Low condom use at the last sexual intercourse among university students in sub-Saharan Africa: Evidence from a systematic review and meta-analysis.

Background: There is inconsistent data about condom use at the last sexual intercourse (LSI) among university students in sub-Saharan Africa (SSA) and its association with sex, age, and condom negotiation efficacy. The primary objective of this study was to summarize the proportion of condom use at the LSI among university students in SSA. The secondary objective was to determine the association between condom use at the LSI with sex, age, and condom negotiation efficacy among university students in SSA.

Methods: In this systematic review and meta-analysis, two reviewers independently searched electronic databases and grey literature for eligible studies published until July 30, 2020, extracted data, and assessed the risk of bias in the included studies. We used the Dersimonian-Liard random-effects model to pool the proportion of condom use at the LSI and the association between condom use at the LSI with sex, age, and condom negotiation efficacy, reported using risk ratio (RR). We assessed publication bias using funnel plot and Egger's test, and explored sources of heterogeneity using sub-group and meta-regression analyses.

Results: We meta-analyzed 44 studies with a combined sample size of 27,948 participants.Of 14,778 sexually active participants, 8,744 (pooled proportion, 52.9%; 95% CI, 45.0-60.7; 95% prediction interval, 2.8-98.9; I-squared = 99.0%, p< 0.0001) reported condom use at the LSI and the proportion of condom use at the LSI remained stagnant between 2000 and 2019 (p = 0.512). Condom use at the LSI was not associated with being a female compared to a male (pooled RR, 1.08; 95% CI, 0.68-1.71), being of a younger age (≤24 years old) compared to older age (25 years and more) (pooled RR, 1.16; 95% CI, 0-85-1.57), and having a higher condom negotiation efficacy compared to a lower condom negotiation efficacy (pooled RR, 1.54; 95% CI, 0-81-2.94).

Conclusions: We found a low and heterogenous use of a condom at the LSI among university students in SSA which was not associated with sex, age, or condom negotiation efficacy. Accordingly, context-relevant interventions are needed to improve condom use at the LSI among university students in SSA.