Condom efficacy in gay men

What about condoms’ efficacy against HIV in sex between men? Remarkably, despite gay men being the first and still the largest at-risk population in the developed world, and themselves largely responsible for the ‘safer sex’ movement, there has been no similar meta-analysis of the extent to which using condoms actually prevents HIV infection in gay men. This may be because the majority of HIV transmission amongst gay men occurs in casual sex situations, where the HIV serostatus of partners cannot be assessed, and so the degree of HIV exposure risk cannot be ascertained.

The only data we have relating HIV incidence among gay men to condom use come from retrospective studies of gay men diagnosed with HIV who were asked about their condom use. In a 2006 study,¹ gay men diagnosed with HIV in the main HIV clinic in Seattle were asked about whether they had consistently used condoms and also whether they had tried to ‘serosort’, i.e. restricted unprotected sex to men they knew or were sure were HIV-negative. The rate of new HIV diagnosis among men who attempted always to use condoms was 1.5%, among patients who had unprotected sex but tried only to do it with same-status partners was 2.6%, and among men who had unprotected sex regardless was 4.1%. Adjusting for the number of partners (though not for their HIV status), attempted consistent condom use was 76% effective in preventing new HIV infections. This is a retrospective epidemiological study with nothing like the same degree of rigour as the studies of HIV serodiscordant couples, but it does yield an estimate of condom efficacy at least similar to the lower figures in Weller and Davis² and Pinkerton.³

There have been plenty of studies of condom failure (breakages, slipping off, etc.) in gay men. For instance, a Dutch study⁴ of 671 gay men, one-third of them HIV-positive, found that the overall failure rate during male-to-male anal sex was 3.7%. There was a lower failure rate for 'anal condoms' (extra-strong condoms, 3.1%) than for standard 'vaginal condoms' (4.6%). The failure rate with the use of water-based lubricants was 1.7% vs 10.3% for oil-based lubricants. The failure rate was 5.9% for use with no lubricants or saliva only.

However at the Thirteenth International AIDS Conference in Durban, a team of researchers from London's City University^{5 6} presented data from a study of 283 gay male couples who had been randomised to use either standard or thicker condoms for anal sex and additional water-based lubricant. Each couple was provided with nine condoms and completed a questionnaire after each sexual act.

The researchers found that condoms broke for the same reasons as previously identified in studies among heterosexual couples; unrolling the condom before fitting it to the penis, longer duration of intercourse (longer than 45 minutes), and absence of additional lubricant. Use of additional inappropriate lubricant, (oil-based or saliva) was also associated with condom breakage. Penis length was also associated with condom breakage, yet girth was not.

The study found no significant differences between the two types of condoms with respect to breakage or slippage. Condoms were more likely to slip if lubricant was placed on the penis under the condom. A low incidence of breakage was reported for both condom types during appropriate use.

In order to use standard condoms most effectively, the researchers recommended that gay men be reminded of the following:

• unroll the condom after fitting it to the penis.
• use additional lubricant.
• apply the lubricant to the outside of the condom only.
• apply the lubricant in and around the anus.       

The findings of this study called into question the long-standing UK recommendation that gay men should use extra-strong or thicker condoms wherever possible. The researchers proposed that gay men should be advised to use Kitemarked condoms, and noted that inexperience in the use of condoms and use of inappropriate lubricants were far more important factors in explaining condom failure.

Based on the study, gay men’s health charity GMFA launched a mass-media campaign which said that standard-strength condoms are just as reliable for anal sex as extra-strength ones, and other agencies such as HIV charity Terrence Higgins Trust stopped recommending the use of extra-strong condoms. However, not everybody involved in UK HIV prevention agreed, including Camden and Islington's HIV and Sexual Health Promotion Service which continued to recommend extra-strong condoms.

Around the world, the UK had been almost unique in recommending extra-strong condoms to gay men, with HIV prevention agencies in both the USA and Australia happy to say that it is okay for gay men to use standard-strength condoms for anal sex. Only Germany and the Netherlands shared the UK's insistence on extra-strong condoms.