[Question #7075] HIV Heterosexual Transmission Risk with Condoms only 70-80%?
61 months ago
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I am a man in a committed relationship with my girlfriend. We have agreed to the occassional extra-marital sex act for each of us, provided it is safe and doesn't compromise our own love/sex lives. I have sex with escorts and other women, perhaps 1-3 times a year. I have protected vaginal intercourse with latex condoms and unprotected oral sex. I have yearly STD tests. My last 4th gen HIV test as of a few days ago was negative. I got myself tested in a bit of a panic having just read the following papers below:
Giannou FK, Tsiara CG, Nikolopoulos GK, et al. Condom effectiveness in reducing heterosexual HIV transmission: a systematic review and meta-analysis of studies on HIV serodiscordant couples. Expert Rev Pharmacoecon Outcomes Res. 2016;16(4):489-499.
Giannou FK, Tsiara CG, Nikolopoulos GK, et al. Condom effectiveness in reducing heterosexual HIV transmission: a systematic review and meta-analysis of studies on HIV serodiscordant couples. Expert Rev Pharmacoecon Outcomes Res. 2016;16(4):489-499.
Weller S, Davis K. Condom effectiveness in reducing heterosexual HIV transmission. Cochrane Database Syst Rev. 2001;(3):CD003255
I was surprised that the efficacy of condoms was so low. Of course big speculative questions here about condom failure and use before sex act was commenced, plus these seem like high risk populations but it did make me wonder about whether I was doing everything possible to reduce the risk however small.
I have two questions:
- What are your comments re: these papers and their applicability to my situation?
- Would the use of Truvada or PEP be recommended in my situation given my intolerance of even a small risk of transmission?
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H. Hunter Handsfield, MD
61 months ago
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Welcome to the forum. Thanks for your confidence in our services.
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Studies of efficacy of condoms -- indeed almost any safety device -- generally evaluate what is called "use effectiveness", i.e. the effectiveness in day to day use as reported by people who employ them. Use-effectiveness is what was evaluated in the published studies you cite. This is very different than biological effectiveness, which is similar to how well they work with guaranteed proper use on any single occasion. Anallysis of use effectiveness incorporates imperfections of human behavior: the studies are based on persons' statements about condom use, recall of proper vs improper use, and so on, i.e. "real world" efficacy. In pregnancy prevention, couples who use condoms as their only form of contraceptions have pretty high rates of pregnancy compared with hormonal contraception, even though the biological efficacy of condoms in preventing conception is nearly 100%. Same deal for HIV and other STDs. The responsible bacteria and viruses cannot transit intact latex or polyurethane; even natural membrane condoms are virtually 100% effective as barriers, despite theoretical concerns about sizes of pores in such membranes. But condoms sometimes break; sometimes are not properly used; and recall of improper vs proper use is imperfect.
The term "escort" usually implies an expensive female sex worker by appointment, as contrasted with, say, street or brothel workers, bar pick-ups, etc. Such women typically are believed to be at low risk for STDs in general and HIV in particular. They care about their health, select their clients with care (typically men at low risk themselves -- men like you), use condoms, and get tested frequently. In the US and other industrialized countries, probably fewer than 1 in a thousand such women have HIV. With careful condom use, your HIV risk with such partners is far too low, in general, to warrant PEP. If you're in an geographic location where HIV is known to be especially prevalent, or if you experience obvious condom failure, PEP might be warranted, however.
Having said all that, I would strongly recommend that both your and your regular girlfriend -- who presumably may be having her own sexual encounters outside your relationship -- be tested from time to time for HIV and other STDs, especially chlamydia, gonorrhea and syphilis, maybe about once a year. I would do this even if all your extra-regular encounters were condom protected and seemingly safe.
I hope these comments are helpful. Let me know if anything isn't clear.
HHH, MD
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