Chapter 6: Condoms Are Unsafe for HIV Prevention?

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The Truth About AIDS

 

Whenever I talk to young people in Africa, India or Europe about AIDS I find the same thing: they think that using a condom will prevent them from getting HIV. The truth is that it may greatly reduce the risk, but I wouldn't trust my life to a condom.

As every doctor knows, condoms are unreliable. If a hundred couples use condoms for contraception, up to fifteen of them could be in clinics each year asking for abortions. If you are about to take a risk, you should use one, it could save your life, but don't kid yourself it's totally safe. For a start they vary in quality. A survey of 50,000 condoms from 110 brands on sale in Europe, Brazil, Indonesia and Thailand showed only 3% to be `very good' (strength, aging, no holes), 48% `poor' or `very poor'. No condoms on sale in Italy, Portugal or Spain were `very good'.

In one UK survey, holes were found in up to thirty-two out of a hundred condoms of the least reliable makes. These holes were gross defects, not microscopic holes seen in some latex (5 micron, HIV is 0.1 micron), which are worrying but probably far less significant. The British Standards Institute permits up to three out of a hundred to have holes in them when they leave the factory. In the US, government standards allow only four condoms out of every thousand to have leaks. But users still experience a failure rate of between 3% and 15%, which is the percentage of women who have an unwanted pregnancy using this method of birth control over a year.

A spokesman from the London Rubber Company (Durex) admitted that if incorrectly used, the failure rate of condoms could be anything from 25% up to 100%, and there are real problems with teaching people how to use them---not least because of illiteracy.

The condom is the least reliable contraceptive in wide use---it's as bad as the diaphragm or cap with spermicide. Many violently disagree. They say it is a superb contraceptive, it is people who are unreliable: they put it on too late or inside out, tear it, forget it, let it fall off. They say people are unreliable but the condom is reliable, if properly used. It is easy to have an accident with a condom. Condoms are unreliable compared to, for example, the pill. That is why the pill is so popular---not just because it is a more convenient method.

Things are worse than they appear from the pregnancy rates. Out of 100 couples, ten will have great difficulty in conceiving anyway. Five will probably never be able to conceive for various reasons, including previous infections with sexually-transmitted diseases.

After four months of trying to conceive, only about half of an average group of women will succeed in becoming pregnant. If they used a perfectly safe method two out of three times that they had intercourse, it would take a year for half to become pregnant. If they used the method for ten out of twelve months of the year, then twenty-five out of a hundred could be expected to get pregnant in a year. If they had unprotected sex for one month a year and used the method for eleven months, then it could be expected that over twelve would become pregnant in a year.

What this means is that if condoms produce a failure rate of around twelve in a hundred per year, then they must be leaking often. It is about the same thing as having intercourse for a whole month without any protection at all but taking the pill the rest of the year. Somehow or other secretions from a man and a woman are very frequently meeting each other.

This conclusion is confirmed by a study of 2,000 acts of intercourse by eighty heterosexual and seven homosexual couples, with fourteen types of condoms. The overall failure rate from slippage or rupture was 11.3%, even higher than the one in twelve (8.3%) theoretical rate predicted above.

Think about it: a woman can only become pregnant on three days a month---while ovulating and shortly afterwards. After a single accident with a condom there is only a one in ten or so chance of it being a fertile day anyway. Even if it were, pregnancy may not follow. However, it is possible to catch HIV infection every day of the month. The overall risk of pregnancy after one episode of unprotected sex is 2--4%; the risk of HIV from an infected partner after unprotected vaginal sex is probably 0.5%, or 1 in 200 in the absence of other sexually-transmitted diseases. An increasing number of people have become pregnant because they switched from a more reliable contraceptive to the condom because of AIDS.

If up to fifteen out of a hundred couples each year are actually managing to conceive despite condom use, there must be frequent accidents---probably one time out of twelve, from the figures above. If you are having sex regularly with an infected person, it is like throwing dice. Every time you throw a twelve is how often the condom has let you down. Would you trust your life to a condom? Remember that one episode of unprotected sex can be enough to infect you. Over the next few years there will be a growing number of angry men and women who have become infected, despite their using a condom, having thought they were safe.

Various reports have been published on couples using condoms where only one partner is positive. In one study, up to a quarter of the partners became infected with HIV in only one to three years, despite use of the condom. Others may say these people were careless. All I am saying is that if correctly used, the condom can be a reliable contraceptive and will almost certainly reduce enormously your risk of getting AIDS, but the reports show that it is hard to use safely.

Another study of partners using condoms suggests that the risk of catching HIV is reduced by 85%. That sounds excellent, but it is not. If you persist in sleeping regularly with someone who is positive or with numbers of unknown people who are possibly positive, then eventually, condom or no condom, you may get AIDS. Vaginal or anal sex using a condom is not a low-risk or no-risk activity. It carries a medium risk at best.

World Health Organisation: `The most effective way to prevent sexual transmission of HIV is to abstain, or for two people who are not infected to be faithful to one another. Alternatively, the correct use of a condom will reduce the risk significantly.'

World AIDS Day 1991 and 1992.

A calculation can be as follows. Let us assume the estimate many use is correct that the risk of transmission is roughly one in 200 per episode of unprotected sex with an infected partner. Let us assume 95% protection from the condom for the sake of argument, or a twenty-fold risk reduction. This would give a total risk of one in 4,000 per episode of protected sex. Let us assume a couple has sex just under three times a week, or 150 times a year. The risk of the partner becoming infected in one year despite using a condom then becomes 3.7% or almost 20% in five years. If we only rate the condom protection as 90% instead of 95%, then the five-year infection rate could rise to 40% or 7.4% per year.

How do these theoretical estimates fit with experience? An Italian study of almost 400 women with infected partners found the following:

bullet 1.2% always using condoms were infected per year overall.
bullet 7.3% not using condoms regularly infected per year overall.
bullet 12.3% not using condoms regularly with highly-infectious partners became infected per year.
bullet 2.6% not using condoms regularly with partners of low infectiousness became infected per year.

Partners were considered highly infectious if their white cell (CD4) counts were low or if they were becoming unwell. Inconsistent condom use increased risk around six times. Anal sex doubled the risk. AIDS in the partner trebled the risk.

In another study, almost 200 women with HIV-infected haemophiliac partners were studied. Between 1985 and 1992, one in ten became infected. The risk of infection increased with time as the men deteriorated. It is very difficult to obtain meaningful figures for these risks because there are a number of variables: stage of infection, sexual practice, presence of other sex diseases, frequency of intercourse, frequency of condom use. For this reason different studies can give varying results.

A combined European study of 563 heterosexuals with infected partners in stable relationships from nine countries was carried out between 1987 and 1991. People were enrolled in the study month by month so some were part of it for only a short time. Altogether, 12% of the men and 20% of the women became infected. Risk increased to men with stage of illness, and intercourse during menstruation. For women the risk increased with her age, stage of the man's infection and anal intercourse. None of twenty-four couples always using condoms became infected.

We do not know what the risk is from a single sexual contact with someone who is positive. It certainly depends on many other factors such as whether either partner also has gonorrhoea or syphilis. Any sores will be full of white cells and virus. Circumcision reduces risk. It seems people are most infectious for the first twelve to fifteen weeks after infection with HIV, and then years later when beginning to feel unwell again. Some individuals may be more susceptible than others genetically. In conclusion, it seems the risk from a single accident with a condom or a single unprotected contact is small, but some have become infected this way.

Condom manufacturers' literature states that condoms are designed for vaginal sex only and are not suitable for protection from HIV transmission by the anal route. Particularly hazardous is the use of oil-based lubricants as these rot the rubber in minutes. Recently, some new `extra strong' condoms have been marketed with lower failure rates for anal intercourse.

What is safe sex?

So what is the correct health message? It is that condoms do not make sex safe, they simply make it safer. Safe sex is sex between two partners who are not infected. This means a partnership between two people who are uninfected---perhaps they were virgins---and who now remain faithful to each other for life and do not inject drugs. If you are going to have sex in an unsafe situation you are foolish indeed not to use a condom, and you must use it very carefully every single time. But don't kid yourself that you will never get AIDS. (See previous chapter for further background on risks.)

Because condom use also provides a measure of protection against other sexually-transmitted diseases, and because genital ulceration caused by them makes the body so vulnerable to HIV, it may be that a key part of condom protection is reducing the incidence of ulceration. This is so particularly in developing countries.

How to use a condom more safely

A condom is tightly rolled up. Make sure it is the right way around. It will only unroll one way. If you have sex in the dark you may need to turn the light on. The teat at the end is there to collect all semen and fluids from the man. This needs to be squeezed empty of air or the condom may leak. With one hand holding the teat, the other is used to roll the condom gently over the entire length of the erect penis. This needs to happen soon after the man is aroused for two reasons: first a small amount of fluid emerges from the end of the penis during arousal as part of the body's natural lubrication before the man enters the woman. This can be full of virus. Secondly, a woman produces a lot of secretions during arousal for lubrication. These may also contain virus if a woman is infected. The early use of the condom is to keep any genital contact separate from the start.

Wear and tear

A woman usually takes longer than a man to become fully aroused and will usually find things more satisfying if there is continuing caressing before her partner enters her. During this period a condom may unroll partly or fall off altogether. It may also suffer general wear and tear. It can snag on a woman's jewellery or on her fingernails. This can happen if, as advocates of condoms suggest, the woman helps the man put on the condom as part of lovemaking. Damage is usually obvious early on. The real danger time can be when a woman helps her partner come inside her. Fingernails and jewellery can cause a minute tear in the condom which enlarges during intercourse. The result is discovered on withdrawal.

Rapid exit

Withdrawal must be prompt for two reasons: first there is a small risk of semen leakage along the shaft of the penis, especially if the teat was full of air. Secondly, as soon as a man has reached climax, the penis starts to soften and what was a tight fit becomes a very loose fit. Condoms can easily leak or slip off inside a woman. The condom end must be held gently as the man withdraws.

Most people dislike using condoms

A huge international campaign has been carried out to try and make the condom more acceptable. When used carefully as above there is no doubt in many couples' minds that it is disruptive and they dislike it: it is a real turn-off. It is the same in countries like the US or African nations. What's so romantic about a condom? After all, that is one reason why people stopped using condoms when the pill came along. The other was unreliability and constant fear of pregnancy. It was the pill, not the condom, that brought about the so-called sexual revolution of the 1960s.

1. ´To put it on carefully takes precious seconds out of a continuing experience. Some men find that by the time they have got it on so they are happy it is comfortable (may need a couple of tries), their erection has disappeared. A woman is left hanging around and rapidly loses her momentum. Trying to find where you put one, opening the packet, and getting it on correctly can be a joke, but it is disruptive.

2. ´Making sure it does not roll off can cause tension in the pre-intercourse stage of lovemaking.

3. ´Checking it is still intact immediately before entry causes further delay.

4. ´Many men say that the layer of rubber reduces what they can feel (although some who tend to ejaculate too early may find that an advantage). Some women dislike the thought of a piece of rubber in such a personal area.

5. ´For many couples a central part of their celebration of oneness is to be lying together, with the man inside, immediately after both are satisfied. Many people enjoy being able to `cool off' in each other's arms like this. Correct condom use requires the man to withdraw immediately. Some see it as a rather abrupt and savage end to a marvellous experience.

6. ´Some find disposing of the used condom rather revolting. The best method is to tie it up carefully, wrap it up in toilet paper, and flush it away.

In addition there is another vital factor: the very fact that a condom is being used, other than merely to provide some protection against pregnancy, implies slight anxiety about whether a partner is infected. This can cause tension.

Are people using condoms more?

It is extremely difficult for a woman who has no boyfriend at the moment to buy a packet of condoms and keep one in her bag, because in doing so she is having to admit to herself and a prospective partner that she plans to have sex soon with someone perhaps she hardly knows. When she goes out for the evening it can be hard for her to take a condom. In doing so she is admitting that she might have sex with someone tonight. Many women feel carrying a condom makes them look promiscuous, when they feel they are not. A further major problem is when to produce it. A romantic evening is turning rapidly into something more. Are you going to show you don't trust the other person by reaching for a condom? Will the other person take offence at you implying that he or she has been sleeping around? Insisting on a condom may take a lot of self-confidence and courage on the part of the woman. Female condoms may be easier, although pregnancy failure rates can be as high as 12%.

Because there are so many natural social barriers to condom use, a major part of some prevention campaigns has been the message: `Be confident in presenting your partner with a condom.'

How to minimise the disruption

Be prepared. Talk it through with your partner. Practise! But there is another way: change your lifestyle. So many pamphlets tell us how wonderful `safe sex' is. They say how fulfilling it is just to rub bodies together and have a cuddle. They describe a vast number of other things people can do to have sex safely together. That is not what most people call sex .

The choice is so obvious and clear. Find someone you love and trust---someone who is not infected at the moment and will remain faithful to you for life and to whom you will remain faithful. Then you can enjoy unlimited, anxiety-free sex.

Free love

You may reject this. Your philosophy is that if people want to they can sleep together without any great relationship or strings attached. `We live in a free world and people should be free to do what they like.' Maybe you feel that ultimately you want to be married but you want to have fun now. Friends of mine are afraid that their relationships will become tame and boring if they get married. `A piece of paper won't make me love her any more.'

I am constantly seeing the casualties of this, and they are usually women. Life is unfair. Somehow it is usually the woman who comes off worse: she is the one who becomes pregnant and her risk of catching HIV is twice as great as the man's risk from her. She suffers the chronic pain of pelvic inflammatory disease and cervical cancer. And the woman is often the one who is most devastated when a relationship breaks up.

Free love is fine until your lover leaves you at forty-three years of age, and you still have had no children because he would have walked out. A whole generation of people is growing older. Pensioners of tomorrow with no wives, no husbands, no children, no family---only a few casual relationships and old memories. No wonder many are deciding that enough is enough: the right person has not come along so they are staying single and celibate, yet forming long-lasting, warm, caring friendships.

Someone was saying in a newspaper article once how exciting it was to commit adultery. She was saying there was nothing wrong in it. There were some angry letters. One woman said that adultery was wrong for lots of reasons: for her it had meant an elaborate web of cheating, deceits, small lies and big lies. The total betrayal of the trust of another. No wonder it causes such terrible bitterness and hurt. Adultery wrecks marriages and damages children. Surely this is not the best plan for human relationships.

Women leading the way

There are huge differences between the attitudes of boys and the girls in many countries. Some boys want to `score' with as many girls as possible. Their reputations and image may depend on sleeping with every girl they go out with. Many girls are disgusted. They want commitment, friendship, companionship, security---and then they would give themselves in other ways. Romantic ideals live on even though there has been a trend in some Western nations for girls to take the lead a lot more in relationships, and in sexual conquests.

In most countries marriage remains very popular, with girls leading the way. I find similar differences expressed almost every time I go into a school to take an AIDS lesson. Girls are often more worried about consequences of sex than boys. Many boys could not care less. It is the girls who seem to worry most about getting pregnant or being let down. Part of the next education phase needs to be to teenage girls and young women, many of whom need little convincing about the desirability of being in a warm, loving, caring, exclusive relationship. This strategy should be designed to give them moral support when under pressure, not to `sell themselves cheap'.

It is strange that many men want easy women to have fun with, but deep down prefer by far the thought of marrying a virgin. We need to cultivate a new age where romance is in, self-respect is in, faithfulness is in, marriage is in. I don't think it's clever to sleep around or get divorced.

The people I admire are those who work at relationships, who are good at relationships, who have good happy marriages, who can handle things. What's so smart about walking out on every problem? I respect and admire, too, those people who have made a positive decision---for whatever reason---to remain single and celibate.

Advice to someone married to a `positive' spouse

You may be afraid you or your spouse are already positive. For many women with partners infected through medical treatments it has been a terrible shock to discover that their partner may have been HIV-infected several years before, without either of them realising.

This is an agonising situation, in addition to many others where one or other partner is known to be infected through other routes.

Such knowledge can place a severe strain on even the strongest relationships. One big question is over the future of the sexual relationship. Will it continue? What adjustments need to be made? To what degree does the uninfected person wish to `take a chance'? There are no right or wrong answers, and each couple will need to find their own way forward, with the help of those experienced in HIV counselling.

The important thing is to realise that many people are still uninfected after several months, or even years. As we have seen, it seems that the risk of infection rises when the person becomes ill. Before then the risk may be much lower. You may want to be tested yourself. If you are positive, neither of you need to take as many precautions. If you are negative, then the following is sensible:

1. ´Use a thick strong condom carefully---see earlier in the chapter.

2. ´You may want to reduce the frequency of your lovemaking where the end result is penetrative sex, but be sensible. Stopping altogether may cause terrible tensions and actually result in a rushed mistake. Arousal may be much stronger after abstinence and then it is not as easy to be careful. Do not make love while a woman is menstruating, if she is positive, as the blood will probably contain virus. Explore many other ways to express love and affection through sensuous, arousing, intimate touch.

3. ´Deep kissing, where saliva may pass from one mouth to another, is probably not a good idea. Dry kissing carries a much, much lower risk. Oral sex is not sensible.

4. ´An infected woman should probably avoid pregnancy as there is a significant chance that any child born may also be infected. So use a second method of contraception as well, eg the pill, or consider sterilisation very seriously.

This is a very difficult and traumatic area.

In this chapter we have looked only at condom effectiveness and risk reduction using them. There are, however, major questions over their promotion in many developing countries. In African nations or in South East Asia, for example, condoms may be unaffordable, unacceptable and difficult to obtain. There are also many ethical questions linked to the promotion of condoms, especially in the minds of many church leaders. We look in more detail at these issues in Chapter 14.

We have looked at the whole issue of the spread of AIDS and some ways to reduce the risks of getting infected, but we have never been faced with a disease which confronts us with so many conflicting moral choices to do with rights and freedom. Some of these issues threaten to tear society apart. We consider the most important of these in the next chapter.

The Truth About AIDS

 

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