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not another hypothetical risk question
Apr 3, 2006

Hi Dr Bob: After finding out that my bf was HIV positive, I've been a regular in this great site, mining for as much information as I can find and process. I understand people's fears, but somehow I grow tired of the "5 years ago I touched a handkerchief that a prostitute had used to wipe her butt, I washed my hands with bleach 432 times after that and my ELISA, western and PCR came back negative 3, 6, 12 and 24 months after that, what should I do?" type of question. So here are my questions, from a neg. guy who regularly engages in protected sex with a pos. guy: 1- When they say that condoms offer at least 85% protection against HIV, do they mean that out of 100 episodes of protected sex with a pos. individual, 15 result in transmission? I guess not, but what do they actually mean? 2 - The HIV specialist my bf is seeing told him that there is no data to back up PEP, so she doesn't recommend it. Is this true? 3 - How often do you think I should be tested? Thank you so much for the amazing site, it goes to show that information is power.

Response from Dr. Frascino

Hi,

Gosh, if you think you're tired of the "touched a hooker's hankie" type of question, you can just imagine how I must feel as I wade through literally thousands of such questions on a continual basis day after day. So let's proceed to your magnetic couple questions:

1. The bottom line here is that HIV cannot pass through intact latex. No way. No how. Condom statistics (like all statistics) can be a bit misleading. I'll repost below a few questions from the archives that address the condom-efficacy question. I also suggest you check the Planned Parenthood Web site and review their document, "The Truth about Condoms." It's well referenced.

Now let me show you an example of how statistics can be misleading in a very Republican-NRA sort of way. Consider the following stats:

Doctors:

The number of doctors in the U.S. is 700,000

Accidental deaths caused by physicians per year are 120,000

Accidental deaths per physician is 17.14%

(Statistics courtesy of the U.S. Dept. of Health & Human Services)

Guns:

The number of gun owners in the U.S. is 80,000,000 (yes that's 80 million)

The number of accidental gun deaths per year, all age groups, is 1,500

The number of accidental deaths per gun owner is 0.001875%

(Statistics courtesy of the FBI)

Therefore, "statistically speaking," doctors are approximately 9,000 times more dangerous than gun owners, the logical conclusion being "guns don't kill people, doctors do!" See what I mean about statistics and how they can be manipulated to support an illogical conclusion?!?

2. Your boyfriend's HIV specialist doesn't recommend PEP? That's worrisome. The most direct evidence supporting the efficacy of PEP is a case-control study of needlestick injuries to health care workers. In that study the prompt initiation of AZT was associated with an 81% decrease in the risk of acquiring HIV. In the nonoccupational arena we have data from observational studies and registries. Although data from observational studies and case reports may not provide definitive evidence of PEP's efficacy in nonoccupational exposures, the overall cumulative data is so convincing that it would now be considered unethical to run a double-blind, placebo-controlled trial of PEP to scientifically verify what has now become standard of care for most HIV specialist practices. I would suggest you print out a copy of the recommendations from the U.S. Department of Health and Human Services entitled "Antiretroviral Postexposure Prophylaxis After Sexual, Injection-Drug Use, or Other Nonoccupational Exposure to HIV in the United States" (January 2005) and review it with your boyfriend's HIV specialist. If he/she doesn't promptly change his or her opinion on PEP, you might want to consider changing HIV specialists! I also bet that if that specialist found himself/herself on the wrong end of a broken condom with an HIV+ partner, he or she would have PEP meds swallowed faster than Bush can write " I souport publik edekasion"

3. That depends on your level of risk. For instance, some magnetic couples don't use condoms for oral sex, some may not use condoms "properly" each and every time, etc. Some HIV specialists suggest an every-six-month STD/HIV screen for the sexually active "at risk" population. Consequently the answer to how often I would recommend that you be tested would depend on a variety of variables. But remember, the option of testing is always open to you if you feel there has been a potential exposure. Yes, information is indeed power.

Stay well. I hope your magnetic coupling is as successful and satisfying as mine. I think we should change the terminology of "serodiscordant" to "serodiverse," as serodiscordant is so, well, discordant, and that certainly doesn't apply to my relationship!

Dr. Bob

With age comes wisdom, maybe? Jun 29, 2005

Dr.Frascino:

Has there been any known cases of persons getting infected with HIV even though they have consistently and correctly used a latex condom without any breakage of slippage? This may sound like a dumb question to you and others, but me and my friends at my high school are getting different answers from alot of adults here at school and elsewhere about condoms and there effectiveness against HIV. Thanks for reading this letter and it is important to have an expert opinion like yours, I know you know more than these so called other grown-ups.

David (still not sure if I'm bi or just gay) either way would like to do it right.

Response from Dr. Frascino

Hi David,

With age comes wisdom? Maybe. But far too often with age the broadness of the mind and narrowness of the waist change places. So, since I still have a narrow waist, I'll try to clear up the condom efficacy/effectiveness conundrum. Under controlled laboratory conditions, latex condoms are essentially impermeable to particles the size of STD pathogens, including HIV. However, when placed into the context of horned-up mattress mambo with the lights off after a few cosmopolitans, the "real life" large-scale epidemiological studies show condoms to be 80-95% effective in reducing HIV infection. Some folks think they are using condoms properly, when, in reality, they are not. I'll attach a few recent posts from the archives that also address this issue, OK?

David, bi, gay or whatever, it's cool with me. What's most important is that your facts are "straight!"

Stay well! Stay safe.

Dr. Bob

critical: have you shifted your opinion on condoms? Posted: Apr 6, 2005

I am a donor to your organization, a regular reader and an admirer. I have a question for you that has very important ramifications for myself and the entire population that frequents this site. For literally years, your position has been, simply stated, that the proper use of a condom prevents HIV transmission. While "proper use" is somewhat loaded phraseology, and you have always very candidly pointed out that humans are not always perfect, the gist of your position has been that proper use of a condom prevents HIV transmissions and obviates testing. Of course, I realize that this prevention statement incorporates assumptions, e.g., condom did not fall off, break, was not expired, and was put on properly. Now, however, I am reading your posts indicating that "large epidemiological studies" indicate that practically speaking, i.e., in the real world of human error and shortcoming, condoms are (I believe you stated) approximately 80% to 95% effective at preventing transmission. You still state, though, that they are nearly 100% efficacious in the laboratory world. Perhaps I am missing something, but to me, you seemed to have shifted considerably your views on the overall effectiveness (i.e., real world effectiveness) of condoms. The question to you that I think should clarify your position: if you were advising an individual, such as myself, on the safety of using a condom for intercourse with a partner of unknown statuts (and therefore, to error on caution's side, let's say positive); and assuming that I have used many condoms in the past and know how to use them "properly," i.e., leave room at tip, unroll to base, don't put on inside-out, etc.), then would you advise me that using a condom for intercourse with this partner will effectively prevent HIV transmission? I realize that large epidemiological studies are not necessarily reducible to the individual level. But I think your apparent shift (at least as perceived by me) merits elaboration to the "individuals" who visit your site. Thank you, and god bless you!!!!

Dr. Bob's reply:

Hello,

No, my position on condoms has not changed at all over the years and I don't anticipate it will unless new scientific research evolves to support a change.

So, why the confusion??? Like many other current problems, it can be traced back to a "son of a Bush." In the context of U.S. Government policies and programs for combating HIV/AIDS domestically and internationally, a debate has resurfaced about the effectiveness of condoms in preventing sexual transmission of HIV infection. Some recent U.S. Government policies have begun to shift emphasis to the "lack of condom effectiveness" in educational materials and other publications that receive federal funds. This shift has caused confusion in the general public about whether condoms should be used and promoted for preventing HIV infection. I have consistently restated the scientific evidence related to condom efficacy and effectiveness for prevention of HIV/AIDS.

You are correct that I have often quoted the scientific facts from laboratory studies, including those conducted by the FDA, concluding that latex condoms are impermeable to particles the size of STD pathogens, including HIV. Therefore, if you did use a latex condom properly and the condom did not fail, I do not believe HIV testing is warranted.

There are many reasons condom effectiveness in preventing HIV may be compromised. For instance, using natural skin rather than latex or polyurethane condoms, using the wrong type of lubricant (oil-based rather than water-based), not using the condom for the whole sex act (some folks put them on just before ejaculating), compromising the integrity of the condom (excessive heat if kept in the glove compartment of your car, tearing the condom when opening the foil packet, using condoms beyond their expiration date), etc., etc., etc. the list can go on and on and on.

Even with all these "real life" limitations of not using a condom "properly," condoms still remain 80-95% effective in reducing the risk of HIV infection if used consistently. I hope that helps clarify any confusion.

The real take-home message is that scientific evidence does not support the recent shift in U.S. Government policy that stresses lack of condom efficacy. Rather the scientific evidence clearly shows that both male and female condoms are highly effective in preventing the transmission of HIV/AIDS.

Gosh, if I'm getting this many questions about condoms, I can just imagine what the evolution and global warming experts are up against in refuting Dubya's faith-based science initiatives. Stay safe. Stay well.

Dr. Bob

I hope you won't be annoyed. Posted: May 14, 2005

Dr Bob,

You seem to imply that the catholic church's position re: rubbers is wrong. And I agree with you a 100%. However, what I disagree with is your counter-implication that condoms provide almost perfect protection. Fact is, in studies with discordant couples, there were always one or two that got infected with condoms (as opposed to 10 out of a 100 odd couples) implying that the risk is still significant. I want to know if I am misunderstanding you, or what your opinion is on this otherwise.

Thank you for educating us on these issues. You are the best!

Dr. Bob's response:

Hi,

No, of course I'm not annoyed but I do think you are misinterpreting my "counter-implication." If you go back to the archives, what you will find is that my statements are very consistent and reflect what we know about how well condoms work for preventing HIV and other sexually transmitted diseases. Perhaps the easiest way to explain this is to make a distinction between efficacy and effectiveness. Efficacy can be defined as the protection the user would have under "ideal" conditions. Efficacy, therefore, is dependent on the properties of the device, in this case the condom, tested in controlled situations.

Effectiveness can be defined as the protection the user would have under "actual" or "real life" conditions. Effectiveness, therefore, is dependent on both the properties of the device (condom) and the behaviors of the user.

Laboratory studies, including those conducted by the FDA, have shown the latex condom to be essentially impermeable to particles the size of STD germs, including HIV. However, in large-scale, "real life" epidemiological studies, condoms are 80-95% effective in reducing HIV infection.

The bottom line is that condoms provide a highly effective barrier method when used correctly.

The Catholic Church is shamefully wrong in their condemnation of condoms. For example, in El Salvador the Church helped push through a law requiring condom packages to carry a warning label stating that condoms do not protect against AIDS. Studies now show fewer than four percent of Salvadoran couples use condoms the first time they have sex. The result will be more funerals. The Church must choose between obeying tradition and saving lives. Somehow the answer to the often quoted question "What would Jesus do?" seems painfully obvious.

Stay safe. Stay well.

Dr. Bob



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