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Condoms prevent HPV in sexually naïve women
By Carol Kemper, MD, FACP
Dr. Kemper reports no financial relationships relevant to this field of study. This article originally appeared in the June 2005 issue of Infectious Disease Alert. It was peer reviewed by Connie Price, MD and edited by Stan Deresinski, MD. Infectious Disease Alert's Physician Editor, Stan Deresinski, MD, FACP, serves on the speaker's bureau of Merck, Pharmacia, GlaxoSmithKline, Pfizer, Bayer, and Wyeth, and does research for Merck. Peer reviewer Connie Price, MD, reports no consultant, stockholder, speaker's bureau, research, or other financial relationship with any company related to this field of study.
Source: Winer RL, et al. Condom use and the risk of genital human papillomavirus infection in young women. N Engl J Med2006,354,25;2635-2654.
The debate surrounding the relative merits of abstinence and fidelity vs. condom use (as if the two were mutually exclusive) remains a hotly contested issue, at least in the United States, where it has even spilled over into U.S. international family planning policy. In 2001, conservative groups successfully pressured Congress to pass a law requiring the FDA to define the medical accuracy of condom effectiveness in preventing STD's other than HIV. By then, condom use had clearly been shown to reduce the risk of HIV, and, at least in men, gonorrhea. But while most experts agree that condoms were likely to decrease the risk of transmission of other STDs, such as syphilis, HSV, and HPV, clear data was lacking. Indeed, controlled clinical trials to prove that condoms are effective in reducing transmission of such diseases, for example, as syphilis, are not possible, and probably unethical. However, given that sex can often be messy, it is not inherently obvious to what degree condom use may decrease the risk of HSV or HPV transmission.
Fortunately, 6 years later, the group in Seattle has weighed in with a positive result, that young women having sex for the first time whose partners use condoms 100% of the time have a 70% lower risk of HPV infection than a similar group of women whose partners infrequently used condoms.
A total of 210 female university students aged 18 to 22 years who were sexually naive or newly sexually active with a single partner were evaluated at baseline, and every 4 months for up to 2 years. Cervical and vulvovaginal specimens were tested for HPV DNA and routine Papanicolaou smears were performed, as well as testing for other STDs. The data for 82 young women who were sexually active less than 2 weeks prior to enrollment and who kept detailed daily computerized diaries of the sexual activities were analyzed. After first time intercourse with a first time partner, most HPV infections occurred within 8 months (before a second partner), and the shortest interval from the first sexual experience to an HPV event was 20 days. Thus, data for the time period of 20 days to 8 months was analyzed to best answer the FDA's question.
A total of 126 incident infections were identified in 40 women after their first intercourse, for an overall 12-month cumulative incidence of 37.2% (confidence interval, 27 to 49%). The 24-month cumulative incidence of squamous intraepithelial lesions was 15% (confidence interval 8.3 to 26.2%), including one high grade lesion and 14 low grade lesions. Three women were found to have HPV infection at baseline, before any reported sexual intercourse.
Comparing young women who partners used condoms 100% of the time vs those with <5% use, the incidence of genital HPV infection was 38 vs 89 per 100-person years, respectively (adjusted hazard ratio, 0.3). No cervical squamous intraepithelial lesions were detected in women whose partners used condoms 100% of the time, compared with 14 lesions in those whose partners used condoms less consistently. Thus regular consistent condom use resulted in a significant reduction in the transmission of HPV in young women who were sexually active for the first time. Because sex so often may involve genital contact before the application of a condom, it is not surprising that some women who reported consistent condom use nonetheless developed HPV infection, or that a small number had evidence of HPV infection even before experiencing intercourse.
It is important to note that the results may not be generalizable to older women, or women who have already been sexually active for some time, or women of lower socioeconomic class. Nonetheless, the FDA can now prominently and decisively display the benefits of condom use in the reduction of HPV transmission.