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Will you help a Republican in need ?
Apr 18, 2006

Dear Dr Frascino,

Yes I am a Republican, but I am still human and I hope you will keep that in mind and answer my question. My question regards proper use of condoms. I am uncircumcised. I heard that it increases my risk for acquiring HIV. What happens when AFTER using the condom, when taking the condom OFF and I have either blood or vaginal secretons (from deep in the cervix) from the used condom and i touch the foreskin to clean it etc. Do I have a risk with this activity. I would appreciate an answer sire, It will help me in the future. I dont believe this question has been answered before.

Many Many thanks ...

Response from Dr. Frascino

Hello Republican,

1. You don't have to call me "sire." Sir will do just fine.

2. Basic facts about condoms and how to use them properly should not be a mystery. These should be taught to all potentially sexually active young adults. That means high school at the latest! Republicans seem to think that information is taboo and shouldn't be taught. Consequently, if I wasn't such a nice guy, I suppose I could give you a Republican answer and tell you that you don't need to know about nasty dirty stuff like condoms, and besides they don't work and they have more holes in them than Swiss cheese and if you use them, you're going to hell and what about that virginity pledge you made and here's a nice book about abstinence. You can read it on the way to church. But since I'm a nice guy (read Democrat) I'll happily supply you with the information you request. You can read all about the proper use of condoms on this site and related links. I'll post a few examples below. Please note we no longer recomend the use of nonoxyno-9!!! Just follow these guidelines and you'll be fine. Touching the outside of a condom while removing it and then touching your penis or foreskin would not constitute a significant HIV-transmission risk.

Now that I've answered your question, any chance you'll take a closer look at whom and what you've been voting for?

Dr. Bob

How to Use Condoms Correctly Latex Barriers -- for Men and Women -- Prevent Transmission of HIV Virtually 100% of the Time August 1996

Condoms are like cars: If you have an accident with one, the cause is almost certainly operator error, not mechanical failure. Indeed, the estimated failure rate of latex condoms is between 2% and 5% -- and when a condom does tear during intercourse, that failure is most likely the result of misuse, not a manufacturing defect. The federal Food and Drug Administration -- which regards condoms as "medical devices," regulates their production, and makes frequent, unannounced inspections of condom-manufacturing facilities -- has declared that the difference in quality between the best and worst condoms on the market "is tiny compared with the problems that users introduce."

Condoms are like cars in another respect: They work best when they are used according to the manufacturer's instructions. The most common cause of condom failure is almost embarrassingly obvious: If the condom is placed on the penis upside down and unrolled from the inside out, it is more likely to slip off or tear during intercourse. (It should fit over the head of the penis like a dunce's cap, with the rolled "brim" outside the "cap" -- so that it will unroll easily down the shaft of the penis.) This fundamental error occurs far more often than it should, and it reveals the degree to which ignorance and embarrassment contribute to condom failure.

There is no such thing as a learner's permit for condom users, and there are no mandatory driver's education programs -- and that's too bad, because learning how to handle a condom with skill and confidence requires a degree of familiarity with the device. Most sexually-active Americans -- like most practicing physicians -- came of age after the widespread introduction of oral contraceptives. The advent of the birth-control pill eliminated the need for condoms as a means of preventing pregnancy, and the condom -- which was regarded as inhibiting and cumbersome -- fell from favor.

Birth-control pills do prevent pregnancy, but they do not prevent the spread of sexually-transmitted disease like AIDS. Only condoms (and abstinence) do that, and condoms do it remarkably well -- if they are used consistently and correctly. The proper use of latex and polyurethane condoms -- ideally, in combination with the spermicide nonoxynol-9, which kills all the HIV that is present in the condom -- is the keystone of all programs to prevent the transmission of HIV infection. All sexually-active individuals who have sexual relations, however infrequent, with anyone whose HIV status is not known to them should therefore use a new, latex condom for every act of vaginal or anal intercourse.

Condoms do work. But they only work when they are used consistently and correctly. Women as well as men should familiarize themselves with the following diagrams and instructions, and both should know that a newly developed "female condom" offers couples the same effective barrier protection -- with what many users regard as superior comfort and convenience. Familiarity with the use of condoms -- for men and for women -- is like familiarity with sex itself: Experience is the best teacher. And what experience will teach even the most reluctant condom user is that protective latex barriers can be successfully and safely incorporated into the most pleasurable and life-affirming form of human contact.

Correct Use of Condoms Worn by Men

1. Always use a new latex or polyurethane condom for each act of vaginal or anal intercourse. (Condoms are also recommended for oral sex with a partner who is known to be HIV-positive or whose HIV status you do not know.) Open the package carefully, so that you do not tear the condom.

2. Before any form of direct sexual contact with your partner, place the condom over the head of your erect penis, leaving about a half-inch of space at the end (Figure 1). Note: If you are uncircumcised, pull back the foreskin before you place the condom over the head of your penis.

3. The condom should fit over the head of the penis like a small rubber cap, with the rolled "brim" outside the "cap" -- so that it will unroll easily down the shaft of the penis. Gently squeeze the tip of the condom to remove any trapped air.

4. Hold the tip of the condom and unroll it all the way down to the base of your penis (Figure 2). A lubricant, applied to the outside of the condom, will make insertion easier. Use only a water-based lubricant. The lubricant nonoxynol-9, which is available without a prescription in most drug stores and pharmacies, should be used if you know you are HIV-positive or think you are HIV-positive -- because it will kill all the HIV that is released into the condom.

5. If you feel the condom break -- or think it may be broken -- withdraw immediately. Throw the condom away and use a new condom.

6. After you ejaculate, hold the condom to the base of your penis while you withdraw -- to keep it from coming off while it is still in your partner's vagina, anus, or mouth. Gently peel the used condom off the tip of your penis (Figure 3) and throw it away. Never use a condom more than once.

Basic Facts About Condoms and Their Use in Preventing HIV Infection and Other STDs

With more than 1 million Americans infected with HIV, most of them through sexual transmission, and an estimated 12 million other sexually transmitted diseases occurring each year in the United States, effective strategies for preventing these diseases are critical.

The proper and consistent use of latex condoms when engaging in sexual intercourse--vaginal, anal, or oral--can greatly reduce a person's risk of acquiring or transmitting STDs, including HIV infection. In fact, recent studies provide compelling evidence that latex condoms are highly effective in protecting against HIV infection when used properly for every act of intercourse. Latex condoms are highly effective when used consistently and correctly-- new studies provide additional evidence that condoms work The protection that proper use of latex condoms provides against HIV transmission is most evident from studies of couples in which one member is infected with HIV and the other is not, i.e., "discordant couples." In a study of discordant couples in Europe, among 123 couples who reported consistent condom use, none of the uninfected partners became infected. In contrast, among the 122 couples who used condoms inconsistently, 12 of the uninfected partners became infected.

As these studies indicate, condoms must be used consistently and correctly to provide maximum protection. Consistent use means using a condom from start to finish with each act of intercourse. Correct condom use should include the following steps:

Use a new condom for each act of intercourse.

Put on the condom as soon as erection occurs and before any sexual contact (vaginal, anal, or oral).

Hold the tip of the condom and unroll it onto the erect penis, leaving space at the tip of the condom, yet ensuring that no air is trapped in the condom's tip.

Adequate lubrication is important, but use only water-based lubricants, such as glycerine or lubricating jellies (which can be purchased at any pharmacy). Oil-based lubricants, such as petroleum jelly, cold cream, hand lotion, or baby oil, can weaken the condom.

Withdraw from the partner immediately after ejaculation, holding the condom firmly to keep it from slipping off.

Myths About Condoms

There continues to be misinformation and misunderstanding about condom effectiveness. The Centers for Disease Control and Prevention (CDC) provides the following updated information to address some common myths about condoms. This information is based on findings from recent epidemiologic, laboratory, and clinical studies.

Myth #1: Condoms don't work

Some persons have expressed concern about studies that report failure rates among couples using condoms for pregnancy prevention. Analysis of these studies indicates that the large range of efficacy rates is related to incorrect or i inconsistent use. The fact is: latex condoms are highly effective for pregnancy prevention, but only when they are used properly. Research indicates that only 30 to 60 percent of men who claim to use condoms for contraception actually use them for every act of intercourse. Further, even people who use condoms every time may not use them correctly. Incorrect use contributes to the possibility that the condom could leak from the base or break.

Myth #2: HIV can pass through condoms

A commonly held misperception is that latex condoms contain "holes" that allow passage of HIV. Although this may be true for natural membrane condoms, laboratory studies show that intact latex condoms provide a continuous barrier to microorganisms, including HIV, as well as sperm.

Myth #3: Condoms frequently break

Another area of concern expressed by some is about the quality of latex condoms. Condoms are classified as medical devices and are regulated by the FDA. Every latex condom manufactured in the United States is tested for defects before it is packaged. During the manufacturing process, condoms are double-dipped in latex and undergo stringent quality control procedures. Several studies clearly show that condom breakage rates in this country are less than 2 percent. Most of the breakage is due to incorrect usage rather than poor condom quality. Using oil-based lubricants can weaken latex, causing the condom to break. In addition, condoms can be weakened by exposure to heat or sunlight or by age, or they can be torn by teeth or fingernails.

Nonoxynol-9 Harmful, Should Not Be Used in Condoms, Lube

By John S. James

June 28, 2002

On June 25, 2002 the World Health Organization published a 27-page report summarizing what is known about nonoxynol-9 (N-9) -- the failed microbicide that actually increases risk of HIV transmission. They concluded that N-9 should never be used for preventing HIV transmission, has no value in preventing other sexually transmitted diseases, and should never be used rectally, where the problem may be much worse than with vaginal use. (The report acknowledges that women at low risk of HIV infection may use N-9 occasionally as a moderately effective, female-controlled form of birth control, when better means are not available to them.)

Condoms should not include N-9 for any use. However, if the only condom available has N-9, it is better than no condom. On May 10, 2002 the U.S. Centers for Disease Control and Prevention updated its Guidelines for the Treatment of Sexually Transmitted Diseases (PDF), also warning against using N-9 for STD prevention.

Background and Comment

N-9 kills HIV in the laboratory. But it also causes irritation in the vagina or rectum that can allow HIV to infect. A major clinical trial in women, reported two years ago at the International AIDS Conference in Durban, South Africa, studied over 800 sex workers randomly given either an N-9 or placebo gel, and found 48% more new HIV infections among those using N-9.

No one has done such a study with rectal use. But in both humans and animals the irritation is worse, with "sloughing of sheets of epithelium." The damage is later repaired, but by then HIV could have been transmitted.

A recent survey found that about 40% of condoms sold in the U.S. are lubricated with N-9, and about 40% of gay men look for it. Manufacturers of condoms and lube have no incentive to include N-9, except for this mistaken public demand; and all of these manufacturers also market parallel versions of their products without N-9. Now that there is a clear, official consensus that N-9 is harmful, especially for rectal use, it is likely to start disappearing from condoms and lubes.

The community will need to help get the word out, since no one has a commercial incentive to do so, and government agencies are reluctant to speak about anal sex.

References 1. WHO/CONRAD Technical Consultation on Nonoxynol-9, World Health Organization, Geneva 9-10 October 2001, Summary Report. (This is the report published June 25, 2002; the October 2001 meeting brought together experts to examine the evidence and prepare recommendations.) As we go to press the report is available through www.who.int/reproductive-health/rtis/index.htm and also through: www.conrad.org.

2. "World Health Organization/Conrad Report Warns Against Use of Nonoxynol-9 As Microbicide," press statement issued June 25, available at the Web sites above.

Nonox-9 and "Non-Understanding" Jan 29, 2004

Dr. Bob,

Thanks for a terrific site and such a highly informative forum. I am a "questioning my orientation" male and have experienced insertive anal, and oral sex with me over the last year. I am OCD and hyper-sensitive about HIV, so condoms are used for insertive anal sex. And, up until recently, I thought that would protect me from HIV if used correctly (i.e. condom doesn't fall off, doesn't break).

Well, until I read this article on THE BODY: http://www.thebody.com/kaiser/2004/jan21_04/nonoxynol_9.html Now I'm confused and nervous. In previous posts (and believe me I've checked them all pertaining to this!), you had stated HIV really can't "jump" over the latex barrier in condoms - thus providing effective protection. However, this article seems to suggest nonox-9 DOES transmit HIV somehow. Can you elaborate on this? Are we at risk for catching HIV when using a nonox-9 lubricated condom? How exactly does that risk materialize?

Also, unrelated to above, 2-weeks after having protected insertive anal sex with a guy - I experienced a 100.3-degree fever, sore throat, ear ache, stuffy face and nasea. These all lasted less than 24-hours. Two days before all this, I was playing contact football with a cousin who was just getting over the flu. I did have my flu shot in October. Regarding ARS, I know the "symptoms" sound right but would the duration be longer - or not necesisarily so? I'm a regular HIV tester, doing so 3-mons after each episode.

Thanks for your time.... 9

Response from Dr. Frascino

Hello,

You're welcome. I'm pleased you have found the information helpful. As for your being a "questioning my orientation" kind of guy, well from your post, I'd say that question's been answered! I do wonder about your statement, "I have experienced insertive anal and oral sex with me over the last year." Gosh, you must be very talented and remarkably flexible!

I haven't had the chance to review the article you reference, but let me give you the scoop on nonoxynol-9. It is true that the spermicide N-9 has been shown to increase the risk of HIV transmission, because it strips away the protective epithelial cells in the anus and vagina. However I think you may be confused about how this finding pertains --or does not pertain -- to your particular situation.

Ironically, N-9 was once touted as an HIV preventive, because initial tests showed it killed the virus. It was added to lubricants and condoms, and marketed as extra protection against HIV. However, subsequent tests involving human subjects showed that it had the opposite effect, because of its damage to the epithelial cells lining the anus and vagina. Please note these studies were done to see if N-9 would be an effective preventative barrier when condoms were not used or if condoms failed. Clearly that is not the case. If the lining of the anus or vagina is inflamed or damaged by N-9 and then comes into contact with HIV-infected ejaculate, HIV transmission becomes more likely. However, if there is no contact with infected ejaculate (condom remains intact), then HIV transmission still cannot occur. Since there is no upside for using N-9 and there is a definite downside, the product should not be used. Recently Durex, one of the top three condom makers, announced it would no longer make condoms lubricated with N-9. That leaves only the manufacturer of Lifestyles and Trojan brands making N-9 condoms. Pressure is being applied to these companies to discontinue N-9. We advise everyone to stop purchasing N-9 condoms and to ask their local pharmacies to remove the products from their shelves. Educating consumers and encouraging activism should speed the entire process along. Bottom line for your bottom since the condoms didn't fail, you should not be at any risk. But from here on "out" (so to speak), use only non-N-9 lubes and lubricated condoms. Buyer beware!

Stay well.

Dr. Bob



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