Do Condoms Work?
Primary Behavior Change
Do Condoms Work?
A Man2Man Alliance Policy Paper
With thanks to
Chuck Tarver and Dr. Edward C. Green
The Man2Man Alliance is opposed to mainstream HIV prevention strategies in the US and elsewhere which are known generically as "condom campaigns."
"Condom campaigns" take as a given that all men who have sex with men do so anally and promiscuously, and that the best one can do in preventing HIV infection among these men is to persuade them to use condoms "every time" they have sex.
Those who support "condom campaigns" are generally opposed to the other major form of HIV prevention, which is called "primary behavior change."
In programs which promote "primary behavior change," the most prominent of which is Uganda's ABC program, recently endorsed by the Bush administration's African AIDS Initiative, the focus is on changing sexual behavior by directing men and women away from high risk activities to those which carry little or no risk.
"Primary behavior change" strategies include encouraging a later or delayed age of onset of sexual activity -- usually referred to as "abstinence"; partner reduction -- usually referred to as "fidelity," "monogamy," or "be faithful"; and, the avoidance of anal sex.
In Uganda, where HIV prevalence has been reduced by 66%, the acronym used is ABCD, which stands for:
Be faithful / change Behavior;
use a Condom if you won't practice the first two; or
In the United States, frot activist and Alliance strategist Chuck Tarver has suggested that a useful version of ABCD for men who have sex with men (MSM) would read:
Avoid Anal sex;
use a Condom if you can't or won't do the first two; or
A number of recently published studies support our contention that:
1. anal sex is the most important vector for HIV transmission, with far higher rates of heterosexual anal transmission than previously believed;
2. the failure rate of condoms is unacceptably high;
3. Primary Behavior Change is a better strategy both because it's been proven successful in radically reducing HIV prevalence and because it has the potential to reduce risk to zero.
The data for heterosexual anal intercourse as a significant vector for HIV can be found in
Halperin, D. T. (1999). Heterosexual anal intercourse: prevalence, cultural factors, and HIV infection and other health risks, part I. AIDS Patient Care 13 (12): 717-730
The data for condom failure rates can be found in
Weller S, Davis, K. (2003) Condom effectiveness in reducing heterosexual HIV transmission. (Cochrane Review). In: The Cochrane Library
(see abstract below)
(Note that the article addresses vaginal sex and that the article defines failure as HIV infection, which occurs 20% of the time.
Anal sex is far rougher on a condom than vaginal sex, and it's reasonable therefore to assume that the failure rate -- that is, HIV infection rate -- is higher in anal sex.)
An overview of the Uganda experience can be found in
Green, E. C. (2003, March 1). A plan as simple as ABC. New York Times.
And a statistical analysis of the failure of condom campaigns can be found in
Richens, J., Imrie, J., & Weiss, H. (2003). Sex and death: why does HIV continue to spread when so many people know about the risks? J. of R. Statist Soc A 2003;166, 207-215.
"Condom campaigns" are destructive because
1. they re-inforce the idea among MSM that "every time" men have sex with men, it will be anal; and
2. they disinhibit -- by promoting a false sense of safety, they make it more likely that people will have more partners, be less selective about their partners, and choose to do anal sex, the single most dangerous sexual act, with those partners.
That's the reason for the finding, which seems counter-intuitive, that men who use condoms have a *higher* risk of HIV infection than those who don't:
Condom use is associated with a constellation of unsafe behaviors which effectively negate the condom's limited utility.
For those reasons, in HIV and other STD prevention programs, the Man2Man Alliance endorses "Primary Behavior Change," and supports Chuck Tarver's formulation of ABC -- Avoid Anal sex, Be faithful, use a Condom only if you must.
And of course the Alliance recommends that men who avoid anal choose Frot -- which is highly pleasurable, mutually genital, phallus-to-phallus sex, and very low risk.
July 25, 2003
Interested readers can find further discussion of these issues in terms of "risk reduction" (condom campaigns) and "risk avoidance" (primary behavior change) in the introductory section of our Media Watch page.
In addition, readers may wish to consult the entries under risk avoidance and risk reduction on our Definitions page.
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From The Cochrane Library, Issue 1, 2003. Oxford: Update Software Ltd. All rights reserved.
Condom effectiveness in reducing heterosexual HIV transmission (Cochrane Review) Weller S, Davis, K.
A substantive amendment to this systematic review was last made on 19 November 2001. Cochrane reviews are regularly checked and updated if necessary.
Background: The amount of protection that condoms provide for HIV and other sexually transmitted infections is unknown. Cohort studies of sexually active HIV serodiscordant couples with follow-up of the seronegative partner, provide a situation in which a seronegative partner has known exposure to the disease and disease incidence can be estimated. When some individuals use condoms and some do not, namely some individuals use condoms 100% of the time and some never use (0%) condoms, condom effectiveness can be estimated by comparing the two incidence rates. Condom effectiveness is the proportionate reduction in disease due to the use of condoms.
Objectives: The objective of this review is to estimate condom effectiveness in reducing heterosexual transmission of HIV.
Search strategy: Studies were located using electronic databases (AIDSLINE, CINAHL, Embase, and MEDLINE) and handsearched reference lists.
Selection criteria: For inclusion, studies had to have: (1) data concerning sexually active HIV serodiscordant heterosexual couples, (2) a longitudinal study design, (3) HIV status determined by serology, and (4) contain condom usage information on a cohort of always (100%) or never (0%) condom users.
Data collection and analysis: Studies identified through the above search strategy that met the inclusion criteria were reviewed for inclusion in the analysis. Sample sizes, number of seroconversions, and the person-years of disease-free exposure time were recorded for each cohort. If available, the direction of transmission in the cohort (male-to-female, female-to-male), date of study enrollment, source of infection in the index case, and the presence of other STDs was recorded. Duplicate reports on the same cohort and studies with incomplete or nonsepecific information were excluded. HIV incidence was estimated from the cohorts of "always" users and for the cohorts of "never" users. Effectiveness was estimated from these two incidence estimates.
Main results: Of the 4709 references that were initially identified, 14 were included in the final analysis. There were 13 cohorts of "always" users that yielded an homogeneous HIV incidence estimate of 1.14 [95% C.I.: .56, 2.04] per 100 person-years. There were 10 cohorts of "never" users that appeared to be heterogeneous. The studies with the longest follow-up time, consisting mainly of studies of partners of hemophiliac and transfusion patients, yielded an HIV incidence estimate of 5.75 [95% C.I.: 3.16, 9.66] per 100 person-years. Overall effectiveness, the proportionate reduction in HIV seroconversion with condom use, is approximately 80%.
Reviewers' conclusions: This review indicates that consistent use of condoms results in 80% reduction in HIV incidence. Consistent use is defined as using a condom for all acts of penetrative vaginal intercourse. Because the studies used in this review did not report on the "correctness" of use, namely whether condoms were used correctly and perfectly for each and every act of intercourse, effectiveness and not efficacy is estimated. Also, this estimate refers in general to the male condom and not specifically to the latex condom, since studies also tended not to specify the type of condom that was used. Thus, condom effectiveness is similar to, although lower than, that for contraception.
Citation: Weller S, Davis, K. Condom effectiveness in reducing heterosexual HIV transmission (Cochrane Review). In: The Cochrane Library, Issue 1 2003. Oxford: Update Software.
This is an abstract of a regularly updated, systematic review prepared and maintained by the Cochrane Collaboration. The full text of the review is available in The Cochrane Library (ISSN 1464-780X). The Cochrane Library is prepared and published by Update Software Ltd. All rights reserved.
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File Reference: AB003255