[Question #850] Condom effectiveness

53 months ago
Hi there.  I'm concerned about condom effectiveness, particularly manufacturing defects.  In terms of quality control, it is acceptable if less than 4 out of 1000 pass the 'water test'.  But surely this means about 1 out of 500 condoms fail the water test.  Is a condom that fails the water test also ineffective at preventing HIV from being transmitted during sex?

About 3 weeks ago, I had protected oral and vaginal sex with an escort in a brothel.  It was a fairly upmarket establishment. The condom did not break or slip.  Normally I would consider this to  be a no risk event for HIV.  However, after reading about condom manufacturing defects, I'm not so sure anymore. Can someone who uses condoms consistently and correctly still be at risk of contracting HIV?

Last week, I started developing flu-like symptoms. A sore throat, coughing mucus, night sweats, mild fever (99), and headache. My reoccurring cold sore on my lip flared up as well.  But I haven't had a rash or aching muscles and joints. The sore throat and headache have diminishing after a week. But the fever has gotten worse (100.8). And the night sweats are worse too. I'm still coughing a lot, but with only a little but of mucus.  Should I be worried about these symptoms? Could these be ARS?

Thank you in anticipation of your reply.
Edward W. Hook M.D.
Edward W. Hook M.D.
53 months ago

Welcome to the Forum. Condoms have been studied extensively and, when used correctly as you describe. are the most effective means of preventing STI (including HIV) infection from an infected sex partner.  Admittedly, no preventative measure is perfect and in scientific studies of condoms for STI (including HIV) prevention there are typically a tiny proportion of infections which occur despite reported condom use.  However, there are no scientific studies which evaluate the effectiveness of condoms which would fail a "water test" (and I am not aware that condoms are tested this way- most manufactures use inflation with air to test condoms, not water).  Despite that , I would urge you to not worry that your current flu-like illness is the ARS.  The reasons I say this include:

1.  Most commercial sex workers do not have HIV or other STIs, particularly in "higher end" brothels (bad for business).

2.  Even if your partner did have HIV infection (in the U.S. rates would be expected to be less than 1% in CSWs and probably lower in the place you went to), since HIV is transmitted on average once per 1-2000 unprotected sex acts, if the condom had not been worn and your partner had HIV, your risk of infection would be 1 in 100,000.  Using your 1 in 500 figure (I disagree with your estimate but am providing the numbers to point out that even if you are right, there is virtually no chance that you are infected), if the condom did allow HIV to pass as though there was no condom present, the likelihood of HIV now falls to 1 in 5 million.  I would anticipate that a condom with the sort of tiny leak you describe would provide at least partial protection.  You are about a thousand times more likely to be struck by lightening that to get HIV as you describe.

3.  When at risk persons with flu-like illnesses are tested for HIV (I do not consider you to be at risk), fewer than 1% turn out to have HIV.

For all of these reason and statistics provided, I am confident that your current flu-like illness is the ARS.  If my explanations are not sufficient to resolve your anxiety, then you could test with a 4th generation combination HIV antigen/antibody test.  If your symptoms are due to HIV, it will be positive.  Personally, I do not think you need testing at all.

I hope these comments are helpful.  EWH

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53 months ago

Dear Dr Hook, Thank you for your detailed reply. During the day when my flu-like symptoms fade, I readily accept that my anxiety is not well founded. But during the middle of the night, when I wake up soaking wet, I'm less confident.

 

I have been regularly tested for HIV and other STDs, and the results have always been negative. The last time I was tested was a bit over a year ago. So, I'm planning to be tested again soon. But at present, I feel too unwell to drive to the clinic.

 

I have been a follower of your and Dr HHH's writing on Medhelp and this website for some time. I recall Dr HHH ruling out ARS for someone who had a cough with phlegm. I also read the NY health department 2015 guidelines for diagnosing ARS, and a cough was not mentioned at all. Is that your position as well - that a cough indicates garden variety cold/flu?

 

I've been coughing a lot at night, but I'm not coughing up much phlegm /mucous anymore. I've had a bad headache when I wake up each morning, and my temperature is spiking at 102 in the early hours. The night sweats are quite bad. But I don't feel as though this is the worst flu I've ever did, and I feel okay during the day. Is this pattern of symptoms inconsistent with ARS?

 

Lastly, have you ever seen a patient or heard from another doctor of a patient that is genuinely perplexed by an HIV positive diagnosis, i.e. the patient is certain that condoms were always used correctly (no slips, no breaks)? I'm wondering if manufacturing defects are likely to be so rare that no one has acquired HIV that way, or if they are a bit like the lottery in that a few people each year beat the odds.

 

I hope my questions are not too repetitive. Thank you for your time.


 

Edward W. Hook M.D.
Edward W. Hook M.D.
53 months ago

Correct cough and other respiratory symptoms are not a part of the ARS and suggest some other, non-HIV, non-STI process.  Fever and night sweats are non-specific findings and could be due to any of a number of causes.  Further, at this time, you are outside of the time when it would be typical to develop the ARS. 

In general, when condoms fail it is quite obvious and no the sort of "micro-leak" that you suggest.  As I mentioned above, there are occasional, very rare persons who maintain that they used condoms correctly and consistently without breaks but still get HIV but this is so rare as to be almost unquantifiable.  further, when this happens, there is always the issue of whether the person might have failed to use the condom or experienced a break but was unwilling or unable to mention it.  Personally, I think your concerns about condom failures are misplaced and I cam confident that your current symptoms are not due to HIV.  EWH

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53 months ago
Hi Dr Hook. Thanks for your advise.  I've just had a 4th generation combination HIV antigen/antibody test at a sexual health clinic and the result is negative, as you anticipated.  I'm feeling much relieved.  I had also been to my doctor about my cold/flu symptoms and he wasn't too concerned, although he did mention getting blood tests for HIV and TB if the symptoms didn't get better within 2 weeks.  I think my cold/flu is slowly getting better, but the coughing and night sweats are still persisting. I will go back to my doctor if I don't fully recover soon. I suspect that anxiety about HIV has exasperated my cold/flu.  I don't have any further questions, but just thought I should follow up so that this threat can be closed off.  Many thanks for the good work you do.   
Edward W. Hook M.D.
Edward W. Hook M.D.
53 months ago
Thank you for the follow-up.  Congratulations on your continuing commitment to condom use, it will keep you safe.  Take care.  EWH
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