BMJ  2008;336:184 (26 January), doi:10.1136/bmj.39402.488727.AD

Head to Head

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

¹ Family Health International, Research Triangle Park, NC 27709, USA

Related article: doi: 10.1136/bmj.39402.527766.AD

Consistent condom use can reduce the spread of HIV, and Markus Steiner and Willard Cates believe condoms are the answer to other sexually transmitted infections. But Stephen Genuis argues that a more comprehensive approach is needed

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.¹

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,² 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.³ 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.³ 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.⁶

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,^{7 8} 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.⁹ In addition, a recent systematic review showed adding condom promotion to interventions focusing on abstinence does not undermine the abstinence message.¹⁰ 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.¹¹ Controlling the spread of infection will require different, mutually reinforcing techniques.

Although combined prevention strategies can greatly reduce the spread of sexually transmitted infections,¹² 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.¹³ Moreover, a full alphabet of prevention strategies is needed for an optimal effect on HIV transmission, as well as other sexually transmitted infections (box). 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.

A to Z of prevention strategies for HIV and other sexually transmitted infections A Abstinence B Be faithful C Use condoms D Don’t use drugs or share needles E Empower women in sexual decision making F Involve faith based organisations in HIV prevention programmes G Get treated if infected H Avoid high risk, high transmission environments I Promote safe injection J Join groups promoting HIV prevention policies K Know your infection status L Listen to peer educators M Make voluntary male circumcision more available N Get adequate nutrition to promote longer survival O Support orphans and vulnerable children P Implement perinatal HIV prevention programmes Q Improve quality of voluntary counselling and testing services R Reduce other sexually transmitted infections that facilitate HIV transmission S Fight stigma against people infected with HIV T Pursue topical microbicides U Use contraceptives to prevent unintended pregnancies in women who are HIV positive V Support vaccine research W Mobilise for political will X Examine interventions through evidence based reviews Y Engage youth in prevention programmes Z Advocate for comprehensive A to Z programmes

Related article: doi: 10.1136/bmj.39402.527766.AD

---

Competing interests: None declared.

References

1. Carey RF, Lytle CD, Cyr WH. Implications of laboratory tests of condom integrity. Sex Transm Dis 1999;26:216-20.[ISI][Medline]
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.[CrossRef][ISI][Medline]
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.[CrossRef][ISI][Medline]
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.[CrossRef][ISI][Medline]
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.[CrossRef][Medline]
11. Cates W Jr, Hinman AR. AIDS and absolutism—the demand for perfection in prevention. N Engl J Med 1992;327:492-4.[ISI][Medline]
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.[CrossRef][ISI][Medline]
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.[CrossRef][ISI][Medline]

Related Article

Are condoms the answer to rising rates of non-HIV sexually transmitted infection? No

Stephen J Genuis
BMJ 2008 336: 185. [Full Text] [PDF]

Rapid Responses:

Read all Rapid Responses

Condoms and circumcision

David B G Hawker
bmj.com, 25 Jan 2008 [Full text]

condoms not the answer

John Scotson
bmj.com, 25 Jan 2008 [Full text]

condoms not the only answer (& infant circumcision neither an answer, nor acceptable)

A.D. Fontain
bmj.com, 26 Jan 2008 [Full text]

A policy for populations versus one for individuals

Christopher M. Buttery
bmj.com, 27 Jan 2008 [Full text]

The risk left after risk reduction can remain high

JOKIN DE IRALA
bmj.com, 28 Jan 2008 [Full text]

Condoms help STI prevention and curbing teenage pregnancies

DAVID GWYNFOR SAMUEL
bmj.com, 29 Jan 2008 [Full text]

Condoms not "the only solution" to prevent Non HIV STDs

Manthan D. Janodia, et al.
bmj.com, 1 Feb 2008 [Full text]

Condom promotion hand in hand with sex education is the only answer

Teena Mathew
bmj.com, 4 Feb 2008 [Full text]

The impact of condoms depends on biological and behavioural context

Helen Ward, et al.
bmj.com, 4 Feb 2008 [Full text]

real world please

penelope a watson
bmj.com, 22 Feb 2008 [Full text]