If Less Than 17 Percent of Gay Men are Using Condoms Every Time, Where Do We Go From Here? Pt. 1
3/12/2013 1:50:00 PM
Recently a researcher working for the CDC named Dawn Smith made headlines when she gave a presentation at the most recent CROI on the efficacy of condom use by men who have sex with men at preventing the spread of HIV. It is the first study of its kind since the Reagan administration.
The important takeaway is that only 16.4 percent of MSM are using a condom every single time they have sex, and for that small fraction of men, condoms effectively prevent the spread of HIV 70 percent of the time.
These are figures that should give any person who is passionate about ending the the epidemic a serious, concern-fueled pause.
In his most recent column for our “My Life on PrEP” series, Jake Sobo takes a look at this presentation and makes a very compelling argument that it is time to end the “condoms only” approach to sex education, and that it is time to “build a new framework for HIV prevention” that includes biomedical interventions such as PrEP, “Treatment as Prevention” and other strategies.
It’s a great piece, and if you haven’t read it, I encourage you to. But since it went up I have received many emails asking me for clarification on what these numbers really mean, and if we intend to abandon a “condoms-only” strategy to end the epidemic, what do we put in its place?
First of all, lets dig into the presentation. It is an oral abstract awaiting peer review, which might normally give me pause. But the study was done at the behest of the CDC using data culled from two previous studies—EXPLORE, which was a large behavioral intervention study running from 1999 to 2001, and the VAX004 HIV vaccine trial, which ran from 1998 to 1999. Both were subject to high levels of scientific scrutiny and had the benefit of collecting data over several years.The data is pretty solid.
Side note: Many of you are probably asking, “Why would we use this kind of second-hand data? Why not do a longterm clinical study on the effectiveness of condoms?” And the answer is that we can’t for both ethical and practical reasons. Clinical studies require a control group, which in this case would by necessity be men we denied condoms. I think we can all agree that would be kind of monstrous.
Without veering into “Dr. Mengele” territory, this kind of science is probably the best we can do.
Now lets get into the numbers. How can it be possible that for the 16.4 percent of men who say they use a condom every time, condoms are only preventing seven out of 10 HIV infections?
It is important to remember that these numbers reflect self-reported consistent condom use over a period of several years, not any one sexual encounter. Consistent use doesn’t necessarily indicate proper use. Used as directed—by choosing condoms of the appropriate size, applying lube inside and outside of the condom and changing the condom every 30 minutes—the efficacy of condoms at preventing the spread of HIV during any one sexual encounter are almost certainly much greater than 70 percent, possibly even as high as the 99.9 percent often advertised.
But condoms are frequently used in less than ideal situations, in the heat of the moment and under the influence of substances that impair our judgement.
What this study is really telling us is that nobody is perfect, everybody makes mistakes and over time, those mistakes add up to a statistically significant possibility, even when a condom is used every time. When you are only using condoms “sometimes,” that possibility of contracting HIV starts to look more like a probability.
That is the piece of the equation that most of the media coverage has focused on. And while it is an interesting and important piece of tactical information, the real headline news is that after 30 years and millions upon millions of dollars that have been poured into “condoms only” safe-sex campaigns, less than 17 percent of men who have sex with men are reporting that they do in fact use a condom every time they have sex.
And it is probably even lower than that. Keep in mind this data comes from self-reporting. And when it comes to socially taboo subjects like engaging in sex without condoms, people often lie, especially to their doctors. So we can safely assume that 16.4 percent of gay men who use a condom “every time” is an overestimate.
It breaks my heart to say this, but our primary strategy in combating the spread of HIV these past 30 years has been a failure.
As Josh Kruger recently wrote, when it comes to gay men, “condoms only” is no better than “abstinence only.”
So where do we go from here?
Tune in tomorrow for part two of this discussion, where we will look at alternatives to “condoms only” HIV prevention strategies.
A special thank you to Michael Lorin Friedman, Aaron A. Stella, Trevor Hoppe, Josh Kruger and especially Mark “Middle” Hubbard for a series of excellent conversations that helped me to really broaden my understanding of the underlying science of Dawn Knight’s CROI presentation.
And, as always, I invite you to follow me on Twitter at twitter.com/brenshu and join me on Facebook.