TO A CONDOM
TO BE 10%
The Boston Globe June 22, 2003, Sunday
By John Donnelly, Globe Staff section: National/Foreign; pg. a19
WASHINGTON -A draft report for the UN’s AIDS agency has found that even when people use condoms consistently, the failure rate for protection against HIV is an estimated 10 percent, making them a larger risk than portrayed by many advocate groups.
The report, which looked at two decades of scientific literature on condoms, is likely to add fuel to a heated political battle on US policy in fighting AIDS in the developing world.
The debate pits proponents of abstinence, who say that the Bush administration should abandon or sharply reduce condom promotion, against health specialists, who say that condoms play an integral part in preventing the spread of AIDS. The disease has killed more than 20 million people worldwide and now infects 42 million. In previous reports, condom effectiveness against HIV, the virus that causes AIDS, has been widely estimated at between 46 percent and 100 percent. Many advocates of condoms have said they provide nearly 100 percent protection when used correctly.
UNAIDS has voiced hope that the report, which was viewed by the Globe, not only clears up confusion over condom effectiveness but also helps educate people in the United States and worldwide about how to use condoms properly.
The conclusions do not mean that every tenth condom is defective, but rather that something has gone wrong in about 10 percent of their use. In many cases, specialists said, human error is the source of the failure, resulting in condoms slipping off, breaking, or not being put on early enough.
The report is under review by UNAIDS, and a final version will not be released until the end of the month. The organization’s top science adviser said the 10 percent failure estimate was “reasonable.”
The leading author on the report, Norman Hearst, a professor at the University of California at San Francisco, “makes a cogent argument that we should be talking about safer sex, not safe sex, with condoms,” said Catherine A. Hankins, a chief scientific adviser to UNAIDS. The report also said that the failure rate to protect against HIV was probably the same in preventing pregnancies.
Edward C. Green, a senior research scientist at the Harvard School of Public Health, said that the data on condom effectiveness should help set policy and that people in developing countries should know about that risk.
One chance in 10 of condom failure is “not good enough for a fatal disease,” Green said. “The way condoms are marketed in Africa and other developing parts of the world is as if they were 100 percent safe. Condoms have brand names like Shield and Protector that gives the impression that they are 100 percent safe.”
Shepherd Smith, president of the Institute for Youth Development, a group that advocates abstinence, also said the draft report and other reports should lead to an evaluation of HIV-prevention efforts.
“We took an idea that was unproven in the ‘80s, said this was what’s going to work in this epidemic, and clearly it hasn’t,” he said. “The data doesn’t support it.”
Condom promoters have long said that condoms can provide almost complete protection against HIV.
For instance, a September 2002 report, “Condoms Count,” published by Population Action International, a Washington-based policy advocacy group, said, “Public health experts around the globe agree that condoms block contact with bodily fluids that can carry the HIV virus and have nearly 100 percent effectiveness when used correctly and consistently.”
One of its cited sources was a 2001 National Institutes of Health report. The report, which involved four government agencies, 28 condom specialists, and a review of 138 scientific papers, found that “consistent condom use decreased the risk of HIV/ AIDS transmission by approximately 85 percent.”
The National Institutes of Health and draft UNAIDS reports cited inherent difficulties in coming to such an estimate. Health analysts said the only way to arrive at such a figure is to examine a combination of data: interviews with sexually active heterosexual couples; self-reported data on condom use; and long-term HIV testing of uninfected people.
Nada Chaya, a senior research associate at Population Action International and the lead author of “ Condoms Count,” said of the “nearly 100 percent effectiveness” claim, “technically we are right, if condoms are used correctly and consistently.”
She said her group and others “should carry more responsibility” in telling people that condoms do not completely protect against HIV. “There is no safe sex,” she said. “Safer sex? Yes.”
Terri Bartlett, the group’s vice president for public policy, expressed concern that proponents of abstinence alone would use the 10 percent failure estimate to reduce condom availability. This, she said, would lead to more people becoming infected with the deadly virus.
“We are in the midst of a battle in which the opposition seeks to exclude condoms from the mix of HIV prevention,” she said. “It’s an old saying, but vows of abstinence break more often than condoms.”
The review over condom effectiveness closely follows Congress’s passage of President Bush’s $15 billion plan to fight AIDS during the next five years. The president repeatedly has said that nations should follow the example of Uganda, which engineered a dramatic reversal of HIV infection rates in the 1990s through strong political leadership and the ABC program, which stands for abstinence, being faithful to one partner, and, if that fails, use of condoms.
Abstinence advocates, which include many faith-based groups, seized on the Uganda example, cited relatively low condom use there, and won a provision in the legislation that said one-third of the AIDS prevention money must be used in abstinence programs by the third year of the five-year plan.
Green, the Harvard research scientist, and many public health specialists said that a comprehensive approach must be used to fight AIDS and that the most important part of the ABC approach probably is B -being faithful to one partner.
“If we tell youth that if you use condoms, you will be safe, then we are actually fueling the epidemic,” said Vinand M. Nantulya, senior health adviser at the Global Fund to Fight AIDS, Tuberculosis, and Malaria.
Nantulya, formerly a key adviser to President Yoweri Museveni of Uganda, said the key lesson from Uganda was “that it wasn’t a choice between abstinence or condoms, but that it was everything. In Uganda, we promoted condoms in the context of if you stray, use a condom. “
Hankins, the UNAIDS adviser, also argued for a combination of approaches to fight AIDS and said that each country, and areas inside countries, require tailored responses to the epidemic. She said condoms had a role everywhere. The key now, she said, was to teach correct ways to use them.
The most frequent errors: men don’t leave enough space at the end of the condom to collect the sperm; not using lubrication, which reduces the risk of the condom breaking; and not putting on a condom prior to genital contact.
“We need a combination of prevention, postponing sexual activities, reducing partners, and using condoms,” Hankins said.
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