Device may reduce risk of infection by 90% if used consistently
In 1975 a team of researchers surveyed 486 women at a private college, asking them -- by means of an anonymous questionnaire -- how often their male sexual partners used condoms. Only 11% of respondents said that their partners used condoms "always or almost always." Follow-up surveys, conducted at this same academic institution in 1986 and 1989, found the consistent use of condoms doubling with each survey: to 21% in 1986, and to 41% three years later. The most recent survey, conducted last year by Peipert et al., reveals that condom use has doubled again: 87% of respondents now report that their male partners use condoms always or almost always.
This steady rise in condom use is particularly impressive because it is occurring in a population that perceives itself to be at low risk for HIV infection. (According to Choi et al., in an article published earlier this year, adoption of barrier protection against HIV has been slowest among women, whites, the college-educated, and people in their twenties -- and most of the students surveyed by Peipert et al. fall into all four categories.) Significantly, the participants in these serial surveys were all women, who were being asked about condom use by male partners. Many of these participants may not even know that a female condom has been available for more than two years.
Made of strong but lightweight polyurethane, this barrier device -- marketed by Wisconsin Pharmaceuticals as the Reality® Female Condom -- can be inserted up to eight hours before intercourse (see the pull out and save feature, "How to Use Condoms Correctly"). This advantage, coupled with the fact that this barrier device gives women a much greater degree of control over condom use during sexual acts, may make the female condom an appealing alternative to the traditional male condom -- especially for women at risk of HIV infection whose partners use condoms inconsistently or refuse to use them at all. For these women, the price differential -- female condoms cost roughly four times as much as male condoms -- may well be offset by the protection against STDs that consistent use will confer.
Used correctly, the female condom should fail no more than 5% of the time, according to the F.D.A. -- a rate consistent with that for male condoms. The chief impediment to wider adoption of the female condom is not efficacy but novelty: few women have used it. Among those who have -- a group surveyed by Gollub et al. -- it was found that 73% of users preferred it to the male condom, and half the respondents reported that their partners liked the device.
Peipert JF, Domagalski L, Boardman L, Daamen M, Zinner SH. College women and condom use, 1975-1995 (letter). N Engl J Med 1996; 335: 211.
Choi K-H, Catania JA. Changes in multiple sexual partnerships, HIV testing, and condom use among US heterosexuals 18 to 49 years of age, 1990 and 1992. Am J Public Health 1996; 86: 554-6.
Service, now being tested in Texas and Florida, will be available nationwide in 1997
The F.D.A. recently approved the first HIV testing system that can be purchased over-the-counter for home use. Developed by a division of Johnson & Johnson, the Confide® HIV testing service provides at-risk individuals with an opportunity to learn their HIV status in absolute anonymity. This feature may be particularly appealing to sexually-active teenagers, married bisexuals, and others who fear opprobrium if their reasons for seeking an HIV-1 antibody test were ever to be exposed.
During the first phase of marketing, the test will be available -- at a cost of about $40 -- in pharmacies, college health centers, and public health clinics throughout Texas. It will also be available to residents of that state and Florida who call this toll-free number: 1-800-THE TEST. Johnson & Johnson anticipates that the Confide® testing service will be available nationwide in early 1997.
The testing kit includes a booklet prepared by a national panel of experts on HIV testing, laboratory analysis, patient counseling, and public health. All participants in the Confide® program are encouraged to read this information carefully; it explains the purpose of HIV antibody testing and offers step-by-step instructions for home use of the testing kit.
That kit contains a safe, retractable lancet, with which the user pricks a fingertip and blots a few drops of blood onto the test card that is provided with the kit. (Users who are apprehensive about this step may call a special hotline number for additional directions and assistance in collecting the blood sample.) The test card is then placed in the pre-paid, pre-addressed, protective mailer that comes with the kit, and the card goes to a certified laboratory for analysis.
The testing process is consistent with current F.D.A. standards, and any sample that is reactive is retested. If a sample is repeatedly reactive, that reaction is confirmed with a more specific antibody test such as the immunofluorescent assay. The testing system is more than 99% accurate.
Each test card carries a unique 14-digit personal identification number, which only the user knows and which is the only means of identifying the user's blood sample. Seven days after mailing that sample to the laboratory, the participant calls a toll-free number. Results are provided only after the participant keys in his or her 14-digit identification number. If the caller has tested negative, he or she receives a recorded message about HIV prevention -- and has the option of speaking to an experienced professional counselor.
Individuals whose test results are positive or inconclusive receive this news from one of the service's specially trained counselors -- who utilize a national database of more than 10,000 HIV/AIDS organizations and services to provide referrals to healthcare professionals and local support services in the caller's region. Counseling is provided in Spanish as well as in English.
Group hopes to reduce incidence of very risky behavior by not holding gay men to a "zero-risk" standard
The question everyone asks -- and that no one seems to be able to answer in a way that satisfies the competing needs of sexually-active gay men and concerned public health officials -- is: How safe is oral sex? Data from the San Francisco Cohort Study and other sources suggest that receptive oral sex carries some risk of infection, especially if semen is ingested. And a group of investigators recently reported in the journal Science that they were able to give rhesus monkeys the simian form of AIDS by painting the mouths of healthy monkeys with virus -- a finding that confounds the belief, widespread among physicians and laymen alike, that oral sex is safe, at least in the absence of mouth sores or other skin tears.
What data derived from animal studies tell us about risk in human beings is always open to question. What is not questioned, by most professionals engaged in HIV prevention interventions, is that the sexual urge is strong enough that it can override caution even in the best-informed, best-intentioned individuals. Perhaps no professional organization is more aware of this inherent tension than the Gay and Lesbian Medical Association, a 15-year-old, San Francisco-based organization that now includes more than 1,800 physicians and medical students in all 50 states and 11 foreign countries. The GLMA recently asked all those involved in prevention programs to classify male-male oral sex as "low-risk" rather than "high-risk" or "somewhat risky."
The organization's rationale in taking this controversial position -- as Dr. Thomas J. Coates, director of the Center for AIDS Prevention Studies, explains in this issue (see "HIV Prevention in Clinical Practice") -- "is that sexual expression is a fundamental aspect of human nature, and when sexual activity is restricted to zero-risk activities, frustration builds to the point of sexual rebelliousness, which can lead to distinctly unsafe sexual behaviors." It is the group's hope, Dr. Coates continues, that "by offering gay men some sexual leeway, a trade-off will be effected: more very-low-risk activity will occur, but as a result fewer breakouts of very-high-risk activity will take place."
According to Dr. Alvin Novick, a professor at Yale University and chair of the GLMA's policy committee, "Prevention education must consistently acknowledge the essential importance of sexual intimacy" -- for gay men as for all individuals. Dr. Novick urges physicians and others who are engaged in HIV prevention not to impose an unrealistic, zero-risk standard on at-risk individuals. Rather, he says, "our prevention efforts should focus on reducing risk overall, by helping each individual learn how to maximize fulfillment and minimize risk."
Like most successful prevention efforts, the GLMA's statement is based on the principle of "harm reduction." The goal of all such programs is not to achieve perfection, or reduce transmission rates to zero, but simply to move individuals in the direction of safer sexual practices.
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