855

HIV or the infection by the virus

of human immunodefciency which
is responsible for the acquired immu-
nodefciency syndrome or AIDS has
challenged modern medicine, health
and public hygiene services, and in-
ternational organizations since 1981.
No truly curative vaccination or the-
rapy has been found until now. To
prevent the transmission of HIV and
most particularly its sexual transmis-
sion is therefore essential.
Twenty years ago a term was crea-
ted in California and New York the
hotbed of HIV/AIDS - to designate
the best method against contamina-
tion by HIV during sexual activity:
namely safe sex.
1
It later was called
1 R. Stall, L.McKusick, J. Wiley, T.J. Coates,
D.G. Ostrow, Alcohol and drug use during sexual
activity and compliance with safe sexe guidelines
for AIDS: the AIDS Behavioral Research Project,
Health Education Quaterly, Winter 1986, vol.
13, n4, pp. 359-371; J.J. Goedert, What is Safe
Sex? Suggested Standards Linked to Testing for
Human Immunodefciency Virus, Te New
England Journal of Medicine, May 21 1987,
vol. 316, n21, pp. 1339-1342; S. Kippax, J.
Crawford, M. Davis, P. Rodden, G. Dowsett,
Sustaining safe sex: a longitudinal study of a
sample of homosexual men, AIDS, February
1993, vol.7, n2, pp. 257-263; Safe sex triumphs,
New Scientist, 27 June 1998, vol.158, n2140,
p.23; A.Troth, C.C. Peterson, Factors predicting
safe-sex talk and condom use in early sexual
relationships, Health Communication, 2000,
vol. 12, n2, pp. 195-218; A. Mitchell, A. Smith,
Safe sex messages for adolescents. Do they work?,
Safe Sex

Jacques Suaudeau
Te Media hype concerning safe sex or sex without risk conceals some recognized scien-
tifc evidence. In the best of hypotheses the reliability of the condom is so low that the
risk of contamination is estimated by some authors to be around 10 %. Tis is even
acknowledged by journals which regularly publish tests comparing the resistance, the
impermeability and the reliability of condoms. Behind the promotion of condoms which
further a false sense of sexual security they are supposed to ofer, fnancial interests are
concealed. Encouraging hetero- and homosexual use of the condom, because of its high
failure rate, increases in reality the probability of an infection. Tere remains, however,
the well-known position of the Church contradicting this trend for moral reasons. (
Sexual and Reproductive Rights; Sex Education; Sexual Identity and Diference;
New Paradigm of Health Care; Homosexuality and Homophobia; Reproductive
Health)
S
856
SAFE SEx
more modestly safer sex
2
. Tis expres-
Australian Family Physician, January 2000, vol.
29, n1, pp. 31-34; M. Berer, Safe sex, womens
reproductive rights and the need for a feminist
movement in the 21
st
century, Reproductive
Health Matters, May 2000, vol. 8, n15, pp. 7-
11; C. White, Government announces safe sex
campaign for England, British Medical Journal,
4 August 2001, vol. 323, n3707, p. 250; J.
Stephenson, Evaluating Safe Sex Eforts, JAMA,
July 11 2001, vol. 286, n2, p. 159.
2 M.L. Ekstrand, Safer sex maintenance
among gay men: are we making progress?, AIDS,
August 1992, vol. 6, n8, pp. 875-877; A.A.
Ehrhardt, Trends in Sexual Behavior and the HIV
Pandemic, American Journal of Public Health,
November 1992, vol. 82, n11, pp. 1459-1461,
see p. 1460; S. Katz Miller, How to sell safer
sex, New Scientist, 27 February 1993, vol. 137,
n1862, pp. 12-13; A. Messiah, D. Bucquet,
J.-F. Mettetal, B. Larroque, Chr. Rouzioux,
and the Alain Brugeat physician group, Factors
Correlated With Homosexually Acquired
Human Immunodefciency Virus Infection
in the Era of Safer Sex. Was the Prevention
Message Clear and Well Understood?, Sexually
Transmitted diseases, January/February 1993,
vol. 20, n1, pp. 51-59; P. Aggleton, K. OReilly,
G.Slutkin, P. Davies, Risking Everything? Risk
Behavior, Behavior Change, and AIDS, Science,
15 July 1994, vol. 265, n 5170, pp. 341-345, see
p. 344; M. Larkin, Easing the way to safer sex,
Te Lancet, March 28 1998, vol. 351, n9107, p.
964; J.B. Jemmott III, L.S. Jemott, G.T. Fong,
Abstinence and Safer Sex HIV Risk-Reduction
Interventions for African American Adolescents.
A. Randomized Controlled Trial, JAMA, May
20 1998, vol. 279, n19, pp. 1529-1536; K.L.
Parish, D. Cotton, H.C. Huszti, J.T. Parsons,
Hemophilia Behavioral Intervention Study
Group, Safer sex decisions-making among men
with haemophilia and their female partners,
Haemophilia, January 2001, vol. 7, n1, pp. 72-
81; L.A. Shrier, R. Ancheta, E. Goodman, V.M.
sion refers to all precautionary measu-
res taken to diminish the risk of trans-
mitting or acquiring a sexually trans-
mitted disease (such as HIV/AIDS)
in the course of sexual activity
3
. Safer
sex therefore demands prudence in the
choice of ones partners and in the fre-
quency of sexual activity, as well as the
constant use of the condom.
Te latter presupposes high conf-
dence in the efcacy of the condom. Te
manner in which militant activists, public
authorities, the media and publicity have
presented the condom and still do, seems
to indicate that it is almost completely
fool-proof. Te protection of the obe-
lisk of the Place de la Concorde in Paris
by a condom in the presence of all of
Paris as the culminating point of a fervent
campaign in favor of the condom in 1994
has, as D. Folscheid says heightened its
image to a mystical level
4
. To dare to
ask the least question, to raise the smallest
objection, meant that one had an impious
soul and the putrid mouth of the icono-
clast, explains Folscheid.
Te massive, undisputed and undis-
putable promotion of the condom re-
lies on one argument: namely that this
Chiou, M.R. Lyden, Randomized Controlled
Trial of as Safer Sex Intervention for High-risk
Adolescent Medicine, January 2001, vol. 155, n
1, pp. 73-79.
3 MEDLINE plus Health Information,
MEDLINE Medical Encyclopedia, Safer sex
behaviors.
4 D. Folscheid, Billet dhumeur. Faut-il se
prserver de la condomania?, Ethique, La Vie en
Question
857
SAFE SEx
latex shell is at present the only means
available to health services to prevent
the sexual transmission of the AIDS vi-
rus and its difusion. However, since the
beginning of the AIDS/HIV epidemic
and until today numerous authors have
often stressed the fact thatas statistics
show - this device is far from deserving
this confdence.
5
Considering that the
safe sex policy has not caught up with
the epidemic in countries where it has
been promoted for 20 years and that it
is proposed to countries where the epi-
5 B. Voeller, M.Potts, letter, British Medical
Journal, 26 October 1985, vol. 291, n6503,
p. 1196; J.A. Kelly, J.S. StLawrence, Cautions
about condoms in prevention of AIDS, Te
Lancet, February 7 1987, vol. 1, n8258, p.
323; P.S. Gtzsche, M. Hrding, Condoms to
Prevent HIV Transmission Do Not Imply Truly
Safe Sex, Scandinavian Journal of Infectious
Diseases, 1988, vol. 20, n2, pp. 233-234; R.
Kirkman, Condom use and failure, Te Lancet,
Saturday 20 October 1990, vol. 336, n8721, p.
1009; J.T. Vessey, D.B. Larson, J.S. Lyons, J.L.
Rogers, K.I. Howard, Condom Safety and HIV,
Sexually Transmitted Diseases, January-February
1994, vol. 21, n1, pp. 59-60; H. Lestradet,
Rfexions sur le SIDA et sa prevention,
Mdecine de lhomme, Mai-Aot 1994.
n211/212, pp.3-6; S.H. Vermund, Editorial:
Casual sex and HIV Transmission, American
Journal of Public Health, November 1995,
vol. 85, n11, pp. 1488-1489; R. Kss, H.
Lestradet, SIDA: communication, information
et prevention, in Le SIDA, propagation et
prevention, Rapports de la commission VII de
lAcadmie Nationale de Mdecine, Editions de
Paris, 1996, pp. 12-55; J. Kelly, Using condoms
to prevent transmission of HIV. Condoms
have an appreciable failure rate, British Medical
Journal, 8 June 1996, vol. 312, n7044, p. 1478.
demic is in full expansion, it seems jus-
tifed to adopt a critical approach regar-
ding its value for HIV prevention.
In view of this we will frst examine
the physical and mechanical qualities
of the condom such as they appear in
the laboratory and in practice. Ten we
will look at the results of employing the
condom as contraceptive barrier or as
prophylactic. We will end by examining
the performance of the condom in pre-
venting sexual contamination by HIV.
I THE PHYSICAL AND
MECHANICAL QUALITIES OF
CONDOMS
For a long time condoms have been
suspected of having a certain percentage
of micro-defects which would explain
their failures in the area of contraception.
One then tried to verify this hypothesis
through studies using an electron micros-
cope as well as through passage tests of
micro particles.
1. Electron Microscope Studies
Te few studies of latex membranes
using the electron microscope that have
been published raise some questions.
Te suspicion that certain pores may
subsist in the membranes after an im-
perfect coalescence of the latex particles
during vulcanization has been reinfor-
ced by observations made on chirurgical
latex gloves by S.G. Arnold and associa-
tes (1988)
6
. Tese authors found that
6 S.G. Arnold, J.E. Whitman Jr., C.H. Fox,
M.H. Cottler-Fox, Latex gloves not enough
858
SAFE SEx
all examined gloves originating from
four diferent manufacturers presented
hollow parts of 3-15m in width and of
up to 30 m in depth; this was the case
along the exterior and internal surface
of the glove. Te test made on the edge
of these membranes (broken by free-
zing) showed the presence of cavities
and winding fssures (5m) covering the
entire thickness of the glove.
Irregularities of such importance
concerning the surface and thickness
of the latex membrane have not been
signaled in the few available studies on
condoms. Tese studies simply show
that the surface of the condoms mem-
branes is not uniform: one fnds areas
with a soft profle separated by folded
areas; furthermore the surface of the
specimen seems dotted with hollow
parts
7
. Other studies mention a general
irregularity of the surface of the mem-
brane, with irregular caulifower-like
projections, and dense and irregular
inclusions, yet without any evidence of
rupture or of holes.
8
Rosenzweig and
to exclude viruses, Nature, 1 September 1988,
vol.335, n6185, p.19.
7 G.D. Jay, F. Drummond, B.Lane, Altered
Surface Character of Stretched Condom Latex,
Contraception, February 1992, vol.45, n2,
pp.105-110.
8 L.S. Kish, J.T. McMahon, W.F. Bergfeld,
J.M. Pelachyk, An ancient method and a
modern scourge: the condom as a barrier
against herpes, Journal of the American
Academy of Dermatology, November 1983,
vol.9, n.5, pp.769-770.
associates (1997)
9
examined thirty sam-
ples of membranes coming from ffteen
Trojan condoms, none of which were
lubricated. Tey found in fact that a
great proportion of these samples pre-
sented visible anomalies on the surface,
and that only 30% of the condoms tes-
ted were absolutely faultless. 50% of the
samples showed anomalies on the sur-
face of the membrane, fssures (10%),
pleating (37%), as well as pleating and
hollowness (38%).
2. In Vitro Studies concerning Re-
sistance and Permeability
Te integrity of latex condoms is tes-
ted by means of a leak test. But the ac-
curacy of this test is not very high. It de-
tects holes of a diameter of 20 microns
10
.
However, for the HIV virus any hole big-
ger than 0,10 would have to be consi-
dered a possible cause for leakage and the
passage of the virus. Te limited accuracy
of this test means that the defects in the
condoms membranes are signifcant.
In 1977 Dr. Barlow
11
had made the
hypothesis that some pores exist in la-
tex membrane condoms which explains
9 B.A Rozenzweig, A. Even, L.E. Budnick,
Observations of Scanning Electron Microscopy
Detected Abnormalities of Non-lubricated
Latex Condoms, Contraception, January 1996,
vol. 53, n.1, pp.49-53.
10 R.F. Carey, D. Lytle, W.H. Cyr,
Implications of Laboratory Tests of Condom
Integrity, Sexually Transmitted Diseases, April
1999, vol. 26, pp. 216-220.
11 D. Barlow, Te Condom and Gonorrhea,
Te Lancet, October 15 1977, vol.II, n.8042,
pp.812-812, seep.812.
859
SAFE SEx
why they apparently do not protect
against non-gonococcal urethritis and
genital condylomata acuminata infec-
tions. Tis hypothesis was highly dispu-
ted. Diferent in vitro laboratory studies
contradicted it by showing that the la-
tex membranes efciently stopped the
agents of sexually transmitted diseases
(STD)
12
such as: Neisseria gonorrhoea,
simplex herpes type 2 virus
13
, cytome-
galovirus
14
, Hepatitis B virus
15
, Chlamy-
12 Center for Disease Control, Center for
Infectious Diseases, Condoms for Prevention
of Sexually Transmitted Diseases, JAMA, April
1 1988, vol.259, n.13, pp.1925-1927; F.N.
Judson, J.M.Ehret, G.F. Bodin, M.J. Levin, C.A.
Rietmeijer, In Vitro Evaluations of Condoms
with and without Nonoxynol 9 as Physical
and Chemical Barriers Against Chlamydia
Trachomatis, Herpes Simplex virus type 2, and
Human Immunodefciency Virus, Sexually
Transmitted Diseases, April-June 1989, vol. 16,
n.2, pp.51-56; L. Smith Jr., J. Oleske, R. Cooper,
et al., Efcacy of Condoms as barriers to HSV-2
and gonorrhea; an in vitro model (Abstract 77),
In Program and Abstracts of the frst Sexually
Transmitted Diseases World Congress, San Juan,
Puerto Rico, November 15-21 1981.
13 M.A. Conant, D.W. Spicer, C.D. Smith,
Herpes Simplex Virus Transmission: Condom
Studies, Sexually Transmitted Diseases, April-
June 1984, vol. 11, n.2, pp.94-95.
14 S. Katznelson, W. Lawrence Drew,
L.Mintz, Efcacy of the Condom as a Barrier
to the Transmission of Cytomegalovirus, Te
Journal of Infectious Diseases, July 1994, vol.
150, n.1, pp.155-157.
15 G.Y. Minuk, C.E. Bohme, T.J. Bowen,
Condoms and Hepatitis B Virus Infection,
Annals of Internal Medicine, April 1986, vol.
104, n.4, p.584; G.Y. Minuk, C.E. Bohme,
T.J. Bowen, D.I. Hoar, S.Cassol, M.J. Gill,
dia trachomatis
16
, and retroviruses such
as HIV and HIV itself
17
.
However, these reassuring results
have been questioned: for just a few
studies were done, these were limited
to a few tests and performed without
submitting the membrane to pressure
or traction. For S.C. Weller
18
they are
not statistically signifcant. More re-
cent studies made with microspheres
have, in efect, put in doubt the vali-
H. de C. Clarke, Efcacy of Commercial
Condoms in the Prevention of Hepatitis B
Virus Infection, Gastroenterology, October
1987, vol. 93, n.4, pp.710-714.
16 F.N. Judson, G.F. Bodin, M.J. Levin, J.M.
Ehret, H.B. Masters, In Vitro tests demonstrate
condoms provide an efective barrier against
Chlamydia trachomatis and herpes simplex virus
(Abstract 176) In: Program and abstracts of the
ffth international meeting of the International
Society for STD Research, Seattle, Washington,
August 1-3 1983; F.M. Judson, J.M. Ehret,
G.F Bodin, M.J. Levin, C.A. Rietmeijer, In
vitro evaluations of condoms with and without
Nonxynol 9 as physical and chemical barriers
against Chlamydia Trachomatis, Herpes Simplex
virus type 2, and Human Immunodefciency
Virus, op. cit.
17 M. Conant, D. Hardy, J. Sernatinger,
D. Spicer, J.A. Levy, Condoms Prevent
Transmission of AIDS-Associated Retrovirus,
JAMA, April 4 1986, vol.255, n.13, p.1706;
C.A.M. Rietmeijer, J.W. Krebs, P.M. Feorino,
F.N. Judson, Condoms as Physical Chemical
Barrier Against Human Immunodefciency
Virus, JAMA, March 25 1988. vol.259, n.12,
pp.1851-1853.
18 S.C. Keller, A meta-analysis of condom
efectiveness in reducing sexually transmitted
HIV. Social Science Medicine, June 1993,
vol.36, n.12, pp.1635-1644, see p.1635.
860
SAFE SEx
dity of these in vitro tests. During the
Vth International Conference on AIDS in
Montreal it was frst reported that well
tested condoms, issued by known manu-
facturers, had been permeable to micros-
pheres of bigger size than that of HIV (6
condoms out of 69)(1989)
19
. Carey and
associates (1992)
20
observed the passage
of polystyrene microspheres of 110nm
in diameter (therefore similar to the size
of HIV which is between 90nm and
130nm) through 33% of the analyzed
latex condom membranes (29 out of 80
latex non lubricated condoms). More re-
cently, C.D. Lytle and associates (1997)
21

found that 2.6% (12 out of 470) of latex
condoms they used permitted the passage
of a virus, whether they were lubricated
or non lubricated condoms.
In consequence these results allow
for some doubts concerning the capaci-
ty of condoms to stop HIV for certain.
HIV measures between 90 to 120 nm,
19 B.A. Hermann, S.M. Retta, I.E. Rinaldi,
A simulated physiologic test of latex condoms,
Vth Internat. Conf. on AIDS, 1989, Abstracts
WAP 101.
20 R.F. Carey, W.A. Herman, S.M. Retta,
J.E. Rinaldi, B.A. Herman, T.W. Athey,
Efectiveness of Latex Condoms as Barrier
to Human Immunodefciency Virus-sized
Particles Under Conditions of Simulated Use,
Sexually Transmitted Diseases, July-August
1992, vol.19, pp.230-234.
21 C.D. Lytle, L.B. Rouston, G.B. Seaborn,
L.G. Dixon, H.F. Bushar, W.H. Cyr, An in
vitro Evaluation of Condoms as Barriers to
Small Virus, Sexually Transmitted Diseases,
March 1997, vol 24, n.3, pp.161-164.
approximately 0,1 micron
22
. It is 60 ti-
mes smaller than the syphilis bacteria,
and 450 times smaller than spermato-
zoa. If microspheres of a 120nm diame-
ter can pass through the membranes of
some latex condoms which had, howe-
ver, been found sufcient in the leak
tests, it would therefore not be surpri-
sing for HIV to pass through these same
membranes during mechanical disten-
sioneven if there is no actual hole in
the membrane.
3. Te Degradation of Latex
Another reason for the failure of
condoms is due to the degradation of
the latex, leading to leaks or ruptures of
the membrane. In fact latex deteriorates
with time, loses its fexibility and beco-
mes more fragile. Tis deterioration is
accelerated through exposition to the
sun, to heat and humidity (M.J. Free
and associates, 1986; M.F. Goldsmith,
1987; M. Steiner and associates, 1992;
J. Kettering, 1993; M.J. Free and as-
sociates, 1996).
23
Less known perhaps
22 R.C. Gallo, S.Z. Salahuddin, M.
Popovic, G.M. Shearer, M. Kaplan, B.F.
Haynes, T.J. Palker, R. Redfeld, J. Oleske,
B. Safai, G. White, P. Foster, Ph.D.Markham,
Frequent Detection and Isolation of
Cytopathic Retroviruses (HTLV-III) from
Patients with AIDS and at Risk for AIDS,
Science, 4 May 1984, vol.224, n4648,
pp.500-503, see p. 502; J.P. Cassuto, A. Pesce,
J.F. Quaranta, AIDS and HIV Infection,
Masson, 2ed., Paris, 1992, p.27.
23 M.J. Free, J. Hutchings, S. Lubis, An
assessment of burst strength distribution data
from monitoring quality of condom stocks in
developing countries, Contraception, March
861
SAFE SEx
is its degradation due to atmospheric
ozone: the prolonged exposition of la-
tex condoms to partial ozone pressure
identical to the one found in fog brings
up in electronic microscopy the appari-
tion of images reminiscent of the ho-
les described elsewhere on latex gloves
and natural membrane condoms (R.F.
Baker and associates, 1988; L.J. Clark
and associates, 1989)
24
.
4. Te Possibility of Rupture and Slip-
page In Vivo (Table 1)
Most of the condoms failures are
due to its breaking or slipping of du-
ring use. Diferent studies have found
1986, vol.33, n3, pp.285-299; M.F. Goldsmith,
Some Advice on Using Condoms Against STDs:
What Every Man (and Woman) Should Know,
JAMA, May 1 1987, vol. 257, n17, p.2266;
M. Steiner, R. Foldesy, D.Cole, E. Carter,
Study to determine the correlation between
condom breakage in human use and laboratory
test results, Contraception, September 1992,
vol.46, n3, pp.279-288; J. Kettering, Efcacy
of thermoplastic elastomer and latex condoms as
viral barriers, Contraception, June 1993, vol.47,
n6, pp. 559-567; M.J. Free, V. Srisamang, J.
Vail, D. Mercer, R. Kotz, D.E. Marlowe, Latex
Rubber Condoms: Predicting and Extending
Shelf Life, Contraception, April 1996, vol.53,
n4, pp.221-229.
24 R.F. Baker, R.P. Sherwin, G.S. Bernstein,
R.M. Nakamura, Precautions When Lightning
Strikes During the Monsoon: Te Efect of
Ozone on Condoms, Journal of American
Medical Association, September 9 1988,
vol.260, n10, pp.1404-1405; L.J. Clark,
R.P. Sherwin, R.F. Baker, Latex condom
deterioration accelerated by environmental
factors: I Ozone, Contraception, March 1989,
vol.39, n3, pp.245-251.
that the rate of ruptures is between 1%
and 13%, with an average of 5%.
25

25 P.C. Gtzche, M. Hrding, Condoms to
Prevent HIV Transmission Do Not Imply Truly
Safe Sex. Scandinavian Journal of Infectious
Diseases, 1988, vol.20, n2, pp.233-234; C.
Sonnex, G.J. Hart, P. Williams, M.W. Adler,
Condom use by heterosexuals attending a
department of GUM: attitudes and behaviors
in the light of HIV infection, Genitourinary
Medicine, August 1989, vol.65, n4, p.248-251;
T. Karlsmark, E. Segest, J. Grinsted, H. Bay,
AIDS prevention: free condoms from an STD
clinic in Copenhagen, Letter, Genitourinary
Medicine, June 1989, vol.65, n3, p.196; G.
Ahmed, E.C. Liner, N.E. Williamson, W.P.
Shellstade, Characteristics of condom use and
associated problems: experience in Bangladesh,
Contraception, November 1990, vol.42, n5,
pp.523-533; P. Russel-Brown, C. Piedrahita, R.
Foldesy, M. Steiner, J. Townsend, Comparison
of condom breakage during human use with
performance in laboratory testing, Contraception,
May 1992, vol.45, n5, pp.429-437; E.A.
Wright, M.M. Kapu, I. Wada, Use of condoms
as contraceptive and diseases preventive measures
among residents of Jos, Northern Nigeria,
Contraception, December 1990, vol.42, n6,
pp.621-627; C. Lindan, S. Kegeles, N. Hearst, P.
Grant, D. Johnson, G. Bolan, G.W. Rutherford,
California Dept. of Health Svcs, Div. of Sexually
Transmitted Diseases and HIV prevention,
CDC, Heterosexual Behaviors and Factors
that Infuence Condom Use Among Patients
Attending a Sexually Transmitted Disease Clinic
San Francisco, Center for Disease Control,
Morbidity and Mortality Weekly Report,
October 5 1990, vol.39, n39, pp.685-689; R.
Kirkman, Condom use and failure, Te Lancet,
20 October 1990, vol.336, n8721, p.1009;
A.E. Albert, R.A. Hatcher, W. Graves, Condom
use and breakage among women in a municipal
hospital family planning clinic, Contraception,
February 1991, vol.43, n2, pp.167-176;
862
SAFE SEx
TABLE I: INCIDENCE OF RUPTURE AND SLIPPAGE OF CONDOMS IN THE
GENERAL POPULACE
Rupture Slippage
Type of Sexual
Relationship
Type and Num-
ber of Subjects
Place of Study
rate %users* rate %users*
P.C. Gatzsche et al.
(1988)
5% - - - Vaginal
46 persons
(30 prostitutes)
Rigshospitalet,
Copenhagen,
Denmark
C. Sonnex et al. (1989) - 40% - - Heterosex
222 men and
women
Genitourinary Med-
icine, London
T. Karlsmark et al.
(1989)
- 75% - - Heterosex
47 men and
women
Rigshospitalet,
Copenhagen
G. Ahmad et al. (1990)
3.1%
5.1%
30%w
43%m
- - -
4915 men and
women
Bangladesh
Russell-Brown et al.
(1992)
12.9% 74% - - - 50 men
Pop. Council, Bar-
bados
Russell-Brown et al.
(1992)
10.1% 44% - - - 50 men
Pop. Council, Santa
Lucia
Russell-Brown et al.
(1992)
6.7% 35% 50 men
Pop. Council North
Carolina
E. A. Wright et al.
(1990)
11.9% - 10.7% - - 168 men
Family Planning
Clinic, Jos, Nigeria
C. Lindan et. al. (1990) 4.2%-4.3%
27%m
31%w
- -
vaginal or anal
intercourse
162 men
179 women
STD Clinic,
San Francisco
R. Kirkman (1990) - 52% - 52 - -
Family Planning
Clinic, Manchester,
U.K.
A.E. Albert (1991) 1% 36% - - Heterosexual 106 women
Family Planning
Clinic,
Atlanta, USA
C. Chan Chee et al.
(1991)
4.5%
- -
Homobisexual 46 men
EuroHIV, Paris 1.5% Heterosexual 145m, 63w
0.6% - 7 prostitutes
J. Trussell et al.(1992) 7.9%
- 7.2% - -
405 condoms Ofce of Pop. Res.
Princeton Univ.
M. Steiner et al.(1992) 3.5%
262 voluntary
participants
Family Health In-
ternational, US
H.S. Weinstock et al
(1993)
4.2%-
4.3%
29% - - vaginal and anal
136 men
164 women
STD Clinic, San
Francisco, USA
S. Tovey ? et al. (199?) - 22% - 48 - 281 men
Genitourinary
Medicine, South
London
J. Richters et al. (1993) 7.3% - 4.4% - - 544 men
Consult. MST,
Sydney, Australia
M.J. Sparrow et al. 5.6% 40.2 6.5% 40.2% - 540 consultants
Family Planning
Clinic, New Zea-
land
M. Gabbey et al. (1996) - 66% - 66 -
481 students
64% w
Manchester Health
Centre, U.K.

Rate: rate of condom ruptures per sexual relations (number of condoms broken per 100 relations)
* % users: percentage of users having noticed at least one condom breakage during the time of the study
863
SAFE SEx
The risk of rupture or slippage
diminishes with practice (couples
using the condom as a contraceptive
during long periods: 1,46% for Trus-
sell and associates, 1992, 1,04% for
Rosenberg and associates, 1977),
26
or
Chr. Chan-Chee, I. De Vincenzi, M-A Sole-
Pla, R. Ancelle-Park, J.-B. Brunet, Use and
misuse of condoms, Genitourinary Medicine,
April 1991, vol.67, n2, p.173; J. Trussel, D.L.
Warner, R.A. Hatcher, Condom slippage and
breakage rates, Family Planning Perspectives,
January-February 1992, vol.24, n1, pp.20-23;
M. Steiner, R. Foldesy, D. Cole, E. Carter, Study
to determine the correlation between condom
breakage in human use and laboratory test
results, Contraception, September 1992, vol.46,
n3, pp.279-288; H.S. Weinstock, Chr. Lindan,
, G. Bolan, S.M. Kegeles, N. Hearst, Factors
Associated with Condom Use in a High-Risk
Heterosexual Population, Sexually Transmitted
Diseases, January-February 1993, vol.20, n1,
pp.14-20; S.J. Tovey, Chr. P. Bonell, Condoms:
a wider range needed, British Medical Journal,
16 October 1993, vol.307, n6910, p.987; J.
Richters, B. Donovan, J. Gerof, How often do
condoms break or slip of in use?, International
Journal of STD and AIDS, March-April 1993,
vol.4, n2, pp. 90-94 ; M.J. Sparrow, K. Lavill,
Breakage and slippage of condoms in family
planning clients, Contraception, August 1994,
vol. 50, n2, pp. 117-129; M. Gabbay, A. Gibbs,
Does Additional Lubrication Reduce Condom
Failure?, Contraception, vol. 53, n3, March
1996, pp. 155-158.
26 J. Trussel, D.L. Warner, R. Hatcher,
Condom performance during vaginal
intercourse: Comparison of Trojan-Enzand
Tactylon condoms, Contraception, January
1992, vol. 45, n1, pp. 11-19; J. Trussell,
D.L. Warner, R.A. Hatcher, Condom
slippage and breakage rates, Family Planning
Perspectives, January/February 1992, vol. 24,
professional practice (prostitution:
0,5% for Richters and associates in
Australia, 1988; 0% for A.E.Albert
and associates in Nevada, 1995; 0,5%
for C.Chang-Chee and associates in
Paris, 1991
27
).
Te risk of rupturing the condom
appears to be particularly high in ho-
mosexual relations. A. Messiah and
associates (1993)
28
have observed that
the rate of condom rupture in this
group goes from 4.5% to 7.3% and
even as high as 22%. Te failure rate
of the condom during homosexual ac-
tivity is on average 5% (0% to 22%)
n1, pp. 20-23; M.J. Rosenberg, M.S. Waugh,
Latex Condom Breakage and Slippage in a
Controlled Clinical Trial, Contraception, July
1997, vol.56, n1, pp. 17-21.
27 J. Richters, B. Donovan, J. Gerof, L.
Watson, Low Condom Breakage Rate in
Commercial Sex, Te Lancet, December 24/31
1988, vol. II, n8626-8627, pp. 1487-1488;
A.E. Albert, D.I. Warner, R.A. Hatcher, J.
Trussell, Ch. Bennett, Condom use among
Female Commercial Sex Workers in Nevadas
Legal Brothels, American Journal of Public
Health, November 1995, vol. 85, n11, pp.
1514-1520. See in particular table 2.; Chr.
Chan-Chee, I. De Vicenzi, M-A. Sole-Pla, R.
Ancelle-Park, J.-B. Brunet, Use and misuse of
condoms, Genitourinary Medicine, April 1991,
vol. 67, n2, p.173.
28 A. Messiah, D. Bucquet, J.-F. Meitetal,
B. Larroque, Chr. Rouzioux, and the Alain
Brugeat physician group, Factors Correlated
With Homosexually Acquired Human
Immunodefciency Virus Infection in the Era
of Safer Sex. Was the Prevention Message
Clear and Well Understood?, Sexually
Transmitted diseases, January/February 1993,
vol. 20, n1, pp.51-59, see p. 57.
864
SAFE SEx
and the rate of slippage is on average
6% (0% to 15%) (Table II)
29
.
II THE PERFORMANCE OF
THE CONDOM WHEN USED
AS A CONTRACEPTIVE AND
AS A PROPHYLACTIC
1. Te Performance of the Condom
when Used as a Contraceptive
Te Pearl index concerning the
condom when used as barrier contra-
ceptive (i.e. the number of pregnancies
among 100 women using this form of
contraception for 1 year, based on the
theoretical possibility that a woman
could conceive 12 times every year) is
relatively high, between 8 and 15 (in
extreme cases going up to 28).
30
Te
29 K. Wellings, AIDS and the Condom,
British Medical Journal, 15 November 1986,
vol.293, n6557, pp. 1259-1260, see p.1259;
W. Ross, Problems associated with condom
use in heterosexual men, American Journal
of Public Health, July 1987, vol.77, n7,
1987, p.877; J. Richters, B. Donovan, J.
Gerof, How often do condoms break or slip
of in use?, International Journal of Sexually
Transmitted Diseases and AIDS, March/April
1993, vol.4, n2, pp.90-94.
30 D.M. Potts, G.I.M. Swyer, Efectiveness
and risks of birth-control methods, British
Medical Bulletin, January 19 1970, vol.26, n1,
pp.26-32, see Table III, p.29; W.R. Grady, M.D.
Hayward, J. Yaagi, Contraceptive Failure in the
United States: Estimates from 1982 National
Survey of Family Growth, Family Planning
Perspectives, September/October 1986, vol.18,
n5, pp.200-209; E.F. Jones, J.D. Forrest,
Contraceptive Failure in the United States:
failure rate of the condom used for the
prevention of pregnancy (defned as the
probability of pregnancy during one
year for a woman using the condom as
sole means of contraception) is situa-
ted around 15%.
31
After examining the
Revised Estimates from the 1982 National survey
of Family Growth, Family Planning Perspectives,
May/June 1989, vol.21, n3, pp.103-107; E.F.
Jones, J.D. Forrest, Contraceptive Failure Rates
Based on the 1988 NSFG, Family Planning
Perspectives, January/February 1992, vol.24, n1,
pp.12-19; S. Jejeebhoy, Measuring contraceptive
use-failure and continuation: an overview of
new approaches, in Measuring the Dynamics of
Contraceptive Use, United Nations, New York,
1991, pp.21-51, tables 3, 5.
31 Failure rate of the condom used as barrier
contraceptive: 14,1% in the USA in the statistic
of W.R. Grady and associates from 1986;
15,7% in the USA in that of E.F. Jones and
J.D. Forrest from 1989, concerning the same
data; 15,8% in the USA in the 1992 statistic
made by the same authors; 9,8% to 18,5%
in the USA in the statistic of S. Harlap from
1991 for the Alan Guttmacher Institute; 11%
in Great Britain, 14,1% in the USA, 20%
in Panama, 21,6% in Indonesia and 24% in
Bangladesh in the international statistic of S.
Jejeebhoy, 1991, presented in a reunion of experts
from the UN; W.R. Grady, M.D. Hayward,
J. Yaagi, Contraceptive Failure in the United
States: Estimates from 1982 National Survey of
Family Growth, Family Planning Perspectives,
September/October 1986, vol.18, n5. pp.200-
209; E.F. Jones, J.D. Forrest, Contraceptive
Failure in the United States: Revised Estimates
from the 1982 National survey of Family
Growth, Family Planning Perspectives, May/
June 1989, vol.21, n3, pp.103-107, see table
2 p.107; E.F. Jones, J.D. Forrest, Contraceptive
Failure Rates Based on the 1988 NSFG, Family
Planning Perspectives, January/February 1992,
865
SAFE SEx
American studies on the question, S.C.
Weller situates the failure rate of contra-
ception of the condom between 9% and
vol.24, n1, pp.12-19, see table 1, p.15; S. Harlap
and associates, Pregnancies Occurring During
Contraceptive Use, in Preventing Pregnancy,
Protecting Health: A New Look at Birth
Control Choices in the United States, the Alan
Guttmacher Institute, 1991, p.35; S. Jejeebhoy,
Measuring contraceptive use-failure and
continuation: an overview of new approaches, in
Measuring the Dynamics of Contraceptive Use,
United Nations, New York, 1991, pp.21-51,
tables 3, 5.
14% in the USA.
32
Te failure rate diminishes the hi-
gher the competence, cultural level, the
practice and motivation of a married
couple is. Tis explains the incredibly
high failure rates reported by S. Jejeebhoy
(1991) in certain third world countries
(20% in Panama, 21,6% in Indonesia
32 S.C. Weller, A meta-analysis of condom
efectiveness in reducing sexually transmitted
HIV, Social Science Medicine, June 1993,
vol.36, n12, pp.1635-1644, see p.1636.
TABLE II: FREQUENCY OF RUPTURE AND SLIPPAGE OF CONDOMS IN
HOMOSExUAL RELATIONSHIPS WITH ANAL PENETRATION
Rupture Non-Use
Number of Subjects Place of Study
rate %users* rate %users*
M.W.Ross (1987) - 27% - - 70 homosexual men
South Australian Health
Comm.
L.Wigersma et al.
(1987)
11% - 15% - 17 homosexual couples Amsterdam, Netherlands
G.J.P. Van Grievansen
et al. (1988)
5% - 5% - 277 homosexual men msterdam, Netherlands
S. Golombok et al.
(1989)
5.27% 31% 3.8% 28% 262 homosexual men London
B. Tindall et al.(1989) 6% 12% - - 420 homosexual men Sydney, Australia
Chr. Chan Chee et al.
(1991)
4.5% - - - 46 homosexual men Paris
J.L. Tomson et al.
(1993)
3.3% 15% - - 741 homosexual men
Columbia University,
New York City
J. Richters et al. (1993) 2.8% - 3.4% - 36 homosexual men
Clinique MST, Sydney,
Australia
A.Messiah et al. (1993)
4.5%-
7.3%
- 1/3 - 246 homosexual men Enqute INSERM, Paris
B.G. Silverman et al.
(1997)
0.5%-6 - 3.8%-5% - Revue de la littrature
Rate: rate of condom ruptures per sexual relation (anal penetration)(number of condoms broken per 100 relations)
* % users: percentage of users having noticed at least one condom breakage during the time of the study
866
SAFE SEx
and 24% in Bangladesh)
33
. Inversely, the
failure rate of the condom as a contra-
ceptive was only 4% among very motiva-
ted couples enrolled in the Oxford/Family
Planning Association contraceptive study
(1974) according to M.P. Vessey and
associates
34
. However, if the failure rate
of the condom used as a contraceptive
is evaluated at 3% for couples using the
condom
35
perfectly (at every occasion of
sexual activity and in a correct way), this
rather theoretical rate goes up to 12%
when used by typical couples.
36
Te noticeable failure rate of the
condom partly explains the statistical link
33 S. Jejeebhoy, Measuring contraceptive
use-failure and continuation: an overview of
new approaches, in Measuring the Dynamics
of Contraceptive Use, United Nations, New
York, 1991, pp.21-51, tables 3, 5.
34 R. Glass, M. Vessey, P. Wiggins, Use-
efectiveness of the condom in a selected family
planning clinic population in the United
Kingdom, Contraception, 1974, vol.10, pp.591-
598; M. Vessey, M. Lawless, D. Yeates, Efcacy
of diferent contraceptive methods, Te Lancet,
April 10, 1982, vol.I, n8276, pp.841-842; M.P.
Vessey, L. Villard Mackintosh, Condoms and
AIDS prevention, letter, Te Lancet, March 7
1987, vol.I, n8532, p.568.
35 A. Spruyt, M.J. Steiner, C. Joanis, L. H.
Glover, C. Piedrahita, G. Alvarado, R. Ramos,
C. Maglaya, M. Cordero, Identifying Condom
Users at Risk for Breakage and Slippage:
Findings from Tree International sites,
American Journal of Public Health, February
1998, vol.88, n2, pp. 239-244. See p. 239.
36 A. Albert, R.A. Hatcher, W. Graves,
Condom use and breakage among women in
a municipal hospital family planning clinic,
Contraception, February 1991, vol. 43, n2,
pp. 167-176. See p. 168.
found between the use of condoms and
the appearance of undesired pregnancies
among adolescents - given the fact that
the advertisement of the condom to ado-
lescents incites them to engage in greater
sexual promiscuity (E.S.Williams, 1995,
in the USA)
37
. 11% of women with un-
desired pregnancies in the Grady Memo-
rial Hospital in Atlanta (USA) attribu-
ted their pregnancy to the failure of the
condom
38
. 27% of abortions performed
in the Saint Louis Hospital in Paris are
supposedly requested because of condom
failure.
39
Out of the 4666 women who
came to abort at the Mary Stopes Center
in Leeds between 1989 and 1993, 40%
of them made the failure of the condom
responsible for their pregnancy
40
. In the
investigation reported by M. Gabbay
and A. Gibbs (1996), 83% of the
female students who went to get
emergency contraception at the Rushol-
me Health Center in Manchester (UK)
declared they were victims of condom
failure.
41
37 E. S. Williams, Contraceptive failure may
be a major fact in teenage pregnancy, British
Medical Journal, Saturday 23 September 1995,
vol. 311, n7008, pp. 806-807.
38 A. Albert, R.A. Hatcher, W. Graves,
Condom use and breakage among women in
a municipal hospital family planning clinic,
Contraception, February 1991, vol. 43, n2,
pp. 167-176. See table VI, p. 172.
39 Le Monde, 28/5/1996
40 D. Carnall, Condom failure is on the
increase, British Medical Journal, 27 April
1996, vol. 312, n7038, p. 1059.
41 M. Gabbay, A. Gibbs, Does Additional
Lubrication Reduce Condom Failure?,
867
SAFE SEx
2. Te Performance of the Condom
when Used as a Prophylactic (Table III)
Te condom generally diminishes
the risk of infection by STDs, but does
not eliminate it.
42
It efectively protects
Contraception, March 12, 1996, vol. 53, n3,
pp. 155-158.
42 J. Pemberton, J.S. McCann, J.D.H.
Mahony, G. Mackenzie, H. Dougan, I. Hay,
Socio-medical characteristics of patients
attending a V.D. clinic and the circumstances
of infection, British Journal of Venereal
Diseases, October 1972, vol. 48, n5, pp. 391-
396. See table VIII, p. 394; W.M. McCormack,
Yhu-Hshang Lee, S.H. Zinner, Sexual Experience
and Urethral Colonization with Genital
Mycoplasmas, Annals of Internal Medicine, May
1973, vol. 78, n5, p.696-698. See table 2, p.
698; D. Barlow, Te condom and Gonorrhea,
Te Lancet, October 13, 1977, vol. II, n8042,
pp. 811-812; M.J. Rosenberg, A.J. Davidson,
J.H. Chen, F.N. Judson, J.M. Douglas, Barrier
Contraceptives and Sexually Transmitted Diseases
in Women: A Comparison of Female-Dependent
Methods and Condoms, American Journal
of Public Health, May 1992, vol. 82, n5, pp.
669-674. See p. 670; D.A. Cohen, C. Dent, D.
MacKinnon, G. Hahn, Condoms for Men, not
Women, Results of Brief Promotion Campaign,
Sexually Transmitted Diseases, September-
October 1992, vol. 19, n5, pp. 245-251; B.A.
Evans, S.M. McCormack, P.D. Kell, J.V. Parry,
R.A. Bond, K.D. MacRae, Trends in female
sexual behavior and sexually transmitted diseases
in London, 1982-1992, Genitourinary Medicine,
October 1995, vol. 71, n5, pp. 286-290; J.M.
Zenilman, C.S. Weisman, A.M. Rompalo, N.
Ellish, D.M. Upchurch, E.W. Hook III, D.
Celentano, Condom Use to Prevent Incident
STDs: Te Validity of Self-Reported Condom
Use, Sexually Transmitted Diseases, January-
February 1995, vol. 22, n1, pp. 15-21; M. Shaw,
G.J. Remafedi, L.H. Bearinger, P.L. Faulkner,
B.A. Taylor, S.J. Potthof, M.D. Resnick, Te
against syphilis (J. Pemberton and asso-
ciates, 1972; D. Barlow, 1977; J. San-
chez and associates, 1998) (average rate
of infection 0,65% with condom, com-
pared to 1,86% among subjects never
using condoms during sexual activity),
and against gonorrhea (average rate of
gonorrheal infection 8% with condom,
compared to 15% in subjects never using
the condom; J. Pemberton and associates,
1972; D. Barlow, 1977; M.J. Rosenberg
and associates, 1992; B.A. Evans and as-
sociates, 1995, J. Sanchez and associates,
1998; reduction of risk by 39%, Rosen-
berg and associates, 1992).
However, the condom seems less
efcient against infections of chlamydia
(infection rate 3,9% with condom, com-
pared to 7,2% without condom, Evans
and associates, 1995; risk of 0,8 with
condom against 1,2 without condom,
J. Sanchez and associates, 1998) or even
totally inefcient (M.J. Rosenberg and
associates, 1992, risk relative to 0,99).
J.M. Zenilman and associates (1995)
have nevertheless reported a signifcantly
protective efect of the condom against
chlamydia (0/72 infected with condom
versus 16/251 without condom).
43
Validity of Self-Reported Condom Use Among
Adolescents, Sexually Transmitted Diseases,
October 1997, vol. 24, n9, pp. 503-510; J.
Sanchez, E. Gotuzzo, J. Escamilla, C. Carrillo,
L. Moreyra, W. Stamm, R. Ashley, P. Swenson,
K.K. Holmes, Sexually Transmitted Infections
in Female Sex-Workers, Sexually Transmitted
Diseases, February 1998, vol. 25, n2, pp. 82-89.
43 J.M. Zenilman, C.S. Weisman, A.M.
868
SAFE SEx
TABLE III: EFFECTIVENESS OF CONDOMS IN PREVENTING STDs
Reported STDs
percentage
contagion
user
condom
percentage
contagion
user
condom
Type and number of
subjects,
length of study
Place of study
J. Pemberton et
coll. (1972)
syphilis
gonorrhea
non gon. urethritis
other STDs
0.9%
13.4%
34.8%
19.6%
2.7%
26.2%
29.1%
17.3%
1,351 cases of STDs
1,173 male patients,
one year
Royal Victoria Hospi-
tal, Belfast
W. M. McCor-
mack et coll.
(1973)
T-Mycoplasmas 14.3% 42.9%
191 male students,
college, one urethr.
culture
Boston, MA and Provi-
dence, Rhode Island
D. Barlow
(1977)
syphilis
gonorrhea
non gon. urethritis
genital herpes
genital warts
0.39%
9.27%
46.72%
0.37%(?)
5.02%
1.02%
14.39%
47.42%
1.67%
4.60%
3,543 STDs
3,300 male patients,
six months
Genito-Urinary Medi-
cine, St. Tomas Hos-
pital, London
M.J. Rosenberg
et coll. (1992)
gonorrhea
vag. trichomonas
chlamydia
R.R.0.7
R.R.0.86
R.R.0.99
-
4,162 women,
one year
Denver (Colorado),
STD Clinic
D.A. Cohen et
coll. (1992)
STDs (gonorrhea, chla-
mydia, syphilis, tricho-
monas)
19.9% m
12.6% f
-
552 men,
350 women,
9 months
STD clinics,
Los Angeles
B.A. Evans et
coll. (1995)
gonorrhea,
chlamydia,
n.g urethritis,
trichomoniasis,
candidosis,
genital herpes,
genitals warts,
vaginites bact.
infam. pelvienne
0.6%
3.9%
10.5%
1.7%
36.5%
3.9%
13.8%
7.2%
1.1%
3.6%
7.2%
9.6%
3.6%
31.3%
4.8%
3.6%
12%
1.2%
416 women,
without regular part-
ner, questionnaire
Department of Genito-
urinary Medicine,
London, U.K.
J.M. Zenilman
et al. (1995)
male STDs
female STDs
15.3%
23.5%
15.3%
26.8%
323 men,
275 women,
population study,
two years
Baltimore City Health
Department,
STD clinics
M.L. Shaw et
coll. (1997)
STDs 9% 10%
77 men,
321 women,
adolescents,
one year
schools,
community-based clin-
ics, St. Paul, Minnesota
J. Sanchez et
coll. (1998)
gonorrhea,
syphilis,
infact. chlamydia
R.0.3
R.0.3
R.0.8
R.1.7
R.0.4
R.1.2
435 female prostitutes,
one year survey
Centro antivenereo,
Lima, Peru
A. Wald et coll.
(2001)
Herpes Simplex Type 2
R.0.085
woman
R.2.02
man
R.1.16
528 couples,
18 months
Seattle, WA
18 clinics
869
SAFE SEx
Te condom is practically inefec-
tive against non-specifc urethritis (in-
fection rate 30,6% with condom com-
pared to 28,7% without condom)(J.
Pemberton, 1072; D. Barlow, 1077; B.A.
Evans, 1995).
It is equally inefcient against STDs
transmitted through cutaneous or mu-
cous membrane contact, such as the
simplex Herpes virus infection (infec-
tion rate 0,77% with condom, versus
1,67% without condom, D. Barlow,
1977; infection rate 3,9% with condom
versus 4,8% without condom, B.A.
Evans and associates, 1995). A recent
report on type 2 simplex Herpes vi-
rus infections (A. Wald and associates,
2001)
44
shows that the regular use of the
condom during sexual activity reduces
the risk of contamination by this virus
among women, but has no efect against
the contamination of men.
Te condom generally does not
protect against infections of Condylo-
mata acuminate (genital condylomes
genital warts)(infection rate 5,02%
Rompalo, N. Ellish, D.M. Upchurch, E.W.
Hock III, D. Celentano, Condom Use to
Prevent Incident STDs: Te Validity of Self-
Reported Condom Use, Sexually Transmitted
Diseases, January-February, 1995, vol.22, n1,
pp.15-21, see p.18.
44 A.Wald, A.G. Langenberg, K. Link,
A.E. Izu, R. Ashley, T. Warren, S. Tyring, J.M.
Douglas J., L. Corey, Efect of Condoms on
Reducing the Transmission of Herpes Simplex
Virus Type 2 from Men to Women, JAMA, 27
June 2001, vol.285, n24, pp.3100-3106, see
p.3104.
with condom, versus 4,6% without
condom. D. Barlow, 1977; infection
rate 13,8% with condom versus 3,6%
without condom, B.A Evans and asso-
ciates, 1995). L.M. Wen and associates
(1999) have nevertheless shown that the
use of the condom could reduce the risk
of papillomavirus genital infections.
45
While the frequency and gravity
of pelvic infammatory diseases (PID)
(high gonococcal or chlamydic genital
infections) seemed to be reduced due to
the use of the condom (J. Kelaghan and
associates, 1982)
46
, a recent report (R.
Ness, 2001)
47
has in fact demonstrated
the inefcacy of the condom against
these STDs.
Te recent review of the question
48

made at the request of the National Ins-
titutes of Health and of the Center for
45 L.M. Wen, C.S. Estcourt, J.M. Simpson,
A. Mindel, Risk factors for the acquisition of
genital warts: are condoms protective?, Sexually
Transmitted Infections, October 1999, vol.75,
n5, pp.312-316.
46 J. Kelaghan, G.L. Rubin, H.W. Ory,
P.M. Layde, Barrier-Method Contraceptive and
Pelvic Infammatory Disease, Journal of the
American Medical Association, July 9 1982,
vol.248, n2, pp.184-187.
47 M. Larkin, Contraceptives do not protect
against pelvic infammatory, Lancet, 21 April
2001, vol.357, n9264, p.1270.
48 Scientifc Evidence of Condom
Efectiveness for Sexually Transmitted Disease
(STD) Prevention, June 12-13, 2000, Hyatt
Dulles Airport, Herndon, Virginia, Summary
Report, National Institute of Allergy and
Infectious Diseases, National Institutes of
Health, July 20 2001, http://www.niaid.nih.
gov/dmid/stds/condomreport.pdf.
870
SAFE SEx
TABLE IV: EFFECTIVENESS OF CONDOMS IN PREVENTING GENITAL
CONTAMINATION BY HIV RATE OF SEROCONVERSION TO HIV
Condom Users Non-Users Type of sexual
relation
Type of study
Type and num-
ber of subjects
Place of
study rate reduction* rate
J. Mann et coll.
(1987)
25% (0-32%) - 26% heterosexual questionnaire 376 prostitutes
Kinshasa,
Zaire
E.N. Ngugi et
coll. (1988)
46% (23/50) 3 times 71% (20/28) heterosexual
population,
18 months
595 prostitutes
Nairobi,
Kenya
M. Tuliza et coll.
(1991)
70/531 - - heterosexual
population,
23 months
431 prostitutes
Kinshasa,
Zaire
M. Laga et coll.
(1994)
70/531
(13%)(8/100
women/year)
-
11.7/100
women/year
heterosexual
population,
3 years
531 prostitutes
Kinshasa,
Zaire
R.S. Hanenberg
(1994)
29.5%
- - heterosexual -
Direct prostitu-
tion
Tailand
HIV control
program,
4 years
7.7% - - heterosexual -
Indirect prostitu-
tion
1.5% - - heterosexual - Pregnant women
4% - - heterosexual - Army recruits
R. Detels et. coll.
(1989) (?)
3.32% - 3.3% homosexual -
< 2 partners
457 men
Population
2,915 men,
Baltimore 4.4% - 9.5% homosexual -
3-5 partners,
1,132 men
L.I. Levin et coll.
(1995)
insignifcant increase of seroconversion
with condom usage
13% homo.,
59% hetero.
questionnaire
140 men in ac-
tive duty
HIV+
22 centers,
US Army
M.A. Fischl
(1987)
10% - 12/14 (85%) heterosexual
population,
three years
45 couples,
serodiscordant
Miami
School of
Medicine
N.Padian et coll.
(1987)
risk x 4.6 if > 100 sexual acts
no infuence of condoms
heterosexual
population,
two years
97 couples,
serodiscordant
California
P.J.Feldblum
(1991)
3.5/100
couples/year
-
10.1/100
couples/year
heterosexual
population,
13 months
98 couples,
serodiscordant
Zambia
M. Kamenga et
coll. (1991)
4% (3.1/100 couples/year) - heterosexual
followed
6 months
149 couples,
serodiscordant
Kinshasa,
Zaire
I.de Vincenzi et
coll. (1991)
0%-4.8% - 4.8% heterosexual
followed
20 months
256 couples,
serodiscordant
European
Study Group
A. Nicolosi et al.
(1994)
0.1 OR - 1 OR heterosexual -
730 couples,
serodiscordant
Italy
M.D.C. Gui-
mareas et coll.
(1995)
1 OR - 3.91 OR heterosexual -
204 couples,
serodiscordant
Rio de Ja-
neiro

Rate: rate of seroconversion to HIV
* Reduction: reduction of risk of seroconversion to HIV
871
SAFE SEx
Disease Control and Prevention by a
study group in June 2000 corroborates
these results.
III THE PERFORMANCE
OF THE CONDOM IN THE
PROTECTION AGAINST HIV
(TABLE IV)
Concerning the condoms preven-
tion of the sexual transmission of HIV,
it is appropriate to examine separately
the statistics concerning subjects who
are at high risk- homosexuals and
prostitutes in particular - and the sta-
tistics concerning monogamous cou-
ples who are HIV positive/negative
and where the risk of transmission of
HIV is lessened.
1. High Risk Behavior
African and Tai prostitutes de-
mand of their clients to use the
condom; this precaution in general di-
minishes the incidence of HIV infec-
tion, but does not eliminate it; sexual
HIV contamination remains in fact
important, despite the condom (13%
of women in Laga and associates,
1994; 29,5% of women in Hanenberg
and associates, 1994)
49
.
49 J. Mann, T.C. Quinn, P. Piot, N.
Bosenge, N. Nzilambi, M. Kalala, H. Francis,
R. L. Coleblunders, R. Byers, P. Kasa Azila, N.
Kabeya, J.W. Curran, Condom Use and HIV
Infection among Prostitutes in Zaire, Te New
England Journal of Medicine, February 5, 1987,
vol. 316, n6, p. 325; N. Nzila, M. Laga, M.A.
Tiam, K. Mayimona, B. Edidi, E. Van Dyck,
F. Beheta, S. Hassig, A. Nelson, K. Mokwa,
Concerning masculine homosexuals,
the few available statistics show that the
regular use of the condom diminishes the
incidence of genital homosexual contami-
nation by HIV (by a factor of 3,3, in De-
tels and associates, 1989), but that the rate
of seroconversion
50
depends more on the
lifestyle (number of partners, changing of
Rh.L. Ashley, P. Piot, R.W. Ryder, HIV and
other sexually transmitted diseases among female
prostitutes in Kinshasa, AIDS, June 1991, vol.
5, n6, pp. 715-721; A. Johnson, Feedback from
the Six International AIDS Conference, San
Francisco 1990, Genitourinary Medicine, April
1991, vol. 67, n2, pp. 162-171. See pp. 162-
163; M. Laga, M. Alary, N. Nzila, A.T. Manoka,
M. Tuliza, F. Behets, J. Goeman, M. StLouis, P.
Piot, Condom promotion, sexually transmitted
diseases treatment, and declining incidence of
HIV-1 infection in female Zairian sex workers,
Te Lancet, 23 July 1994, vol. 344, n8917, pp.
246-248; E.N. Ngugi, J.N. Simonsen, M.Bosire,
A.R. Ronald, F.A. Plummer, D.W. Cameron, P.
Waiyaki, J.O. Ndinya-Achola, Prevention of
transmission of Human Immunodefciency Virus
in Africa: efectiveness of condom promotion and
health education among prostitutes, Te Lancet,
October 15 1988, vol. II, n8616, pp. 887-890;
R.S. Hannenberg, W. Rojanapithayakorn, P.
Kunasol, D.C. Sokal, Impact of Tailands HIV
control programme as indicated by the decline of
sexually transmitted diseases, Te Lancet, 23 July
1994, vol. 344, n8917, pp. 243-245.
50 Seroconversion: in the blood of HIV
contaminated persons apparition of composites
objectifying the reaction of the organism to the
presence of the virus. Seroconversion which
leads to seropositivity is in a sense the signature
of the viral contamination. In the case of the
HIV, several months can go by between the
moment of contamination and the apparition of
seropositivity.
872
SAFE SEx
partners) than on the use of the condom
51
.
In some cases (L.I. Levin and associates,
1995), the rate of seroconversion parado-
xically appears proportional to the sub-
jects use of the condom, because persons
with sexual behavior involving greater risk
more willingly use the condom.
52
2. Monogamous Serodiscordant-
53
Couples
Te efcacy of the condom in the
context of the prevention of HIV infec-
tion in HIV-serodiscordant couples
(where one of the spouses is HIV-seropo-
sitive and the other still HIV-seronegati-
ve) is not so much related to the condom
itself than to the sexual behavior of the
partners. Even in the cases where the
51 R. Detels, P. English, B.R. Visscher, L.
Jacobson, L.A. Kingsley, J.S. Chmiel, J.P. Dudley,
L.J. Eldred, H.M. Ginzburg, Seroconversion,
Sexual activity, and Condom Use Among 2915
HIV seronegative Men Followed for up to 2
Years, Journal of Acquired Immune Defciency,
1989, vol. 2, n1, pp. 77-83.
52 L.I. Levin, T.A. Peterman, P.O.
Renzullo, V. Lasley-Bibbs, xiao-ou Shu,
J.F. Brundage, J.G. MacNeil, HIV-1
Seroconversion and Risk Behaviors among
Young Men in the US Army, American Journal
of Public Health, November 1995, vol. 85,
n11, pp. 1500-1506.
53 serodiscordant couples: couples where
one partner has not been contaminated by
HIV, and therefore remains seronegative,
while the other has been contaminated
and is seropositive. If the partners have
sexual relations, the still unharmed partner
will be contaminated by HIV within a
shorter or a longer period, and will also
become seropositive, thus ending the
serodiscordance between the partners.
risk of contamination without condom
is already very low (4,8%), the condom
does not ofer absolute protection, since
the rate of contamination despite the
use of the condom has been found to be
according to statistics 0% (De Vincenzi,
1994), 2% (Nicolasi, 1994), 3,5% (Fel-
dblum, 1991), 4% (Kamenga, 1991),
10% (Fischl, 1987). In these cases the
condom diminishes the risk of genital
contamination of HIV by a factor of
3,91 (Guimaraes, 1995).
54
54 M.A. Fischl, G.M. Dickinson, G.B.
Scott, N. Klimas, M.A. Fletcher, W. Parks,
Evaluation of Heterosexual Partners, Children
and Household Contacts of Adults with AIDS,
Journal of the American Medical Association,
February 6 1987, vol.257, n5, pp.640-644; P.J.
Feldblum, Results from prospective studies of
HIV-discordant people, AIDS, October 1991,
vol.5, n10, pp.1265-1266; M. Kamenga, R.W.
Ryder, M. Jingu, N. Nbuyi, L. Mbu, F. Behets,
Chr. Brown, W.L. Heyward, Evidence of marked
sexual behavior change associated with low HIV-
I seroconversion in 149 married couples with
discordant HIV-I serostatus: experience at an
HIV counseling center in Zaire, AIDS, January
1991, vol.5, n1, pp.61-67; I. de Vincenzi, for
Te European Study Group on Heterosexual
Transmission of HIV, a longitudinal Study of
Human immunodefciency virus transmission
by heterosexual partners, the New England
Journal of Medicine, Aug.1 1994, vol.331, n6,
pp.341-346; A. Nicolasi, M.L. Corra Leite, M.
Musicco, Cl. Arici, G. Gavazzeni, A. Lazzarin, for
the Italian Study Group on HIV Heterosexual
Transmission, the Efciency of Male-to-Female
and Female-to-Male Sexual Transmission of the
Human Immunodefciency Virus: A Study of
730 Stable Couples, Epidemiology, November
1994, vol.5, n6, pp.570-575; M.D.C.
Guimaraes, A. Muoz, C. Boschi-Pinto, E.A.
873
SAFE SEx
It has been observed, furthermore,
that among HIV-serodiscordant cou-
ples who use the condom irregularly,
the rate of seroconversion for the sero-
negative partner is low (4,8%)(cumula-
tive index of seroconversion 7,8%)(P.J.
Feldblum, I. De Vincenzi) when the se-
ropositive partner is asymptomatic, and
is identical to the one found in couples
who never use the condom.
However, once the infected par-
tner has reached the symptomatic stage
or when this partner engages in risky
sexual behavior, the risk of seroconver-
sion for the negative partner becomes
serious (cumulative index of seroconver-
sion 48,7%) and the use of the condom
does not change this (N. Padian, I. De
Vincenzi). Tis is shown by Feldblums
statistic (1991) and much more by the
disastrous numbers delivered by N. Pa-
dian and associates (1987) with up to
35% failures.
55
Among all these statistics the
constant and correct use of the condom
(perfect use) seems to be the excep-
Castilho, from the Rio de Janeiro Heterosexual
Study Group, HIV infection among Female
Partners of Seropositive Men in Brazil, American
Journal of Epidemiology, September 1 1995,
vol.142, n5, pp.538-547.
55 N. Padian, L. Marquis, D.P. Francis, R.E.
Anderson, G.W. Rutherford, P.M. OMalley,
W. Winkelstein, Male-to-Female Transmission
of Human Immunodefciency Virus, JAMA,
August 14 1987, vol.258, n6, pp.788-790; P.J.
Feldblum, Results from prospective studies of
HIV-discordant people, AIDS, October 1991,
vol.5, n10, pp.1265-1266.
tion rather than the rule.
56
Te best do-
56 In the evaluation of condom failures one
must also take into account that these condoms
are used more or less correctly. For Hawkins and
Elder, the most common reason for failure
when using the condom as a contraceptive is its
incorrect use. A frst way in which the condom
can be used incorrectly is in what A. Quirk and
associates call unsafe protected sex, that is
the practice of a protected sexual relation but
which does not belong to the category of safe
sex, because its use does not cover the entire
period of the relation. In consequence warnings
have been issued (G. Ilaria, J. Pudney) about the
presence of HIV in pre-ejaculatory secretions.
A second reason for condom failure is tied to
the contamination of the external surface of
the condom. A third source of condom failure
is found in the use of inappropriate lubricants,
in particular oily ones (White, Voeller, Chan-
Chee, Messiah, Gabbay), which weaken the
latex and render it permeable; D.F. Hawkins,
M.G. Elder, Condoms, Diaphragms and Caps,
in Human Fertility Control, Teory and
Practice, Butterworth & co, London, 1979,
p.138; A. Quirk, T. Rhodes, G.V. Stimson,
Unsafe protected sex: qualitative insights on
measures of sexual risk, AIDS care, February
1988, vol.10, n1, pp.105-114; G. Ilaria, J.L.
Jacobs, B. Poisky, B. Koll, P. Baron, Cl. MacLow,
D. Armstrong, Detection of HIV-1 DNA
sequences in pre-ejaculatory fuid, Te Lancet,
December 12 1992, vol.340, n8833, p.1469;
J. Pudney, M. Oneta, K. Mayer, G. Seage III,
D. Anderson, Pre-ejaculatory fuid as potential
vector for sexual transmission of HIV-1, the
Lancet, December 12 1992, vol.340, n8833,
p.1470; N. White, K. Taylor, A. Lyszkowski, J.
Tullett, C. Morris, Dangers of lubricants used
with condoms, Nature, 1 September 1988,
vol.335, n6185, p.19; B. Voeller, A.H. Coulson,
G.S. Bernstein, R.M. Nakamura, Mineral oil
lubricants cause rapid deterioration of latex
condoms, Contraception, January 1989, vol.39,
874
SAFE SEx
cumented publication on the matter by
the European Group of Study on hete-
rosexual transmission of HIV (De Vin-
cenzi) indicates that only 32% of all mo-
nitored couples were capable of it, while
34% opted for abstinence, and 34% for
the irregular use of the condom (non-use
in 16% of the cases).
3. Meta-Analysis
R. Gordon (1989)
57
estimates that
the rate of condom failure in the preven-
tion of the sexual transmission of HIV
(5 to 23%) is higher than the one obser-
ved during the use of the condom as a
contraceptive.
In a meta-analysis based on 11 pu-
blications S.C. Weller (1993) situates
the rate of the protection by the condom
against sexual contamination by HIV at
only 69% (failure in 31% of the cases).
58
n1, pp. 95-102; Chr. Chan-Chee, I. De Vicenzi,
M-A. Sole-Pia, R. Ancelle-Park, J.-B. Brunet,
Use and misuse of condoms, Genitourinary
Medicine, April 1991, vol. 67, n2, p. 173; A.
Messiah, D. Buoquet, J.-F. Mettetal, B. Larroque,
Chr. Rouzioux, and the Alain Brugeat physician
group, Factors Correlated With Homosexually
Acquired Human Immunodefciency Virus
Infection in the Era of Safer Sex, Was the
Prevention Message Clear and Well Understood?,
Sexually Transmitted Diseases, January-February
1993, vol. 20, n1, pp. 51-59. See p. 56; M.
Gabbay, A. Gibbs, Does Additional Lubrication
Reduce Condom Failure?, Contraception, March
1996, vol. 53, n3, pp. 155-158. See p. 157.
57 R. Gordon, A critical Review of the
physics and statistics of condoms and their
role in individual versus societal survival of the
AIDS epidemic, Journal of Sex and Marital
Terapy, Spring 1989, vol. 15, n1, pp. 5-30.
58 S.C. Weller, A Meta-analysis of condom
K. April, W. Schreiner and associates
(1994),
59
analyzing 14 studies focused
on serodiscordant couples for observa-
tion periods between six months and
three years, fnd that 8% was the avera-
ge percentage of seroconversion among
couples always using the condom com-
pared to 35% as the average percentage
of seroconversion among couples never
using it.
K.R. Davis and S.C. Weller
60

(1999) analyzing results from 25 studies
concerning serodiscordant couples fnd
an average condom failure rate of 13%.
In conclusion, the efcacy of the
condom in the prevention of the sexual
transmission of HIV seems similar to
when it is used as a barrier contracep-
efectiveness in reducing sexually transmitted
HIV, Social Science Medicine, June 1993, vol.
36, n12, pp. 1635-1644.
59 K. April, R. Kster, G. Fantacci,
W. Schreiner, Quale il grado efettivo di
protezione dallHIV del proflattivo?, Medicina
e Morale, October 1994, vol. xLIV, n5, pp.
903-924.
60 12 population studies showed an
incidence of HIV transmission despite the
constant use of the condom of 0,9 for 100
persons per year. Te same incidence was 5,9
per 100 persons per year (transmission from
woman to man) and of 6,8 for 100 persons per
year (transmission from man to woman) in the
11 studied populations where no one ever used
the condom. Te efcacy of the condom was
in general estimated at 87%, but it could be as
low as 60% and as high as 96%; K.R. Davis,
S.C. Weller, Te efectiveness of Condoms in
Reducing Heterosexual Transmission of HIV,
Family Planning Perspectives, November-
December 1999, vol.31, n6, pp.272-279.
875
SAFE SEx
tive or even slightly lower than that (R.
Gordon, C. Weller, P.J. Feldblum, K.R.
Davis).
4. Discussion
a-Te Defects of the Condom and
Mistaken Beliefs Concerning Safe Sex.
Te frst conclusion to be drawn
from this analysis is that the condom
is in and of itself only relatively relia-
ble, even though manufacturers have
tried to improve its mechanical qualities
and though latex still remains the best
material for the condom. Te error is
to have thought that to accurately use
the condom would be the same as to
prevent the sexual transmission of HIV;
for it was well known that such accu-
rate use was an exception and that no
condom could ever be guaranteed to be
100% efcient.
Knowing the limits of the condom
as a contraceptive and as barrier to STD
bacterial and viral agents, one should
have expected the same type of result
concerning the prevention of the pas-
sage of HIV; statistics in fact show that
its average failure rate is 13%. Te sta-
tistic of the European group (De Vin-
cenzi)0% of sexual contamination by
HIV among the 124 HIV serodiscor-
dant couples (out of 378) who always
used a condom during their relations
is, from this standpoint, the exception
rather than the rule.
However, the failure rates of the
condom are variable from one statistic
to another, depending upon which part
of the population is studied. It is in fact
the more or less risky sexual lifestyle
of the subject which is of greater impor-
tance than the simple use or non-use of
the condom. It is therefore not so much
the use of the condom which makes
sexsafe, but rather refraining from
sexual promiscuity, limiting the number
of partners and abstaining from homo-
sexual practices. Tere is no true safe
sex except in conjugal fdelity which
renders the condom useless.
b-Te Possible Negative Efects of
safe sex Campaigns.
Not only is the expression safe
sex inaccurate, but it also fosters dan-
gerous illusions and leads to the very
consequences it tries to prevent. Pu-
blicity made for the condom against
HIV/AIDS could in fact have an efect
contrary to the one desired. Tis has
recently been heard from researchers at
the University College Medical School in
London,
61
who were basing themselves
on the results concerning the publicity
made for safety belts in cars. In Great
Britain this publicity has in fact had the
opposite efect, causing a higher num-
ber of victims in trafc accidents, be-
cause of the feeling of security people
associated with the use of safety belts.
It could be the same with the publi-
city for condoms, as mentioned by N.
Hearst and S.B. Hulley
62
of the Center
61 J. Richens, J. Inrie, a. Copas, Condoms
and seat belts: the parallels and the lessons, the
Lancet, 2000, vol. 355, n9201, pp. 400-403.
62 N. Hearst, S.B. Hulley, Preventing the
Heterosexual Spread of AIDS: Are We Giving
876
SAFE SEx
for AIDS Prevention Studies at the Uni-
versity of California in San Francisco.
Tis paradoxical efect has in fact been
observed by I. Levin and associates
63
in
their report of 1995 on HIV infections
in the military: the condom, used by
these military in their homosexual en-
counters, not only did not prevent HIV
infection, but appeared to facilitate it,
because the usersthinking they were
protected - multiplied their partners and
their sexual experiences of all types.
c-Safe Sex or Sexual Health?
In the prevention of any type of ca-
lamity, we can distinguish between the
means of containment which aim at
limiting the expansion of the calamity
from the actual means of prevention
which aim at eliminating the roots of the
disorder. Malaria for example is compara-
ble to HIV/AIDS in terms of the number
of contaminated persons in the world, in
terms of the mortality it causes and the dif-
fculty of its treatment, and in terms of the
preventive measures developed over the
yearsand which particularly concern the
battle against the anopheles; the measures
taken have been measures of contain-
Our Patients the Best Advice?, JAMA, April
22/29 1988, vol. 259, n16, pp. 2428-2432;
see p. 2431.
63 L.I. Levin, T.A. Peterman, P.O.
Renzullo, V. Lasley-Bibbs, xiao-ou Shu,
J.F. Brundage, J.G. MacNeil, HIV-1
Seroconversion and Risk Behaviors among
Young Men in the US Army, American Journal
of Public Health, November 1995, vol. 85,
n11, pp. 1500-1506.
ment rather than being truly preventive,
because they have not been able to get to
the root of the problem. Tough theore-
tically efective, these measures have re-
vealed themselves to be not very efective,
because it is impossible to destroy all the
larvae and to eliminate all stagnant water.
In the case of typhoid fever, in contrast,
prevention has been efective because one
has been able to get the population to take
care of its drinking water. True prevention
has occurred in this case, because human
behavior which had favored contamina-
tion was changed.
Te condom is presented as a means
by which to contain the sexual transmis-
sion of HIV/AIDS, to limit its transmis-
sion by reducing its incidence by a factor
of 3 or 4. It does not provide a true pre-
vention of the epidemic, since it leaves its
roots intact, namely the human behavior
responsible for the transmission of HIV.
True prevention of sexually transmitted
HIV/AIDS aims to bring to an end risky
sexual behavior and to guide the young
toward a balanced and fulflling sexua-
lity by embracing pre-marital and marital
chastity. We cannot hope to stop the HIV/
AIDS epidemic by simply advertising the
condom, no more than we can hope to
stop a fooding river with a few bags of
sand once the dykes have broken. People
should be encouraged to be truly sexually
healthy rather than believing in an illusory
safe sex. As long as serious eforts will
not be made in this direction, the AIDS
epidemic will persist as one can see in rich
countries where sexual contamination of
877
SAFE SEx
HIV continues at the same pace, despite
years of massive advertisement for the
condom.
Te encouragement towards conjugal
chastity and to sexual abstinence outside
of marriage have been excluded a priori
from AIDS prevention programs with
the pretext that such ideals were utopist
and do not correspond to concrete, daily
life. Yet, what does one notice in daily life?
Particularly in countries where AIDS has
been rampant for several years already one
can observe a salutary reaction of the po-
pulation, marked by the diminishing of
extra-marital sexual relations and a delay
of frst sexual relations among the young.
One can observe this today in Uganda, for
example, where the AIDS epidemic has
slowed down,
64
with a lessening of HIV
prevalence from 45% to 35% among mas-
culine subjects examined in STD clinics
in Kampala and from 21% to 5% among
pregnant women examined in Jinja from
1990 to 1996. Tough sexually active
men and women report a more frequent
use of the condom in their answers to sur-
veys, the most important factor seems to
be the noticeable change observed in the
sexual behavior of the young which is cha-
racterized by a markedly later age of frst
sexual relations (56% of boys aged 15 to
19 declared in 1995 not to have had any
64 G. Asjimwe-Okiror, A.A. Opio, J.
Musinguzi, E. Madraa, G. Tembo, M. Carsl,
Changes in sexual behavior and decline in HIV
infection among young pregnant women in
urban Uganda, AIDS, 15 November 1997, vol.
11, n14, pp. 1757-1764.
sexual relations yet, versus 31% in 1989,
and 46% young girls in 1995 versus 26%
in 1989). It is also characterized by a later
marriage age and by a lessening of extra-
marital relations (from 22,6% in 1989 to
18,1% in 1995 for men).
65
In the particular case of monoga-
mous serodiscordant couples, the use of
the condom has been presented as quasi
obligatory, because of the serious threat of
contamination of the HIV-seronegative
spouse by the seropositive one. Te very
idea of sexual abstinence was set aside. But
the statistics mentioned above show that a
signifcant number of these couples (11 to
25%)(M.A. Fischl, 1987, I. De Vincenzi,
1994) choose of their own accord to no
longer have any sexual relations nor to
separate.
By reducing the efort at preventing
HIV/AIDS to the simple promotion of
the condom, we have dealt with what was
65 Tese data are in accord with a recent
study concerning the diferences in sexual
behavior of the population in four African
cities which present diferent HIV prevalence
rates (from 3,3% in Cotonou, Benin, to 31,9%
in Ndola, Zambia). Tis study shows, among
other things, that there is a link between the
earliness of frst sexual relations in young girls
and the prevalence of the HIV in their group.
Female adolescents from Kisumu and Ndola were
having particularly early sexual relations with
older men, and the prevalence of STDs among
these adolescents was higher than in the other
studied cities; J. Cohen, AIDS Researchers Look
to Africa for New Insights, Science, 11 February
2000, vol.287, n5455, pp.942-943: Diferences
in HIV Spread in four sub-Saharan African cities,
UNAIDS, Lusaka, 14 September 1999.
878
SAFE SEx
most urgent in those milieus most favor-
able to the development of the epidemic
because of the sexual habits which char-
acterized them. But a real prevention for
the population in general has not been put
into place, in particular with regard to the
young. Some have said we must not scare
people. Some have also said that sexual
choices are a private matter and that it is
not the task of the authorities to preach
to people. Epidemiological measures re-
quired by the gravity of the situation were
not taken. We have been satisfed merely to
propose the condom. Te result is that the
HIV/AIDS epidemic which could have
been easily stopped at the beginning of its
expansion, has spread throughout the en-
tire world causing the millions of victims
we now know about.
4. Conclusion
Te ofcial discourse on the preven-
tion of sexual contamination by HIV/
AIDS has been limited for the past 20
to the promotion of the condom in the
context of safe sex. Behavior changing
campaigns have only aimed at its promo-
tion. However, one should not speak of
real prevention, but of protection or of a
prophylaxis, since the root of the problem,
namely risky behavior, remains.
Using a condom as protection against
HIV is like playing at Russian roulette:
the more sexual experiences one engages
in - convinced of the safety ofered by the
prophylactic - the higher the probability
of contamination will be. In the end, HIV
is the winner. Regarding HIV/AIDS, the
risk - even though it is reduced to 10% - of
contracting an infection believing oneself
to be protected by the condom is exces-
sively high. Tere is no such thing as safe
sex. Tis leaves a probability curve hang-
ing like the sword of Damocles over the
heads of all those who wrongly feel safe be-
cause they use the condom. What would
one say of a plane model with 10% of its
fights ending up in a crash?
All authors interested in the preven-
tion of the HIV infection agree in one
point: only a radical change in sexual be-
havior can guarantee complete protection
which the condom alone cannot do. Te
advocates of a greater publicity for the
condom admit it themselves: Clearly the
dangers of relying solely on barrier methods to
prevent AIDS must be emphasized, wrote
K. Wellings
66
in 1986, and the subsequent
history of the epidemic has proven this to
have been a well-founded fear. Te only
strategy that is completely efcient con-
cerning HIV is abstinence, or sexual rela-
tions within a monogamous marriage as
well as fdelity, according to the formula
given by Centers for Disease Control in At-
lanta (USA): Abstinence and sexual inter-
course with one mutually faithful uninfected
partner are the only totally efective preven-
tion strategies.
67
66 K. Wellings, AIDS and the condom,
British Medical Journal, 15 November 1986,
vol. 293, N6557, p. 1259.
67 Centers for Disease Control, Condoms
for Prevention of Sexually Transmitted
Diseases, op. cit., p. 133.