Interview with Dr Kevin M. De Cock
Can you tell me about the WHO position on condoms for the prevention of HIV transmission?
WHO is a public health organization and its responsibility is to give advice about public health based on the best scientific evidence. The evidence around the use of male condoms to prevent HIV transmission is that latex condoms if used consistently and correctly are highly effective in preventing the transmission of HIV. They are not the only important prevention strategy but they are an important component of comprehensive prevention efforts worldwide in association with other interventions as well. Importantly, there is no scientific evidence that promoting the correct and consistent use of condoms has led to alterations in sexual behaviour or increased risk taking.
Can you give me some specific examples of where the use of condoms has been particularly successful?
Let me describe the sorts of scientific evidence that is gathered and then also give some programmatic experience. The best information on the effectiveness of condoms comes from looking at large numbers of couples where one person is infected and the other is not, and following those over time, and comparing the rates of transmission of infection in those groups - comparing high condom users and people who did not use condoms. Such studies - and there have been a fair number of them, and they have all been put together and analysed collectively - such studies suggest that condoms are at least 80% and possibly more effective in reducing the transmission of HIV for co-habiting couples. And there are a number of other types of analytic approaches, comparing rates of infection in people who say they have used condoms with irregular partners compared to those who don't. The body of evidence is conclusive. We are very confident that WHO recommendations are based on good scientific information.
There is also a lot of programmatic experience and some countries, some cities have had programmes that have had really quite remarkable effects. The best known country is probably Thailand, that in the 1990s led a programme to very strongly promote correct and consistent condom use in sex workers and their clients. There was a major reduction not only in HIV transmission, but also in other sexually transmitted infections. But there have been other very successful sex-worker programmes in different parts of the world, in Kinshasa, in the Democratic Republic of Congo in the 1980s, in Côte d'Ivoire in the 1990s, in Nairobi, and in groups where we knew that the rates of infection were very very high and as condom uptake increased, rates of transmission declined substantially. There is also a whole body of evidence from men who have sex with men, where in the 1980s early in the epidemic, condom promotion was extremely important and contributed to that initial reduction of transmission. So we are on good scientific and programmatic grounds.
What other factors do we need to consider for the prevention of HIV/AIDS? Is using condoms really enough?
No, absolutely not. Condoms are an important component of a comprehensive prevention programme but only one component of what today we refer to as combination prevention. I think other factors that are important are reducing numbers of sex partners, abstinence is an important strategy for certain age groups, for children and young adolescents perhaps and for those who choose it, some choose that method of protection.
But there are additional prevention approaches; testing and counselling so that one knows one's HIV status and that of one's regular sex partner. The control of other sexually transmitted infections, particularly in high-risk groups such as sex workers and men who have sex with men is important. In heterosexual epidemics, male circumcision protects against the acquisition of HIV in men in those who are circumcised.
There are a number of other technologies that are coming along. The two I want to mention are microbicides and antiretroviral drugs. Microbicides are compounds used by women, applied in the vagina, usually prior to sex, and such products are now being studied and actually the first successful result has just been achieved. I would predict that in the future we will be hearing more about microbicides. And then antiretroviral drugs themselves have preventive benefit either in HIV-infected people taking the drugs, lowering the amount of virus so that they become less infectious themselves or use of drugs by HIV-negative people taking before they are exposed to HIV. But all of those approaches - therapy, pre-exposure prophylaxis with antiretroviral drugs and microbicides - are under study and are not yet WHO recommendations, but these are emerging areas to watch.
Can we talk a little bit about the global situation and the number of cases. Are they growing or are they falling?
The number of people living with HIV continues to increase. In 2007 there were an estimated 2.7 million new HIV infections and about 2 million deaths. We estimated that at the end of 2007 there were about 33 million people living with HIV. Although the epidemic has stabilized in that the rate of new infections seems to have levelled off, this remains probably the leading challenge in global health. We have as a global community done relatively well scaling up therapy, we estimated at the end of 2007 that there were some 3 million people receiving antiretroviral drugs in low- and middle-income countries, and that represented a coverage of about 31% of those who needed those medicines. But that means that over two thirds in danger of their lives needing these drugs were not accessing the therapy and, as I said, even though the rate of new infections has levelled off, the absolute number of people living with HIV continues to increase. The emergency of HIV/AIDS is by no means over, even if we have managed to blunt some of it with some of our interventions.
What would be the final WHO message regarding the use of condoms?
That the correct and consistent use of male latex condoms is an integral part of a comprehensive prevention programme. This is one very important element of a number of interventions that countries need to make available for the prevention of HIV transmission.