Sex, Condoms & STDs: What We Now Know

This excerpt from The Medical Institute's report, Sex, Condoms & STDs: What We Now Know, provides a quick reference and offers an easy-to-understand look at the currently available research conducted on condom effectiveness. However, we cannot overstate the importance of reading the entire report – only then can the reader gain a complete appreciation for the impact and importance of this research. To get a copy of the 2003 monograph, please call (900) 892-9484. The cost is $10 plus shipping.

Key findings:

• Consistent (always) condom use is defined as 100 percent condom use during all sex acts indefinitely. 

• To provide any reasonable hope of avoiding most STD infections condoms must be used 100 percent of the time by individuals outside of lifelong mutually faithful monogamous relationships (usually found in marriage).

• Even 100 percent condom use does not eliminate the risk of any STD including HIV.

• Condoms slip or break on average 1.6 percent to 3.6 percent of the time even when used 100 percent of the time, potentially exposing sexual partners to STD infection.  [72, 34, 35, 46]

• “Protection” is the term often applied to condom use.  This can be misleading because condoms only reduce the risk of infection.  They do not “protect” 100 percent of the time from any STD.

• Condoms do not prevent the transmission of STDs from lesions outside the areas covered by, or “protected” by, condoms. [72]

• All studies of condom use are done for a limited period of time – from a few acts of sex to two or three years of activity.  Single individuals who are sexually active usually continue sexual activity year after year. With an increasing number of sexual partners and sex acts comes an increasing risk of STD infection, even with 100 percent condom use.  (See discussion in the section “The Impact of Cumulative Effectiveness.”)

• One hundred percent use of condoms for many years is so uncommon that it is almost a purely theoretical concept except for very few, very meticulous individuals.  Even among adults who knew that their partner had HIV, only 56 percent used condoms every time (and the median follow up was only 24 months). [61]

• There is very limited reduction for sexual transmission of human papillomavirus infection (HPV) even with 100 percent condom use. There is some evidence that condom use “might afford some reduction in risk of HPV associated disease including genital warts in men and cervical neoplasia in women.”  Neoplasia means cervical precancer or cervical cancer.  [72]   (The scientific explanation for this phenomenon is beyond the scope of this paper.)

• Current evidence does not show that Trichomonas vaginalis sexual transmission is reduced even with 100 percent condom use.  [1, 72]

• Syphilis transmission is reduced by 29 percent to 50 percent with 100 percent condom use. Although the data about syphilis transmission is limited, current data show that even with 100 percent condom use, there remains a 50 percent to 71 percent relative risk of syphilis infection.  [1, 9]  (See the definition of relative risk in the section “Scientific Language and the Discussion of Condom Effectiveness.”)

• Gonorrhea transmission is reduced by approximately 50 percent with 100 percent condom use.  Although the data about gonorrhea transmission is limited, current evidence shows that even with 100 percent condom use there remains a 50 percent relative risk of gonorrhea infection.  [72, 1, 9]

• Chlamydia transmission is reduced by approximately 50 percent with 100 percent condom use.  Although the data about chlamydia transmission is limited, current evidence shows that even with 100 percent condom use, there remains a 50 percent relative risk of chlamydia infection.  [1, 9]

• Genital herpes sexual transmission: A recent study showed that with 25 percent or more condom use, there was risk reduction for females but not for males.  [70]  Expanded data by the same author, as yet unpublished but presented at a national conference, show risk reduction of approximately 40 percent for both males and females when condoms were used for 65 percent or more of sex acts.  Although the data about herpes transmission is limited, current evidence shows that even with condom use there remains a 60 percent relative risk of herpes infection.  [69]

• HIV sexual transmission is reduced by approximately 85 percent with 100 percent condom use, leaving approximately 15 percent relative risk – even with 100 percent condom use.  [72, 26]   Inconsistent condom use affords significantly less risk reduction.  As discussed later in this monograph, 85 percent risk reduction rates were found in an ideal situation for condoms reducing the risk of HIV transmission.

• For the approximately twenty other STDs, not enough data exist to say whether or not condoms offer any risk reduction from sexual transmission. 

• Approximately 25 percent of adolescents report alcohol or drug use during their most recent sexual behavior, compromising their ability to use condoms correctly or at all.  [23]

• There are certain groups that are more susceptible to some STDs.  These groups include those already infected with an STD.  For example, the presence of another STD, particularly an ulcerative disease, can significantly increase the risk of acquiring (or transmitting) HIV if an individual is exposed to a sexual partner who is HIV positive.  [30, 38]

• Females are more susceptible to many STDs than are males because they have a larger surface susceptible to infection (the lining of the vagina) than males (the lining of the urethra). Mucous membranes provide an easier route of entry for most STDs than intact skin.  In addition, adolescent females are at higher risk of certain STDs than are adult women, due to anatomical differences of the uterine cervix associated with age.  [30]  Condom effectiveness is decreased due to the increased susceptibility of the individual.  In addition, women suffer more of the severe complications of STDs than men do (e.g., cervical cancer, infertility).

• Most people infected with an STD do not know it.  For example, a study of adolescent females who had one or more of six STDs studied (genital herpes, chlamydia, gonorrhea, syphilis, hepatitis B, trichomoniasis) showed that 87 percent had no symptoms.  [13]   Individuals and their partners who do not think they have an STD may not be highly motivated to use condoms consistently.

Report's Bibliography:

1.   Ahmed S, Lutalo T, Wawer M, et al. HIV incidence and sexually transmitted disease prevalence associated with condom use: A population study in Rakai, Uganda. AIDS. 2001;15:2171-2179. 

2.   Alary M, Mukenge-Tshibaka L, Bernier F, et al.  Decline in the prevalence of HIV and sexually transmitted diseases among female sex workers in Cotonou, Benin, 1993-1999. AIDS. 2002;16:463-470.

3.    Albert AE, Warner DL, Hatcher RA, Trussell J, Bennett C. Condom use among female commercial sex workers in Nevada's legal brothels. Am J Public Health. 1995;85:1514-1519.

4.    Alter MJ, Coleman PJ, Alexander WJ, et al. Importance of heterosexual activity in the transmission of hepatitis B and non-A, non-B hepatitis. JAMA. 1989;262:1201-66.

5.    American Cancer Society. Cancer Facts and Figures 1999. Surveillance Research. 1999. Available at: http://www.cancer.org/

6.   Anderson JE, Wilson R, Doll L, Jones TS, Barker P. Condom use and HIV risk behaviors among U.S. adults: Data from a national survey. Fam Plann Perspect. 1999;31:24-28.

7.    Anderson JE, Brackbill R, Mosher WD. Condom use for disease prevention among unmarried U.S. women. Fam Plann Perspect. 1996;28:25-39.

8.    Aral SO, Peterman TA. Do we know the effectiveness of behavioral interventions? Lancet. 1998;3513:33-36.

9.    Baeten JM, Nyange PM, Richardson BA, et al. Hormonal contraception and risk of sexually transmitted acquisition: Results from a prospective study. Am J Obstet Gynecol. 2001;185:380-385.

10.  Bankole A, Darroch JE, Singh S. Determinants of trends in condom use in the United States, 1988-1995. Fam Plann Perspect. 1999;31:264-271.

11.  Barlow D. The condom and gonorrhea. Lancet. 1977;222:811.

12.  Blum RW, Rinehart PM. Reducing the risk: Connections that make a difference in the lives of youth. Division of general pediatrics and adolescent health, University of Minnesota, Box 721, 420 Delaware St., S.E., Minneapolis, MN 55455. 

      Resnick MD, Bearman PS, Blum RW, et al. Protecting adolescents from harm—Findings from the National Longitudinal Study on Adolescent Health. JAMA. 1997;278:823-832.

13.  Bunnell RE, Dahlberg L, Rolfs R, et al. High prevalence and incidence of sexually transmitted diseases in urban adolescent females despite moderate risk behaviors. J Infect Dis. 1999;180:1624-1631.

14.  Carey RF, Lytle CD, Cyr WH. Implications of laboratory tests of condom integrity. Sex Transm Dis. 1999;26:216-20.

15.  Cates W. American Social Health Association Panel. Estimates of the incidence and prevalence of sexually transmitted diseases in the United States. Sex Transm Dis. 1999;26:52-57.

16.  Cates W. Editorial: The Condom Forgiveness Factor. Sex Transm Dis. 2002;29:350-352.

17.  Centers for Disease Control and Prevention. 1998 Guidelines for treatment of sexually transmitted diseases. MMWR. 1997;47.

18.  Centers for Disease Control and Prevention. 1999 Assisted reproductive technology success rates – National summary and fertility clinic reports. 2001.

19.  Centers for Disease Control and Prevention, National Center for HIV, STD and TB Prevention. Surveillance Report. 2002;13. Accessed at: www.cdcc.gov/hiv/stats/hasr1301/table30.htm

20.  Centers for Disease Control and Prevention, National Center for Infectious Diseases. Hepatitis B Fact Sheet. Available at: www.cdc.gov/ncidod/diseases/hepatitis

21.  Centers for Disease Control and Prevention. Recommendations for prevention and control of hepatitis C Virus (HCV) infection and HCV-related chronic disease. MMWR. 1998;47:3.

22.  Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines 2002. MMWR. 2002;51:1-80.

23.  Centers for Disease Control and Prevention. Youth Risk Behavior Surveillance – United States, 2001. MMWR. 2002;51:1-64.

24.  Contraceptive Technology. 17^th ed. Hatcher RA, Trussell J, Stewart F, et al., eds. New York, NY: Irvington Publishers; 1998:328. 

25.  Cooper ML, Agocha VB, Powers AM. Motivations for condom use: Do pregnancy prevention goals undermine disease prevention among heterosexual young adults? Health Psychology. 1999;18:464-474.

26.  Davis KR, Weller SC. The effectiveness of condoms in reducing heterosexual transmission of HIV. Fam Plann Perspect. 1999;31:272-279.

27.  de Vincenzi I. A longitudinal study of human immunodeficiency virus transmission by heterosexual partners. NEJM. 1994;331:341-346.

28.  Dorland’s Illustrated Medical Dictionary. 27^th ed. Philadelphia, PA: Harcourt, Brace, Javanovich; 1988:566.

29.  Durex High Sensation condom box - lubricated premium latex condoms, No. 246, lubricated. Manufactured in Spain. Expiration 2004/05. Distributed by Durex Consumer Products, Inc., Norcross, GA 30092.

30.  Eng TR, Butler WT, eds. The Hidden Epidemic: Confronting Sexually Transmitted Disease. Institute of Medicine. Washington, DC: National Academy Press; 1997.

31.  Feldblum PJ, Morrison CS, Roddy RE, Cates W. The effectiveness of barrier methods of contraception in preventing the spread of HIV. AIDS. 1995;9:585-593.

32.  Fleming DT, McQuillan GM, Johnson RE, et al. Herpes Simplex Virus Type 2 in the United States, 1976-1994. NEJM. 1997;337:1105-1111.

33.  Fortenberry JD, Wanzhu T, Hareziak J, Kats BP, Orr DP. Condom use as a function of time in new and established adolescent sexual relationships. Am J Public Health. 2002;92:211-213.

34.  Frezieres RG, Walsh TL, Nelson AL, Clark VA, Coulson AH. Breakage and acceptability of a polyurethane condom: A randomized, controlled study. Fam Plann Perspect. 1998;30:73-78.

35.  Frezieres RG, Walsh TL, Nelson AL, Clark VA, Coulson AH. Evaluation of the efficacy of a polyurethane condom: Results from a randomized, controlled, clinical trial. Fam Plann Perspect. 1999;31:81-87.

36.  Gaydos CA, Howell MR, Pare B, et al. Chlamydia trachomatis infections in female military recruits. NEJM. 1998;339:739-744.

37.  Ghys PD, Diallo O, Ettiegne-Traore V, et al. Increase in condom use and decline in HIV and sexually transmitted diseases among female sex workers in Abidjan, Cote d’Ivoire, 1991-1998. AIDS. 2002;16:251-258.

38.  Gray RH, Wawer MJ, Brookmeyer R, et. al. Probability of HIV-1 transmission per coital act in monogamous, heterosexual, HIV-1-discordant couples in Rakai, Uganda. Lancet. 2001;357:1149-1153.

39.  Hanenberg RS, Rojanapithayakorn W, Kunasol P, Sokal, DC. The impact of Thailand’s HIV-control program as indicated by the decline of sexually transmitted diseases. Lancet. 1994;344:243-245.

40.  Hooper RR, Reynolds GH, Jones OG, et al. Cohort study of venereal disease. I: The risk of gonorrhea transmission from infected women to men. Am J Epidemiol. 1978;108:136-144.

41.  Judson FN, Ehret JM, Bodin GF, Levin MJ, Rietmeijer CAM. 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 Immunodeficiency Virus. Sex Transm Dis. 1989;16:51-55.

42.  Koutsky L. Epidemiology of genital human papillomavirus infection. Amer Jour of Med. 1997;102:3-8.

43.  Lytle CD, Duff JE, Fleharty B, Bidinger RL, Cyr WH. A sensitive method for evaluating condoms as virus barriers. JAOAC Int. 1997;80:319-324.

44.  Lytle CD, Routson LB, Seaborn GB, et al. An in vitro evaluation of condoms as barriers to a small virus. Sex Transm Dis. 1997;24:161-164.

45.  Lytle CD, Routson LB. Lack of latex porosity: A review of virus barrier tests. J Rubb Res. 1999;2:29-39.

46.  Macaluso M, Kelaghan J, Artz L, et al. Mechanical failure of the latex condom in a cohort of women at high STD risk. Sex Transm Dis. 1999;26:450-458.

47.  Mann JR, Stine CC, Vessey J. The role of disease-specific infectivity and number of disease exposures on the long-term effectiveness of the latex condom. Sex Transm Dis. 2002;29:344-349.

48.  Mead PB, Hager WD, eds.  Infection Protocols for Obstetrics and Gynecology. Montvale, NJ: Contemporary OB/GYN; 1992:152.

49.  Messiah A, Dart T, Spencer BE, et al. Condom breakage and slippage during heterosexual intercourse: A French national survey. Am J Public Health. 1997;87:421-424.

50.  Michael RT, Gagnon JH, Laumann EO, Kolata G.  Sex in America: A Definitive Study. Boston, MA: Little Brown and Company; 1994.

51.  Myers T. Condom use and attitudes among heterosexual college students. Can J Public Health. 1994;85:53-55.

52.  National Institutes of Health Consensus Development Conference Statement Cervical Cancer, April 1-3, 1996. In press 10/10/96 and released Spring of 1997:6.

53.  Nelson KE, Celentano DD, Eiumtrakol S, et al. Changes in sexual behavior and decline in HIV infection among young men in Thailand. NEJM. 1996;335:297-303.

54.  Paz-Bailey G, Koumans E, Pierce A, et al. Condom protection against STD: A study among adolescents attending a primary care clinic in Atlanta. Abstract BO9D, 2002 National STD Prevention Conference, San Diego, CA, March 4-7, 2002. Available at: http://www.stdconference.org/

55.  Peyton CL, Gravitt PE, Hunt WC, et al. Determinants of genital human papillomavirus detection in a US Population. J Infect Dis. 2001;83:1554-1564.

56.  Platt R, Rice PS, McCormack WM. Risk of acquiring gonorrhea and prevalence of abnormal adnexal findings among women recently exposed to gonorrhea. JAMA. 1983;250:3205-3209.

57.  Plummer FA, D’Costa LJ, Nsanze H, Dylewski J, Karasira P, Ronald AR. Epidemiology of chancroid and Haemophilus ducreyi in Nairobi, Kenya. Lancet. 1983;2:1293-1295.

58.  Roddy RE, Zekeng L, Ryan KA, Tamoufe U, Tweedy KG. Effect of Nonoxynol-9 gel on urogenital gonorrhea and chlamydial infection. JAMA. 2002;287:1117-1122.

59.  Roumeliotou A, Papautsakis G, Kallinikos G, Papaevangelou G. Effectiveness of condom use in preventing HIV infection in prostitutes. Lancet. 1988;2:1249.

60.  Royce RA, Sena A, Cates W, Cohen MS, et al. Sexual transmission of HIV. NEJM. 1997;336:1072-1078.

61.  Saracco A, Musicco M, Nicolosi A, et al. Man-to-woman sexual transmission of HIV: Longitudinal study of 343 steady partners of infected men. Journal of Acquired Immune Deficiency Syndromes. 1993;6:497-502.

62.  Schwartz MA, Lafferty WE, Hughes JP, Handsfield HH. Risk factors for urethritis in heterosexual men. The role of fellatio and other sexual practices. Sex Transm Dis. 1997;24:449-455.

63.  Sonenstein FL, Stryker J. Why some men don’t use condoms: Male attitudes about condoms and other contraceptives. Henry J. Kaiser Family Foundation. 1997:4.

64.  Sonenstein FL, Ku L, Lindberg LD, Turner CF, Pleck JH. Changes in sexual behavior and condom use among teenaged males: 1988 to 1995. Am J Public Health. 1998;88:956-959.

65.  Thin RN, Williams IA, Nicol CS. Direct and delayed methods of immunofluorescent diagnosis of gonorrhea in women. Br J Vener Dis. 1970;47:27-30.

66.  Turner CF, Rogers SM, Miller HB, et al. Untreated gonoccoccal and chlamydial infection in a probability sample of adults. JAMA. 2002;287:726-733.

67.  Vessey M, Lawless M, Yeates D. Efficacy of different contraceptive methods. Lancet. 1982;841-842.

68.  Vessey MP, Villard-Mackintosh L, McPherson K, Yeates D. Factors influencing use-effectiveness of the condom. British Journal of Family Planning. 1988;14: 40-43.

69.  Wald A, Langengerg A, Kexel E, Izu AE, Ashley R, Corey, L. Condoms protect men and women against Herpes Simplex Virus Type 2 (HSV-2 Acquisition). Abstract B09E, 2002 National STD Prevention Conference, San Diego, CA, March 4-7, 2002. Available at http://www.stdconference.org/

70.  Wald A, Langengerg AG, Link K, et al. Effect of condoms on reducing the transmission of herpes simplex virus type 2 from men to women. JAMA. 2001;285:3100-3106.

71.  Warner L, Clay-Warner J, Boles J, Williamson J. Assessing condom use practices. Sex Transm Dis. 1998;25:273-277.

72.  Workshop Summary: Scientific Evidence on Condom Effectiveness for Sexually Transmitted Disease (STD) Prevention. July 20, 2001. National Institute of Allergy and Infectious Diseases, National Institutes of Health, Department of Health and Human Services. Available at: http://www.niaid.nih.gov/dmid/stds/condomreport.pdf

73.  Workshop Summary: Scientific Evidence on Condom Effectiveness for Sexually Transmitted Disease (STD) Prevention. July 20, 2001. National Institute of Allergy and Infectious Diseases, National Institutes of Health, Department of Health and Human Services. Cassette tapes of the June 12-13, 2000 conference can be obtained from Audio Transcripts, Ltd., 3660-B Wheeler Avenue, Alexandria, Virginia, 22304, Conference #1561.(703/370-8273, 800/-338-2111). The “Open Discussion” tape is tape #13 or 13-1561.

74.  Zenilman JM, Weisman CS, Rompalo AM, et al. Condom use to prevent incident STDs: The validity of self-reported condom use. Sex Transm Dis. 1995;22:15-21.