HIV or the infection by the virus of human immunodefciency which is responsible for the acquired immunity syndrome or "AIDS" has challenged modern medicine, health and public hygiene services since 1981. To prevent the transmission of HIV and most particularly its sexual transmission is essential.
HIV or the infection by the virus of human immunodefciency which is responsible for the acquired immunity syndrome or "AIDS" has challenged modern medicine, health and public hygiene services since 1981. To prevent the transmission of HIV and most particularly its sexual transmission is essential.
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HIV or the infection by the virus of human immunodefciency which is responsible for the acquired immunity syndrome or "AIDS" has challenged modern medicine, health and public hygiene services since 1981. To prevent the transmission of HIV and most particularly its sexual transmission is essential.
Direitos autorais:
Attribution Non-Commercial (BY-NC)
Formatos disponíveis
Baixe no formato PDF, TXT ou leia online no Scribd
of human immunodefciency which is responsible for the acquired immu- nodefciency syndrome or AIDS has challenged modern medicine, health and public hygiene services, and in- ternational organizations since 1981. No truly curative vaccination or the- rapy has been found until now. To prevent the transmission of HIV and most particularly its sexual transmis- sion is therefore essential. Twenty years ago a term was crea- ted in California and New York the hotbed of HIV/AIDS - to designate the best method against contamina- tion by HIV during sexual activity: namely safe sex. 1 It later was called 1 R. Stall, L.McKusick, J. Wiley, T.J. Coates, D.G. Ostrow, Alcohol and drug use during sexual activity and compliance with safe sexe guidelines for AIDS: the AIDS Behavioral Research Project, Health Education Quaterly, Winter 1986, vol. 13, n4, pp. 359-371; J.J. Goedert, What is Safe Sex? Suggested Standards Linked to Testing for Human Immunodefciency Virus, Te New England Journal of Medicine, May 21 1987, vol. 316, n21, pp. 1339-1342; S. Kippax, J. Crawford, M. Davis, P. Rodden, G. Dowsett, Sustaining safe sex: a longitudinal study of a sample of homosexual men, AIDS, February 1993, vol.7, n2, pp. 257-263; Safe sex triumphs, New Scientist, 27 June 1998, vol.158, n2140, p.23; A.Troth, C.C. Peterson, Factors predicting safe-sex talk and condom use in early sexual relationships, Health Communication, 2000, vol. 12, n2, pp. 195-218; A. Mitchell, A. Smith, Safe sex messages for adolescents. Do they work?, Safe Sex
Jacques Suaudeau Te Media hype concerning safe sex or sex without risk conceals some recognized scien- tifc evidence. In the best of hypotheses the reliability of the condom is so low that the risk of contamination is estimated by some authors to be around 10 %. Tis is even acknowledged by journals which regularly publish tests comparing the resistance, the impermeability and the reliability of condoms. Behind the promotion of condoms which further a false sense of sexual security they are supposed to ofer, fnancial interests are concealed. Encouraging hetero- and homosexual use of the condom, because of its high failure rate, increases in reality the probability of an infection. Tere remains, however, the well-known position of the Church contradicting this trend for moral reasons. ( Sexual and Reproductive Rights; Sex Education; Sexual Identity and Diference; New Paradigm of Health Care; Homosexuality and Homophobia; Reproductive Health) S 856 SAFE SEx more modestly safer sex 2 . Tis expres- Australian Family Physician, January 2000, vol. 29, n1, pp. 31-34; M. Berer, Safe sex, womens reproductive rights and the need for a feminist movement in the 21 st century, Reproductive Health Matters, May 2000, vol. 8, n15, pp. 7- 11; C. White, Government announces safe sex campaign for England, British Medical Journal, 4 August 2001, vol. 323, n3707, p. 250; J. Stephenson, Evaluating Safe Sex Eforts, JAMA, July 11 2001, vol. 286, n2, p. 159. 2 M.L. Ekstrand, Safer sex maintenance among gay men: are we making progress?, AIDS, August 1992, vol. 6, n8, pp. 875-877; A.A. Ehrhardt, Trends in Sexual Behavior and the HIV Pandemic, American Journal of Public Health, November 1992, vol. 82, n11, pp. 1459-1461, see p. 1460; S. Katz Miller, How to sell safer sex, New Scientist, 27 February 1993, vol. 137, n1862, pp. 12-13; A. Messiah, D. Bucquet, J.-F. Mettetal, B. Larroque, Chr. Rouzioux, and the Alain Brugeat physician group, Factors Correlated With Homosexually Acquired Human Immunodefciency Virus Infection in the Era of Safer Sex. Was the Prevention Message Clear and Well Understood?, Sexually Transmitted diseases, January/February 1993, vol. 20, n1, pp. 51-59; P. Aggleton, K. OReilly, G.Slutkin, P. Davies, Risking Everything? Risk Behavior, Behavior Change, and AIDS, Science, 15 July 1994, vol. 265, n 5170, pp. 341-345, see p. 344; M. Larkin, Easing the way to safer sex, Te Lancet, March 28 1998, vol. 351, n9107, p. 964; J.B. Jemmott III, L.S. Jemott, G.T. Fong, Abstinence and Safer Sex HIV Risk-Reduction Interventions for African American Adolescents. A. Randomized Controlled Trial, JAMA, May 20 1998, vol. 279, n19, pp. 1529-1536; K.L. Parish, D. Cotton, H.C. Huszti, J.T. Parsons, Hemophilia Behavioral Intervention Study Group, Safer sex decisions-making among men with haemophilia and their female partners, Haemophilia, January 2001, vol. 7, n1, pp. 72- 81; L.A. Shrier, R. Ancheta, E. Goodman, V.M. sion refers to all precautionary measu- res taken to diminish the risk of trans- mitting or acquiring a sexually trans- mitted disease (such as HIV/AIDS) in the course of sexual activity 3 . Safer sex therefore demands prudence in the choice of ones partners and in the fre- quency of sexual activity, as well as the constant use of the condom. Te latter presupposes high conf- dence in the efcacy of the condom. Te manner in which militant activists, public authorities, the media and publicity have presented the condom and still do, seems to indicate that it is almost completely fool-proof. Te protection of the obe- lisk of the Place de la Concorde in Paris by a condom in the presence of all of Paris as the culminating point of a fervent campaign in favor of the condom in 1994 has, as D. Folscheid says heightened its image to a mystical level 4 . To dare to ask the least question, to raise the smallest objection, meant that one had an impious soul and the putrid mouth of the icono- clast, explains Folscheid. Te massive, undisputed and undis- putable promotion of the condom re- lies on one argument: namely that this Chiou, M.R. Lyden, Randomized Controlled Trial of as Safer Sex Intervention for High-risk Adolescent Medicine, January 2001, vol. 155, n 1, pp. 73-79. 3 MEDLINE plus Health Information, MEDLINE Medical Encyclopedia, Safer sex behaviors. 4 D. Folscheid, Billet dhumeur. Faut-il se prserver de la condomania?, Ethique, La Vie en Question 857 SAFE SEx latex shell is at present the only means available to health services to prevent the sexual transmission of the AIDS vi- rus and its difusion. However, since the beginning of the AIDS/HIV epidemic and until today numerous authors have often stressed the fact thatas statistics show - this device is far from deserving this confdence. 5 Considering that the safe sex policy has not caught up with the epidemic in countries where it has been promoted for 20 years and that it is proposed to countries where the epi- 5 B. Voeller, M.Potts, letter, British Medical Journal, 26 October 1985, vol. 291, n6503, p. 1196; J.A. Kelly, J.S. StLawrence, Cautions about condoms in prevention of AIDS, Te Lancet, February 7 1987, vol. 1, n8258, p. 323; P.S. Gtzsche, M. Hrding, Condoms to Prevent HIV Transmission Do Not Imply Truly Safe Sex, Scandinavian Journal of Infectious Diseases, 1988, vol. 20, n2, pp. 233-234; R. Kirkman, Condom use and failure, Te Lancet, Saturday 20 October 1990, vol. 336, n8721, p. 1009; J.T. Vessey, D.B. Larson, J.S. Lyons, J.L. Rogers, K.I. Howard, Condom Safety and HIV, Sexually Transmitted Diseases, January-February 1994, vol. 21, n1, pp. 59-60; H. Lestradet, Rfexions sur le SIDA et sa prevention, Mdecine de lhomme, Mai-Aot 1994. n211/212, pp.3-6; S.H. Vermund, Editorial: Casual sex and HIV Transmission, American Journal of Public Health, November 1995, vol. 85, n11, pp. 1488-1489; R. Kss, H. Lestradet, SIDA: communication, information et prevention, in Le SIDA, propagation et prevention, Rapports de la commission VII de lAcadmie Nationale de Mdecine, Editions de Paris, 1996, pp. 12-55; J. Kelly, Using condoms to prevent transmission of HIV. Condoms have an appreciable failure rate, British Medical Journal, 8 June 1996, vol. 312, n7044, p. 1478. demic is in full expansion, it seems jus- tifed to adopt a critical approach regar- ding its value for HIV prevention. In view of this we will frst examine the physical and mechanical qualities of the condom such as they appear in the laboratory and in practice. Ten we will look at the results of employing the condom as contraceptive barrier or as prophylactic. We will end by examining the performance of the condom in pre- venting sexual contamination by HIV. I THE PHYSICAL AND MECHANICAL QUALITIES OF CONDOMS For a long time condoms have been suspected of having a certain percentage of micro-defects which would explain their failures in the area of contraception. One then tried to verify this hypothesis through studies using an electron micros- cope as well as through passage tests of micro particles. 1. Electron Microscope Studies Te few studies of latex membranes using the electron microscope that have been published raise some questions. Te suspicion that certain pores may subsist in the membranes after an im- perfect coalescence of the latex particles during vulcanization has been reinfor- ced by observations made on chirurgical latex gloves by S.G. Arnold and associa- tes (1988) 6 . Tese authors found that 6 S.G. Arnold, J.E. Whitman Jr., C.H. Fox, M.H. Cottler-Fox, Latex gloves not enough 858 SAFE SEx all examined gloves originating from four diferent manufacturers presented hollow parts of 3-15m in width and of up to 30 m in depth; this was the case along the exterior and internal surface of the glove. Te test made on the edge of these membranes (broken by free- zing) showed the presence of cavities and winding fssures (5m) covering the entire thickness of the glove. Irregularities of such importance concerning the surface and thickness of the latex membrane have not been signaled in the few available studies on condoms. Tese studies simply show that the surface of the condoms mem- branes is not uniform: one fnds areas with a soft profle separated by folded areas; furthermore the surface of the specimen seems dotted with hollow parts 7 . Other studies mention a general irregularity of the surface of the mem- brane, with irregular caulifower-like projections, and dense and irregular inclusions, yet without any evidence of rupture or of holes. 8 Rosenzweig and to exclude viruses, Nature, 1 September 1988, vol.335, n6185, p.19. 7 G.D. Jay, F. Drummond, B.Lane, Altered Surface Character of Stretched Condom Latex, Contraception, February 1992, vol.45, n2, pp.105-110. 8 L.S. Kish, J.T. McMahon, W.F. Bergfeld, J.M. Pelachyk, An ancient method and a modern scourge: the condom as a barrier against herpes, Journal of the American Academy of Dermatology, November 1983, vol.9, n.5, pp.769-770. associates (1997) 9 examined thirty sam- ples of membranes coming from ffteen Trojan condoms, none of which were lubricated. Tey found in fact that a great proportion of these samples pre- sented visible anomalies on the surface, and that only 30% of the condoms tes- ted were absolutely faultless. 50% of the samples showed anomalies on the sur- face of the membrane, fssures (10%), pleating (37%), as well as pleating and hollowness (38%). 2. In Vitro Studies concerning Re- sistance and Permeability Te integrity of latex condoms is tes- ted by means of a leak test. But the ac- curacy of this test is not very high. It de- tects holes of a diameter of 20 microns 10 . However, for the HIV virus any hole big- ger than 0,10 would have to be consi- dered a possible cause for leakage and the passage of the virus. Te limited accuracy of this test means that the defects in the condoms membranes are signifcant. In 1977 Dr. Barlow 11 had made the hypothesis that some pores exist in la- tex membrane condoms which explains 9 B.A Rozenzweig, A. Even, L.E. Budnick, Observations of Scanning Electron Microscopy Detected Abnormalities of Non-lubricated Latex Condoms, Contraception, January 1996, vol. 53, n.1, pp.49-53. 10 R.F. Carey, D. Lytle, W.H. Cyr, Implications of Laboratory Tests of Condom Integrity, Sexually Transmitted Diseases, April 1999, vol. 26, pp. 216-220. 11 D. Barlow, Te Condom and Gonorrhea, Te Lancet, October 15 1977, vol.II, n.8042, pp.812-812, seep.812. 859 SAFE SEx why they apparently do not protect against non-gonococcal urethritis and genital condylomata acuminata infec- tions. Tis hypothesis was highly dispu- ted. Diferent in vitro laboratory studies contradicted it by showing that the la- tex membranes efciently stopped the agents of sexually transmitted diseases (STD) 12 such as: Neisseria gonorrhoea, simplex herpes type 2 virus 13 , cytome- galovirus 14 , Hepatitis B virus 15 , Chlamy- 12 Center for Disease Control, Center for Infectious Diseases, Condoms for Prevention of Sexually Transmitted Diseases, JAMA, April 1 1988, vol.259, n.13, pp.1925-1927; F.N. Judson, J.M.Ehret, G.F. Bodin, M.J. Levin, C.A. Rietmeijer, In Vitro Evaluations of Condoms with and without Nonoxynol 9 as Physical and Chemical Barriers Against Chlamydia Trachomatis, Herpes Simplex virus type 2, and Human Immunodefciency Virus, Sexually Transmitted Diseases, April-June 1989, vol. 16, n.2, pp.51-56; L. Smith Jr., J. Oleske, R. Cooper, et al., Efcacy of Condoms as barriers to HSV-2 and gonorrhea; an in vitro model (Abstract 77), In Program and Abstracts of the frst Sexually Transmitted Diseases World Congress, San Juan, Puerto Rico, November 15-21 1981. 13 M.A. Conant, D.W. Spicer, C.D. Smith, Herpes Simplex Virus Transmission: Condom Studies, Sexually Transmitted Diseases, April- June 1984, vol. 11, n.2, pp.94-95. 14 S. Katznelson, W. Lawrence Drew, L.Mintz, Efcacy of the Condom as a Barrier to the Transmission of Cytomegalovirus, Te Journal of Infectious Diseases, July 1994, vol. 150, n.1, pp.155-157. 15 G.Y. Minuk, C.E. Bohme, T.J. Bowen, Condoms and Hepatitis B Virus Infection, Annals of Internal Medicine, April 1986, vol. 104, n.4, p.584; G.Y. Minuk, C.E. Bohme, T.J. Bowen, D.I. Hoar, S.Cassol, M.J. Gill, dia trachomatis 16 , and retroviruses such as HIV and HIV itself 17 . However, these reassuring results have been questioned: for just a few studies were done, these were limited to a few tests and performed without submitting the membrane to pressure or traction. For S.C. Weller 18 they are not statistically signifcant. More re- cent studies made with microspheres have, in efect, put in doubt the vali- H. de C. Clarke, Efcacy of Commercial Condoms in the Prevention of Hepatitis B Virus Infection, Gastroenterology, October 1987, vol. 93, n.4, pp.710-714. 16 F.N. Judson, G.F. Bodin, M.J. Levin, J.M. Ehret, H.B. Masters, In Vitro tests demonstrate condoms provide an efective barrier against Chlamydia trachomatis and herpes simplex virus (Abstract 176) In: Program and abstracts of the ffth international meeting of the International Society for STD Research, Seattle, Washington, August 1-3 1983; F.M. Judson, J.M. Ehret, G.F Bodin, M.J. Levin, C.A. Rietmeijer, In vitro evaluations of condoms with and without Nonxynol 9 as physical and chemical barriers against Chlamydia Trachomatis, Herpes Simplex virus type 2, and Human Immunodefciency Virus, op. cit. 17 M. Conant, D. Hardy, J. Sernatinger, D. Spicer, J.A. Levy, Condoms Prevent Transmission of AIDS-Associated Retrovirus, JAMA, April 4 1986, vol.255, n.13, p.1706; C.A.M. Rietmeijer, J.W. Krebs, P.M. Feorino, F.N. Judson, Condoms as Physical Chemical Barrier Against Human Immunodefciency Virus, JAMA, March 25 1988. vol.259, n.12, pp.1851-1853. 18 S.C. Keller, A meta-analysis of condom efectiveness in reducing sexually transmitted HIV. Social Science Medicine, June 1993, vol.36, n.12, pp.1635-1644, see p.1635. 860 SAFE SEx dity of these in vitro tests. During the Vth International Conference on AIDS in Montreal it was frst reported that well tested condoms, issued by known manu- facturers, had been permeable to micros- pheres of bigger size than that of HIV (6 condoms out of 69)(1989) 19 . Carey and associates (1992) 20 observed the passage of polystyrene microspheres of 110nm in diameter (therefore similar to the size of HIV which is between 90nm and 130nm) through 33% of the analyzed latex condom membranes (29 out of 80 latex non lubricated condoms). More re- cently, C.D. Lytle and associates (1997) 21
found that 2.6% (12 out of 470) of latex condoms they used permitted the passage of a virus, whether they were lubricated or non lubricated condoms. In consequence these results allow for some doubts concerning the capaci- ty of condoms to stop HIV for certain. HIV measures between 90 to 120 nm, 19 B.A. Hermann, S.M. Retta, I.E. Rinaldi, A simulated physiologic test of latex condoms, Vth Internat. Conf. on AIDS, 1989, Abstracts WAP 101. 20 R.F. Carey, W.A. Herman, S.M. Retta, J.E. Rinaldi, B.A. Herman, T.W. Athey, Efectiveness of Latex Condoms as Barrier to Human Immunodefciency Virus-sized Particles Under Conditions of Simulated Use, Sexually Transmitted Diseases, July-August 1992, vol.19, pp.230-234. 21 C.D. Lytle, L.B. Rouston, G.B. Seaborn, L.G. Dixon, H.F. Bushar, W.H. Cyr, An in vitro Evaluation of Condoms as Barriers to Small Virus, Sexually Transmitted Diseases, March 1997, vol 24, n.3, pp.161-164. approximately 0,1 micron 22 . It is 60 ti- mes smaller than the syphilis bacteria, and 450 times smaller than spermato- zoa. If microspheres of a 120nm diame- ter can pass through the membranes of some latex condoms which had, howe- ver, been found sufcient in the leak tests, it would therefore not be surpri- sing for HIV to pass through these same membranes during mechanical disten- sioneven if there is no actual hole in the membrane. 3. Te Degradation of Latex Another reason for the failure of condoms is due to the degradation of the latex, leading to leaks or ruptures of the membrane. In fact latex deteriorates with time, loses its fexibility and beco- mes more fragile. Tis deterioration is accelerated through exposition to the sun, to heat and humidity (M.J. Free and associates, 1986; M.F. Goldsmith, 1987; M. Steiner and associates, 1992; J. Kettering, 1993; M.J. Free and as- sociates, 1996). 23 Less known perhaps 22 R.C. Gallo, S.Z. Salahuddin, M. Popovic, G.M. Shearer, M. Kaplan, B.F. Haynes, T.J. Palker, R. Redfeld, J. Oleske, B. Safai, G. White, P. Foster, Ph.D.Markham, Frequent Detection and Isolation of Cytopathic Retroviruses (HTLV-III) from Patients with AIDS and at Risk for AIDS, Science, 4 May 1984, vol.224, n4648, pp.500-503, see p. 502; J.P. Cassuto, A. Pesce, J.F. Quaranta, AIDS and HIV Infection, Masson, 2ed., Paris, 1992, p.27. 23 M.J. Free, J. Hutchings, S. Lubis, An assessment of burst strength distribution data from monitoring quality of condom stocks in developing countries, Contraception, March 861 SAFE SEx is its degradation due to atmospheric ozone: the prolonged exposition of la- tex condoms to partial ozone pressure identical to the one found in fog brings up in electronic microscopy the appari- tion of images reminiscent of the ho- les described elsewhere on latex gloves and natural membrane condoms (R.F. Baker and associates, 1988; L.J. Clark and associates, 1989) 24 . 4. Te Possibility of Rupture and Slip- page In Vivo (Table 1) Most of the condoms failures are due to its breaking or slipping of du- ring use. Diferent studies have found 1986, vol.33, n3, pp.285-299; M.F. Goldsmith, Some Advice on Using Condoms Against STDs: What Every Man (and Woman) Should Know, JAMA, May 1 1987, vol. 257, n17, p.2266; M. Steiner, R. Foldesy, D.Cole, E. Carter, Study to determine the correlation between condom breakage in human use and laboratory test results, Contraception, September 1992, vol.46, n3, pp.279-288; J. Kettering, Efcacy of thermoplastic elastomer and latex condoms as viral barriers, Contraception, June 1993, vol.47, n6, pp. 559-567; M.J. Free, V. Srisamang, J. Vail, D. Mercer, R. Kotz, D.E. Marlowe, Latex Rubber Condoms: Predicting and Extending Shelf Life, Contraception, April 1996, vol.53, n4, pp.221-229. 24 R.F. Baker, R.P. Sherwin, G.S. Bernstein, R.M. Nakamura, Precautions When Lightning Strikes During the Monsoon: Te Efect of Ozone on Condoms, Journal of American Medical Association, September 9 1988, vol.260, n10, pp.1404-1405; L.J. Clark, R.P. Sherwin, R.F. Baker, Latex condom deterioration accelerated by environmental factors: I Ozone, Contraception, March 1989, vol.39, n3, pp.245-251. that the rate of ruptures is between 1% and 13%, with an average of 5%. 25
25 P.C. Gtzche, M. Hrding, Condoms to Prevent HIV Transmission Do Not Imply Truly Safe Sex. Scandinavian Journal of Infectious Diseases, 1988, vol.20, n2, pp.233-234; C. Sonnex, G.J. Hart, P. Williams, M.W. Adler, Condom use by heterosexuals attending a department of GUM: attitudes and behaviors in the light of HIV infection, Genitourinary Medicine, August 1989, vol.65, n4, p.248-251; T. Karlsmark, E. Segest, J. Grinsted, H. Bay, AIDS prevention: free condoms from an STD clinic in Copenhagen, Letter, Genitourinary Medicine, June 1989, vol.65, n3, p.196; G. Ahmed, E.C. Liner, N.E. Williamson, W.P. Shellstade, Characteristics of condom use and associated problems: experience in Bangladesh, Contraception, November 1990, vol.42, n5, pp.523-533; P. Russel-Brown, C. Piedrahita, R. Foldesy, M. Steiner, J. Townsend, Comparison of condom breakage during human use with performance in laboratory testing, Contraception, May 1992, vol.45, n5, pp.429-437; E.A. Wright, M.M. Kapu, I. Wada, Use of condoms as contraceptive and diseases preventive measures among residents of Jos, Northern Nigeria, Contraception, December 1990, vol.42, n6, pp.621-627; C. Lindan, S. Kegeles, N. Hearst, P. Grant, D. Johnson, G. Bolan, G.W. Rutherford, California Dept. of Health Svcs, Div. of Sexually Transmitted Diseases and HIV prevention, CDC, Heterosexual Behaviors and Factors that Infuence Condom Use Among Patients Attending a Sexually Transmitted Disease Clinic San Francisco, Center for Disease Control, Morbidity and Mortality Weekly Report, October 5 1990, vol.39, n39, pp.685-689; R. Kirkman, Condom use and failure, Te Lancet, 20 October 1990, vol.336, n8721, p.1009; A.E. Albert, R.A. Hatcher, W. Graves, Condom use and breakage among women in a municipal hospital family planning clinic, Contraception, February 1991, vol.43, n2, pp.167-176; 862 SAFE SEx TABLE I: INCIDENCE OF RUPTURE AND SLIPPAGE OF CONDOMS IN THE GENERAL POPULACE Rupture Slippage Type of Sexual Relationship Type and Num- ber of Subjects Place of Study rate %users* rate %users* P.C. Gatzsche et al. (1988) 5% - - - Vaginal 46 persons (30 prostitutes) Rigshospitalet, Copenhagen, Denmark C. Sonnex et al. (1989) - 40% - - Heterosex 222 men and women Genitourinary Med- icine, London T. Karlsmark et al. (1989) - 75% - - Heterosex 47 men and women Rigshospitalet, Copenhagen G. Ahmad et al. (1990) 3.1% 5.1% 30%w 43%m - - - 4915 men and women Bangladesh Russell-Brown et al. (1992) 12.9% 74% - - - 50 men Pop. Council, Bar- bados Russell-Brown et al. (1992) 10.1% 44% - - - 50 men Pop. Council, Santa Lucia Russell-Brown et al. (1992) 6.7% 35% 50 men Pop. Council North Carolina E. A. Wright et al. (1990) 11.9% - 10.7% - - 168 men Family Planning Clinic, Jos, Nigeria C. Lindan et. al. (1990) 4.2%-4.3% 27%m 31%w - - vaginal or anal intercourse 162 men 179 women STD Clinic, San Francisco R. Kirkman (1990) - 52% - 52 - - Family Planning Clinic, Manchester, U.K. A.E. Albert (1991) 1% 36% - - Heterosexual 106 women Family Planning Clinic, Atlanta, USA C. Chan Chee et al. (1991) 4.5% - - Homobisexual 46 men EuroHIV, Paris 1.5% Heterosexual 145m, 63w 0.6% - 7 prostitutes J. Trussell et al.(1992) 7.9% - 7.2% - - 405 condoms Ofce of Pop. Res. Princeton Univ. M. Steiner et al.(1992) 3.5% 262 voluntary participants Family Health In- ternational, US H.S. Weinstock et al (1993) 4.2%- 4.3% 29% - - vaginal and anal 136 men 164 women STD Clinic, San Francisco, USA S. Tovey ? et al. (199?) - 22% - 48 - 281 men Genitourinary Medicine, South London J. Richters et al. (1993) 7.3% - 4.4% - - 544 men Consult. MST, Sydney, Australia M.J. Sparrow et al. 5.6% 40.2 6.5% 40.2% - 540 consultants Family Planning Clinic, New Zea- land M. Gabbey et al. (1996) - 66% - 66 - 481 students 64% w Manchester Health Centre, U.K.
Rate: rate of condom ruptures per sexual relations (number of condoms broken per 100 relations) * % users: percentage of users having noticed at least one condom breakage during the time of the study 863 SAFE SEx The risk of rupture or slippage diminishes with practice (couples using the condom as a contraceptive during long periods: 1,46% for Trus- sell and associates, 1992, 1,04% for Rosenberg and associates, 1977), 26 or Chr. Chan-Chee, I. De Vincenzi, M-A Sole- Pla, R. Ancelle-Park, J.-B. Brunet, Use and misuse of condoms, Genitourinary Medicine, April 1991, vol.67, n2, p.173; J. Trussel, D.L. Warner, R.A. Hatcher, Condom slippage and breakage rates, Family Planning Perspectives, January-February 1992, vol.24, n1, pp.20-23; M. Steiner, R. Foldesy, D. Cole, E. Carter, Study to determine the correlation between condom breakage in human use and laboratory test results, Contraception, September 1992, vol.46, n3, pp.279-288; H.S. Weinstock, Chr. Lindan, , G. Bolan, S.M. Kegeles, N. Hearst, Factors Associated with Condom Use in a High-Risk Heterosexual Population, Sexually Transmitted Diseases, January-February 1993, vol.20, n1, pp.14-20; S.J. Tovey, Chr. P. Bonell, Condoms: a wider range needed, British Medical Journal, 16 October 1993, vol.307, n6910, p.987; J. Richters, B. Donovan, J. Gerof, How often do condoms break or slip of in use?, International Journal of STD and AIDS, March-April 1993, vol.4, n2, pp. 90-94 ; M.J. Sparrow, K. Lavill, Breakage and slippage of condoms in family planning clients, Contraception, August 1994, vol. 50, n2, pp. 117-129; M. Gabbay, A. Gibbs, Does Additional Lubrication Reduce Condom Failure?, Contraception, vol. 53, n3, March 1996, pp. 155-158. 26 J. Trussel, D.L. Warner, R. Hatcher, Condom performance during vaginal intercourse: Comparison of Trojan-Enzand Tactylon condoms, Contraception, January 1992, vol. 45, n1, pp. 11-19; J. Trussell, D.L. Warner, R.A. Hatcher, Condom slippage and breakage rates, Family Planning Perspectives, January/February 1992, vol. 24, professional practice (prostitution: 0,5% for Richters and associates in Australia, 1988; 0% for A.E.Albert and associates in Nevada, 1995; 0,5% for C.Chang-Chee and associates in Paris, 1991 27 ). Te risk of rupturing the condom appears to be particularly high in ho- mosexual relations. A. Messiah and associates (1993) 28 have observed that the rate of condom rupture in this group goes from 4.5% to 7.3% and even as high as 22%. Te failure rate of the condom during homosexual ac- tivity is on average 5% (0% to 22%) n1, pp. 20-23; M.J. Rosenberg, M.S. Waugh, Latex Condom Breakage and Slippage in a Controlled Clinical Trial, Contraception, July 1997, vol.56, n1, pp. 17-21. 27 J. Richters, B. Donovan, J. Gerof, L. Watson, Low Condom Breakage Rate in Commercial Sex, Te Lancet, December 24/31 1988, vol. II, n8626-8627, pp. 1487-1488; A.E. Albert, D.I. Warner, R.A. Hatcher, J. Trussell, Ch. Bennett, Condom use among Female Commercial Sex Workers in Nevadas Legal Brothels, American Journal of Public Health, November 1995, vol. 85, n11, pp. 1514-1520. See in particular table 2.; Chr. Chan-Chee, I. De Vicenzi, M-A. Sole-Pla, R. Ancelle-Park, J.-B. Brunet, Use and misuse of condoms, Genitourinary Medicine, April 1991, vol. 67, n2, p.173. 28 A. Messiah, D. Bucquet, J.-F. Meitetal, B. Larroque, Chr. Rouzioux, and the Alain Brugeat physician group, Factors Correlated With Homosexually Acquired Human Immunodefciency Virus Infection in the Era of Safer Sex. Was the Prevention Message Clear and Well Understood?, Sexually Transmitted diseases, January/February 1993, vol. 20, n1, pp.51-59, see p. 57. 864 SAFE SEx and the rate of slippage is on average 6% (0% to 15%) (Table II) 29 . II THE PERFORMANCE OF THE CONDOM WHEN USED AS A CONTRACEPTIVE AND AS A PROPHYLACTIC 1. Te Performance of the Condom when Used as a Contraceptive Te Pearl index concerning the condom when used as barrier contra- ceptive (i.e. the number of pregnancies among 100 women using this form of contraception for 1 year, based on the theoretical possibility that a woman could conceive 12 times every year) is relatively high, between 8 and 15 (in extreme cases going up to 28). 30 Te 29 K. Wellings, AIDS and the Condom, British Medical Journal, 15 November 1986, vol.293, n6557, pp. 1259-1260, see p.1259; W. Ross, Problems associated with condom use in heterosexual men, American Journal of Public Health, July 1987, vol.77, n7, 1987, p.877; J. Richters, B. Donovan, J. Gerof, How often do condoms break or slip of in use?, International Journal of Sexually Transmitted Diseases and AIDS, March/April 1993, vol.4, n2, pp.90-94. 30 D.M. Potts, G.I.M. Swyer, Efectiveness and risks of birth-control methods, British Medical Bulletin, January 19 1970, vol.26, n1, pp.26-32, see Table III, p.29; W.R. Grady, M.D. Hayward, J. Yaagi, Contraceptive Failure in the United States: Estimates from 1982 National Survey of Family Growth, Family Planning Perspectives, September/October 1986, vol.18, n5, pp.200-209; E.F. Jones, J.D. Forrest, Contraceptive Failure in the United States: failure rate of the condom used for the prevention of pregnancy (defned as the probability of pregnancy during one year for a woman using the condom as sole means of contraception) is situa- ted around 15%. 31 After examining the Revised Estimates from the 1982 National survey of Family Growth, Family Planning Perspectives, May/June 1989, vol.21, n3, pp.103-107; E.F. Jones, J.D. Forrest, Contraceptive Failure Rates Based on the 1988 NSFG, Family Planning Perspectives, January/February 1992, vol.24, n1, pp.12-19; S. Jejeebhoy, Measuring contraceptive use-failure and continuation: an overview of new approaches, in Measuring the Dynamics of Contraceptive Use, United Nations, New York, 1991, pp.21-51, tables 3, 5. 31 Failure rate of the condom used as barrier contraceptive: 14,1% in the USA in the statistic of W.R. Grady and associates from 1986; 15,7% in the USA in that of E.F. Jones and J.D. Forrest from 1989, concerning the same data; 15,8% in the USA in the 1992 statistic made by the same authors; 9,8% to 18,5% in the USA in the statistic of S. Harlap from 1991 for the Alan Guttmacher Institute; 11% in Great Britain, 14,1% in the USA, 20% in Panama, 21,6% in Indonesia and 24% in Bangladesh in the international statistic of S. Jejeebhoy, 1991, presented in a reunion of experts from the UN; W.R. Grady, M.D. Hayward, J. Yaagi, Contraceptive Failure in the United States: Estimates from 1982 National Survey of Family Growth, Family Planning Perspectives, September/October 1986, vol.18, n5. pp.200- 209; E.F. Jones, J.D. Forrest, Contraceptive Failure in the United States: Revised Estimates from the 1982 National survey of Family Growth, Family Planning Perspectives, May/ June 1989, vol.21, n3, pp.103-107, see table 2 p.107; E.F. Jones, J.D. Forrest, Contraceptive Failure Rates Based on the 1988 NSFG, Family Planning Perspectives, January/February 1992, 865 SAFE SEx American studies on the question, S.C. Weller situates the failure rate of contra- ception of the condom between 9% and vol.24, n1, pp.12-19, see table 1, p.15; S. Harlap and associates, Pregnancies Occurring During Contraceptive Use, in Preventing Pregnancy, Protecting Health: A New Look at Birth Control Choices in the United States, the Alan Guttmacher Institute, 1991, p.35; S. Jejeebhoy, Measuring contraceptive use-failure and continuation: an overview of new approaches, in Measuring the Dynamics of Contraceptive Use, United Nations, New York, 1991, pp.21-51, tables 3, 5. 14% in the USA. 32 Te failure rate diminishes the hi- gher the competence, cultural level, the practice and motivation of a married couple is. Tis explains the incredibly high failure rates reported by S. Jejeebhoy (1991) in certain third world countries (20% in Panama, 21,6% in Indonesia 32 S.C. Weller, A meta-analysis of condom efectiveness in reducing sexually transmitted HIV, Social Science Medicine, June 1993, vol.36, n12, pp.1635-1644, see p.1636. TABLE II: FREQUENCY OF RUPTURE AND SLIPPAGE OF CONDOMS IN HOMOSExUAL RELATIONSHIPS WITH ANAL PENETRATION Rupture Non-Use Number of Subjects Place of Study rate %users* rate %users* M.W.Ross (1987) - 27% - - 70 homosexual men South Australian Health Comm. L.Wigersma et al. (1987) 11% - 15% - 17 homosexual couples Amsterdam, Netherlands G.J.P. Van Grievansen et al. (1988) 5% - 5% - 277 homosexual men msterdam, Netherlands S. Golombok et al. (1989) 5.27% 31% 3.8% 28% 262 homosexual men London B. Tindall et al.(1989) 6% 12% - - 420 homosexual men Sydney, Australia Chr. Chan Chee et al. (1991) 4.5% - - - 46 homosexual men Paris J.L. Tomson et al. (1993) 3.3% 15% - - 741 homosexual men Columbia University, New York City J. Richters et al. (1993) 2.8% - 3.4% - 36 homosexual men Clinique MST, Sydney, Australia A.Messiah et al. (1993) 4.5%- 7.3% - 1/3 - 246 homosexual men Enqute INSERM, Paris B.G. Silverman et al. (1997) 0.5%-6 - 3.8%-5% - Revue de la littrature Rate: rate of condom ruptures per sexual relation (anal penetration)(number of condoms broken per 100 relations) * % users: percentage of users having noticed at least one condom breakage during the time of the study 866 SAFE SEx and 24% in Bangladesh) 33 . Inversely, the failure rate of the condom as a contra- ceptive was only 4% among very motiva- ted couples enrolled in the Oxford/Family Planning Association contraceptive study (1974) according to M.P. Vessey and associates 34 . However, if the failure rate of the condom used as a contraceptive is evaluated at 3% for couples using the condom 35 perfectly (at every occasion of sexual activity and in a correct way), this rather theoretical rate goes up to 12% when used by typical couples. 36 Te noticeable failure rate of the condom partly explains the statistical link 33 S. Jejeebhoy, Measuring contraceptive use-failure and continuation: an overview of new approaches, in Measuring the Dynamics of Contraceptive Use, United Nations, New York, 1991, pp.21-51, tables 3, 5. 34 R. Glass, M. Vessey, P. Wiggins, Use- efectiveness of the condom in a selected family planning clinic population in the United Kingdom, Contraception, 1974, vol.10, pp.591- 598; M. Vessey, M. Lawless, D. Yeates, Efcacy of diferent contraceptive methods, Te Lancet, April 10, 1982, vol.I, n8276, pp.841-842; M.P. Vessey, L. Villard Mackintosh, Condoms and AIDS prevention, letter, Te Lancet, March 7 1987, vol.I, n8532, p.568. 35 A. Spruyt, M.J. Steiner, C. Joanis, L. H. Glover, C. Piedrahita, G. Alvarado, R. Ramos, C. Maglaya, M. Cordero, Identifying Condom Users at Risk for Breakage and Slippage: Findings from Tree International sites, American Journal of Public Health, February 1998, vol.88, n2, pp. 239-244. See p. 239. 36 A. Albert, R.A. Hatcher, W. Graves, Condom use and breakage among women in a municipal hospital family planning clinic, Contraception, February 1991, vol. 43, n2, pp. 167-176. See p. 168. found between the use of condoms and the appearance of undesired pregnancies among adolescents - given the fact that the advertisement of the condom to ado- lescents incites them to engage in greater sexual promiscuity (E.S.Williams, 1995, in the USA) 37 . 11% of women with un- desired pregnancies in the Grady Memo- rial Hospital in Atlanta (USA) attribu- ted their pregnancy to the failure of the condom 38 . 27% of abortions performed in the Saint Louis Hospital in Paris are supposedly requested because of condom failure. 39 Out of the 4666 women who came to abort at the Mary Stopes Center in Leeds between 1989 and 1993, 40% of them made the failure of the condom responsible for their pregnancy 40 . In the investigation reported by M. Gabbay and A. Gibbs (1996), 83% of the female students who went to get emergency contraception at the Rushol- me Health Center in Manchester (UK) declared they were victims of condom failure. 41 37 E. S. Williams, Contraceptive failure may be a major fact in teenage pregnancy, British Medical Journal, Saturday 23 September 1995, vol. 311, n7008, pp. 806-807. 38 A. Albert, R.A. Hatcher, W. Graves, Condom use and breakage among women in a municipal hospital family planning clinic, Contraception, February 1991, vol. 43, n2, pp. 167-176. See table VI, p. 172. 39 Le Monde, 28/5/1996 40 D. Carnall, Condom failure is on the increase, British Medical Journal, 27 April 1996, vol. 312, n7038, p. 1059. 41 M. Gabbay, A. Gibbs, Does Additional Lubrication Reduce Condom Failure?, 867 SAFE SEx 2. Te Performance of the Condom when Used as a Prophylactic (Table III) Te condom generally diminishes the risk of infection by STDs, but does not eliminate it. 42 It efectively protects Contraception, March 12, 1996, vol. 53, n3, pp. 155-158. 42 J. Pemberton, J.S. McCann, J.D.H. Mahony, G. Mackenzie, H. Dougan, I. Hay, Socio-medical characteristics of patients attending a V.D. clinic and the circumstances of infection, British Journal of Venereal Diseases, October 1972, vol. 48, n5, pp. 391- 396. See table VIII, p. 394; W.M. McCormack, Yhu-Hshang Lee, S.H. Zinner, Sexual Experience and Urethral Colonization with Genital Mycoplasmas, Annals of Internal Medicine, May 1973, vol. 78, n5, p.696-698. See table 2, p. 698; D. Barlow, Te condom and Gonorrhea, Te Lancet, October 13, 1977, vol. II, n8042, pp. 811-812; M.J. Rosenberg, A.J. Davidson, J.H. Chen, F.N. Judson, J.M. Douglas, Barrier Contraceptives and Sexually Transmitted Diseases in Women: A Comparison of Female-Dependent Methods and Condoms, American Journal of Public Health, May 1992, vol. 82, n5, pp. 669-674. See p. 670; D.A. Cohen, C. Dent, D. MacKinnon, G. Hahn, Condoms for Men, not Women, Results of Brief Promotion Campaign, Sexually Transmitted Diseases, September- October 1992, vol. 19, n5, pp. 245-251; B.A. Evans, S.M. McCormack, P.D. Kell, J.V. Parry, R.A. Bond, K.D. MacRae, Trends in female sexual behavior and sexually transmitted diseases in London, 1982-1992, Genitourinary Medicine, October 1995, vol. 71, n5, pp. 286-290; J.M. Zenilman, C.S. Weisman, A.M. Rompalo, N. Ellish, D.M. Upchurch, E.W. Hook III, D. Celentano, Condom Use to Prevent Incident STDs: Te Validity of Self-Reported Condom Use, Sexually Transmitted Diseases, January- February 1995, vol. 22, n1, pp. 15-21; M. Shaw, G.J. Remafedi, L.H. Bearinger, P.L. Faulkner, B.A. Taylor, S.J. Potthof, M.D. Resnick, Te against syphilis (J. Pemberton and asso- ciates, 1972; D. Barlow, 1977; J. San- chez and associates, 1998) (average rate of infection 0,65% with condom, com- pared to 1,86% among subjects never using condoms during sexual activity), and against gonorrhea (average rate of gonorrheal infection 8% with condom, compared to 15% in subjects never using the condom; J. Pemberton and associates, 1972; D. Barlow, 1977; M.J. Rosenberg and associates, 1992; B.A. Evans and as- sociates, 1995, J. Sanchez and associates, 1998; reduction of risk by 39%, Rosen- berg and associates, 1992). However, the condom seems less efcient against infections of chlamydia (infection rate 3,9% with condom, com- pared to 7,2% without condom, Evans and associates, 1995; risk of 0,8 with condom against 1,2 without condom, J. Sanchez and associates, 1998) or even totally inefcient (M.J. Rosenberg and associates, 1992, risk relative to 0,99). J.M. Zenilman and associates (1995) have nevertheless reported a signifcantly protective efect of the condom against chlamydia (0/72 infected with condom versus 16/251 without condom). 43 Validity of Self-Reported Condom Use Among Adolescents, Sexually Transmitted Diseases, October 1997, vol. 24, n9, pp. 503-510; J. Sanchez, E. Gotuzzo, J. Escamilla, C. Carrillo, L. Moreyra, W. Stamm, R. Ashley, P. Swenson, K.K. Holmes, Sexually Transmitted Infections in Female Sex-Workers, Sexually Transmitted Diseases, February 1998, vol. 25, n2, pp. 82-89. 43 J.M. Zenilman, C.S. Weisman, A.M. 868 SAFE SEx TABLE III: EFFECTIVENESS OF CONDOMS IN PREVENTING STDs Reported STDs percentage contagion user condom percentage contagion user condom Type and number of subjects, length of study Place of study J. Pemberton et coll. (1972) syphilis gonorrhea non gon. urethritis other STDs 0.9% 13.4% 34.8% 19.6% 2.7% 26.2% 29.1% 17.3% 1,351 cases of STDs 1,173 male patients, one year Royal Victoria Hospi- tal, Belfast W. M. McCor- mack et coll. (1973) T-Mycoplasmas 14.3% 42.9% 191 male students, college, one urethr. culture Boston, MA and Provi- dence, Rhode Island D. Barlow (1977) syphilis gonorrhea non gon. urethritis genital herpes genital warts 0.39% 9.27% 46.72% 0.37%(?) 5.02% 1.02% 14.39% 47.42% 1.67% 4.60% 3,543 STDs 3,300 male patients, six months Genito-Urinary Medi- cine, St. Tomas Hos- pital, London M.J. Rosenberg et coll. (1992) gonorrhea vag. trichomonas chlamydia R.R.0.7 R.R.0.86 R.R.0.99 - 4,162 women, one year Denver (Colorado), STD Clinic D.A. Cohen et coll. (1992) STDs (gonorrhea, chla- mydia, syphilis, tricho- monas) 19.9% m 12.6% f - 552 men, 350 women, 9 months STD clinics, Los Angeles B.A. Evans et coll. (1995) gonorrhea, chlamydia, n.g urethritis, trichomoniasis, candidosis, genital herpes, genitals warts, vaginites bact. infam. pelvienne 0.6% 3.9% 10.5% 1.7% 36.5% 3.9% 13.8% 7.2% 1.1% 3.6% 7.2% 9.6% 3.6% 31.3% 4.8% 3.6% 12% 1.2% 416 women, without regular part- ner, questionnaire Department of Genito- urinary Medicine, London, U.K. J.M. Zenilman et al. (1995) male STDs female STDs 15.3% 23.5% 15.3% 26.8% 323 men, 275 women, population study, two years Baltimore City Health Department, STD clinics M.L. Shaw et coll. (1997) STDs 9% 10% 77 men, 321 women, adolescents, one year schools, community-based clin- ics, St. Paul, Minnesota J. Sanchez et coll. (1998) gonorrhea, syphilis, infact. chlamydia R.0.3 R.0.3 R.0.8 R.1.7 R.0.4 R.1.2 435 female prostitutes, one year survey Centro antivenereo, Lima, Peru A. Wald et coll. (2001) Herpes Simplex Type 2 R.0.085 woman R.2.02 man R.1.16 528 couples, 18 months Seattle, WA 18 clinics 869 SAFE SEx Te condom is practically inefec- tive against non-specifc urethritis (in- fection rate 30,6% with condom com- pared to 28,7% without condom)(J. Pemberton, 1072; D. Barlow, 1077; B.A. Evans, 1995). It is equally inefcient against STDs transmitted through cutaneous or mu- cous membrane contact, such as the simplex Herpes virus infection (infec- tion rate 0,77% with condom, versus 1,67% without condom, D. Barlow, 1977; infection rate 3,9% with condom versus 4,8% without condom, B.A. Evans and associates, 1995). A recent report on type 2 simplex Herpes vi- rus infections (A. Wald and associates, 2001) 44 shows that the regular use of the condom during sexual activity reduces the risk of contamination by this virus among women, but has no efect against the contamination of men. Te condom generally does not protect against infections of Condylo- mata acuminate (genital condylomes genital warts)(infection rate 5,02% Rompalo, N. Ellish, D.M. Upchurch, E.W. Hock III, D. Celentano, Condom Use to Prevent Incident STDs: Te Validity of Self- Reported Condom Use, Sexually Transmitted Diseases, January-February, 1995, vol.22, n1, pp.15-21, see p.18. 44 A.Wald, A.G. Langenberg, K. Link, A.E. Izu, R. Ashley, T. Warren, S. Tyring, J.M. Douglas J., L. Corey, Efect of Condoms on Reducing the Transmission of Herpes Simplex Virus Type 2 from Men to Women, JAMA, 27 June 2001, vol.285, n24, pp.3100-3106, see p.3104. with condom, versus 4,6% without condom. D. Barlow, 1977; infection rate 13,8% with condom versus 3,6% without condom, B.A Evans and asso- ciates, 1995). L.M. Wen and associates (1999) have nevertheless shown that the use of the condom could reduce the risk of papillomavirus genital infections. 45 While the frequency and gravity of pelvic infammatory diseases (PID) (high gonococcal or chlamydic genital infections) seemed to be reduced due to the use of the condom (J. Kelaghan and associates, 1982) 46 , a recent report (R. Ness, 2001) 47 has in fact demonstrated the inefcacy of the condom against these STDs. Te recent review of the question 48
made at the request of the National Ins- titutes of Health and of the Center for 45 L.M. Wen, C.S. Estcourt, J.M. Simpson, A. Mindel, Risk factors for the acquisition of genital warts: are condoms protective?, Sexually Transmitted Infections, October 1999, vol.75, n5, pp.312-316. 46 J. Kelaghan, G.L. Rubin, H.W. Ory, P.M. Layde, Barrier-Method Contraceptive and Pelvic Infammatory Disease, Journal of the American Medical Association, July 9 1982, vol.248, n2, pp.184-187. 47 M. Larkin, Contraceptives do not protect against pelvic infammatory, Lancet, 21 April 2001, vol.357, n9264, p.1270. 48 Scientifc Evidence of Condom Efectiveness for Sexually Transmitted Disease (STD) Prevention, June 12-13, 2000, Hyatt Dulles Airport, Herndon, Virginia, Summary Report, National Institute of Allergy and Infectious Diseases, National Institutes of Health, July 20 2001, http://www.niaid.nih. gov/dmid/stds/condomreport.pdf. 870 SAFE SEx TABLE IV: EFFECTIVENESS OF CONDOMS IN PREVENTING GENITAL CONTAMINATION BY HIV RATE OF SEROCONVERSION TO HIV Condom Users Non-Users Type of sexual relation Type of study Type and num- ber of subjects Place of study rate reduction* rate J. Mann et coll. (1987) 25% (0-32%) - 26% heterosexual questionnaire 376 prostitutes Kinshasa, Zaire E.N. Ngugi et coll. (1988) 46% (23/50) 3 times 71% (20/28) heterosexual population, 18 months 595 prostitutes Nairobi, Kenya M. Tuliza et coll. (1991) 70/531 - - heterosexual population, 23 months 431 prostitutes Kinshasa, Zaire M. Laga et coll. (1994) 70/531 (13%)(8/100 women/year) - 11.7/100 women/year heterosexual population, 3 years 531 prostitutes Kinshasa, Zaire R.S. Hanenberg (1994) 29.5% - - heterosexual - Direct prostitu- tion Tailand HIV control program, 4 years 7.7% - - heterosexual - Indirect prostitu- tion 1.5% - - heterosexual - Pregnant women 4% - - heterosexual - Army recruits R. Detels et. coll. (1989) (?) 3.32% - 3.3% homosexual - < 2 partners 457 men Population 2,915 men, Baltimore 4.4% - 9.5% homosexual - 3-5 partners, 1,132 men L.I. Levin et coll. (1995) insignifcant increase of seroconversion with condom usage 13% homo., 59% hetero. questionnaire 140 men in ac- tive duty HIV+ 22 centers, US Army M.A. Fischl (1987) 10% - 12/14 (85%) heterosexual population, three years 45 couples, serodiscordant Miami School of Medicine N.Padian et coll. (1987) risk x 4.6 if > 100 sexual acts no infuence of condoms heterosexual population, two years 97 couples, serodiscordant California P.J.Feldblum (1991) 3.5/100 couples/year - 10.1/100 couples/year heterosexual population, 13 months 98 couples, serodiscordant Zambia M. Kamenga et coll. (1991) 4% (3.1/100 couples/year) - heterosexual followed 6 months 149 couples, serodiscordant Kinshasa, Zaire I.de Vincenzi et coll. (1991) 0%-4.8% - 4.8% heterosexual followed 20 months 256 couples, serodiscordant European Study Group A. Nicolosi et al. (1994) 0.1 OR - 1 OR heterosexual - 730 couples, serodiscordant Italy M.D.C. Gui- mareas et coll. (1995) 1 OR - 3.91 OR heterosexual - 204 couples, serodiscordant Rio de Ja- neiro
Rate: rate of seroconversion to HIV * Reduction: reduction of risk of seroconversion to HIV 871 SAFE SEx Disease Control and Prevention by a study group in June 2000 corroborates these results. III THE PERFORMANCE OF THE CONDOM IN THE PROTECTION AGAINST HIV (TABLE IV) Concerning the condoms preven- tion of the sexual transmission of HIV, it is appropriate to examine separately the statistics concerning subjects who are at high risk- homosexuals and prostitutes in particular - and the sta- tistics concerning monogamous cou- ples who are HIV positive/negative and where the risk of transmission of HIV is lessened. 1. High Risk Behavior African and Tai prostitutes de- mand of their clients to use the condom; this precaution in general di- minishes the incidence of HIV infec- tion, but does not eliminate it; sexual HIV contamination remains in fact important, despite the condom (13% of women in Laga and associates, 1994; 29,5% of women in Hanenberg and associates, 1994) 49 . 49 J. Mann, T.C. Quinn, P. Piot, N. Bosenge, N. Nzilambi, M. Kalala, H. Francis, R. L. Coleblunders, R. Byers, P. Kasa Azila, N. Kabeya, J.W. Curran, Condom Use and HIV Infection among Prostitutes in Zaire, Te New England Journal of Medicine, February 5, 1987, vol. 316, n6, p. 325; N. Nzila, M. Laga, M.A. Tiam, K. Mayimona, B. Edidi, E. Van Dyck, F. Beheta, S. Hassig, A. Nelson, K. Mokwa, Concerning masculine homosexuals, the few available statistics show that the regular use of the condom diminishes the incidence of genital homosexual contami- nation by HIV (by a factor of 3,3, in De- tels and associates, 1989), but that the rate of seroconversion 50 depends more on the lifestyle (number of partners, changing of Rh.L. Ashley, P. Piot, R.W. Ryder, HIV and other sexually transmitted diseases among female prostitutes in Kinshasa, AIDS, June 1991, vol. 5, n6, pp. 715-721; A. Johnson, Feedback from the Six International AIDS Conference, San Francisco 1990, Genitourinary Medicine, April 1991, vol. 67, n2, pp. 162-171. See pp. 162- 163; M. Laga, M. Alary, N. Nzila, A.T. Manoka, M. Tuliza, F. Behets, J. Goeman, M. StLouis, P. Piot, Condom promotion, sexually transmitted diseases treatment, and declining incidence of HIV-1 infection in female Zairian sex workers, Te Lancet, 23 July 1994, vol. 344, n8917, pp. 246-248; E.N. Ngugi, J.N. Simonsen, M.Bosire, A.R. Ronald, F.A. Plummer, D.W. Cameron, P. Waiyaki, J.O. Ndinya-Achola, Prevention of transmission of Human Immunodefciency Virus in Africa: efectiveness of condom promotion and health education among prostitutes, Te Lancet, October 15 1988, vol. II, n8616, pp. 887-890; R.S. Hannenberg, W. Rojanapithayakorn, P. Kunasol, D.C. Sokal, Impact of Tailands HIV control programme as indicated by the decline of sexually transmitted diseases, Te Lancet, 23 July 1994, vol. 344, n8917, pp. 243-245. 50 Seroconversion: in the blood of HIV contaminated persons apparition of composites objectifying the reaction of the organism to the presence of the virus. Seroconversion which leads to seropositivity is in a sense the signature of the viral contamination. In the case of the HIV, several months can go by between the moment of contamination and the apparition of seropositivity. 872 SAFE SEx partners) than on the use of the condom 51 . In some cases (L.I. Levin and associates, 1995), the rate of seroconversion parado- xically appears proportional to the sub- jects use of the condom, because persons with sexual behavior involving greater risk more willingly use the condom. 52 2. Monogamous Serodiscordant- 53 Couples Te efcacy of the condom in the context of the prevention of HIV infec- tion in HIV-serodiscordant couples (where one of the spouses is HIV-seropo- sitive and the other still HIV-seronegati- ve) is not so much related to the condom itself than to the sexual behavior of the partners. Even in the cases where the 51 R. Detels, P. English, B.R. Visscher, L. Jacobson, L.A. Kingsley, J.S. Chmiel, J.P. Dudley, L.J. Eldred, H.M. Ginzburg, Seroconversion, Sexual activity, and Condom Use Among 2915 HIV seronegative Men Followed for up to 2 Years, Journal of Acquired Immune Defciency, 1989, vol. 2, n1, pp. 77-83. 52 L.I. Levin, T.A. Peterman, P.O. Renzullo, V. Lasley-Bibbs, xiao-ou Shu, J.F. Brundage, J.G. MacNeil, HIV-1 Seroconversion and Risk Behaviors among Young Men in the US Army, American Journal of Public Health, November 1995, vol. 85, n11, pp. 1500-1506. 53 serodiscordant couples: couples where one partner has not been contaminated by HIV, and therefore remains seronegative, while the other has been contaminated and is seropositive. If the partners have sexual relations, the still unharmed partner will be contaminated by HIV within a shorter or a longer period, and will also become seropositive, thus ending the serodiscordance between the partners. risk of contamination without condom is already very low (4,8%), the condom does not ofer absolute protection, since the rate of contamination despite the use of the condom has been found to be according to statistics 0% (De Vincenzi, 1994), 2% (Nicolasi, 1994), 3,5% (Fel- dblum, 1991), 4% (Kamenga, 1991), 10% (Fischl, 1987). In these cases the condom diminishes the risk of genital contamination of HIV by a factor of 3,91 (Guimaraes, 1995). 54 54 M.A. Fischl, G.M. Dickinson, G.B. Scott, N. Klimas, M.A. Fletcher, W. Parks, Evaluation of Heterosexual Partners, Children and Household Contacts of Adults with AIDS, Journal of the American Medical Association, February 6 1987, vol.257, n5, pp.640-644; P.J. Feldblum, Results from prospective studies of HIV-discordant people, AIDS, October 1991, vol.5, n10, pp.1265-1266; M. Kamenga, R.W. Ryder, M. Jingu, N. Nbuyi, L. Mbu, F. Behets, Chr. Brown, W.L. Heyward, Evidence of marked sexual behavior change associated with low HIV- I seroconversion in 149 married couples with discordant HIV-I serostatus: experience at an HIV counseling center in Zaire, AIDS, January 1991, vol.5, n1, pp.61-67; I. de Vincenzi, for Te European Study Group on Heterosexual Transmission of HIV, a longitudinal Study of Human immunodefciency virus transmission by heterosexual partners, the New England Journal of Medicine, Aug.1 1994, vol.331, n6, pp.341-346; A. Nicolasi, M.L. Corra Leite, M. Musicco, Cl. Arici, G. Gavazzeni, A. Lazzarin, for the Italian Study Group on HIV Heterosexual Transmission, the Efciency of Male-to-Female and Female-to-Male Sexual Transmission of the Human Immunodefciency Virus: A Study of 730 Stable Couples, Epidemiology, November 1994, vol.5, n6, pp.570-575; M.D.C. Guimaraes, A. Muoz, C. Boschi-Pinto, E.A. 873 SAFE SEx It has been observed, furthermore, that among HIV-serodiscordant cou- ples who use the condom irregularly, the rate of seroconversion for the sero- negative partner is low (4,8%)(cumula- tive index of seroconversion 7,8%)(P.J. Feldblum, I. De Vincenzi) when the se- ropositive partner is asymptomatic, and is identical to the one found in couples who never use the condom. However, once the infected par- tner has reached the symptomatic stage or when this partner engages in risky sexual behavior, the risk of seroconver- sion for the negative partner becomes serious (cumulative index of seroconver- sion 48,7%) and the use of the condom does not change this (N. Padian, I. De Vincenzi). Tis is shown by Feldblums statistic (1991) and much more by the disastrous numbers delivered by N. Pa- dian and associates (1987) with up to 35% failures. 55 Among all these statistics the constant and correct use of the condom (perfect use) seems to be the excep- Castilho, from the Rio de Janeiro Heterosexual Study Group, HIV infection among Female Partners of Seropositive Men in Brazil, American Journal of Epidemiology, September 1 1995, vol.142, n5, pp.538-547. 55 N. Padian, L. Marquis, D.P. Francis, R.E. Anderson, G.W. Rutherford, P.M. OMalley, W. Winkelstein, Male-to-Female Transmission of Human Immunodefciency Virus, JAMA, August 14 1987, vol.258, n6, pp.788-790; P.J. Feldblum, Results from prospective studies of HIV-discordant people, AIDS, October 1991, vol.5, n10, pp.1265-1266. tion rather than the rule. 56 Te best do- 56 In the evaluation of condom failures one must also take into account that these condoms are used more or less correctly. For Hawkins and Elder, the most common reason for failure when using the condom as a contraceptive is its incorrect use. A frst way in which the condom can be used incorrectly is in what A. Quirk and associates call unsafe protected sex, that is the practice of a protected sexual relation but which does not belong to the category of safe sex, because its use does not cover the entire period of the relation. In consequence warnings have been issued (G. Ilaria, J. Pudney) about the presence of HIV in pre-ejaculatory secretions. A second reason for condom failure is tied to the contamination of the external surface of the condom. A third source of condom failure is found in the use of inappropriate lubricants, in particular oily ones (White, Voeller, Chan- Chee, Messiah, Gabbay), which weaken the latex and render it permeable; D.F. Hawkins, M.G. Elder, Condoms, Diaphragms and Caps, in Human Fertility Control, Teory and Practice, Butterworth & co, London, 1979, p.138; A. Quirk, T. Rhodes, G.V. Stimson, Unsafe protected sex: qualitative insights on measures of sexual risk, AIDS care, February 1988, vol.10, n1, pp.105-114; G. Ilaria, J.L. Jacobs, B. Poisky, B. Koll, P. Baron, Cl. MacLow, D. Armstrong, Detection of HIV-1 DNA sequences in pre-ejaculatory fuid, Te Lancet, December 12 1992, vol.340, n8833, p.1469; J. Pudney, M. Oneta, K. Mayer, G. Seage III, D. Anderson, Pre-ejaculatory fuid as potential vector for sexual transmission of HIV-1, the Lancet, December 12 1992, vol.340, n8833, p.1470; N. White, K. Taylor, A. Lyszkowski, J. Tullett, C. Morris, Dangers of lubricants used with condoms, Nature, 1 September 1988, vol.335, n6185, p.19; B. Voeller, A.H. Coulson, G.S. Bernstein, R.M. Nakamura, Mineral oil lubricants cause rapid deterioration of latex condoms, Contraception, January 1989, vol.39, 874 SAFE SEx cumented publication on the matter by the European Group of Study on hete- rosexual transmission of HIV (De Vin- cenzi) indicates that only 32% of all mo- nitored couples were capable of it, while 34% opted for abstinence, and 34% for the irregular use of the condom (non-use in 16% of the cases). 3. Meta-Analysis R. Gordon (1989) 57 estimates that the rate of condom failure in the preven- tion of the sexual transmission of HIV (5 to 23%) is higher than the one obser- ved during the use of the condom as a contraceptive. In a meta-analysis based on 11 pu- blications S.C. Weller (1993) situates the rate of the protection by the condom against sexual contamination by HIV at only 69% (failure in 31% of the cases). 58 n1, pp. 95-102; Chr. Chan-Chee, I. De Vicenzi, M-A. Sole-Pia, R. Ancelle-Park, J.-B. Brunet, Use and misuse of condoms, Genitourinary Medicine, April 1991, vol. 67, n2, p. 173; A. Messiah, D. Buoquet, J.-F. Mettetal, B. Larroque, Chr. Rouzioux, and the Alain Brugeat physician group, Factors Correlated With Homosexually Acquired Human Immunodefciency Virus Infection in the Era of Safer Sex, Was the Prevention Message Clear and Well Understood?, Sexually Transmitted Diseases, January-February 1993, vol. 20, n1, pp. 51-59. See p. 56; M. Gabbay, A. Gibbs, Does Additional Lubrication Reduce Condom Failure?, Contraception, March 1996, vol. 53, n3, pp. 155-158. See p. 157. 57 R. Gordon, A critical Review of the physics and statistics of condoms and their role in individual versus societal survival of the AIDS epidemic, Journal of Sex and Marital Terapy, Spring 1989, vol. 15, n1, pp. 5-30. 58 S.C. Weller, A Meta-analysis of condom K. April, W. Schreiner and associates (1994), 59 analyzing 14 studies focused on serodiscordant couples for observa- tion periods between six months and three years, fnd that 8% was the avera- ge percentage of seroconversion among couples always using the condom com- pared to 35% as the average percentage of seroconversion among couples never using it. K.R. Davis and S.C. Weller 60
(1999) analyzing results from 25 studies concerning serodiscordant couples fnd an average condom failure rate of 13%. In conclusion, the efcacy of the condom in the prevention of the sexual transmission of HIV seems similar to when it is used as a barrier contracep- efectiveness in reducing sexually transmitted HIV, Social Science Medicine, June 1993, vol. 36, n12, pp. 1635-1644. 59 K. April, R. Kster, G. Fantacci, W. Schreiner, Quale il grado efettivo di protezione dallHIV del proflattivo?, Medicina e Morale, October 1994, vol. xLIV, n5, pp. 903-924. 60 12 population studies showed an incidence of HIV transmission despite the constant use of the condom of 0,9 for 100 persons per year. Te same incidence was 5,9 per 100 persons per year (transmission from woman to man) and of 6,8 for 100 persons per year (transmission from man to woman) in the 11 studied populations where no one ever used the condom. Te efcacy of the condom was in general estimated at 87%, but it could be as low as 60% and as high as 96%; K.R. Davis, S.C. Weller, Te efectiveness of Condoms in Reducing Heterosexual Transmission of HIV, Family Planning Perspectives, November- December 1999, vol.31, n6, pp.272-279. 875 SAFE SEx tive or even slightly lower than that (R. Gordon, C. Weller, P.J. Feldblum, K.R. Davis). 4. Discussion a-Te Defects of the Condom and Mistaken Beliefs Concerning Safe Sex. Te frst conclusion to be drawn from this analysis is that the condom is in and of itself only relatively relia- ble, even though manufacturers have tried to improve its mechanical qualities and though latex still remains the best material for the condom. Te error is to have thought that to accurately use the condom would be the same as to prevent the sexual transmission of HIV; for it was well known that such accu- rate use was an exception and that no condom could ever be guaranteed to be 100% efcient. Knowing the limits of the condom as a contraceptive and as barrier to STD bacterial and viral agents, one should have expected the same type of result concerning the prevention of the pas- sage of HIV; statistics in fact show that its average failure rate is 13%. Te sta- tistic of the European group (De Vin- cenzi)0% of sexual contamination by HIV among the 124 HIV serodiscor- dant couples (out of 378) who always used a condom during their relations is, from this standpoint, the exception rather than the rule. However, the failure rates of the condom are variable from one statistic to another, depending upon which part of the population is studied. It is in fact the more or less risky sexual lifestyle of the subject which is of greater impor- tance than the simple use or non-use of the condom. It is therefore not so much the use of the condom which makes sexsafe, but rather refraining from sexual promiscuity, limiting the number of partners and abstaining from homo- sexual practices. Tere is no true safe sex except in conjugal fdelity which renders the condom useless. b-Te Possible Negative Efects of safe sex Campaigns. Not only is the expression safe sex inaccurate, but it also fosters dan- gerous illusions and leads to the very consequences it tries to prevent. Pu- blicity made for the condom against HIV/AIDS could in fact have an efect contrary to the one desired. Tis has recently been heard from researchers at the University College Medical School in London, 61 who were basing themselves on the results concerning the publicity made for safety belts in cars. In Great Britain this publicity has in fact had the opposite efect, causing a higher num- ber of victims in trafc accidents, be- cause of the feeling of security people associated with the use of safety belts. It could be the same with the publi- city for condoms, as mentioned by N. Hearst and S.B. Hulley 62 of the Center 61 J. Richens, J. Inrie, a. Copas, Condoms and seat belts: the parallels and the lessons, the Lancet, 2000, vol. 355, n9201, pp. 400-403. 62 N. Hearst, S.B. Hulley, Preventing the Heterosexual Spread of AIDS: Are We Giving 876 SAFE SEx for AIDS Prevention Studies at the Uni- versity of California in San Francisco. Tis paradoxical efect has in fact been observed by I. Levin and associates 63 in their report of 1995 on HIV infections in the military: the condom, used by these military in their homosexual en- counters, not only did not prevent HIV infection, but appeared to facilitate it, because the usersthinking they were protected - multiplied their partners and their sexual experiences of all types. c-Safe Sex or Sexual Health? In the prevention of any type of ca- lamity, we can distinguish between the means of containment which aim at limiting the expansion of the calamity from the actual means of prevention which aim at eliminating the roots of the disorder. Malaria for example is compara- ble to HIV/AIDS in terms of the number of contaminated persons in the world, in terms of the mortality it causes and the dif- fculty of its treatment, and in terms of the preventive measures developed over the yearsand which particularly concern the battle against the anopheles; the measures taken have been measures of contain- Our Patients the Best Advice?, JAMA, April 22/29 1988, vol. 259, n16, pp. 2428-2432; see p. 2431. 63 L.I. Levin, T.A. Peterman, P.O. Renzullo, V. Lasley-Bibbs, xiao-ou Shu, J.F. Brundage, J.G. MacNeil, HIV-1 Seroconversion and Risk Behaviors among Young Men in the US Army, American Journal of Public Health, November 1995, vol. 85, n11, pp. 1500-1506. ment rather than being truly preventive, because they have not been able to get to the root of the problem. Tough theore- tically efective, these measures have re- vealed themselves to be not very efective, because it is impossible to destroy all the larvae and to eliminate all stagnant water. In the case of typhoid fever, in contrast, prevention has been efective because one has been able to get the population to take care of its drinking water. True prevention has occurred in this case, because human behavior which had favored contamina- tion was changed. Te condom is presented as a means by which to contain the sexual transmis- sion of HIV/AIDS, to limit its transmis- sion by reducing its incidence by a factor of 3 or 4. It does not provide a true pre- vention of the epidemic, since it leaves its roots intact, namely the human behavior responsible for the transmission of HIV. True prevention of sexually transmitted HIV/AIDS aims to bring to an end risky sexual behavior and to guide the young toward a balanced and fulflling sexua- lity by embracing pre-marital and marital chastity. We cannot hope to stop the HIV/ AIDS epidemic by simply advertising the condom, no more than we can hope to stop a fooding river with a few bags of sand once the dykes have broken. People should be encouraged to be truly sexually healthy rather than believing in an illusory safe sex. As long as serious eforts will not be made in this direction, the AIDS epidemic will persist as one can see in rich countries where sexual contamination of 877 SAFE SEx HIV continues at the same pace, despite years of massive advertisement for the condom. Te encouragement towards conjugal chastity and to sexual abstinence outside of marriage have been excluded a priori from AIDS prevention programs with the pretext that such ideals were utopist and do not correspond to concrete, daily life. Yet, what does one notice in daily life? Particularly in countries where AIDS has been rampant for several years already one can observe a salutary reaction of the po- pulation, marked by the diminishing of extra-marital sexual relations and a delay of frst sexual relations among the young. One can observe this today in Uganda, for example, where the AIDS epidemic has slowed down, 64 with a lessening of HIV prevalence from 45% to 35% among mas- culine subjects examined in STD clinics in Kampala and from 21% to 5% among pregnant women examined in Jinja from 1990 to 1996. Tough sexually active men and women report a more frequent use of the condom in their answers to sur- veys, the most important factor seems to be the noticeable change observed in the sexual behavior of the young which is cha- racterized by a markedly later age of frst sexual relations (56% of boys aged 15 to 19 declared in 1995 not to have had any 64 G. Asjimwe-Okiror, A.A. Opio, J. Musinguzi, E. Madraa, G. Tembo, M. Carsl, Changes in sexual behavior and decline in HIV infection among young pregnant women in urban Uganda, AIDS, 15 November 1997, vol. 11, n14, pp. 1757-1764. sexual relations yet, versus 31% in 1989, and 46% young girls in 1995 versus 26% in 1989). It is also characterized by a later marriage age and by a lessening of extra- marital relations (from 22,6% in 1989 to 18,1% in 1995 for men). 65 In the particular case of monoga- mous serodiscordant couples, the use of the condom has been presented as quasi obligatory, because of the serious threat of contamination of the HIV-seronegative spouse by the seropositive one. Te very idea of sexual abstinence was set aside. But the statistics mentioned above show that a signifcant number of these couples (11 to 25%)(M.A. Fischl, 1987, I. De Vincenzi, 1994) choose of their own accord to no longer have any sexual relations nor to separate. By reducing the efort at preventing HIV/AIDS to the simple promotion of the condom, we have dealt with what was 65 Tese data are in accord with a recent study concerning the diferences in sexual behavior of the population in four African cities which present diferent HIV prevalence rates (from 3,3% in Cotonou, Benin, to 31,9% in Ndola, Zambia). Tis study shows, among other things, that there is a link between the earliness of frst sexual relations in young girls and the prevalence of the HIV in their group. Female adolescents from Kisumu and Ndola were having particularly early sexual relations with older men, and the prevalence of STDs among these adolescents was higher than in the other studied cities; J. Cohen, AIDS Researchers Look to Africa for New Insights, Science, 11 February 2000, vol.287, n5455, pp.942-943: Diferences in HIV Spread in four sub-Saharan African cities, UNAIDS, Lusaka, 14 September 1999. 878 SAFE SEx most urgent in those milieus most favor- able to the development of the epidemic because of the sexual habits which char- acterized them. But a real prevention for the population in general has not been put into place, in particular with regard to the young. Some have said we must not scare people. Some have also said that sexual choices are a private matter and that it is not the task of the authorities to preach to people. Epidemiological measures re- quired by the gravity of the situation were not taken. We have been satisfed merely to propose the condom. Te result is that the HIV/AIDS epidemic which could have been easily stopped at the beginning of its expansion, has spread throughout the en- tire world causing the millions of victims we now know about. 4. Conclusion Te ofcial discourse on the preven- tion of sexual contamination by HIV/ AIDS has been limited for the past 20 to the promotion of the condom in the context of safe sex. Behavior changing campaigns have only aimed at its promo- tion. However, one should not speak of real prevention, but of protection or of a prophylaxis, since the root of the problem, namely risky behavior, remains. Using a condom as protection against HIV is like playing at Russian roulette: the more sexual experiences one engages in - convinced of the safety ofered by the prophylactic - the higher the probability of contamination will be. In the end, HIV is the winner. Regarding HIV/AIDS, the risk - even though it is reduced to 10% - of contracting an infection believing oneself to be protected by the condom is exces- sively high. Tere is no such thing as safe sex. Tis leaves a probability curve hang- ing like the sword of Damocles over the heads of all those who wrongly feel safe be- cause they use the condom. What would one say of a plane model with 10% of its fights ending up in a crash? All authors interested in the preven- tion of the HIV infection agree in one point: only a radical change in sexual be- havior can guarantee complete protection which the condom alone cannot do. Te advocates of a greater publicity for the condom admit it themselves: Clearly the dangers of relying solely on barrier methods to prevent AIDS must be emphasized, wrote K. Wellings 66 in 1986, and the subsequent history of the epidemic has proven this to have been a well-founded fear. Te only strategy that is completely efcient con- cerning HIV is abstinence, or sexual rela- tions within a monogamous marriage as well as fdelity, according to the formula given by Centers for Disease Control in At- lanta (USA): Abstinence and sexual inter- course with one mutually faithful uninfected partner are the only totally efective preven- tion strategies. 67 66 K. Wellings, AIDS and the condom, British Medical Journal, 15 November 1986, vol. 293, N6557, p. 1259. 67 Centers for Disease Control, Condoms for Prevention of Sexually Transmitted Diseases, op. cit., p. 133.
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