Putting the Nail in the Coffin of Condom-Only HIV Prevention

Published: March 7, 2013

Dearly beloved, we gather here to say our goodbyes. For over thirty years, condoms have been our only lifesavers in the face of HIV. Gay men invented their promotion at a time when death was the only seeming alternative. When treatment did not exist. When Kaposi’s sarcoma was a visible reminder of the epidemic.  It was a different world. To quote Mr. Kushner, “You can never make that crossing that she made, for such great voyages in this world do not any more exist.”

Weep not, dear friends, for the passing of our friend. For a new era is dawning in HIV prevention.

If we needed any additional evidence of the need to turn the page, it came in the form of a seemingly banal conference presentation this week in Atlanta at the 20th Conference on Retroviruses and Opportunistic Infections. While CDC staff scientist’s Dawn Smith analysis of data from two previous HIV clinical trials seems at first glance to be of little import, its findings scream a different truth. (You can watch her presentation here – it’s the last paper in the session.)

The study’s aim may seem modest to many readers: to estimate how effective condoms are at reducing the risk of HIV transmission among men who have sex with men. But you may be surprised to learn that we have surprisingly little evidence to support the promotion of condoms to gay men for HIV prevention.

Don’t get me wrong. I’m no denialist. We have good reason to believe they work – all the evidence strongly suggests that they do. But how effective are they precisely? And in what context? Well, for many years, your guess was as good as mine. The last time a major study attempted to tackle this question, the year was 1989 – nearly a quarter-century ago. When Ronald Reagan was President.

But while the aim of the CDC’s study itself makes it important, it is what they found that should have every condom-thumping prevention activist in the country questioning their strategies. While most condom studies just look at whether guys have used them in the past six months, this analysis based on two independent, large studies employs data collected over a three to four year period. And rather than just asking guys once how often they used a rubber, researchers asked them every six months.

Since I began writing this column, I have said more than once that the condom use of most gay men I knew could only be said to be “inconsistent” – at best. But this study puts a more precise figure to my anecdotal evidence. Let’s start with the basic question: How many guys said they used a condom every time during every single six-month check-in? While over two-thirds of participants said they used a condom every time during at least one of the six month intervals, just 16.4% said they used a condom every time every single time they were interviewed. Not 50%. Not even 25%. 16.4%.

Now the more complicated question: By how much did reported use of a condom every time reduce the risk of HIV infection? This is sticky. As you know, guys lie left and right about how often they use condoms. Social scientists call this “social desirability bias.”

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