Noticias© Comunicación Institucional, 28/01/2008

Universidad de Navarra

The risk left after risk reduction can remain high

Autor: Miguel A. Martínez-González
Departamento de Salud Pública y Medicina Preventiva
Universidad de Navarra

Fecha: 28 de enero de 2008

Publicado en: BMJ

I was pleased to read the “head to head” articles on whether condoms are, or not, the answer for the prevention of sexually transmitted infections, defended by Markus Steiner and Willard Cates on the “yes side” and Stephen Genuis on the “no side” (1). Pleased, because it was a nice scientific discussion and “ideologically free”. I have some points to add on the discussion. We need to be careful when relying on laboratory studies such as Steiner and Cates argue when affirming that condoms are effective barriers against “passage” of even the smallest sexually transmitted pathogens.

This is efficacy and obviously needs to be addressed in the first place, but it is not the ultimate criteria to evaluate condoms. In practice, the problems with condoms are not due to “passage of pathogens”. They rather have to do with issues such as breakage or slippage when the aroused young and inexperienced male unexpectedly looses his erection, for example. Furthermore, condoms do not cover all surfaces that can be infectious. A study by Winer in 2003 showed that some women got infected with HPV without having had penetrative sex (2).

The second issue I would like to address is the misinformation that can be conveyed when affirming that condoms “reduce the risk” of an infection. It is indeed important to reduce a risk but one has to understand the magnitude of this risk reduction, and the magnitude of the remaining risk thereafter, in order to make wise decisions. The 2006 study of Winer indeed showed that condoms were effective to reduce risks because the risk of infection decreased from 89% to 38% when comparing those that used condoms consistently with those using them in less than 5% of their sexual encounters(3).

But what these data also show is that condoms are not as effective as we would want hem to be to “avoid” an infection because, in spite of consistent use, 37% still became infected after one year, and this is a very serious public health problem. Is it sound to inform an adolescent girl not to worry because “condoms are good in reducing the risk of HPV”, when one still has a 37% risk of infection in spite of consistent condom use? I do not think so, and similar situations can be observed with other infections that have no satisfactory treatment. Giving these facts to youth is not “denigrating condoms”, this is simply giving them the facts. Hiding these facts would conversely be discriminatory to the large youth population that is not having sex and that would benefit with clear messages that help them maintain their risk avoidance choice.

And those that decide to have sex need to know this truth as well because it is their health that is at sake after all. Abstinence can be more or less difficult depending on what society chooses to promote but youth have the right and responsibility to face and respond to their own difficulties in life and make their own informed choices. Many crucial behavior changes can be difficult. Millions of young people around the world have made the difficult choice of abstaining. Thirdly, the information on condoms do not undermine abstinence programs when interventions are indeed “abstinence centered” (4).

However when condoms and abstinence are presented as equally valid choices for youth without sexual experience, risk compensation is an obvious possible outcome (5). Yes, we should feel relieved if a program does not increase risk taking. However, a good program should go beyond and achieve a decrease in risk taking. Both the yes and the no sides seemed to agree that messages have to be tailored to specific target populations.

This is what was basically endorsed in the consensus published in The Lancet that called for the promotion of sexual delay and mutual monogamy among youth and sexually active adults respectively, and condom use to those who freely chose not to accept risk avoidance (6).

But a recent Lancet editorial on this same issue has very much disappointed me (7). I am surprised to see a scientific journal such as The Lancet taking such unscientific and partisan stances. It is not the first time this journal uses editorials to convey a certain anti pope agenda. In “The Pope and science” they state that Pope Benedict XVI was forced to cancel a speech at La Sapienza University in Rome “because of his past defense of the Church’s 1663 heresy trial of Galileo”.

The editorial then goes “guestimating” the number of Catholics that are against the Church’s teachings and uses terms such as “conservative” or “progressive” Catholics to finish up giving the impression that the Pope is alone with his teaching on abortion or condom use. The Pope has never ever defended Galileo’s trial, The Lancet has simply misquoted him because it seems they have unfortunately not read his original speech where this issue was brought up. The cancellation of La Sapienza was due to the “democratic” protest of 67 out of the 4.500 professors of that university.

Two hundred thousand persons gathered at Saint Peter’s place on the Sunday after this event to show their Papal support. The Church has its views on condom use and has a specific teaching on sexuality that one is free to accept or not. Scientific journals have nothing to say on this personal choice. But studies have showed that the only countries that have really been able to curb the HIV epidemic are those that have seriously implemented A and B instead of relying solely on condom promotion (8). Furthermore, the church has been promoting A and B
along centuries and instead of concentrating on trying to change its teachings on sexuality and condom use, we could rather learn and benefit more from church experience fostering sexual delay and mutual monogamy among youth.

References:

(1) Steiner MJ, Cates W. “yes” and Genuis S “no”. Are condoms the answer to rising rates of non-HIV sexually transmitted infections? BMJ 2008;336:184-185.
(2) Winer RL, Lee SK, Hughes JP, Adam DE, Kiviat NB, Koutsky LA. Genital human papillomavirus infection: incidence and risk factors in a cohort of female university students. Am J Epidemiol 2003; 157: 218-26.
(3) Winer RL, Hughes JP, Feng Q, O'Reilly S, Kiviat NB, Holmes KK, et al. Condom use and the risk of genital human papillomavirus infection in young women. N Engl J Med 2006; 354: 2645-54.
(4) Cabezon C, Vigil P, Rojas I, Leiva ME, Riquelme R, Aranda W, Garcia C. Adolescent pregnancy prevention: An abstinence-centered randomized controlled intervention in a Chilean public high school. J Adolesc Health. 2005;36:64
(5) de Irala J, Alonso A. Changes in sexual behaviours to prevent HIV: the need for comprehensive information. Lancet 2006; 368:1749-1750
(6) Haleprin D, Steiner M, Cassel M, Green E, Hearts N, Kirby D, et al. The time has come for common ground on preventing sexual transmission of HIV. Lancet 2004; 364: 1913-1915.
(7) Editorial. The Pope and science. The Lancet 2008;371:276
(8) Hearst N, Chen S. Condom promotion for AIDS prevention in the developing world: is it working? Stud Fam Plann 2004; 35: 39-47.

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