Are condoms the answer to rising rates of non-HIV sexually transmitted infection?

YES Condoms can and should play a central role in halting the rising rates of sexually transmitted infection other than HIV. For people who are sexually active, condoms remain our best solution to reducing risks of acquiring sexually transmitted infections (if uninfected) or transmitting these infections (if infected). Strong evidence from laboratory studies and mounting clinical studies shows that condoms effectively reduce the risk of transmission. In addition, for specific populations, increased levels of condom use have been associated with decreases in reported sexually transmitted infections.

Condoms work

Condoms protect the wearer and his partner from infection by covering the penile glans and shaft, which are the major portals of entry and exit of sexually transmitted pathogens. Laboratory studies indicate that latex condoms are an effective physical barrier against passage of even the smallest sexually transmitted pathogens.^w1

When placed on the penis before any genital contact and used throughout intercourse, the condom prevents direct contact with semen; genital lesions and subclinical viral shedding on the glans and shaft of the penis; and penile, vaginal, or anal discharges. Thus, condoms reduce the risk of infections that are transmitted primarily to or from the penile urethra such as HIV, gonorrhoea, chlamydia, trichomoniasis, and hepatitis B. Condoms also reduce the risk of infections that are transmitted primarily through skin or mucosal surfaces when these areas are covered by the condom, such as genital herpes, syphilis, chancroid, and human papillomavirus infection.

Although clinical studies have shown inconsistent protective effects for most sexually transmitted infections other than HIV,^w2 much of this can be attributed to limitations in study design. Limitations in measurement of self reported condom use and exposure to infected partners complicate interpretation of results.^w3 Moreover, the levels of protection from condoms are likely to differ between infections because of variations in their routes of transmission, infectivity, and prevalence.

Despite these limitations, a recent systematic literature review of 45 published studies of condom use and gonorrhea and chlamydia provides strong evidence that condoms reduce risk in both men and women.^w3 Many of these studies did not measure critical factors such as exposure to infected partners, consistent and correct condom use, or incident infection. The observed protective effects are therefore likely to be underestimates. When one of the 45 studies was adjusted for infection status by using a case crossover analysis, the protective effect of condoms increased dramatically.4 Recent well designed studies have also shown consistent and correct use of condoms can reduce herpes simplex virus5 and cervical human papillomavirus infection.^w6

One problem with relying on condoms to halt the rising rates of infection is that the promotion of condoms remains controversial in many countries, including the United States. The data are clear, however. Other than abstinence, which is difficult to achieve, condoms are the most effective means of stopping the spread of sexually transmitted infections. We need to focus on ensuring consistent and correct condom use rather than denigrating condoms as being less than perfect.

Two recent reviews,^{w7 w8} show that behavioural interventions featuring condom promotion are associated with increases in reported condom use and, to a lesser extent, decreases in incidence of sexually transmitted infection. One theoretical concern is that condom promotion could lead to risk compensation—men who use condoms may feel safer and consequently engage in more frequent sex or sex with more partners, thus increasing the risk of transmission. The most recent review of 174 condom related prevention approaches, however, concluded that sexual risk reduction interventions do not increase unsafe sexual behaviour.^w9 In addition, a recent systematic review showed adding condom promotion to interventions focusing on abstinence does not undermine the abstinence message.^w10 Despite this reassurance, we must continue to be vigilant when promoting the use of condoms to avoid giving users a false sense of security; we should refer, for example, to safer sex rather than safe sex.

Condoms in context

Like any prevention tool (such as seat belts, airbags, smoking cessation programmes, virginity pledges) condoms are not 100% effective. Preventing sexually transmitted infection, just as with other health conditions, requires incremental, partially effective steps to produce collectively effective (but not perfect) prevention programmes.^w11 Controlling the spread of infection will require different, mutually reinforcing techniques.

Although combined prevention strategies can greatly reduce the spread of sexually transmitted infections,^w12 they need to be carefully designed and implemented. Accurate messages about condoms must build on a wide range of risk avoidance and risk reduction approaches. These approaches include delayed initiation of sexual intercourse, mutual faithfulness, and selection of low risk partners.

Together with condoms, these reinforcing epidemiologic truisms have been labelled both now and in the past as an ABC strategy: abstinence, be faithful to one partner, and use condoms.^w13 Moreover, a full alphabet of prevention strategies is needed for an optimal effect on HIV transmission, as well as other sexually transmitted infections (see box on student.bmj.com). Condoms have a pivotal role in this larger armamentarium of strategies.

What does this mean for clinicians who counsel patients about sexual health? Firstly, people who abstain from intercourse or who are uninfected and mutually monogamous eliminate the risk of infection entirely. Secondly, people who choose to be sexually active can be reassured that condom use reduces the risk of most infections. Thirdly, condoms, like any other prevention tool, work only when used properly—consistent and correct use is essential for optimal risk reduction.

This article was first published in the BMJ (2008;336:184-5).

References w1-w13 and a box giving the A to Z of prevention strategies for HIV and other sexually transmitted infections are on student.bmj.com.

See Stephen Genuis’s argument against, http://student.bmj.com/issues/08/03/life/097.php.

Where do you stand on the issue? Let us know by sending a rapid response at student.bmj.com.

1. Carey RF, Lytle CD, Cyr WH. Implications of laboratory tests of condom integrity. Sex Transm Dis 1999;26:216-20.
2. National Institute of Allergy and Infectious Diseases. Workshop summary: scientific evidence on condom effectiveness for sexually transmitted diseases (STD) prevention. NIAID, 2001. www3.niaid.nih.gov/research/topics/STI/pdf/condomreport.pdf.
3. Warner L, Stone KM, Macaluso M, Buehler JW, Austin HD. Condom use and risk of gonorrhea and Chlamydia: a systematic review of design and measurement factors assessed in epidemiologic studies. Sex Transm Dis 2006;33:36-51.
4. Warner L, Macaluso M, Austin HD, Kleinbaum DK, Artz L, Fleenor ME, et al. Application of the case-crossover design to reduce unmeasured confounding in studies of condom effectiveness. Am J Epidemiol 2005;161:765-73.[Abstract/Free Full Text]
5. Wald A, Langenberg AG, Krantz E, Douglas JM Jr, Handsfield HH, DiCarlo RP, et al. The relationship between condom use and herpes simplex virus acquisition. Ann Intern Med 2005;143:707-13.[Abstract/Free Full Text]
6. Winer RL, Hughes JP, Feng Q, O’Reilly S, Kiviat NB, Holmes KK, et al. Condom use and the risk of genital human papillomavirus infection in young women. N Engl J Med 2006;354:2645-54.[Abstract/Free Full Text]
7. Golden MR, Manhart LE. Innovative approaches to the prevention and control of bacterial sexually transmitted infections. Infect Dis Clin North Am 2005;19:513-40.
8. Ward DJ, Rowe B, Pattison H, Taylor RS, Radcliffe KW. Reducing the risk of sexually transmitted infections in genitourinary medicine clinic patients: a systematic review and meta-analysis of behavioural interventions. Sex Transm Infect 2005;81:386-93.[Abstract/Free Full Text]
9. Smoak ND, Scott-Sheldon LA, Johnson BT, Carey MP. Sexual risk reduction interventions do not inadvertently increase the overall frequency of sexual behavior: a meta-analysis of 174 studies with 116,735 participants. J Acquir Immune Defic Syndr 2006;41:374-84.
10. Underhill K, Operario D, Montgomery P. Systematic review of abstinence-plus HIV prevention programs in high-income countries. PLoS Med 2007;4(9):e275.
11. Cates W Jr, Hinman AR. AIDS and absolutism—the demand for perfection in prevention. N Engl J Med 1992;327:492-4.
12. Chesson HW. Estimated effectiveness and cost-effectiveness of federally funded prevention efforts on gonorrhea rates in the United States, 1971-2003, under various assumptions about the impact of prevention funding. Sex Transm Dis 2006;33(suppl):S140-4.
13. Halperin DT, Steiner MJ, Cassell MM, Green EC, Hearst N, Kirby D, et al. The time has come for common ground on preventing sexual transmission of HIV. Lancet 2004;364:1913-5.

NO Clinical considerations surrounding the science of sexuality and reproductive health have routinely been hijacked by philosophical perspectives, economic interests, religious bias, and sexual ideology. Rather than dialogue about evidence based outcomes and credible health policy, most talk about prevention of sexually transmitted infections involves debate over mutually exclusive perspectives on sexual morality.

Proponents of approaches encouraging safe sex (or safer sex) are accused of corrupting youth with amoral values, and opponents are perceived as zealots who disregard scientific fact in imposing their fanaticism on society. We need to look beyond vested interests to focus on clinical science and public health evidence.

A fundamental tenet of medicine is adherence to scientific fact and experiential evidence to develop treatments and programmes that maximise and sustain health. That evidence shows that effective population control of non-HIV sexually transmitted infections requires more than condom focused approaches.

Scope of protection

Firstly, condoms cannot be the definitive answer to sexually transmitted infection because they provide insufficient protection against transmission of many common diseases. “Skin to skin” and “skin to sore” infections such as human papillomavirus, herpes simplex virus, syphilis, lymphomagranuloma venereum, or chancroid often transmit despite barrier protection.^{w1 w2} Although condoms prevent contact between the skin of the penis and the vaginal mucosa, intercourse generally involves skin to skin contact in the external genital area; the condom gives limited protection against pathogens found throughout the external genital tract.

As barriers only protect the area they cover, clinical and subclinical lesions on the mons pubis or on the woman’s vulva or the male scrotum, for example, are not covered and readily transmit despite condom use. Rather than remaining contained within the vagina, some communicable pathogens are routinely encountered on the vulva and perineum of women. The most common sexually transmitted pathogens, human papillomavirus and herpes simplex virus, are often dispersed on infected genitalia and transmit through skin to skin contact. As the sequelae of these common infections may include various cancers,^{w2 w3} chronic sexual dysfunction,^{w2 w4} as well as vertical transmission,^{w2 w5} contracting such organisms is not inconsequential.

Practical effectiveness

The main problem with condoms is that average people, particularly aroused youth, do not use them consistently, regardless of knowledge or education.^{w2 w6} Although condoms offer some protection against discharge related infections such as chlamydia and gonorrhoea, protection is usually compromised by compliance issues, incorrect use, or mechanical failure.^w2

In theory, condoms offer some protection against sexually transmitted infection; practically, however, epidemiological research repeatedly shows that condom familiarity and risk awareness do not result in sustained safer sex choices in real life. Only a minority of people engaging in risky sexual behaviour use condoms consistently.^{w2 w6 w7} A recent study found that less than 8% of couples discordant for herpes used condoms for each sex act, despite ongoing counselling.^w7 Even among stable, adult couples who were HIV discordant and received extensive ongoing counselling about HIV risk and condom use, only 48.4% used condoms consistently.8 Irregular use of condoms will not provide sustained protection against sexually transmitted infection.^w9

The relentless rise of sexually transmitted infection in the face of unprecedented education about and promotion of condoms is testament to the lack of success of this approach. In numerous large studies, concerted efforts to promote use of condoms has consistently failed to control rates of sexually transmitted infection—even in countries with advanced sex education programmes such as Canada, Sweden, and Switzerland.10 In my home province of Alberta, rates of chlamydia and gonorrhoea have tripled since 1998 despite ubiquitous “safer sex” education. The ongoing assertion that condoms are “the” answer to this escalating pandemic reminds me of Einstein’s words, “The definition of insanity is doing the same thing over and over again and expecting different results.”

Reports of diminished rates of sexually transmitted infection as a result of widespread condom use in countries such as Thailand and Cambodia are reinforcing the focus on condoms as the primary strategy. Careful scrutiny of the data, however, suggests that changes in sexual behaviour (fewer partners, less casual sex, and less use of sex workers) after mass educational campaigns rather than widespread condom use by ordinary citizens was instrumental in reducing infection rates.^{w2 w11}

Tackling the root cause

The World Health Organization estimates that two thirds of sexually transmitted infections worldwide occur in teenagers and young adults.^w12 Extensive research shows that, not unlike other high risk behaviour in young people, risky sexual activity is often an expression of non-sexual need and associated with fundamental problems and difficulties.^{w2 w13}

Promoting condoms as ‘the’ answer disregards the complex nature of human sexuality and fails to tackle the underlying social and emotional needs of young people, who are often trapped in high risk sexual behaviour as a consequence of difficult life circumstances. Innumerable adolescents saturated with condom focused sex education fail to have their fundamental human needs met and end up contracting sexually transmitted infections. For some, risky sex is one component of self destructive behaviour that includes substance misuse and delinquency.

Political correctness and ideological interests need to be usurped by sound science. After repeated failure, the altar of safe sex needs to be dismantled in favour of credible public health policy. Although factual information about barrier protection should be included in any discussion of sexually transmitted infections, narrow condom focused initiatives should be replaced with comprehensive programmes discussed in the medical literature that have evidence-based success at reducing rates of infection.w2

Only a minority of people engaging in risky sexual behaviour use condoms consistently

Competing interests: None declared.

See Markus Steiner and Willard Cates’s argument for, http://student.bmj.com/issues/08/03/life/096.php.

Where do you stand on the issue? Let us know by sending a rapid response at student.bmj.com.

1. w1 Workowski KA, Levine WC. Sexually transmitted diseases treatment guidelines 2002. Centers for Disease Control and Prevention. MMWR Recomm Rep 2002;51(RR-6):1-78.
2. w2 Genuis SJ, Genuis SK. Managing the sexually transmitted disease pandemic: a time for re-evaluation. Am J Obstet Gynecol 2004;191:1103-12.
3. w3 Gillison ML, Koch WM, Capone RB, Spafford M, Westra WH, Wu L, et al. Evidence for a causal association between human papillomavirus and a subset of head and neck cancers. J Natl Cancer Inst 2000;92:709-20.[Abstract/Free Full Text]
4. w4 Vezina C, Steben M. Psychosexual impacts of human papillomavirus. Can J Cont Med Ed 2001;13:139-53.
5. w5 Buka SL, Tsuang MT, Torrey EF, Klebanoff MA, Bernstein D, Yolken RH. Maternal infections and subsequent psychosis among offspring. Arch Gen Psychiatry 2001;58:1032-7.[Abstract/Free Full Text]
6. w6 Madhok R, McCallum AK, McEwan R, Bhopal RS. Students’ knowledge and behavior concerning safer sex: a UK study. J Am Coll Health. 1993;42:121-5.
7. w7 Wald A, Langenberg AG, Link K, Izu AE, Ashley R, Warren T, et al. Effect of condoms on reducing the transmission of herpes simplex virus type 2 from men to women. JAMA 2001;285:3100-6.[Abstract/Free Full Text]
8. w8 De Vincenzi I. A longitudinal study of human immunodeficiency virus transmission by heterosexual partners. European Study Group on Heterosexual Transmission of HIV. N Engl J Med 1994;331:341-6.[Abstract/Free Full Text]
9. w9 Ahmed S, Lutalo T, Wawer M, Serwadda D, Sewankambo NK, Nalugoda F, et al. HIV incidence and sexually transmitted disease prevalence associated with condom use: a population study in Rakai, Uganda. AIDS 2001;15:2171-9.
10. w10 Genuis SJ, Genuis SK. Adolescent sexual involvement: time for primary prevention. Lancet 1995;345:240-1.
11. w11 Thato S, Charron-Prochownik D, Dorn LD, Albrecht SA, Stone CA. Predictors of condom use among adolescent Thai vocational students. J Nurs Scholarsh 2003;35:157-63.
12. w12 Dehne KL, Riedner G. Sexually transmitted infections among adolescents: the need for adequate health services. Reprod Health Matters 2001;17:170-83.
13. w13 Cohen MW. Adolescent sexual activity as an expression of nonsexual needs. Pediatr Ann 1995;24:324-9.

   

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