hcp/acip-recs/vacc-specific/hpv.html).
Recommendations and Reports
US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / July 23, 2021 / Vol. 70 / No. 4 5
Hepatitis B vaccination is recommended for all unvaccinated,
uninfected persons who are sexually active with more than
one partner or are being evaluated or treated for an STI (12).
In addition, hepatitis A and B vaccines are recommended for
MSM, persons who inject drugs, persons with chronic liver
disease, and persons with HIV or hepatitis C infections who
have not had hepatitis A or hepatitis B (12). HAV vaccine is
also recommended for persons who are homeless (13). Details
regarding HAV and HBV vaccination, including routine
childhood vaccination, are available at https://www.cdc.gov/
hepatitis and at the ACIP website (https://www.cdc.gov/
vaccines/hcp/acip-recs/vacc-specific/index.html).
Condoms
External Condoms
When used consistently and correctly, external latex
condoms, also known as male condoms, are effective in
preventing the sexual transmission of HIV infection (http://
www.ashasexualhealth.org/pdfs/Male_and_Female_Condoms.
pdf). In heterosexual HIV mixed-status relationships (i.e., those
involving one infected and one uninfected partner) in which
condoms were used consistently, HIV-negative partners were
71%–80% less likely to become infected with HIV, compared
with persons in similar relationships in which condoms were
not used (14,15). Two analyses of MSM mixed-status couple
studies estimated the protective effect of condom use to be 70%
and 91%, respectively (16,17). Moreover, studies demonstrate
that consistent condom use reduces the risk for other STIs,
including chlamydia, gonorrhea, hepatitis B, and trichomoniasis
(18–21). By limiting lower genital tract infections, condoms
also might reduce the risk for pelvic inflammatory disease
(PID) among women (22). In addition, consistent and correct
use of latex condoms reduces the risk for HPV infection
and HPV-associated diseases, genital herpes, syphilis, and
chancroid when the infected area or site of potential exposure
is covered (23–27). Additional information is available at
https://www.cdc.gov/condomeffectiveness/index.html and
www.factsaboutcondoms.com/professional.php. Condoms
are regulated as medical devices and are subject to random
sampling and testing by the Food and Drug Administration
(FDA). Each latex condom manufactured in the United States
is tested electronically for holes before packaging. The rate of
condom breakage during sexual intercourse and withdrawal in
the United States is approximately two broken condoms per
100 condoms. Rates of breakage and slippage might be slightly
higher during anal intercourse (28,29). The failure of condoms
to protect against STIs or unintended pregnancy usually results
from inconsistent or incorrect use rather than condom breakage
(30). Users should check the expiration or manufacture date
on the box or individual package. Latex condoms should not
be used beyond their expiration date or >5 years after the
manufacturing date. Condoms made of materials other than
latex are available in the United States and can be classified
into two general categories: 1) polyurethane, polyisoprene, or
other synthetic condoms and 2) natural membrane condoms.
Polyurethane external condoms provide protection against
STIs and HIV and pregnancy comparable to that of latex
condoms (20,31). These can be substituted for latex condoms
by persons with latex sensitivity, are typically more resistant to
deterioration, and are compatible with use of both oil-based
and water-based lubricants. The effectiveness of other synthetic
external condoms to prevent STIs has not been extensively
studied, and FDA labeling restricts their recommended use
to persons who are sensitive to or allergic to latex. Natural
membrane condoms (frequently called natural skin condoms
or [incorrectly] lambskin condoms) are made from lamb cecum
and can have pores up to 1,500 nm in diameter. Although
these pores do not allow the passage of sperm, they are more
than 10 times the diameter of HIV and more than 25 times
that of HBV. Moreover, laboratory studies demonstrate that
sexual transmission of viruses, including HBV, herpes simplex
virus (HSV), and HIV, can occur with natural membrane
condoms (31). Therefore, natural membrane condoms are not
recommended for prevention of STIs and HIV.
Providers should advise that condoms must be used
consistently and correctly to be effective in preventing STIs and
HIV while noting that any condom use is better than no condom
use. Providing instructions about the correct use of condoms
can be useful. Communicating the following recommendations
can help ensure that patients use external condoms correctly:
• Use a new condom with each sex act (i.e., oral, vaginal,
and anal).
• Carefully handle the condom to avoid damaging it with
fingernails, teeth, or other sharp objects.
• Put the condom on after the penis is erect and before any
genital, oral, or anal contact with the partner.
• Use only water-based or silicone-based lubricants (e.g.,
K-Y Jelly, Astroglide, AquaLube, or glycerin) with latex
condoms. Oil-based lubricants (e.g., petroleum jelly,
shortening, mineral oil, massage oils, body lotions, or
cooking oil) can weaken latex and should not be used;
however, oil-based lubricants typically can be used with
polyurethane or other synthetic condoms.
• Ensure adequate lubrication during vaginal and anal sex,
which might require using exogenous water-based
lubricants.
• Hold the condom firmly against the base of the penis
during withdrawal, and withdraw while the penis is still
erect to prevent the condom from slipping off.
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6 MMWR / July 23, 2021 / Vol. 70 / No. 4 US Department of Health and Human Services/Centers for Disease Control and Prevention
Additional information about external condoms is available
at https://www.cdc.gov/condomeffectiveness.