The article is "Comparison of Sexually Transmitted Disease Prevalence by Reported Level of Condom Use Among Patients Attending an Urban Sexually Transmitted Disease Clinic", by Judith C. Shlay, MD, MSPH, et al., Sexually Transmitted Diseases (Journal of the American Sexually Transmitted Diseases Association), March 2004, Pages 154-160.

I shall quote the opening paragraph and the closing paragraph of the article. I shall quote selected material in between. I will attempt to be "fair and balanced" (apologies to Fox News).

I will not quote many statistics (there are enough to make even my eyes glaze over) nor much of the explanation of technical limitations and uncertainties of the study. You will have find the magazine and go to the full text if you want those details.

The study was done at the Denver Metro Health Clinic (DMHC), the STD clinic operated by the Denver Public Health Department.

Before I get into the article itself I will quote a paragraph from the Editorial Response that appears on pages 161-162 of the same issue. If you read nothing more, you should read this paragraph.

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Nevertheless, in this issue of Sexually Transmitted Diseases, Shlay et al. offer data that suggest that consistent condom use is effective for the prevention of a variety of viral and nonviral STDs. In their study of over 75,000 patients seen over a 12 year period at one urban STD clinic, condom use was reported by 54% of sexually active patients presenting to the clinic with a new problem. Of these patients, fewer than one-third of condom users (16% overall) gave a history of consistent condom use in the prior four months. Prevalence rates were calculated for gonorrhea, chlamydia, trichomonas, genital herpes, and genital warts that were first onset and symptomatic for only the prior month, trichomonas and molluscum contagiosum, and presented by frequency of condom use in the prior 4 months. Overall, condom use showed only modest protection against the commonly seen STDs for both men and women. However, when the data were analyzed for condom users, comparing consistent versus inconsistent users strong and relatively consistent findings emerged. For both men and women, prevalent gonorrhea and chlamydia were significantly reduced among consistent condom users, whreas genital herpes was lower for men, and trichomonas was lower for women, who reported consistent condom use.


David D. Celentano, SCD, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore MD

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Now for the quotes from the article itself. My remarks (primarily to summarize omitted material) are enclosed between braces {} to distinguish them from the text of the article.

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Condoms have long been considered to be one of the most effective practical means of reducing the risk of sexually transmitted diseases (STDs) among sexually active adolescents and adults. Male latex condoms provide a virtually impermeable barrier to a variety of STD agents in laboratory studies. Because condoms cover the shaft of the penis, they should provide protection against diseases transmitted by semen and other genital secretions and, to a lesser extent, provide protection against infections transmitted by contact with skin lesions. For HIV, several prospective studies conducted on discordant couples have provided convincing clinical evidence that consistent condom use is effective in preventing HIV. For other STDs, data on effectiveness is largely based on cross-sectional studies, with some demonstrating a protective effect against a variety of STD and others demonstrating variable protection.

Recently, the effectiveness of condoms has been challenged by a well-publicized report by the National Institues of Health. The report concluded that there was good evidence of condom effectiveness only for HIV and for gonorrhea in men, and that published data were insufficient to draw definite conclusions about other STDs. {This report is: National Institute of Allergy, Infectious Diseases, Workshop Summary: Scientific Evidence on Condom Effectiveness for Sexually Transmitted Disease (STD) Prevention, Herdon, VA, July 20, 2001.}

Methods

{I will skip the Methods section entirely. For the few who are interested you should find the magazine and read the article.}

Results

{Much of this section gives statistics on who uses condoms and who does not by race/ethnicity as well as by age and gender and risk behavior (defined mostly number of sexual partners).}

Table 5 compares the rates of STD by condom use categories, controlling for demographic and risk behavior variables, by logistic regression. Among men, when all condom users were compared with nonusers, condom users had lower rates of genital herpes (adjusted odds ratio [AOR], 0.79; 95% confidence interval [CI], 0.71-0.89), but slightly higher rates of genital warts (AOR, 1.17; 95% CI, 1.04-1.31) with no significant differences for the other STDs. In contrast, among those men who used condoms, consistent users had significantly lower rates of gonorrhea (AOR, 0.87: 95% CI 0.81-0.94), chlamydia (AOR, 0.66; 95% CI 0.60-0.73), and genital herpes (AOR, 0.73; 95% CI 0.61-0.88) than inconsistent users. Similar patterns were seen for women. Compared with nonusers, condom users had similar rates of STDs except for lower rates of gonorrhea (OR, 0.89; 95% CI, 0.83-0.96) and higher rates for chlamydia (AOR, 1.18; 95% CI 1.07-1.30). However, among women using condoms, consistent users had significantly lower rates of gonorrhea (OR, 0.71; 95% CI 0.63-0.80), chlamydia (OR, 0.74; 95% CI, 0.65-0.84), and trichomoniasis (OR, 0.87; 95% CI 0.78-0.97) than inconsistent users. In addition, for women, there was a trend toward a lower rate of genital herpes, as seen by men, although this difference was not statistically significant (P = 0.09).

Discussion

{Much of this section talks about the difficulties involved in determining the protection provided by condoms. In particular, persons choosing to use condoms do so in the context of greater sexual risk than nonusers.}

Although difficulty in defining incident infection and incubation period for viral STDs reduces precision, the consistency of condom effectiveness was less for viral than nonviral STDs. The viral STD for which we saw the greatest benefit was genital herpes. For men the level of protection was statistically significant and was similar to that seen for gonorrhea and chlamydia, whereas for women there was a trend toward benefit, which was not statistically significant (P = 0.09).

Although rates of nonviral STD were consistently lower in consistent than inconsistent users, the level of demonstrated protection (13-30%) is admittedly modest, even if statistically significant. In this regard, several aspects of our study design that likely led to underestimates of the protective effect of condoms should be pointed out. {Lengthy technical discussion follows.}

Despite these limitations, our study showed that, although imperfect, consistent use of condoms provides at least a partially effective approach for sexually active persons wanting to decrease their risk of a variety of STDs. Thus, although clearly not as efficacious as abstinence, or a substitute for other prevention approaches such as care in partner selection, mutual faithfulness, and screening/treatment for STDs, consistent use of condoms remains an important strategy in reducing the risk of STDs among sexually active adolescents and adults.


-- Modified on 4/29/2004 2:01:24 AM

This study is yet one more epidemiologic study on condom use.  As far as I know, there are NO randomized controlled trials on condom use to prevent any STD.  The authors go too far using non-randomized data and then drawing a causal inference.  Because epidemiologic studies suffer from selection bias, randomized trials remain the standard for assessing efficacy.  However, randomized trials of condoms would not be considered ethical and would never get past ethics review.  All we can say from this paper is that condom use is associated with slightly lower rates of some STDs.  

I will try to read the original article, and may comment more on methods, but probably not for a while.

You will note that there is no mention of syphilis or HIV, prosumably because of too low incidence for inference testing.

Given these limitations where are we?  There is probably a big difference between contact type transmission (syphilis) and body fluid type transmission (HIV).  Ecologic studies, some in sex workers in countries with high HIV prevalence, suggest that the prevalence can be cut dramatically, much more than in the Shlay article, with condoms.  When therapy is really profound, randomization is not needed.  Thus, there are no randomized trials of penicillin for primary syphilis -- it works every time.  Randomized trials were needed for protease inhibitors for HIV.

Bottom line: stay covered up; it may save your life.

FS

--->  "In particular, persons choosing to use condoms do so in the context of greater sexual risk than nonusers."

The point being that in NO SENSE, is the comparison between consistent users, inconsistent users, and non-users, an apples to apples comparison.

As a result, the relative rate of protection that condoms provide, while it SEEMS to be lower than might have been imagined, is almost certainly significantly UNDER-stated in the comparison of infection rates across the groups.

This can be intuitively surmised by the fact that the infection rate for consistent users was higher for genital warts.  That would be counter-intuitive, except that one must realize that the protection provided by condoms against genital warts is certainly not complete, and the relative risk environment being endured by consistent condom users is CERTAINLY SIGNIFICANTLY GREATER than the population as a whole.

Thanks for posting the study results. I appreciate your taking the time to research and post the information, including the supporting documents (as you've done with other posts.)

Sometimes, though, busy people want the "punchline" first because they may balk at reading a lengthy scientific article.

It would be a more user-friendly post if you posted the conclusions first, then delved into the details afterwards.

the scientific research is giving results that contradict deeply held beliefs of so much of this community.

If you read the condom threads here you will find that many people (both men and women) deeply believe that if a condom is used that they are safe from STDs.

At the same time cross-sectional studies are having difficulty in showing more than very modest benefits from condoms.

The failure of cross-sectional studies to show more benefits to condom usage is very troubling. This is especially true since laboratory studies indicate that male latex condoms provide a virtually impermeaable barrier.

Studies such as the discordant couples studies for HIV that track a group of people over time do better in showing benefits to condom usage. (The Haiti study shows that the rate of infection drops from about 7 infections in 100 person years for unprotected sex to about 1 infection in 100 person years if condoms are used correctly and consistently. A study of female brothel-based sex workers in Singapore shows that unprotected oral sex increased the women's risk of acquiring pharyngeal gonorrhea from their clients by 17 times, 95% CI 8.0-36.5.)

Why do cross-sectional studies have such difficulty in showing benefits to condom usage?

I have a hypothesis, but this is just my own opinion and I am not a doctor nor a researcher in the field so it may well be completely wrong.

Think about a population in which everyone is having sex with everyone else and condoms are not being used. There are a few infected individuals in the population. The infection spreads and in the end everyone is infected.

Now let us say that everyone is using condoms correctly and consistently. Because condoms provide only partial protection the end state is the same. Everyone is infected.

However, there is a difference. In the second case (depending on the disease) it takes 7 (or 17) times as long to reach the end state.

This gives much more time for intervention. Screening and treatment become much more effective at eliminating the disease from the population (or at least in keeping the fraction of the population that is infected low) if the rate of transmission of the disease is slowed.

I think (my personal opinion) that cross-sectional studies have difficulty in showing the benefit to slowing the spread of an infection in a population. What they show is that in the absence of screening and treatment everyone ultimately becomes infected whether or not condoms are used.

As I say, this post is just my opinion and this is not my field so I may well be completely wrong.

Mathesar


-- Modified on 4/29/2004 4:05:44 PM

Simple suggestion, to put a summary first and then follow with details for those that are interested.

He answers with another long winded posting!  LOL

I am reluctant to assume that all people in the test case used condoms 100% of the time.  I think such committment is difficult to acheive over a long period of time.  Most of the science has shown that condoms are effective against STDs.  I would be more interested in a laboratory test where penetration of the material by a virus, bacteria - whatever - was observed under specific conditions, such as high friction, long term exposure to the virii etc.

Then what about viruses which are on the condom when you take it off ... you could potentially get the virus on your hand, then when you grab your cock to finish up, you have evaded the whole purpose of the condom.  Then when she sucks you to completion - again - you pass the virus onto yet another area which can be passed to the next person on the next BBBJ.  But who the hell wants to be clinical during a session?

I also think that STDs get passed onto people who use condoms because lets face it ... the shaft is not the only flesh which makes contact.  Someone needs to invent the 'cock-n-balls condom', where everything is all protected up and ready to rock.

Also, I am fairly certain that condom use among providers is fairly consistent.  I realize there are those providers who are not using them, and that definately poses a problem for the rest of us.

Getting an STD would absolutely suck ass! (not that I have anything against sucking ass)



I wonder how often STDs really happen amongst the higher paid providers - or how often they get tested.  If this profession could were legal, mandatory testing could help aleviate some of the fear.  Although I heard (or read) somewhere that the porn industry is seeing an influx of STDs, and I know they require testing.

Some day this will not be an issue.  Our knowledge of DNA and genetic drugs will make all of this a thing of the past.

Since Mathesar is a respected member ofthe community, let's give him the benefit of the doubt-  I think he means to say that it is difficult to sum up and that one has to view the data to draw one's own conclusions

I know we are a spoon fed society , but some things needs perusal.

Albert Einstein said: "If you cannot explain it simply, you do not understand it well enough".

It's great that he cared enough to do the work--but the message will get lost on most people just on aesthetics alone.

Black holes (as found in the center of galaxies, no pun intended) still make my head hurt.

Even my doctor is under the impression that if you're using condoms, you're fine and no need to test! Yeah, that's what three of them told me. I said, great - I'm testing anyway.

He probably would have posted the entire thing on a discussion board and lost everybody with excessive information anyway. Sound familiar?

sort of Thrust-  but verify to paraphrase Ronnie Pops' paraphrasal of a russian proverb.

Actually it's a french saying as everyone knows I love les francais...

Jes' bein' a dick...

I think the Doctors are motivated financially when they don't want us to test frequently.

I just say "I had a high risk sexual contact" (which I consider any contact with a person I'm not committed to that hasn't presented me with a clean test & six months of exclusivity) and if they start to give me a lecture, I tell them I came for tests, not judgements.

I pay dearly for insurance coverage and the doctors will serve MY needs.

xoxo
Elise

-- Modified on 4/29/2004 6:36:19 PM

I think AIM's monitoring of the porn community indicates how valuable testing can be in preventing HIV infection from spreading through a community. As sdstud indicated elsewhere the porn community does not embrace condoms and safe sex--to put it mildly. Yet from 1999 (where there was one HIV infection) to the present where time where we have (probably only) two infections we had four years with no HIV infections in that community whatsoever.

And the present HIV infection appears to have been imported from Brazil where the infection rate in the major cities is pretty high.

Of course, HIV testing isn't voluntary in the porn community. Without a recent test to prove you aren't infected you don't work. I do wish a similar system could be created for our community for both clients and providers.

Felicia Foxx indicated that providers could register with AIM as CSWs and that anybody could call in and verify their HIV status using the provider's stage name. Unfortunately, the seizing of AIM's records by the Health Department puts a chill on that and it didn't solve the problem of client HIV status in any case.

About the best we can do is (1) use condoms for however much good they do, (2) get tested frequently to make sure we aren't passing anything on, (3) avoid IV drug users, and (4) hope that the ladies avoid MSMs (men who have sex with men).

Incidentally, according to an article in Sexually Transmitted Diseases they are now seeing what they call "superinfections" in MSMs. This is where a HIV positive male who appears to be in good health because of drug therapy resumes sexual activity and gets infected a second time with a different substrain of HIV.





-- Modified on 4/29/2004 7:07:43 PM

-- Modified on 4/29/2004 7:09:18 PM