Foss, Anna M

Heise, Lori

Vickerman, Peter

Watts, Charlotte H

LSHTM Research Online

Foss, AM; Watts, CH; Vickerman, P; Heise, L (2004) Condoms andprevention of HIV - Are essential and effective, but additional meth-ods are also needed. BMJ, 329 (7459). p. 185. ISSN 1468-5833 DOI:10.1136/bmj.329.7459.185Downloaded from: http://researchonline.lshtm.ac.uk/14540/DOI: 10.1136/bmj.329.7459.185Usage GuidelinesPlease refer to usage guidelines at http://researchonline.lshtm.ac.uk/policies.html or alterna-tively contact researchonline@lshtm.ac.uk.Available under license: Creative Commons Attribution Non-commercialhttp://creativecommons.org/licenses/by-nc/2.5/screening or choose particular treatments.9 10 Vaccinat-ing some people in a population may cause others (forexample, immunocompromised people) to becomesick through the spread of the vaccine virus or,conversely, to remain well through the effect of herdimmunity.The existence of collateral health effects and thefact that each individual may be connected tonumerous others, including relatives, friends, neigh-bours, and co-workers, implies developments inresearch and policy. To explore such effects, new data-sets and methods will be needed. Most prospectivecohort studies and randomised controlled trials todayinclude only individuals who are followed to observeoutcomes. Some social science and epidemiologicalcohort studies do ask individuals about the health sta-tus of their spouse or some other social contact, butonly a few (for example, the US health and retirementsurvey) actually include the spouse or other social con-tacts in the study cohort. Developing datasets with suchfeatures and measurements is necessary to understandfully collateral health effects. Collecting informationabout the various contacts of people enrolled inclinical trials or epidemiological studies may representan extension to study design similar to the extension inthe 1990s of including cost effectiveness analyses as astandard feature of clinical trials.Network phenomena are receiving increased atten-tion in fields as diverse as engineering, biology, andsociology,11 12 but they are also relevant to health andmedicine. Networks have emergent properties notexplained by the constituent parts and not present inthe parts. Understanding such properties requiresseeing whole groups of individuals and theirinterconnections at once. The existence of socialnetworks means that people and events are interde-pendent and that health and health care can transcendthe individual in ways that patients, doctors, policymakers, and researchers should care about.Nicholas A Christakis professorDepartment of Health Care Policy, Harvard Medical School, 180Longwood Avenue, Boston, MA 02115(christakis@hcp.med.harvard.edu)Competing interests: None declared.1 Christakis NA, Iwashyna TJ. The health impact on families of health care:a matched cohort study of hospice use by decedents and mortalityoutcomes in surviving, widowed spouses. Soc Sci Med 2003;57:465-75.2 Steinhauser KE, Christakis NA, Clipp EC, McNeilly M, McIntyre L, TulskyJA. Factors considered important at the end of life by patients, family,physicians, and other care providers. JAMA 2000;284:2476-82.3 D Crane. The sanctity of social life: physicians’ treatment of critically ill patients.New Brunswick, NJ: Transaction Books, 1990.4 Schaefer C, Quesenberry CP, Soora W. Mortality following conjugalbereavement and the effects of a shared environment. Am J Epidemiol1995;141:1142-52.5 Lillard LA, Waite LJ. ‘Til death do us part: marital disruption and mortal-ity. Am J Sociol 1995;100:1131-56.6 Schulz R, Beach SR. Caregiving as a risk factor for mortality: thecaregiver health effects study. JAMA, 1999;282:2215-9.7 Murabito JM, Evans JC, Larson MG, Kreger BE, Splansky GL, MutalikKM, et al. Family breast cancer history and mammography. FraminghamOffspring Study. Am J Epidemiol 2001;154:916-23.8 Andrews JA. Tildesley E. Hops H. Li F. The influence of peers on youngadult substance use. Health Psychol 2002;21:349-57.9 Nattinger AB,Hoffmann RG,Howell-Pelz A,Goodwin JS. Effect of NancyRegan’s mastectomy on choice of surgery for breast cancer by USwomen. N Engl J Med 1998;279:762-6.10 Cram P, Fendrick M, Inadomi J, Cowen ME, Carpenter D, Vijan S. Theimpact of a celebrity promotional campaign on the use of colon cancerscreening: the Katie Couric effect. Arch Intern Med 2003;163:1601-5.11 B Wellman, SD Berkowitz. Social structures:a network approach. Cambridge:Cambridge University Press, 1988.12 Watts DJ, Strogatz SH. Collective dynamics of “Small World” networks.Nature 1998;393:440-2.Condoms and prevention of HIVAre essential and effective, but additional methods are also neededPromotion of condoms has been a mainstay ofHIV prevention policy. Over the past few years,however, the value and effectiveness of condomshave increasingly been called into question. The grow-ing “abstinence only” movement in the United Statesquestions the provision of condoms as part of thepolicy and messaging of the US Agency forInternational Development (USAID) and claims thatcondoms have had little to do with the successesachieved in reducing HIV in countries such asUganda.1–2 Senior officials in the Roman CatholicChurch also continue to argue about the morality ofcondom use and dispute its efficacy.3But what does the evidence tell us? A recent reviewfrom the National Institutes for Health says thatcondoms are protective against HIV infection,4 reduc-ing the probability of HIV transmission per sex act byas much as 95% and reducing the annual HIVincidence in serodiscordant couples by 90-95% whenused consistently.5 However, the impact of inconsistentuse of condoms is less substantial: a meta-analysisfound that condom use of variable consistency amongserodiscordant couples reduced the annual HIVincidence by 69%.6 This illustrates how the protectionprovided by a condom is dependent both on itsefficacy against HIV transmission per sex act and theconsistency with which it is used. This is intuitive, yetthe consistency of condom use is less commonlyfactored into scientific and policy debate.Evidence from around the world highlights theextent to which patterns of condom use are influencedby the form of partnership in which they are beingused. Interventions can achieve substantial increases inthe use of condoms in commercial and casual sex part-nerships. Several studies report high levels of condomuse after interventions in commercial sex.7–9 But evenin settings where HIV infection is widespread, the useof condoms in primary partnerships remains low—representative surveys of women in 13 Africancountries found that fewer than 7% report condom usein the last sex act with their regular partner.10 Surveysof sex workers in Asia generally find that, althoughmany use condoms with their clients, fewer than 40%report using condoms in their last non-commercial sexact. Unless one partner knows they are HIV positive orAdditional references w1 and w2 appear on bmj.comEditorialsBMJ 2004;329:185–6185BMJ VOLUME 329 24 JULY 2004 bmj.comfeels substantially at risk, interventions generally havelimited success at achieving consistent use of condomsin primary partnerships.10These low levels of use are in part due to problemsof supply, access, and affordability: Shelton et alestimated that 724 million condoms (an average of fivecondoms per man) were distributed in sub-SaharanAfrica in 1999—excessively low for a region ravaged bythe HIV epidemic.11 The limited availability ofcondoms reflects the failure of HIV prevention to go toscale—the 2003 progress report from the joint UnitedNations programme on HIV/AIDS (UNAIDS) on theglobal response to the HIV/AIDS epidemic concludedthat only a fraction of people at risk of contracting HIVhave meaningful access to basic prevention services.12Improvements in the supply and distribution ofcondoms are likely to occur as initiatives to expandHIV prevention and provide widespread antiretroviraltherapy are implemented.Yet are a lack of supply and inadequateprogramming the only problems? Surveys indicatethat even when people have access to condoms theyare still selective about which partnerships to use themin.10 The low levels of condom use in primary partner-ships reflect an important limitation of condoms. Inpart because of the successes in promotion, thecondom is commonly conceptualised as somethingthat is used in less meaningful or more risky sex and istherefore associated with a lack of intimacy and trust.Sex workers report using condoms to distinguishbetween commercial and non-commercial partners.Practically too, their use may interrupt sex and, forwomen, require negotiation with their male partnerwho may resist use. Although female condomsincrease women’s options, they are costly and their usemay still require their partner’s consent. Both male andfemale condoms are unsuitable for couples wanting toconceive. These barriers and evidence on patterns ofcondom use imply that, with increased investment andprogrammatic effort, consistent use of condoms maybe substantially increased in commercial and casualpartnerships and between discordant couples. How-ever, despite our best efforts, consistent use ofcondoms in primary partnerships is likely to remaindifficult to achieve. This key failure of condoms needsto be factored into future prevention planning.Given the strengths and challenges of achievinghigh levels of condom use we need to expand bothinvestment in the provision of male and femalecondoms, and research into alternatives such as thediaphragm and microbicides.w1 The experience of fam-ily planning has taught us that additional options arelikely to increase overall levels of consistent use—thesame should be true for prevention of HIV.w2 Condomsremain an essential weapon in the fight against HIV,but the armoury needs to be expanded if we are toenable women in regular partnerships to protectthemselves.Anna M Foss research fellow in mathematical modelling(anna.foss@lshtm.ac.uk)Charlotte H Watts senior lecturer in epidemiology andhealth policyPeter Vickerman lecturer in mathematical modellingLori Heise visiting research fellowHealth Policy Unit, Department of Public Health and Policy, LondonSchool of Hygiene and Tropical Medicine, London WC1E 7HTFunding: The review was conducted as part of the MicrobicidesAdvocacy and Networking Project managed by InternationalFamily Health with financial assistance from the EuropeanCommunity. The views expressed herein are those of theauthors and can therefore in no way be taken to reflect the offi-cial opinion of the European Commission or InternationalFamily Health.Competing interests: LH has a dual appointment as a seniorprogramme officer at the Program for Appropriate Technologyin Health (PATH) and as a research fellow at the Health PolicyUnit of the London School of Hygiene and Tropical Medicine.She serves as director of the Global campaign for Microbicides,an international network of non-governmental organisationsworking to ensure that as the science of microbicides proceeds,the needs and interests of users, trial communities, and the gen-eral public are respected and protected. The campaign has asmall staff housed at PATH that provides technical assistanceand small grants to partner groups in the developing world. Itreceives funding from the Ford Foundation, US Agency forInternational Development, the Moriah Fund, and otherfoundation donors. It does not accept funding from productsponsors.1 Boonstra H. US AIDS policy: priority on treatment, conservatives’approach to prevention. Guttmacher Report on Public Policy 2003;6:1-3.www.guttmacher.org/pubs/journals/gr060301.pdf (accessed 15 March2004).2 Sterritt C. Bush on AIDS: competing moral imperatives. AIDS 2003;17(suppl 4):s15-8.3 BBC. The Vatican’s condom challenge. 25 Nov 2003. http://news.bbc.co.uk/1/hi/world/europe/3237358.stm (accessed 15 March 2004).4 National Institutes of Health (NIH), US Department of Health andHuman Services. Workshop summary: scientific evidence on condomeffectiveness for sexually transmitted disease (STD) prevention. 12-13 June2000. www.niaid.nih.gov/dmid/stds/condomreport.pdf (accessed 15March 2004).5 Pinkerton SD, Abramson PR. Effectiveness of condoms in preventingHIV transmission. Social Science and Medicine 1997;44:1303-12.6 Weller SC. A meta-analysis of condom effectiveness in reducing sexuallytransmitted HIV. Soc Sci Med 1993;36:1635-44.7 Ghys PD, Diallo MO, Ettiegne Traore V, Kale K, Tawil O, Carael M, et al.Increase in condom use and decline in HIV and sexually transmitted dis-eases among female sex workers in Abidjan, Côte d’Ivoire, 1991-1998.AIDS 2002;16:251-8.8 Ward H, Day S, Weber J. Risky business: health and safety in the sexindustry over a 9 year period. Sex Transm Infect 1999;75:340-3.9 Wong ML, Chan KW, Koh D. A sustainable behavioral intervention toincrease condom use and reduce gonorrhea among sex workers in Sin-gapore: 2-year follow-up. Prev Med 1998;27:891-900.10 Foss A, Watts C, Vickerman P, Kumaranayake L. HIVTools ResearchGroup, London School of Hygiene and Tropical Medicine.Mimeo reportfor International Family Health. Are people using condoms? Current evidencefrom Sub-Saharan Africa and Asia and the implications for microbicides. Dec2003. www.ifh.org.uk/condom%20policy.htm (accessed 15 Mar 2004).11 Shelton JD, Johnston B. Condom gap in Africa: evidence from donoragencies and key informants. BMJ 2001;323:139.12 United Nations General Assembly Special Session on HIV/AIDS(UNGASS), Joint United Nations Programme on HIV/AIDS (UNAIDS).Progress report on the global response to the HIV/AIDS epidemic. 2003.www.unaids.org/ungass/en/global/UNGASS_Report_2003_en.pdf(accessed 15 Mar 2004).Editorials186 BMJ VOLUME 329 24 JULY 2004 bmj.com

Condoms and prevention of HIV.

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