BMJ editorial backs 'essential and effective' condoms for HIV prevention

A robust defence of the importance of condoms in preventing the spread of HIV is contained in an editorial in the July 24^th edition of the British Medical Journal. High levels of condom use in casual sexual encounters are highlighted by the editorial, however the editorial points to problems with supply, cost and low condom use in primary relationships as hampering their effectiveness as preventing the spread of AIDS. Pointedly, the editorial does not endorse abstinence as a strategy to replace condom use for either casual or regular sexual relationships.

American-backed “abstinence” HIV prevention campaigns and the Roman Catholic church’s questioning of the morality and efficacy of condoms have meant that the importance of condoms to HIV prevention has been questioned recently.

However, as the editorial points out, statistics from the US government’s National Institutes for Health show that condoms are highly effective at preventing HIV infection, reducing the probability of HIV by as much as 95% per sexual act. Consistent condom use by serodiscordant couples was also shown by the NIH to be able to reduce the annual risk of HIV transmission by between 90-95%.

An Achilles' heel of condoms is, however, inconsistency in their use. An analysis of studies quoted in the editorial found that even amongst serodiscordant couples condom use was variable, meaning that the annual risk of HIV infection was reduced by 69%.

Individuals are also making decisions about whether or not to use a condom dependent on the sexual circumstances they would be used in. For example, condom use is high for casual sexual encounters, but low for sex between primary partners, with a recent study finding that in 13 African countries with high HIV prevalence only 7% of women reported using a condom during their last sex act with their regular partner. Further, a study conducted amongst African sex workers found that although most reported using condoms with their clients, only 40% said they used condoms with their main partner.

There are problems with the supply, access and affordability of condoms in much of the world, the editorial points out. Earlier this month, UNAIDS said that there was a massive shortfall in the number of condoms needed to fight the spread of HIV.

However, even if these issues were to be addressed practical problems concerning condom use still remain. Condoms interrupt sex, and importantly, men must consent to their use. Female condoms are not a realistic alternative, believes the editorial’s author, as supply is limited, they are costly, and men could still refuse to use them. Further, condoms of any kind are not an option for couples wishing to conceive.

Increased investment and effort could, the editorial suggests, increase condom use in commercial and casual partnerships, but consistent condom use in primary partnerships is likely to prove difficult to achieve.

The editorial concludes, “given the strengths and challenges of achieving high levels of condom use we need to expand both investment and provision of male and female condoms, and research alternatives such as the diaphragm and microbicides. The experience of family planning has taught us that additional options are likely to increase overall levels of consistent use – the same should be true for the prevention of HIV.” The author emphasises, “condoms remain an essential weapon in the fight against HIV, but the armoury needs to be expanded if we are to enable women in regular partnerships to protect themselves.”