When Gay Men Have Less-Than-Perfect Condom Use, How Much Is Enough?
April 7, 2015
If you've ever chosen to forego a condom or had difficulty using them correctly, you are far from alone. Few gay or bisexual men or couples use them every time, despite their power to prevent sexually transmitted infections (STIs). We forget. We make mistakes. And, we take calculated risks.
These days, additional strategies such as pre-exposure prophylaxis (PrEP) and sex with HIV-positive partners who have an undetectable viral load have expanded the palette of HIV prevention options. But there are plenty of times and places where condoms have a key role in HIV prevention among gay and bisexual men, as well as in the prevention of a whole lot of other STIs.
Whether you aim for perfect use and miss or make the decision to skip condoms a few times, you might start to wonder whether imperfect condom use is even worth the trouble. Are condoms an all-or-nothing proposition?
But the research on this topic is far more complicated and does not provide as clear an argument for condom use as some public health experts would hope. A recent study on men who have sex with men (MSM) and HIV transmission, for example, found that consistent condom use only reduced HIV risk by 70% -- and inconsistent use reduced risk by a mere 8%. Then again, research on this topic is tricky and prone to flaws.
How STI Risk and Condom Efficacy Are Calculated
Many research studies gather participants with similar backgrounds and behavior and divide them into groups. One group is given the intervention (whether it's a drug or a behavioral program), another is offered some sort of placebo (a pill or a program not under investigation). There may even be a third group that serves as a control to show what would happen without any interference at all.
But when it comes to STIs, such studies would be unethical. Researchers can't, for example, determine how likely it is to get an STI from each act of sex with an infected partner by asking uninfected men to sleep with infected men and taking samples after every act. Nor could they, say, gather men with gonorrhea, pair them with uninfected partners, and then tell one group to use condoms and another to leave the condoms in the drawer. Such studies could certainly provide some answers, but would be highly unethical. The priority has to be limiting the spread of infections and, when it comes to curable STIs like gonorrhea, treating people as soon as possible.
This means we're left with observational studies that look at couples' behaviors -- often after the fact -- and try to estimate both how infectious an STI really is and how well condom use can help reduce infections. These studies can be pretty error-prone. People may not recall their past behavior accurately and they may not tell the truth. Researchers believe that participants often overstate how often they use condoms, for example, because they think it is the right or socially acceptable answer. Moreover, few studies have asked participants whether they used a condom correctly during sex. Research has found that condom users often make mistakes -- like putting the condom on after sex has already started or taking it off before ejaculation -- which make condoms less effective.
Attempts to measure condom efficacy have historically had other flaws as well. A 1989 study on HIV transmission in MSM, for example, asked participants, "Since your last visit, with how many of your partners did you use a condom?" It did not ask, however, if they used a condom every time they had sex with that partner. Even men who used a condom with every partner could have been having a lot of unprotected sex.
Similarly, many studies ask participants if they "always or almost always use a condom" or "sometimes or never use a condom." The vagueness of the categories makes it very hard to figure out how well inconsistent condom use compares to no use.
What's important to remember is that all of these methodological flaws and challenges suggest that condom efficacy in preventing STIs is currently underestimated.
There is one more issue that has to be addressed before we look at the best guess estimates on condom protection. Many studies are done with ostensibly heterosexual couples and focus on women who, as the receptive partner in vaginal sex, are at higher risk of contracting STIs. Some of these data are useful to MSM attempting to calculate their own risk, but some are not.
Condom Efficacy Estimates
As mentioned earlier, the most recent study on condoms and HIV came to some discouraging conclusions. It found that MSM who always use condoms have a 70% lower risk of HIV than those who never use condoms. It further found that those who sometimes use condoms lower their risk of contracting HIV by just 8% when compared to those who never use condoms.
This is much lower than estimates from a 2002 meta-analysis that suggested condoms reduce the risk of HIV transmission by between 80% and 94%. However, that analysis had a limited number of participants and was not done specifically with MSM.
Still, some are critical of the new estimates, in large part because they are based on condom use with partners known to be living with HIV. The men were not asked about whether they used condoms with partners whose serostatus was unknown. Partners with unknown serostatus may present a bigger risk of HIV transmission because couples may not take extra precautions (like practicing serosorting), and thus condoms may be more protective.
There is less information on STIs other than HIV, especially regarding MSM. With herpes, for example, we know that using condoms during more than 25% of sex acts led to a 92% reduction in the risk of acquisition for women but no similar reduction was found for men. One study did find that using condoms more than 65% of the time during acts of vaginal or rectal penetration could lead to some protection for men.
A study of men seeking treatment at an STI clinic in Jamaica for gonorrhea, chlamydia or trichomoniasis seems to suggest that inconsistent condom use was no better than no condom use: 39.1% of men who always used condoms had a prevalent STI when they returned for follow-up compared to 55.5% who sometimes used them and 55.6% who never used them. But, another study showed a rather straightforward relationship between condoms and risk for gonorrhea and chlamydia; those who reported one to 10 acts of condomless sex had a lower risk than those who reported 10 or more.
So What, Now What?
Ultimately, math may not answer the question of whether part-time condom use is worthwhile. We might have to continue to rely on common sense.
Every time a person has sex, he faces a different level of risk depending on the partner, the activity and the disease in question. Certain STIs are much more easily transmitted than others -- estimates suggest that one act of sex with an HIV-infected partner carries a 0.001 chance of transmission but sex with a partner who has gonorrhea has between a 0.20 and a 0.50 chance of transmission. And condoms don't even out the risk -- they are more effective at preventing diseases spread through bodily fluids than those spread through skin-to-skin contact, for the simple reason that infected skin can be outside the area covered by a condom (such as on the scrotum).
We are all capable of making personal risk calculations without perfect statistics. In recent years, many people -- especially MSM -- have gotten very adept at assessing their risk for HIV based on their serostatus and that of their partner, treatment success and viral load. Couples use this information to decide how to protect each other whether by using condoms, starting PrEP, serosorting or choosing less risky activities.
The same type of calculation is important for other STIs as well. How likely is it that you or your partner are infected? Are you engaging in regular STI testing following the U.S. Centers for Disease Control and Prevention guidelines? How easy is it to transmit the particular infection? Do you have any factors (such as another STI) that would make transmission more likely? How well do condoms work to reduce this risk?
What doesn't make sense, however, is to say that since you didn't use a condom yesterday, there's no point in using one today, if risk exists.
Remember that each act is a separate equation and unless your risk factor is zero (which we might define as a truly mutually monogamous relationship between partners who have been recently tested for all STIs), condoms can be considered anew every time. But if you think you are at risk in significant ways, and find yourself falling short of your condom goals over time, you can also talk to your provider and advocates about other strategies and tools for reducing the risk of HIV and other STIs.
Martha Kempner is a freelance writer, consultant and sexual health expert.
Follow Martha on Twitter: @marthakempner.
Copyright © 2015 Remedy Health Media, LLC. All rights reserved.
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