Safety and acceptability of condoms for use by homosexual men as a prophylactic against transmission of HIV during anogenital sexual intercourse

An evaluation of a thicker versus a standard condom with gay men

OBJECTIVES

Although thicker (stronger) condoms are advocated in western Europe for anal intercourse between men, empirical evidence supporting their greater efficacy is lacking. The present study aimed to determine whether a thicker condom is less likely to fail (break or slip off) than a standard (regular thickness) condom, and to establish factors associated with condom failure among gay men.

DESIGN

A total of 283 homosexual couples participated in a double-blind, randomized, controlled trial of a standard and a thicker condom.

METHODS

Each couple was allocated nine of either condom type. Data were collected on user characteristics, and a questionnaire completed immediately after the use of each condom. The thicker and the standard condoms were used by 142 and 141 couples, respectively.

RESULTS

No significant differences were found between the two condom types with respect to either clinical or non-clinical definitions of failure (breakage and slippage). With instances of inappropriate use removed, failure rates for the standard and the thicker condom were low at 2.5 and 2.3%, respectively. User characteristics associated with breakage were lower educational achievement, lack of confidence in condom use, and a history of condom breakage. Behaviours associated with breakage were unrolling the condom before fitting to the penis, longer penis length, absence of additional lubricant, the use of inappropriate lubricant, and longer duration of intercourse.

CONCLUSION

Breakage and slippage rates were low for both condom types. There is no evidence from the present investigation to support the use of stronger (thicker) condoms over standard strength condoms among gay men. The appropriate use of additional lubricant should be encouraged.

Condom breakage and slippage during heterosexual intercourse: a French national survey. French National Survey on Sexual Behavior Group (ACSF)

OBJECTIVES

This study examined condom failure rates in a representative sample of French men and women.

METHODS

Condom users who experienced breakage or slippage were compared with those who reported no difficulties.

RESULTS

The rate of breakage at last heterosexual intercourse was 3.4%, and the slippage rate was 1.1%. Significantly associated with breakage and slippage were being age 25 through 34, being sexually active for more than 5 years, condom use for less than 5 years, condom not used for contraception, and sexual intercourse 12 or more times per month.

CONCLUSIONS

People who became sexually active before the era of acquired immunodeficiency syndrome, who began condom use in recent years, and who have frequent sex are at increased risk. The low risk observed among experienced condom users below age 25 supports condom promotion to youth.

Use and effectiveness of condoms during anal intercourse. A review

BACKGROUND AND OBJECTIVES

Anal intercourse has been associated with a high risk of human immunodeficiency virus transmission. Survey data suggest that unprotected anal intercourse is practiced by a substantial proportion of the sexually active population, regardless of sexual orientation.

GOAL

To review the literature related to the use and effectiveness of condoms during anal intercourse, with emphasis on prevention of human immunodeficiency virus transmission.

STUDY DESIGN

Literature review.

RESULTS

Epidemiologic studies have shown that consistent, correct condom use reduces the overall risk of sexual transmission of human immunodeficiency virus. Evidence for the effectiveness of condoms used during anal intercourse is less definitive. Survey and clinical trials data indicate that condom breakage and slippage rates vary during anal intercourse and may be considerably higher than during vaginal intercourse. Although condoms designed for anal intercourse have been studied and marketed in Europe, data on their actual performance are scarce. In addition, no information exists on the effectiveness of polyurethane or other nonlatex condoms for use during anal intercourse.

CONCLUSIONS

Development of newer and more effective condoms for use during anal intercourse requires consideration of the ethical issues involved in testing and marketing devices used during an activity that carries with it the potential for a substantial risk to health.

Estimated condom failure and frequency of condom use among gay men

OBJECTIVES

Condoms are designed to bar transmission of the human immunodeficiency virus (HIV), but they sometimes fail. This paper explores the effect of experience with condoms on condom failure among gay men.

METHODS

Risk of condom failure (breakage or slippage) on a single occasion is estimated for four sexual acts reported over 12 months by a sample of gay New York City men (n = 741). The estimation procedure assumes that each episode in which a condom is used is an independent event. Evidence is offered to support this assumption.

RESULTS

Risk of condom failure in a single episode was fairly high, particularly in anal intercourse, for men who had engaged in each act only a few times in the previous year. It declined rapidly with experience (e.g., to below 1% for receptive anal intercourse after about 10 episodes in the previous year). Condoms failed less often in oral than anal sex, but estimated risk of failure also decreased with experience.

CONCLUSIONS

Gay men should be especially cautious the first few times they use a condom; after moderate experience, however, they may expect a low risk of condom failure.

A meta-analysis of condom effectiveness in reducing sexually transmitted HIV

Before condoms can be considered as a prophylaxis for sexually transmitted human immunodeficiency virus (HIV), their efficacy must be considered. This paper reviews evidence on condom effectiveness in reducing the risk of heterosexually transmitted human HIV. A meta-analysis conducted on data from in vivo studies of HIV discordant sexual partners is used to estimate the protective effect of condoms. Although contraceptive research indicates that condoms are 87% effective in preventing pregnancy, results of HIV transmission studies indicate that condoms may reduce risk of HIV infection by approximately 69%. Thus, efficacy may be much lower than commonly assumed, although results should be viewed tentatively due to design limitations in the original studies.

How often do condoms break or slip off in use?

Men attending 3 sexually transmissible disease clinics and a university health service in Sydney were given a questionnaire asking how many condoms they had used in the past year and how many broke during application or use or slipped off. Respondents were 544 men aged 18 to 54 years. Of these, 402 men reported using 13,691 condoms for vaginal or anal intercourse; 7.3% reportedly broke during application or use and 4.4% slipped off. Men having sex with men reported slightly higher slippage rates than those having sex with women. Breakage and slippage were unevenly distributed among the sample: a few men experienced very high failure rates. A volunteer subsample reported 3 months later on condoms supplied to them: 36 men used 529 condoms, of which 2.8% broke during application or use and 3.4% slipped off. Many of these failures pose no risk to the user, especially those occurring during application, as long as they are noticed at the time, but failure may discourage future use. Research is needed to identify user behaviours related to breakage.

Altered surface character of stretched condom latex

A new type of imperfection in condom latex, present during moderate stretching, was observed by low magnification scanning electron microscopy. The normally smooth surface of relaxed natural latex was transformed into an accordion-like arrangement of ripples in addition to tears. A corollary experiment with Alcian blue dye placed into both stretched and unstretched condoms leaked no dye. These surface features are consistent with latex acting as a molecular barrier. The tears may represent areas of lowered mechanical resistance and raise questions concerning quality control.

Failure rate of condoms during anogenital intercourse in homosexual men

Two hundred and seventy seven homosexual men participating in an AIDS study in Amsterdam, The Netherlands, were interviewed in July to December 1986 regarding their experiences with the use of condoms during anogenital intercourse. It appeared that in many cases the condoms used could not be described as reliable, or were not used safely. In 8% (117/1468) of cases the condom tore or slipped off. When different condoms were compared, it was seen that "qualified" anal condoms functioned best. Other anal condoms functioned worse, and in many cases even worse than classic vaginal condoms. Whether these differences exclusively depended on differences in quality cannot be assessed. Men who buy a qualified anal condom are possibly more motivated and thus also less likely to have failures. Regarding the apparent unreliability of the condoms used, homosexual men are advised to refrain from anogenital intercourse. When this is not feasible, a qualified anal condom should be used.

Are general practitioners ready to prevent the spread of HIV?

General practitioners are excellently placed to assess a person's risk of being infected with the human immunodeficiency virus (HIV) and to give advice on reducing that risk. Their attitudes to the acquired immune deficiency syndrome (AIDS) and infection with HIV are, however, unknown. A questionnaire survey of 196 general practitioners in East Berkshire Health District was used to assess general practitioners' readiness to undertake opportunistic health education to prevent the spread of infection with HIV. Altogether 132 replied. Sixty four of them expressed little interest in health education about HIV, and one in six would not dissent from the notion that AIDS could be controlled only by criminalising homosexuality. Only 75 of them had initiated discussions about HIV with patients. Moreover, many underestimated the risks from heterosexual sex while exaggerating the risks from non-sexual contact. Advice from general practitioners if given extensively might reduce the spread of infection with HIV. How best this may be achieved needs to be considered urgently.

Condoms to prevent HIV transmission do not imply truly safe sex

30 female prostitutes and 16 persons from the hospital staff each tested 10 latex condoms by vaginal intercourse. Six dropped out. Condom rupture occurred at least once for 7/40 persons (95% confidence interval 7-33%). Total condom rupture rate was 5%. Although encouragement to condom use is prudent in an epidemiological scale, truly safe sex with an HIV-positive partner using condoms is a dangerous illusion.