The Almighty Condom: Defeater of HPV?

“Condoms Found to Block a Virus Harmful to Women,” headlines the New York Times article about a study on condoms and HPV (human papilloma virus) published today in the New England Journal of Medicine. In many circles, the study is being touted as a boon for proponents of condom-based sex education and a setback for abstinence education supporters. A closer look at the study, however, reveals that the tired old message of “Use condoms” is hardly an advisable strategy for HPV prevention. Among the study’s findings:

The incidence of genital HPV infection was 37.8 per 100 patient-years at risk among women whose partners used condoms for all instances of intercourse during the eight months before testing, as compared with 89.3 per 100 patient-years at risk in women whose partners used condoms less than 5 percent of the time (adjusted hazard ratio, 0.3; 95 percent confidence interval, 0.1 to 0.6, adjusted for the number of new partners and the number of previous partners of the male partner).

Read that alarmingly high 100% condom use failure rate again in light of the New York Times headline. The study itself uses considerably less stronger language:

Conclusions Among newly sexually active women, consistent condom use by their partners appears to reduce the risk of cervical and vulvovaginal HPV infection [emphasis added].

The uncritical NYT article went on to say:

The study “provided a very clear answer” to the question of the protective benefits of condoms and papillomavirus infection, said Dr. [James] Allen of the American Social Health Association.

Earlier, the article quoted Dr. Allen as saying, “The findings are definitive.” Apparently the reporter saw no need to ask Dr. Allen any follow-up questions. ‘Tis a pity, especially considering these caveats from the study’s authors:

Some limitations of the study should be noted. First, it is difficult to determine the optimal time frame for an assessment of risk factors for acquiring HPV infection. In retrospect, the 20-day lag period was relevant not only because it was the shortest observed interval between first intercourse and the detection of HPV infection in this study but also because it is within the range of time estimated for epithelial cells to mature and differentiate, cellular events that are required for HPV replication. Although an eight-month period was used because the majority of first infections associated with a first partner occurred within this time frame, not all partners are infectious, a partner’s infectivity may change, and infection could have occurred at any time within the eight-month period. If infection occurred early, for example, condom use for intercourse reported later in the interval would be unrelated to HPV status, and the true effect of condoms might be diluted. Furthermore, incomplete reporting could have created a misclassification of the frequency of condom use, although such an effect probably would have been minimal, given the small percentage of days with missing data regarding sexual behavior. Incomplete follow-up and delayed or missed clinical visits were other potential sources of bias. For example, outcomes of short duration could be missed with less frequent follow-up, potentially leading to underestimates of the cumulative incidences of infection and lesions. However, when we compared women with average visit intervals of less than four months with those with intervals of four months or more, we observed similar rates of HPV infection (P=0.43). In a comparison of women who were eventually lost to follow-up with those who were not, similar rates of HPV infection were observed during the study (P=0.56). Finally, although the newly sexually active women in our cohort reported a yearly median number of instances of intercourse (48) and a yearly median number of new partners (1) that were similar to those reported in a large national survey of a random sample of women of a similar age, our results may not be generalizable to populations of older women or women of lower socioeconomic status [emphasis added].

The study’s authors went on to note:

Given that HPV is transmissible through nonpenetrative sexual contact with both male and female partners and that imperfect condom use does occur, it is not surprising that some infections were still detected among women reporting consistent use.

Ay, there’s the rub. Human nature being what it is, not only does imperfect condom use occur, but surely it’s the norm–especially among teens. The more pertinent question is: Does “perfect condom use” occur? My guess is rarely, if ever. But these minor details weren’t considered by liberal bloggers who treated the news of the study as a death blow to abstinence education advocates. At The Stranger, Dan Savage writes:

The religious f***tards opposed the recently-approved HPV vaccine because it removes one scary threat from their scare-based abstinence education programs: a highly contagious STI, for which there was no effective treatment, no cure, and which leads, in a small percentage of cases, to cervical cancer, sterility and death. Well, guess what? So do condoms… The same cracked, misogynist logic that prompted the religious f***tards to oppose the HPV vaccine should prompt them to oppose the availability of condoms. They want sex—casual or not—to always and everywhere have the direst of consequences, from pregnancy to death, for both men and women, but especially for women.

In a post titled “Condoms Block HPV”, Jill at Feministe writes :

This a great news. Of course, condoms don’t prevent HPV 100% of the time because HPV is transmitted through skin-to-skin contact, and there are obviously some areas of the body where HPV might be present which aren’t covered by a condom during sex. But they’re damn effective if used correctly and consistently. Further, internal (or “female”) condoms cover a greater external area of the vulva, and might be a good option, especially if you know that your partner is infected [emphasis added].

Russian roulette, anyone? Anyone? At Feministing, Samhita noted the study’s limited scope, but couldn’t help reverting to a familiar mantra:

Of course I just noticed that it says *newly* active sexual partners. Oh well. But you should use condoms anyway.

I guess old habits die hard. ***UPDATE 6/30/06, 11:10am: Additional parsing of the study from an Illinois Right to Life Committee e-mail sent by IRLC executive director Bill Beckman:

Additional Concerns about the condom usage / HPV study After reviewing the June 22, 2006 New England Journal of Medicine article covering the study on condom effectiveness in preventing HPV, I find that the study appears to have serious problems. The key to my concerns is revealed in Table 1. That table presents the HPV infection rate based on various “risk factors”. As would be expected, the risk of infection goes up for women who have multiple sex partners or whose partners had previous or other sex partners. The same 122 cases of infection are also analyzed at various rates of condom usage. Since there is no evidence of exclusion from the results of women who only had sex with one partner, who only had sex with them, these guaranteed successes (no risk of infection) are included in the results with the reduced infections attributed to condom usage. This situation could help explain why the infection rate is greater for 5-49% condom users than for under 5% condom users; namely, it just depends on what percentage of the no risk couples fall into which category of condom usage. If this conclusion about the study is correct, it seems the claimed results of 70% reduction in risk with 100% condom usage become totally bogus. The IRLC press release above pointed out that 12 out of 42 women (28.5%) still got infected even with 100% condom usage, but these additional considerations make the study’s misrepresentation of condum protection that much worse. I would also note that the study must have had participants who knew the purpose of the study, so that knowledge would seem to give them higher motivation to ensure use of a condom than in normal life. Even with that factor, only about 25% achieved 100% condom usage. Beyond that distortion, there was no attempt or ability to validate the accuracy of the journal reports filed by the women or provide any blind or double-blind protection to prevent participant or research bias from further distorting the study results.

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