A multi-agency government report issued on July 20 has raised questions about the role of condoms in preventing sexually transmitted diseases (STD). In the first of two articles, SexHealth.com reviews the background to the report and its key findings.

Last June (2000), four U.S. government agencies responsible for condom research, regulation, and condom-use recommendations conducted a two-day workshop to begin evaluating the scientific evidence for condoms as a means of preventing sexually transmitted diseases (STDs).

A total of 180 medical and public health professionals participated in the two-day workshop, which drew upon the evidence from 138 peer-reviewed studies on condom use and STD protection. (Peer review refers to the editorial practice of requiring that papers submitted to scientific journals be checked by independent experts prior to publication.) Subsequently, a select panel of 28 experts, applying rigorous standards for scientific evidence, summarized the workshop proceedings and generated a report, recently published by the National Institutes of Health (NIH): Scientific Evidence on Condom Effectiveness for Sexually Transmitted Disease Prevention.

Scope and findings

The scope of inquiry was limited in three ways. First, the experts considered only latex condoms designed to be worn by men, thus excluding the data on condoms made from plastics and other materials, and also excluding female condoms. Second, the focus was on STD transmission resulting from penile-vaginal intercourse (no other forms of sexual contact were considered). Third, among 20 or more possible infections, eight specific STDs were considered: human immunodeficiency virus (HIV), gonorrhea, chlamydia, syphilis, chancroid, trichomoniasis, genital herpes, and human papillomavirus (HPV).

The report found strong scientific evidence that condom use can reduce the risk of HIV/AIDS transmission among men and women by 85% and substantially reduce the risk of gonorrhea for men; the available studies were deemed insufficient to judge the degree to which condoms may reduce the risk of gonorrhea among women. With regard to transmission of human papillomavirus (HPV)--the virus responsible for genital warts and cervical cancer--the panel found insufficient evidence that condom use reduces the risk of HPV infection, per se, but did find evidence that condoms may reduce the risk of some diseases caused by HPV, such as genital warts.

As for the other STDs evaluated, the report says the following:

Chlamydia: "Taken together, the available epidemiologic literature does not allow an accurate assessment of the degree of potential protection against chlamydia offered by correct and consistent condom usage."

Trichomoniasis: "The paucity of epidemiologic studies on condom effectiveness for trichomoniasis does not allow an accurate assessment of the reduction in risk of trichomoniasis offered by condom usage."

Genital herpes, syphilis, and chancroid (genital ulcer diseases): "The potential of the latex male condom to reduce the risk of transmission, even when used correctly and without slippage or breakage, would be expected to depend on the site of the sore/ulcer or infection and the ability of the condom to fully cover the lesion." Study limitations precluded an assessment of specific risk reduction for all three genital ulcer diseases.

The "fallout"

In the weeks since it's release, the NIH report has become something of a political football, as members of Congress and advocacy groups have jockeyed for public relations advantage in interpreting its results. The government review was launched in response to pressure from Congressional conservatives such as former U.S. Rep. Thomas Coburn (R-OK), who had requested the NIH to declare condoms ineffective in preventing HIV infection. Coburn and others charged that condoms were being oversold to the public as effective STD prevention in spite of their limitations, and questioned the use of public monies to fuel "safer sex" campaigns.

Following its publication late last month, a number of politically conservative voices have leveraged the report to criticize government policy on public health messages regarding condoms. Some have called for the resignation of Dr. Jeffrey Koplan, the head of the U.S. Centers for Disease Control and Prevention (CDC), citing the agency's consistent promotion of condoms as a means of STD prevention. The Physicians Consortium--a group of 2000 conservative U.S. doctors--charges in a letter to President Bush that the CDC has "misled millions of women into believing that condoms provide safety."

Public health officials and specialists in STD control, however, have argued that the government report centers on scientific study design and should not be interpreted as a reason to second-guess the usefulness of condoms for disease prevention. In particular, condom proponents point to an 85% risk reduction for HIV as reason enough to promote them to sexually active adults. Defenders of the CDC also point out that the agency has long placed qualifiers on its endorsement of condoms. In its 1998 Guidelines for the Treatment of Sexually Transmitted Diseases, for example, CDC states: "Because condoms do not cover all exposed areas, they may be more effective in preventing infections transmitted between mucosal surfaces than those transmitted by skin-to-skin contact."

A Bottom Line?

The political fallout notwithstanding, a careful reading shows that the government report sought to avoid making health policy pronouncements. "The meeting was not intended," says the final report, "to make public health policy recommendations regarding the role of condoms in HIV/STD prevention policy and programs." Indeed, the report does not conclude that condoms fail to provide protection against some major STDs, only that methodological limitations of the available studies prevented the panel from drawing conclusions about STDs other than HIV/AIDS, gonorrhea in men, and HPV-associated disease.

So, what does it all mean? In the second half of this two-part series, a number of medical and public health experts comment on the government report and the ensuing controversy.