Condom effectiveness

Treatment Review

Condom Effectiveness Demetrius J. Porche, DNS, RN, CS, CCRN A b s t i n e n c e from sexual intercourse with human immunodeficiency virus (HIV) infected partners is the most effective strategy for preventing the sexual transmission of HIV and other sexually transmitted diseases (STDs). Individuals who choose not to abstain from sexual intercourse can use barrier methods, such as condoms, to reduce the risk of exposure to HIV and other STDs. Health care practitioners who conduct safer sex education and counseling should provide information on condoms as a method of reducing the risk of HIV and STD transmission. These health care practitioners are frequently questioned regarding the effectiveness of condoms. This article presents information on condom-testingprocedures, correct condom usage, and condom effectiveness.

quality control standards as U.S.-produced condoms (Centers for Disease Control and Prevention [CDC], 1993a).

Testing Procedures

Male Condom

Latex condoms are regulated by the Food and Drug Administration (FDA) as medical devices. These FDA regulations govern latex condom manufacturing and testing in accordance with stringent national standards. Every condom sold in the United States is electronically tested by the manufacturer for defects in the integrity of the latex, including holes and thin areas before packaging. Random latex-condom testing is conducted using a water-leak test on the entire product batch of condoms. In a water-leak test, the condom is filled with 300 ml of water, which stretches the condom to about four times its original size. If more than 4 per 1,000 condoms leak, the entire product batch of condoms is discarded and not allowed to be sold. FDA data report that the average batch of condoms has a water-leak rate of 0.3%. The FDA randomly tests imported condoms according to the same stringent

Male condoms are made of natural membranes or latex. Natural-membrane condoms have pores that allow viruses to permeate the condom (CDC, 1993b). Natural membrane condoms are not recommended for use in the prevention of HIV and other STD transmission (CDC, 1993b). Intact male latex condoms are a barrier to HIV, herpes simplex virus, hepatitis B virus, chlamydia trachomatis, and neisseria gonorrhea (Carey et al., 1992; Weller, 1993). The CDC recommends the consistent and correct usage of male latex condoms with or without spermicides with each sexual act (CDC, 1993b) to prevent HIV transmission. Weller's (1993) meta-analysis supports this recommenda-

Correct Condom Usage Condom effectiveness is dependent on consistent and correct usage during every sexual act. Health care practitioner's health education programs on the prevention of HIV transmission must include guidelines on the correct usage of condoms. Table 1 provides guidelines on the correct usage of male latex condoms (CDC, 1993b; Gerchufsky, 1996). Guidelines for the correct usage of the female polyurethane condom are presented in Table 2 (Gollub, 1995).

Demetrius J. Porche is the director and associate professor the of Bachelor of Science in Nursing Program at Nicholls State University

JOURNALOF THE ASSOCIATION OF NURSES IN AIDS CARE, Vol, 9, No. 3, May/June 1998, 91-94 Copyright 9 1998 Association of Nurses in AIDS Care

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Table 1. Guidelines on Correct Use of Male Latex Condoms

Condoms should be stored in a cool, dry place and out of direct sunlight. Do not use condoms after the expiration date. Condoms with a spermicide have a shelf life of about 2 to 3 years, whereas condoms without spermicides have a shelf life of about 5 years. Do not use condoms that are gummy or sticky. Use a new condom with each sex act. Handle condoms carefully. Avoid puncturing holes in the condom with fingernails. Use a condom that covers the entire penis. Put the condom on the penis after it is erect and prior to any genital contact. Uncircumcised men should pull the foreskin back before putting the condom on the erect penis. Unroll the condom all the way down the entire length of the penis. Ensure no air is trapped in the condom's reservoir tip. If the condom does not have a reservoir tip, leave about 1/2 inch free at the tip of the condom to serve as a semen receptacle. Be sure there is no air in the semen receptacle. Ensure there is adequate water-based lubricant during the entire sexual act. If the condom breaks or slips offduring sex, stop and put on a new condom. Hold the condom firmly against the base of the penis during withdrawal of the penis and condom from the partner's orifice. Wrap the used condom in a tissue and throw it into the trash. Wash your hands with soap and water. Do not reuse the latex condom.

Table 2. Guidelines on Correct Use of Female Polyurethane Condom

Female condoms should be inspected for any holes or tears. Handle female condoms carefully. Avoid puncturing holes in the condom with fingernails. It is generally not recommended for female condoms to be used at the same time as male condoms. Check the manufacturer's instructions on this. Be sure that lubricant is evenly spread inside the pouch from the bottom to the top by rubbing the outsides of the pouch together. Hold the pouch with the open end hanging down. Squeeze inner ring of female condom for insertion. Insert inner ring of female condom into vaginal canal similar to a tampon. Push inner ring of female condom as far up into the vaginal canal as possible. Ensure that outer ring is positioned to cover vulva. After intercourse, squeeze and twist the outer ring to keep any fluid inside the pouch. Pull the pouch out gently. Wrap the pouch in a tissue and discard in the trash. Do not reuse the female condom.

tion. He reports that c o n d o m s m a y reduce the risk o f H I V transmission by approximately 69%. L e a k a g e o f HIV-sized particles through latex c o n d o m s is identified for 29 o f the c o n d o m s tested. However, e v e n in the worst case, c o n d o m barrier effectiveness is estimated to be at least 10 times better than not using a c o n d o m (Carey et al,, 1992). These findings reiterate that consistent and correct usage of male latex condoms substantially reduces the risk o f H I V transmission, but it does not eliminate the risk completely. Effectiveness o f male c o n d o m s are measured indirectly through pregnancy rates and c o n d o m b r e a k a g e rates. Pregnancy rates are estimated to be as low as 2% for couples who consistently and correctly use m a l e latex c o n d o m s (TrusseU, Hatcher, Cates, Stewart, & Kost, 1990). G o l o m b o k , Sketchley, and Rust (1989) identified a mean c o n d o m breakage rate of 4.73% and c o n d o m slippage rate o f 28% in h o m o s e x u a l men. C o m m o n reasons for c o n d o m b r e a k a g e or slippage were powerful thrusting; no extra, insufficient, or too much lubrication; prolonged anal intercourse; tightfitting condom; and c o n d o m torn by fingernails. A serodiscordant couples c o n d o m study identified that only 2% of consistent c o n d o m users H I V seroconverted, but 15% o f the inconsistent c o n d o m users H I V seroconverted. Based on this data, the rate o f H I V transmission a m o n g couples reporting consistent cond o m usage was 1.1/100 person years of observation and 9.7/100 person years o f observation for inconsistent users (Saracco et al., 1993). The European Study Group on Heterosexual H I V Transmission reported that none o f the HIV-negative partners in 123 couples b e c a m e H I V infected with consistent and correct m a l e latex c o n d o m usage. H o w e v e r , 12 (10%) o f the HIVnegative partners in a control group o f 122 couples b e c a m e H I V infected with inconsistent c o n d o m usage (De Vincenzi & the European s t u d y Group, 1993). Female

Condom

The female c o n d o m is the first female controlled barrier method for preventing H I V transmission. T h e female c o n d o m was a p p r o v e d in D e c e m b e r 1992 b y the F D A for use as a contraceptive and method to prevent the t r a n s m i s s i o n o f H I V and other S T D s

Porche / Condom Effectiveness 93 (Gollub & Stein, 1993). Candidates for the female condom include sexually active women whose partners will not wear a male latex condom, women who are with multiple sexual partners, women in serial monogamous sexual relationships, who want a barrier method of contraception and STD prevention, and who are allergic to latex (Gerchufsky, 1996). The female condom is made of polyurethane. Polyurethane permits the transfer of heat during sexual intercourse. Polyurethane condoms are thinner than latex, have no odor, and some can be used with oilbased lubricants (clients should be instructed to follow the manufacturer's instructions). The female condom is considered to be impermeable to sperm, HIV, and other organisms that transmit STDs (Leeper & Conrardy, 1989). Additionally, other advantages of the female condom are the following: It can be inserted in advance, it permits more sexual spontaneity, it allows for sexual intercourse to begin before full erection is attained, it covers the internal and external female genitalia, it permits intimacy after intercourse because the female condom does not have to be removed immediately after intercourse, and polyurethane is stronger (Farr, Gabelnick, Sturgen, & Dorflinger, 1994). Health care practitioners should be aware that the female condom (with the inner ring removed) is also being used for protection during anal intercourse by heterosexual as well as male homosexual couples. A paucity of research exists on the effectiveness of the female condom to prevent HIV and STD transmission. The effectiveness of the female condom is measured indirectly based on contraception data. The annual contraceptive-failure rates of the female condom are 5% to 21%, which is comparable to other barrier methods for women and men (Trussell, Sturgen, Strickler, & Dominik, 1994). In a study of 147 women, 86 reported consistent and correct usage of the female condom over a 12-month period. These 86 women had an 11% failure rate for pregnancy (CDC, 1993b). Gollub and Stein (1993) reported a 6-month pregnancy rate that ranged from 5% for perfect users to 12% for average users of the female condom. Farr et al. (1994) reported cumulative pregnancy rates of 1.6/100, 2.6/100, and 2.6/100 at 1, 3, and 6 months for U.S. women who maintained

perfect use of the female condom. In comparison, Latin American women's cumulative pregnancy rates were 1.6/100, 1.6/100, and 9.5/100 at 1, 3, and 6 months.

Conclusion The FDA has stringent, high-quality standards for the manufacturing and testing of condoms. Male latex condoms and female polyurethane condoms are both protective against HIV and other organisms that transmit STDs. The protection provided by these barriers is dependent on consistent and correct usage. Although condoms may not completely eliminate the risk of HIV and STD transmission, it is clear that consistent and correct usage of condoms reduces the risk of disease transmission. Education using the guidelines for correct male and female condom usage will provide clients with some essential information that can be used in self-protection. There is an urgent need for continued research on measures, such as other barrier devices and vaginal microbicides, to prevent the transmission of HIV.

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risk: Issues in primary prevention of AIDS (pp. 43-82). New York: Plenum. Gollub, E., & Stein, Z. (1993). Commentary--The new female condom: Item 1 on a women's AIDS prevention agenda. American Journal of Public Health, 83, 498-500. Golombok, S., Sketchley, J., & Rust, J. (1989). Condom failure among homosexual men. Journal of Acquired Immune Deftciency Syndrome, 2(4), 404-409. Leeper, M., & Conrardy, M. (1989). Preliminary evaluation of REALITY, a condom for women to wear. Advances in Contraception, 5, 229-235. Saracco, A., Musicco, M., Nicholosi, A., Angarano, S., Arici, C., Gavazzeni, G., Costigliola, P., Gafa, S., Gervasoni, C., &

Luzzati, R. (1993). Man to woman sexual transmission of HIV: Longitudinal study of 343 steady partners of infected men. Journal of Acquired Immune Deficiency Syndrome, 6, 497-502. Trussell, J., Hatcher, R., Cates, W., Stewart, E, & Kost, K. (1990). Contraceptive failure in the United States: An update. Studies in Family Planning, 21, 51-54. Trussell, J., Sturgen, J., Strickler, J., & Dominik, R. (1994). Comparative contraceptive efficacy of the female condom and other barrier methods. Family Planning Perspectives, 26, 66-72. Weller, S. (1993). A meta-analysis of condom effectiveness in reducing sexually transmitted HIV. Social Science in Medicine, 36(12), 1635-1644.