NIH condom review sends message that prevention efforts need fine-tuning

Clinicians should emphasize proof of HIV protection

A recent National Institutes of Health (NIH) review of condom use among heterosexuals may have stirred some political dust when first released in July, but the ultimate take-home message has to be that condoms provide the best proven protection against HIV infection during sexual intercourse and may reduce the risk of acquiring some other sexually transmitted diseases (STDs), according to researchers, physicians, and others who discussed the report with AIDS Alert.

"The condom is the only protection we have right now if you are engaging in sexual activity," says Scott Brawley, MSW, policy and program analyst for AIDS Action in Washington, DC.

A workshop involving 28 panel members, including physicians, researchers, professors, and others, reviewed 138 peer-reviewed papers published before June 2000 about condom effectiveness in preventing STDs between heterosexual partners. The review was requested by Tom Coburn, a former Oklahoma Republican member of the House of Representatives. The published report is titled, "Workshop Summary: Scientific Evidence on Condom Effectiveness for Sexually Transmitted Disease (STD) Prevention."

"I think the greatest value of this report is its ability to educate physicians, patients, and other health care providers on the accurate facts about condoms," says Mary B. Adam, MD, a researcher at Informatics and Decision Making Laboratory and a lecturer at the University of Arizona College of Medicine in Tucson. Adam was one of the panel members involved in the condom research review. "There has to be a heavy emphasis on screening and treatment of STDs, and that’s been an underpublicized, readily available option," Adam adds.

Some media reports chose to emphasize the report’s finding that the available research is limited in supporting conclusions about the effectiveness of condoms in reducing transmission of certain STDs, such as syphilis and human papillomavirus.

The Physicians Consortium of Washington, DC, a group of socially conservative doctors, jumped into the political fray in late July by calling for the resignation of Jeffrey Koplan, MD, chief of the Centers for Disease Control and Prevention of Atlanta. The group accused the CDC of failing to protect public health by advocating a safe-sex message. However, the NIH report’s conclusion was that the published data are strong in supporting the use of condoms in preventing HIV, the most deadly of the STDs.1 (See "Here’s a look at the NIH condom review’s findings," in this issue.)

"This is a pretty volatile subject, and various groups will choose to interpret this report in various ways," says Carole Heilman, PhD, director of the Division of Microbiology and Infectious Diseases at the NIH in Bethesda, MD. "In terms of HIV prevention, this is an additional piece of information that supports the stance [clinicians] have already taken with regard to condoms and HIV prevention," Heilman states.

Condom use coincides with STD decline

Also, a study published in August 2001 in the Journal of Acquired Immune Deficiency Syndromes concluded that the recent increases in condom use found in national surveys of at-risk heterosexuals are consistent with observed declines of HIV and syphilis in the 1990s. The study authors said this confirms that prevention messages stressing condom use are successfully containing HIV and syphilis infection rates among the at-risk heterosexual population.2

The clinician’s role in screening and counseling at-risk patients continues to be a major focus of prevention strategies as the epidemic shows signs of rapid growth, particularly among certain high-risk groups, such as minority men who have sex with men (MSM). One recent study showed that HIV prevalence among urban MSM in the United States is as high as the prevalence rates in sub-Saharan countries.3

"In this world of HIV, we’ve been taught that a condom is our armor and that as long as we wear a condom we won’t transmit or catch anything," says Stephen Goldstone, MD, medical director of GayHealth.com. "The fact of the matter is that most STDs are spread by skin-to-skin contact and during foreplay, rubbing, fingers, and toys that carry STDs from one partner to another," Goldstone adds. "So just because you’ve had anal sex with a condom does not mean you could not have caught an STD, but I think a condom still is our best protection after abstinence."

Some research has shown that there has been an increase in high-risk sexual behavior in the years since highly active antiretroviral therapy (HAART) has become widely available and that people on HAART are more likely to develop an STD, which means they need more intensive risk-reduction counseling and screening.4

The NIH report’s meta-analysis showed that condoms prevented HIV infection 85% of the time and that latex condoms potentially could prevent the spread of STDs based on their impermeability, Heilman says. However, the actual data showed questionable prevention for women with regard to gonorrhea, although research suggests condoms are effective prevention against gonorrhea transmission to men.1

Clinicians should caution patients that condom use is not effective protection against STDs when there are open sores through which disease may be transmitted, says Patricia R. Cohen, PhD, professor of clinical public health at the Columbia University School of Public Health, Epidemiology in New York City. Cohen was on the NIH condom review panel. "For HIV, there is no doubt at all of its effectiveness, and of all these diseases, that is the most threatening," Cohen adds. "So whenever you don’t know the STD status of your partner, you should use condoms."

CDC investigators have found that primary care providers often fail to ask patients about STDs. Only 28% of adults ages 16 to 64 surveyed in 1994 reported being asked about STDs during routine check-ups, and there is no evidence that this statistic has changed in recent years, says Kathleen Irwin, MD, MPH, chief of the health services research and evaluation branch in the Division of STD Prevention at the CDC. "Therefore, we have lost opportunities to screen people for STDs, treat them, and prevent future STDs from being acquired," Irwin says.

The CDC research found that adults were significantly more likely to be asked about STDs if they were under 45, male, single, poor, or were insured by a health maintenance organization or public coverage.5

CDC funds assessment training

The CDC funds training centers for HIV/ AIDS/STDs throughout the United States. These centers provide information for physicians, nurses, nurse practitioners, health educators, and counselors on how to do a good risk assessment, how to take a sexual history, and how to use innovative methods for collecting information other than through a face-to-face interview, Irwin says. (See "Doctors overlook sexual histories too often," in this issue.) "We’re also developing web-based materials to allow people to get training on-line if they’re not actually able to attend a session in person," Irwin says.

HIV providers who would like to provide education and training to their local primary care provider communities may use risk assessment and counseling materials available from the Agency for Healthcare Research and Quality (AHRQ) of Washington, DC. The AHRQ’s materials can be can be obtained from the agency’s web site: www.ahcpr.gov.

In light of the NIH review, HIV providers need to give more detailed messages to patients than the simple admonishment to use a condom, experts say. "As physicians, we need to do a better job of first asking our patients what’s going on in their lives and then what risk behaviors they have, because if there’s one risk behavior, there may be others," says J. Thomas Fitch, MD, a pediatrician from San Antonio, TX, who was on the NIH panel.

Providing a clear picture of risk

"The message we haven’t gotten out to patients is that if you’re involved sexually outside of a long-term relationship with someone who’s not been tested, you’re at risk for an STD, and you need to be screened once a year by a physician," Fitch says. "Adolescents should be screened twice a year."

HIV clinicians also need to make certain their patients don’t conclude that they shouldn’t bother using condoms because they’re not 100% effective in preventing STDs, Fitch adds. "The problem is that in the attempt to get people to use condoms, we’ve implied they’re 100% effective or close to 100%, and the public says, If I use a condom, I should be okay,’ and that’s not necessarily the case," he explains. "The message I’ve given all along to my patients is that having sex outside of a monogamous relationship is a risk, but the best prevention for HIV is to use a condom."

References

1. National Institute of Allergy and Infectious Diseases, National Institutes of Health, Department of Health and Human Services. "Workshop Summary: Scientific Evidence on Condom Effectiveness for Sexually Transmitted Disease (STD) Prevention." Herndon, VA; July 20, 2001:1-27.

2. Catania JA, Canchola J, Binson D, et al. National trends in condom use among at-risk heterosexuals in the United States. JAIDS 2001; 27:176-182.

3. Catania JA, Osmond D, Stall RD, et al. The continuing HIV epidemic among men who have sex with men. Am J Public Health 2001; 91:907-914.

4. Scheer S, Chu PL, Klausner JD, et al. Effect of highly active antiretroviral therapy on diagnoses of sexually transmitted diseases in people with AIDS. Lancet 2001; 357:432-435.

5. Tao G, Irwin KL, Kassler WJ. Missed opportunities to assess sexually transmitted diseases in U.S. adults during routine medical checkups. Am J Prev Med 2000; 18:183-185.