If Less Than 17 Percent of Gay Men are Using Condoms Every Time, Where Do We Go From Here? Pt. 1
Posted 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.

Posted By: Positive Frontiers  

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  1. Mark Hubbard posted on 03/12/2013 04:07 PM
    I appreciate the mention from Brendon in this article very much. I really like the piece, and think Brandon gets it right in the body of the article.

    That it's perilous to attempt to summarize very specific science findings, however, is demonstrated in the second paragraph, which is extremely problematic in terms of being confusing and inaccurate.

    First, a 70% reduction of risk of acquisition does NOT mean that condoms "effectively prevent the spread 70 percent of the time." It's more complicated than that and it conflates the device with its use.

    70% is a reduction in relative risk. We want to avoid leading people to believe that 70% is a) as a measure of the performance of the device alone, and b) as a measure of absolute effectiveness - in other words we don't want folks to imagine that 7 out of 10 folks who use condoms will become infected. That's far from true.

    Second, the 70% comes from a different subset of the data set than the 16.4%. Any attempt to draw a direct connection between the two figures is destined to confuse or mislead but this one is just plain wrong.

    The relative reduction in risk realized did NOT come exclusively from the small percentage of persons who reported "always" use in every period. It came from all the men who reported "always" use in any period, and to some small extent it could have come from others.

    I is true that Dawn's analysis found that the *relative level* of protection for those who describe themselves as "sometimes users" was indistinguishable from those who describe themselves as "never users," most likely because of the accumulation of risk while having anal sex with positive partners. Media hasn't highlighted, however, that Dawn reported finding that signficantly higher condom use was associated with having partners of "unknown" or "positive" HIV status.

    My suggested replacement for the paragraph would be:

    "The important takeaway is that men who reported "always" condom use experienced 70% likelihood of contracting HIV compared to those who reported "never" use. Interestingly,, only 16.4% of men reported "always condom use in every period they were questioned."
    1. Mark Hubbard posted on 03/13/2013 05:48 AM
      @Mark Hubbard A couple of corrections to my post above:
      In the 4th paragraph I should have written: “in other words we don't want folks to imagine that 3 out of 10 folks who use condoms will become infected”

      and in the 6th paragraph, I should have omitted the phrase “and to some small extent it could have come from others.”

      Corrected post below:
      -----------------------------
      “I appreciate the mention from Brendon in this article very much. I really like the piece, and think Brandon gets it right in the body of the article.

      That it's perilous to attempt to summarize very specific science findings, however, is demonstrated in the second paragraph, which is extremely problematic in terms of being confusing and inaccurate.

      First, a 70% reduction of risk of acquisition does NOT mean that condoms "effectively prevent the spread 70 percent of the time." It's more complicated than that and it conflates the device with its use.

      70% is a reduction in relative risk. We want to avoid leading people to believe that 70% is a) as a measure of the performance of the device alone, and b) as a measure of absolute effectiveness - in other words we don't want folks to imagine that 3 out of 10 folks who use condoms will become infected. That's far from true.

      Second, the 70% comes from a different subset of the data set than the 16.4%. Any attempt to draw a direct connection between the two figures is destined to confuse or mislead but this one is just plain wrong.

      The relative reduction in risk realized did NOT come exclusively from the small percentage of persons who reported "always" use in every period. It came from all the men who reported "always" use in any period.

      It is true that Dawn's analysis found that the *relative level* of protection for those who describe themselves as "sometimes users" was indistinguishable from those who describe themselves as "never users," most likely because of the accumulation of risk while having anal sex with positive partners. Media hasn't highlighted, however, that Dawn reported finding that significantly higher condom use was associated with having partners of "unknown" or "positive" HIV status.

      My suggested replacement for the paragraph would be:

      "The important takeaway is that men who reported "always" condom use experienced 70% likelihood of contracting HIV compared to those who reported "never" use. Interestingly,, only 16.4% of men reported "always" condom use in every period they were questioned."
    2. Mark Hubbard posted on 03/13/2013 09:36 AM
      @Mark Hubbard Eating humble pie this morning, the "corrected" post still contained a glaring error. A 3rd attempt:

      My apologies.

      A couple of corrections to my post above:
      In the 4th paragraph I should have written: “in other words we don't want folks to imagine that 3 out of 10 folks who use condoms will become infected”

      In the 6th paragraph, I should have omitted the phrase “and to some small extent it could have come from others.”

      My suggested replacement paragraph should have said:

      "The important takeaway is that men who reported "always" condom use experienced a 70% reduction in the likelihood of contracting HIV compared to those who reported "never" use. Interestingly,, only 16.4% of men reported "always" condom use in every period they were questioned."

      Corrected post below:
      -----------------------------
      “I appreciate the mention from Brendon in this article very much. I really like the piece, and think Brandon gets it right in the body of the article.

      That it's perilous to attempt to summarize very specific science findings, however, is demonstrated in the second paragraph, which is extremely problematic in terms of being confusing and inaccurate.

      First, a 70% reduction of risk of acquisition does NOT mean that condoms "effectively prevent the spread 70 percent of the time." It's more complicated than that and it conflates the device with its use.

      70% is a reduction in relative risk. We want to avoid leading people to believe that 70% is a) as a measure of the performance of the device alone, and b) as a measure of absolute effectiveness - in other words we don't want folks to imagine that 3 out of 10 folks who use condoms will become infected. That's far from true.

      Second, the 70% comes from a different subset of the data set than the 16.4%. Any attempt to draw a direct connection between the two figures is destined to confuse or mislead but this one is just plain wrong.

      The relative reduction in risk realized did NOT come exclusively from the small percentage of persons who reported "always" use in every period. It came from all the men who reported "always" use in any period.

      It is true that Dawn's analysis found that the *relative level* of protection for those who describe themselves as "sometimes users" was indistinguishable from those who describe themselves as "never users," most likely because of the accumulation of risk while having anal sex with positive partners. Media hasn't highlighted, however, that Dawn reported finding that significantly higher condom use was associated with having partners of "unknown" or "positive" HIV status.

      My suggested replacement for the paragraph would be:

      "The important takeaway is that men who reported "always" condom use experienced a 70% reduction in the likelihood of contracting HIV compared to those who reported "never" use. Interestingly,, only 16.4% of men reported "always" condom use in every period they were questioned."
  2. Doug Moon posted on 03/13/2013 08:14 AM
    Two things from a gay man that spent two decades on the front lines of HIV prevention education, policy, research, and practice...

    The article, and I fear the CDC, neglects the strategy (or the data just aren't mentioned) that gay men use to negotiate the relative importance of using condoms during any one encounter. If we have tested negative-- or positive--and can be honest with one another about and during intimate settings, we are more likely to make better choices, especially when to or if to wear condoms. Not every condo less encounter carries the same level of risk--and we know that.

    It is not a strategy without its challenges. Compared to condom use forever, whenever, whatever, it's a path much more pursued in reality. Building competence and community norms that promote healthier and honest choices about behaviour is needed, and a political backbone among public health professionals and legislators is needed.

    As far as the second point, I defer to a friend, who said to me years ago, "Give us reasons to live, and we can figure out how to use condoms." We need to push back homophobia, and racism, and classism, and ageism, and looksism, within and outside our communities. Setting all the collective stages properly, if not lovingly, will serve us well.
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