Trends in condom use and its socioeconomic inequalities among men in Sierra Leone for HIV prevention, 2008-2019: A longitudinal analysis

INTRODUCTION: Health equity is a central objective of global health, requiring the removal of barriers to ensure equitable access and use of services for all. Monitoring inequalities in health service use is critical to evaluate progress toward this goal. This study analyses longitudinal trends in condom use, a key HIV prevention service and the associated socioeconomic inequalities among men in Sierra Leone to assess whether access and use are becoming more equitable. METHODS: We conducted a secondary analysis of data from the 2008, 2013, and 2019 Sierra Leone Demographic and Health Surveys. The sample included 9 375 men aged 15 to 59 years who reported sex with a non-marital, non-cohabiting partner in the past 12 months. Using the World Health Organization's Health Equity Assessment Toolkit (HEAT), we calculated absolute (Difference, Slope Index of Inequality) and relative (Ratio, Relative Index of Inequality) measures to quantify inequalities across economic status, education, age, marital status, residence, and region. RESULTS: National condom use at last higher-risk sex remained stable at 23.0% in 2008, 21.4% in 2013, and 22.5% in 2019. However, disaggregated analysis revealed persistent absolute inequalities. In 2019, the absolute gap (D) by economic status was 12.4 percentage points and by education was 18.0 percentage points. A notable finding was the decline in condom use among the richest (40.4% to 31.7%) and most educated (53.6% to 34.2%) men, even as use increased among the poorest (4.7% to 19.3%) and least educated (10.2% to 16.2%). CONCLUSION: While improvements among the most disadvantaged men are encouraging, persistent absolute inequalities and declining use among more privileged groups highlight a complex landscape for HIV prevention. Achieving health equity requires targeted interventions that address the specific barriers faced by disadvantaged groups while countering risk compensation in higher socioeconomic strata. Longitudinal inequality monitoring is vital for guiding these efforts.