Design, measurement, and analytical considerations for testing hypotheses relative to condom effectiveness against non-viral STIs
- R Crosby1,
- R J DiClemente1,2,
- D R Holtgrave1,
- G M Wingood1
- 1Rollins School of Public Health, Department of Behavioral Sciences and Health Education, and Emory Center for AIDS Research, Atlanta, Georgia, USA
- 2Emory University School of Medicine, Department of Pediatrics, Division of Infectious Diseases, Epidemiology, and Immunology and Department of Medicine (Infectious Diseases), Atlanta, Georgia, USA
- Correspondence to: Richard Crosby, PhD, Rollins School of Public Health of Emory University, Department of Behavioral Sciences and Health Education, 1518 Clifton Road, NE, Room 542, Atlanta, GA 30322, USA; rcrosby{at}sph.emory.edu
Recently, the US Department of Health and Human Services (DHHS) issued a report on a workshop that synthesised evidence regarding the effectiveness of latex condoms for the prevention of sexually transmitted infections (STIs).1 The report cited evidence that condoms are effective in preventing HIV transmission and female to male transmission of gonorrhoea, but stated that empirical evidence was insufficient to evaluate the degree of risk reduction provided by condoms with regard to chlamydia, syphilis, chancroid, trichomoniasis, genital herpes, and human papillomavirus. One important implication of the report is that there is a need for further research on condom effectiveness. As the report noted, “to definitively answer the remaining questions about condom effectiveness for preventing STD infections will require well designed and ethically sound clinical studies.”1
Besides the research perspective, from an applied public health perspective, intensified efforts to test condom effectiveness are urgently needed. Firstly, the DHHS report may have eroded public confidence in an otherwise widely recommended method of STI prevention (see Centers for Disease Control and Prevention, 1996 for public recommendations2). In addition, if confidence in the effectiveness of condoms declines among health professionals and other policy makers, then their efforts to promote condom use also may wane. Consequently, people at risk of STI infection may be less likely to adopt or sustain condom use as a STI prevention strategy.
Given the in vitro evidence that intact latex condoms are virtually impermeable to even the smallest of STI pathogens,3–5 the present lack of in vivo evidence supporting condom effectiveness against many STIs should not be counted as evidence that condoms are ineffective. Numerous, complex challenges are inherent in the design and analysis of in vivo tests of condom effectiveness.
In this editorial, we describe selected key issues that should be addressed and resolved …
