Peter W. Plumley, an independent consulting actuary, is a Fellow of the Society of Actuaries and a member of the American Academy of Actuaries. He has had six papers published in the Transactions of the Society of Actuaries, including "Modeling the AIDS Epidemic by Analysis of Sexual and Intravenous Drug Behavior" (1989) and "An Actuarial Analysis of the AIDS Epidemic as it Affects Heterosexuals" (1992). He also has had three articles on AIDS published in Contingencies, the Journal of the American Academy of Actuaries. These are "AIDS - Is the Prognosis for the Future Really so Dire?" (1990), "Has the AIDS Epidemic Peaked?" (1991), and "The Magic of Risk - The Risk of Magic" (1992).
Mr. Plumley is Chairperson of the Society of Actuaries Non-Insurance HIV/AIDS Task Force and is a member of the Society of Actuaries Committee on HIV/AIDS (which deals with insurance-related AIDS is- sues). He served on the Board of Governors of the Society of Actuaries from 1981-1984.
"Always wear a condom!!" "Safe sex for all!"
How often have we heard this? Plenty - that's how often. Now that Bill Clinton is in the White House, condoms have replaced abstinence as the centerpiece of "AIDS prevention" efforts for heterosexuals. They are handed out in schools, in some cases to children who are too young to even care about matters sexual. Any talk show dealing with sex emphasizes the need to practice "safe sex". Those who claim to use condoms get applauded; those who don't get booed.
These "AIDS prevention" warnings are based on the assumption that AIDS is caused by the human immunodeficiency virus, known as "HIV", and therefore to control the AIDS epidemic we must prevent the transmission of HIV.
Later we'll discuss whether HIV really does cause AIDS by itself, or requires some cofactor, or even is unrelated to AIDS. However, for the moment, let's assume that HIV infection is bad for you, and then analyze whether these "safe sex" warnings are desirable for those who make up the great majority of the American public - the heterosexuals who are not into the drug culture .From a public health point of view, does "condomania" make sense for the average American?
Condoms and hard hats
Do you wear a hard hat all the time? No, of course not. Neither does anyone else. Yes, construction workers do while at work, and so do others such as football and hockey players, some motorcyclists and bicyclists, and people who are engaged in work or play where there is a special risk of injury to the head.
But how many hard hats do you see on the heads of people walking down Main Street or riding in a car? Few, if any. Is this because there is no risk at all of getting hit on the head? Not at all. Many people have been hurt or killed from head injuries that would have been prevented if they had worn a hard hat while going about their daily activities.
Then why doesn't everyone wear a hard hat all day long? The answer is simple. It's because (1) for most people the risk of a head injury is very small, and (2) a hard hat is inconvenient and uncomfortable to wear. So unless you are a construction worker or an athlete, you probably are willing to take this small risk in order to avoid the inconvenience and discomfort.
What about condoms? Isn't it possible that the failure to use a condom could cause you to become infected with a sexually transmitted disease ("STD")? Certainly - we've known that for years!
And what about the dreaded HIV? That's supposed to spread sexually, too. Yet we know that the majority of men are not using condoms, in spite of all the "safe sex" messages. Why aren't they? Are they foolhardy and irresponsible? Or are condoms like hard hats - awkward and uncomfortable to wear, and designed to prevent a risk too small to be of concern for most people?
Who is really at risk of getting HIV?
A recent study of the sexual lifestyles of Americans titled "Sex in America" confirms that, not only is HIV infection currently confined largely to such "high-risk" groups as homosexual men, drug users, and their sexual partners and children, but also that it will stay that way. In other words,HIV will not spread generally into the heterosexual population through sexual contact.
There are two reasons for this. First, according to the study there isn't that much sexual contact between those in the drug community and the rest of the heterosexual population. But another, more important reason, is that, unlike other sexually transmitted diseases, HIV is extremely difficult to transmit sexually, particularly from a female to a male. It can be mathematically demonstrated that the more difficult it is to transmit an STD, the greater the proportion of such transmissions occur between primary, regular, and possibly monogamous partners, rather than between those involved with "one night stands". Because HIV is so difficult to transmit heterosexually, HIV infections that are caused by heterosexual contact usually arise from a regular, long term sexual relationship with an IV drug user. (Occasionally, though, an individual has an unusual susceptibility to HIV infection, perhaps because of genital sores or lesions from some other STD).
As a result, while other, more easily transmitted, STDs go from a man to a woman to a man to a woman, etc. by sexual contact, HIV typically goes from an IV drug user to his regular sexual partner, and no further.
What about homosexual men? Are they all at high risk for HIV infection? Not really. Typically, HIV is confined to a relatively small subset of homosexual men. Those at risk usually have engaged in repeated (and frequently drug induced) anal sexual practices which have put them at risk for a variety of diseases, which in turn make it easy for HIV to be transmitted. But it is not all homosexual men that are at risk - only a specific subset of them.
So while there is a significant risk of HIV infection for many of those in the "high risk" groups, the typical healthy heterosexual who is not involved with the drug community has virtually no risk.
Will urging the use of condoms reduce the spread of HIV? If so, is the right population being targeted? We have seen that the "politically correct" position is to urge everyone to use a condom, every time sex takes place.
But, wait a minute - if that really happened (and the condoms always worked properly), wouldn't the human race eventually die out because no more babies would be conceived? Of course it would. So let's say that we don't need to use condoms when having sex with our primary partner; however, if we have multiple partners, then we should pull out the condom.
Nice idea, and one which might help reduce the spread of some of the more easily transmitted STDs. But it won't do much for the reduction of HIV transmission, because as we have seen, HIV is so difficult to transmit sexually that HIV infection usually requires a regular, long term sexual relationship with an HIV infected partner, not just a one night stand. (Furthermore, contrary to popular belief, the risk of HIV infection does not increase with the number of sexual partners.)
So we are faced with a dilemma. If we are able to get everyone to use condoms all the time, we eventually wipe out the human race. (Now that will stop the spread of AIDS!) On the other hand, if we concentrate only on those who are engaging in sex with secondary partners, very few HIV transmissions will be prevented.
Fortunately, the dilemma solves itself. The extreme difficulty with which HIV transmits by heterosexual intercourse also is the reason that most HIV transmissions are drug related, involving either sharing needles or anal sex not vaginal sex. These easily identifiable groups are and continue to by the correct target groups for both HIV infection and prevention. Even if every heterosexual used a condom all of the time, only a very small percentage of new HIV infections would be prevented.
Therefore, assuming HIV infection to be a matter of concern, the place to look for significant ways to reduce its spread is not by "condomania" for heterosexuals, but by focusing in on the real, significant risk groups.
Who is really at risk for AIDS?
Up to this point, we've been assuming that HIV is the cause of AIDS. However, in the last few years, an increasing number of respected scientists have come to the conclusion that the relationship of HIV to AIDS is far more complicated than simply that "HIV causes AIDS". Some of these people, such as Dr. Peter Duesberg, one of the world's leading authorities on retroviruses such as HIV, believe that HIV is a harmless virus that has nothing to do with AIDS. Others, such as Dr. Robert Root-Bernstein, author of the book Rethinking AIDS, believe that HIV is related to AIDS in some way, but that it requires some immune system damaging "co-factor" to be harmful.
Analysis of this issue is complicated by several factors. One is that AIDS is not a disease - it is a syndrome consisting of a number of diseases which have been around for years, but have become much more prevalent in recent years. The conventional theory is that this increase has occurred because of the spread of the virus known as "HIV". However, others believe that it is the result of other causes such as the dramatic increase in recreational drug use, drug-driven anal sex and its associated diseases and treatments, and other immune suppressing activities.
A second problem is that the definition of "AIDS" has been expanded several times, most recently in 1993. It is a complicated definition, which in most (but not all!) cases requires that the person test positive for HIV. As a result, when developing AIDS statistics, people with these diseases who are HIV-positive are diagnosed with "AIDS", while those who test HIV-negative are simply diagnosed as having the underlying disease (which may not even have to be reported to the local health department). Naturally there is a high correlation between HIV and AIDS!
While we don't know all the answers, we do know that in virtually every case in which "AIDS" has been diagnosed, there is some provable and identifiable risk factor present (besides HIV) which would tend to damage the immune system. In his book, Dr. Root-Bernstein gives a lengthy list of drugs and other conditions which are known to damage the immune system. These include not only IV drugs, but also non-IV "recreational" drugs such as crack, "poppers", etc., as well as certain prescription drugs such as AZT, and even some of the stronger drugs prescribed for the treatment of some sexually transmitted diseases (and which are frequently taken in large quantities by those infected with such diseases). It also includes immune system abnormalities such as hemophilia.
These provable and identifiable risk factors have been known for years to cause immune system deficiencies, for both homosexuals and heterosexuals. So regardless of whether or not HIV "causes" AIDS, it is clear that the people who really are at significant risk for developing potentially fatal diseases related to immune system deficiencies - whether these diseases are called "AIDS" or something else - are those who in one way or another have damaged immune systems.
These are the people who need attention and education, if a significant number of lives are to be saved. Urging the use of condoms will not have a significant impact on the prevention of AIDS, because condoms do not affect the root causes of immune deficiency problems.
AIDS and young people
We frequently hear about the "exploding" AIDS epidemic among our young people. This is used as a compelling reason for passing out condoms in the public schools. Yet the government's own data indicates to the contrary.
The total number of AIDS cases reported to the Centers for Disease Control in 1990 for ages 13-24 was 1796. In 1991, the number was 1633 - a decrease of 163, or 9%. In 1992, the number decreased further, to 1605. Not exactly an "exploding" epidemic. (A comparison with 1993 data is meaningless because of the expanded definition of AIDS which took effect on January 1, 1993.) Furthermore, as with all age groups, the majority of these cases were attributed to high risk homosexual sex or IV drug use. And the majority of those attributed to heterosexual contact involved sexual contact with drug users. For ages 13-24, deaths from AIDS are less than 2% of the total deaths for those ages - and most of this 2% are drug-related. So when young people compare the risks of getting AIDS from heterosexual contact with the other, much greater, hazards they face in their daily lives - guns, auto accidents, drugs, etc. - it is no wonder that so many of them pay little attention to "safe sex" warnings. Once again, the solution is not condoms, but education about other STDs and the dangers of drug use - but even more important, solving the other,more serious problems facing our youth. (Dave's note: Later data for 1995 and mid 1996 continues to show the clear almost insignificnt risk for healthy heterosexuals that don't do drugs. See our other AIDS articles and CDC data).
The dangers of "condomania"
Public health authorities have mounted a massive campaign to urge the use of condoms to prevent the spread of AIDS. However, as we have just seen, "safe sex" campaigns for heterosexuals are destined to fail as a significant AIDS prevention method. But are they doing any harm? After all, considering the number of illegitimate births, isn't it a good idea to try to scare young people into using condoms, and thereby reduce the number of teenage pregnancies?
Some may think so, but this writer disagrees. We are telling everyone that "Unprotected sex means HIV infection", and "HIV infection means certain death". In the process we are terrorizing the entire population about a virus of questionable pathogenicity and about a disease that significantly affects only certain specific and easily identifiable groups.
Does terrorizing the population do harm? You bet it does! Think what is happening here. It is one thing to tell our daughters not to get pregnant until they are married and ready for children. But we are teaching our children (and everyone else) that "intimacy means death". In the process, we are interfering with one of the most basic human desires - that of sexual intimacy - by telling millions of people, most of whom have little or no risk of HIV infection, that sex may kill them unless they "protect" themselves from a partner who may be carrying a deadly, and transmittable, virus. We are telling them that they may die a horrible death unless they intrude on the lovemaking process by using some artificial means to prevent their body fluids from intermingling, even though for many that is an important part of the sexual experience.
Unfortunately, while most people understand that hard hats aren't worth the bother when walking down Main Street, few understand how difficult it is to get infected with HIV from sexual intercourse. A survey conducted in 1987 by the National Center for Health Statistics indicated that 97% of those surveyed believed that unprotected sex with someone with AIDS was either "very likely" or "quite likely" to result in HIV infection. Only 3% understood that it really was highly unlikely, because the HIV is so difficult to transmit in that manner.
One must wonder how many millions live in constant fear of a disease they will never get, and how much harm this fear is doing to their lives. On two occasions this author has talked with women who expressed their reluctance to develop relationships with men because of their fear of AIDS. On both occasions, they were chain smoking as they talked - a habit ten thousand times as dangerous as the sexual contact that they feared. One has to wonder how many others have destroyed their health from some unhealthy habit that they might have been able to break if they had felt free to seek out the comfort of a loving relationship with someone.
Today our nation is terrorized by violence. Most of this violence has nothing to do with AIDS. However, for years many prisons have allowed conjugal visits in order to reduce the stress, and resulting violence, among prisoners. If sex can reduce violence, doesn't it follow that lack of sex will increase violence? How many of the acts of violence in today's society are in some way related to stress caused by the lack of a good sexual relationship due to an unwarranted fear of AIDS?
And finally, consider what "AIDS paranoia" in general has done. Today we have a population which not only has become fearful of sex, but of almost any other type of contact with someone with who has tested HIV antibody positive. A 1990 report by the American Civil Liberties Union documented 13,000 complaints of AIDS-related discrimination. Laws have been passed to prevent some of this discrimination, but these laws cannot correct public attitudes - only better public education can do that, through a reduction in "AIDS paranoia".
Unfortunately, "condomania" is doing just the opposite.
So, should anyone bother with condoms?
It is clear that not everyone needs to use a condom, any more than we all should wear hard hats. But should anyone use a condom? Certainly, just as some people should use hard hats.
Condoms can be used to reduce the risk of unwanted pregnancy, if no other method of birth control is being used.
Condoms should be used by homosexual men when engaging in anal sex, particularly if many partners are involved, to prevent the transmission of STDs.
Condoms should be used by heterosexuals for the prevention of other STDs when one's sexual partner is at increased risk for such diseases. For example, they should be used when one's partner has a history of STDs, or has some current symptoms, such as lesions, sores, or genital warts, or is particularly suseptible to exposure to STDs (such as might be the case with a street prostitute). But in many cases, if your concern about sexually transmitted disease is so great that you feel the need to use a condom, you probably shouldn't be in the bedroom in the first place! (Would you feel safe walking through a bad neighborhood, just because you were wearing a hard hat to protect yourself from a rap on the head by a mugger?)
Is there a better way?
When articles such as this one suggest that condoms aren't always needed, someone is always quick to condemn the writer as "irresponsible" and "risking the lives of others".
However, the same statement could be made about an article urging any activity involving even the smallest risk - boating, riding in a car, skiing, etc. Yet those articles don't get criticized. Why not? Because we all recognize that we must take some small risks in order to enjoy life's pleasures.
The same is true for sexual pleasure. A good sexual relationship is a normal and healthy part of human existence. However, such relationships nearly always involve small risks of some sort, even if only emotional. So while sexual responsibility is important, paranoia about such "one-in-a- million" risks where common sense should be sufficient protection can destroy the pleasure that nature intended.
If "condomania" isn't the answer, is there a better way to be safe from AIDS?
The good news is that there is.
We know that persons testing HIV-positive from sexual contact nearly always either have a long term relationship with someone who is HIV-positive, or have some STD or involvement with drugs which makes him or her unusually susceptible to HIV infection.
We also know that the vast majority of AIDS cases continue to be associated with substance abusers, both homosexual and heterosexual, and their regular sexual partners (most of whom are also substance abusers).
So a sensible way to avoid getting AIDS is not "condomania". Instead, it is to keep your own body healthy and not infected with any other sexually transmitted disease (recognize the symptoms, and get prompt treatment, if you get one), and to avoid street drugs and those who use them. In other words, avoid the various activities which have always caused damage to the immune system.
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