Intended for healthcare professionals

Head To Head

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

BMJ 2008; 336 doi: (Published 24 January 2008) Cite this as: BMJ 2008;336:184

The risk left after risk reduction can remain high

I was pleased to read the “head to head” articles on whether condoms
are, or not, the answer for the prevention of sexually transmitted
infections, defended by Markus Steiner and Willard Cates on the “yes side”
and Stephen Genuis on the “no side”1. Pleased, because it was a nice
scientific discussion and “ideologically free”. I have some points to add
on the discussion. We need to be careful when relying on laboratory
studies such as Steiner and Cates argue when affirming that condoms are
effective barriers against “passage” of even the smallest sexually
transmitted pathogens. This is efficacy and obviously needs to be
addressed in the first place, but it is not the ultimate criteria to
evaluate condoms. In practice, the problems with condoms are not due to
“passage of pathogens”. They rather have to do with issues such as
breakage or slippage when the aroused young and inexperienced male
unexpectedly looses his erection, for example. Furthermore, condoms do not
cover all surfaces that can be infectious. A study by Winer in 2003 showed
that some women got infected with HPV without having had penetrative sex2.

The second issue I would like to address is the misinformation that can be
conveyed when affirming that condoms “reduce the risk” of an infection. It
is indeed important to reduce a risk but one has to understand the
magnitude of this risk reduction, and the magnitude of the remaining risk
thereafter, in order to make wise decisions. The 2006 study of Winer
indeed showed that condoms were effective to reduce risks because the risk
of infection decreased from 89% to 38% when comparing those that used
condoms consistently with those using them in less than 5% of their sexual
encounters3. But what these data also show is that condoms are not as
effective as we would want hem to be to “avoid” an infection because, in
spite of consistent use, 37% still became infected after one year, and
this is a very serious public health problem. Is it sound to inform an
adolescent girl not to worry because “condoms are good in reducing the
risk of HPV”, when one still has a 37% risk of infection in spite of
consistent condom use? I do not think so, and similar situations can be
observed with other infections that have no satisfactory treatment. Giving
these facts to youth is not “denigrating condoms”, this is simply giving
them the facts. Hiding these facts would conversely be discriminatory to
the large youth population that is not having sex and that would benefit
with clear messages that help them maintain their risk avoidance choice.

And those that decide to have sex need to know this truth as well because
it is their health that is at sake after all. Abstinence can be more or
less difficult depending on what society chooses to promote but youth have
the right and responsibility to face and respond to their own difficulties
in life and make their own informed choices. Many crucial behavior changes
can be difficult. Millions of young people around the world have made the
difficult choice of abstaining. Thirdly, the information on condoms do not
undermine abstinence programs when interventions are indeed “abstinence
centered”4. However when condoms and abstinence are presented as equally
valid choices for youth without sexual experience, risk compensation is an
obvious possible outcome5. Yes, we should feel relieved if a program does
not increase risk taking. However, a good program should go beyond and
achieve a decrease in risk taking.
Both the yes and the no sides seemed to agree that messages have to be
tailored to specific target populations. This is what was basically
endorsed in the consensus published in The Lancet that called for the
promotion of sexual delay and mutual monogamy among youth and sexually
active adults respectively, and condom use to those who freely chose not
to accept risk avoidance6.

But a recent Lancet editorial on this same issue has very much
disappointed me7. I am surprised to see a scientific journal such as The
Lancet taking such unscientific and partisan stances. It is not the first
time this journal uses editorials to convey a certain anti pope agenda. In
“The Pope and science” they state that Pope Benedict XVI was forced to
cancel a speech at La Sapienza University in Rome “because of his past
defense of the Church’s 1663 heresy trial of Galileo”. The editorial then
goes “guestimating” the number of Catholics that are against the Church’s
teachings and uses terms such as “conservative” or “progressive” Catholics
to finish up giving the impression that the Pope is alone with his
teaching on abortion or condom use. The Pope has never ever defended
Galileo’s trial, The Lancet has simply misquoted him because it seems they
have unfortunately not read his original speech where this issue was
brought up. The cancellation of La Sapienza was due to the “democratic”
protest of 67 out of the 4.500 professors of that university. Two hundred
thousand persons gathered at Saint Peter’s place on the Sunday after this
event to show their Papal support. The Church has its views on condom use
and has a specific teaching on sexuality that one is free to accept or
not. Scientific journals have nothing to say on this personal choice. But
studies have showed that the only countries that have really been able to
curb the HIV epidemic are those that have seriously implemented A and B
instead of relying solely on condom promotion8. Furthermore, the church
has been promoting A and B along centuries and instead of concentrating on
trying to change its teachings on sexuality and condom use, we could
rather learn and benefit more from church experience fostering sexual
delay and mutual monogamy among youth.

Jokin de Irala MD, PhD

Professor of Epidemiology,
University of Navarre

1 Steiner MJ, Cates W. “yes” and Genuis S “no”. Are condoms the
answer to rising rates of non-HIV sexually transmitted infections? BMJ

2 Winer RL, Lee SK, Hughes JP, Adam DE, Kiviat NB, Koutsky LA. Genital
human papillomavirus infection: incidence and risk factors in a cohort of
female university students. Am J Epidemiol 2003; 157: 218-26.

3 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.

4 Cabezon C, Vigil P, Rojas I, Leiva ME, Riquelme R, Aranda W, Garcia C.
Adolescent pregnancy prevention: An abstinence-centered randomized
controlled intervention in a Chilean public high school. J Adolesc Health.

5 de Irala J, Alonso A. Changes in sexual behaviours to prevent HIV: the
need for comprehensive information. Lancet 2006; 368:1749-1750

6 Haleprin D, Steiner M, Cassel M, Green E, Hearts N, Kirby D, et al. The
time has come for common ground on preventing sexual transmission of HIV.
Lancet 2004; 364: 1913-1915.

7 Editorial. The Pope and science. The Lancet 2008;371:276

8 Hearst N, Chen S. Condom promotion for AIDS prevention in the
developing world: is it working? Stud Fam Plann 2004; 35: 39-47.

Competing interests:
None declared

Competing interests: No competing interests

28 January 2008
Professor Epidemiology
University of Navarre