For the past 15 years one of the cornerstones of gay men’s HIV prevention in the UK has been the recommendation to use extra-strong condoms for anal sex.
However, this view is not universally shared. Around the world, the UK is 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’s okay for gay men to use standard strength condoms for anal sex. Only Germany and the Netherlands share the UK's insistence on extra-strong condoms.
HIV agencies in the UK are now starting to question the advice that extra-strong is best, not least because research conducted in 1999-2000, using a sample of almost 300 gay couples, found that standard strength condoms are no more likely to ‘fail’ during anal sex than extra-strong condoms.
Based on this research GMFA (Gay Men Fighting AIDS) is planning a mass media campaign which says that standard strength condoms are just as reliable for anal sex as extra-strength ones.
But, not everybody involved in UK HIV prevention agrees, most notably and vocally, Mark Maguire of Camden and Islington gay men’s team, who insists that there’s not enough evidence showing the reliability of standard strength condoms for anal sex. This means that gay men in the UK will be offered conflicting advice on condoms by two equally well respected HIV prevention agencies, which in theory, should cooperate to ensure the coordination of gay men’s HIV and sexual health education across London.
In early June the two sides came head-to-head to discuss the issues at a debate at the University of London Union. At the core of the discussion was the reliability of the research undertaken by a team the City University in London which was published in the journal AIDS in 2001, and which found no difference in the reliability of standard and extra-strong condoms when used by gay men for anal sex.
The researchers recruited 283 gay male couples who were split into two groups; one was given extra-strong condoms and the other standard condoms. They were asked to complete a questionnaire describing their use of the condoms and whether or not the condom split. The study showed that the failure rate of extra-strong condoms was 2.5% compared to 2.3% for standard strength condoms, leading the study authors to conclude that ‘our findings suggest that gay men no longer need to be encouraged to buy, or be provided with extra-strong condoms, as failure rates did not differ between the two different types of condoms.’
At the debate Richard Harding, on of the study’s authors, stood by his research, adding that in the majority of cases condom failure was the result of slippage rather than breakage.
No clear basis for the advice, say new generation of health promoters
His research findings were backed by Alan Hildon of Basildon Primary Care Trust, who presented a literature review which showed that in recommending extra-strong condoms for gay men to use for anal sex, the British are, as in so many other things, eccentric.
"Few other countries offering HIV prevention advice to gay men highlight the need to use extra-strong condoms for anal sex," he said. "What’s more, there was never any data from properly conducted studies to show that extra-strong condoms are any safer than standard strength condoms for anal sex."
The advice to use them was based on "the plausible assumption that thick equalled safer, when in fact the thickness of the rubber in extra-strong condoms may make them more rigid and reduce flexibility, a risk factor for breakage". Nor, Hildon argued, is there any evidence that anal sex does put more strain on condoms than vaginal sex. The belief that the `hostile anus` would cause greater wear and tear on a condom may have been an issue in the issuing of the advice, Hildon added.
It is perhaps worth recalling that UK government backed advice about the effectiveness of condoms at preventing the transmission of HIV and other sexually transmitted infections, carried the caveat that no UK condom brand was designed or tested for anal sex, with the implication that even if a condom was used correctly with a water based lubricant anal sex still wasn’t safer sex.
Commenting after the debate, Edward King, author of Safety in Numbers, the influential history of debates on gay men's HIV prevention, noted that a 1987 study in the Netherlands using an extra-strong condom and a historical comparison with breakage rates in vaginal sex had probably been influential in influencing advice in the UK. "As late as 1987 the Terrence Higgins Trust's Policy Group was still spilt over whether the Trust could recommend anal sex with condoms in any circumstances" he said.
NAM's International Editor Julian Meldrum, who wrote the first regular column on AIDS between 1984 and 1986 for the London weekly Capital Gay, said "I think the existence of extra-strong condoms drove their adoption, at a time when companies were very nervous of the liability issues involved in recommending standard condoms, and there was no commitment to obtaining evidence".
In defence of the status quo
Whilst acknowledging that the City University team had produced a good piece of research, Mark Maguire did not believe that it provided a firm enough foundation for the advice on extra strong condoms to be changed. Hence the decision of the Camden and Islington gay men’s team to produce the booklet, Condoms: everything a gay man needs to know, with the traditional advice about extra-strong condoms included. Maguire argues that the City University trial merely demonstrated that normal strength condoms were equally safe for anal sex when used by gay couples who had sexual experience of one another. The results of the trial would not necessarily be applicable to casual sexual encounters, particularly in public or semi-public environments. He noted however, that standard HIV prevention advice has always been to use a standard strength condom if a stronger condom was unavailable, under the principle that any condom is better than no condom at all. He therefore stood by the existing advice.
Supporters of the current stance on extra-strong condoms also quote epidemiological data. The UK has a much lower rate of HIV prevalence amongst gay men than, for instance, the USA, which has never recommended stronger condoms for gay anal sex. However, there may be other historical reasons for this, not least that the epidemic went undetected for longer in the USA. In addition, US gay men had a much more developed commercial sex scene offering more opportunities for multiple sexual contacts between gay men than the UK in the early years of the HIV epidemic.
The argument about prevalence rates is further undermined when Australia is considered. With only 15,000 cases of diagnosed HIV, Australia is regarded as an HIV prevention success. Indeed when the UK government first announced that it was to have a national HIV strategy Australia was held up as a model to follow. But Australia has never recommended extra-strong condoms to gay men.
The united front of HIV prevention agencies in the UK capital on the type of condoms to use for anal sex is going to be broken with GMFA and Camden and Islington gay men's team offering conflicting advice. Will it matter to UK gay men? Or will it simply reflect what gay men are doing already, two years after the reseacrh was first publicised, assuming that they’re not one of the estimated 40% of UK gay men who will have unprotected anal sex this year.
Golombok et al. An evaluation of thicker versus a standard condom with gay men. AIDS 115: 245-250, 2001.