Safe Sex

There are reputable houses - like Nevada or La Yegua in Mexico, where the girls are checked by a doctor each week and given an HIV test. They also require that the women visually check each client and always use a condom and lubricant. The odds of catching something under these circumstances are pretty low - even if the rubber should break.

But when you search out women who ALLOW unprotected sex and then HAVE unprotected sex with them, you are swimming in the deep end of the pool. The "window" of exposure scares me along with the 1 in 25 odds of a false negative. And certainly the odds of having some other infection not tested for is much higher. To me, finding providers who have little chance of HIV is more important. Supposedly, the HIV rate in Nevada brothels is near zero and much lower than the population at large.

Combining the test and a condom would be as safe as possible, but kind of defeats the whole idea . . .

Prokofiev:

Thank you for your response. Here are my comments on some of the points you raised.

[i]
>The odds of catching HIV or Herpes with a provider using a condom is an unknown number. [/i]

I am only using the [b]relative[/b] odds (with versus without condoms), and that is a known number (see the NIH report).

[i]
>It is almost totally dependent upon the rubber breaking[/i]

No, it is not. Read the report. If you believe that your assessment of the effectiveness of condoms is better than that of the NIH study, I cannot help you.

[i]
>But when you search out women who ALLOW unprotected sex and then HAVE unprotected
>sex with them, you are swimming in the deep end of the pool.[/i]

You got it backwards. I am not searching out women who allow unprotected sex. I am searching out women who allow being tested. I am not having unprotected sex. I am having uncovered sex with a provider who tested negative, which is safer than having covered sex with a provider who was not tested.

[i]
>The "window" of exposure scares me along with the 1 in 25 odds of a false negative.[/i]

I wanted to be objective rather than emotional, and that's why I took the trouble to calculate the bottom line. The bottom line is that, [b]all things considered[/b], the testing scenario is safer than the covering scenario.

[i]
>2) Whether your provider is going to allow you to administer medical tests in a bar
>or hotel room.
>3) Whether your provider is going to let you have sex with her without a condom no
>matter WHAT tests you give her and yourself. How does she know that you don't have
>HIV? How does she know if your testing is real or bogus? Maybe in Thailand but most
>professional professionals I know in the US or Mexico want it covered.[/i]

These practical points are well taken, and need to be addressed. I believe it can be done, but this is just an opinion, not a data-based calculation like the safety issue. For example, I am fairly confident that a provider will accept testing and uncovered sex after you "hit it off" with her the first time (covered), and propose to stay with her for a few days. Anyway, I will be happy to discuss it and will benefit from the different opinions.

[i]
>Combining the test and a condom would be as safe as possible, but kind of defeats the whole idea[/i]

This is definitely a valid approach, but I agree with you that it is not likely to happen.

[QUOTE]Originally posted by joe_zop
[i]Personally, I find the bottom line to be this -- three times safer is still substantially lower than the degree of safety you get using condoms.
You want to combine testing with condoms and you're safer still, but one missed per 25 or one missed per 250 is still pretty lousy when you consider the potential consequences.
[/i][/QUOTE]
Just to be sure there is no confusion, it is three times safer [b]than using condoms[/b].

Again, I agree that if you consider the down side, you will be scared even if the odds are small. Objectively, this would be an argument for abstinence :( . Condoms are certainly safer than bareback (when no testing is involved), but one needs to realize that it is only seven times safer. That is, seven covered encounters carry the risk of one uncovered encounter.

If you are not going to use testing, by all means use condoms without fail. What I am reporting is that [i]testing and bareback[/i] is safer than [i]no testing and condom[/i].

Ah, sorry, I misread the statement as being uncovered. Mea culpa on that; needed to drink my coffee before wading in. Have done so now :)

That said, months back I read the entire NIH review cited in your link, and I disagree that it conclusively shows a one in seven rate. In fact, this review stated that the vast majority of the studies out there were so poorly constructed that it was basically impossible to draw any decent scientific conclusions on condom effectiveness, period. It should be kept in mind that this was not a study, but a two-day literature review panel attempting to answer the following: “What is the scientific evidence of the effectiveness of latex male condom-use to prevent STD transmission?” What the panel actually concluded is that most studies looking at the issue were not designed using the optimal method to assess that effectiveness. That 85% decrease rate was simply not a hard and fast number, most certainly not one that was consistent across studies, so drawing probability conclusions from it is rather dicey.

To quote from the study’s executive summary, “The Panel stressed that the absence of definitive conclusions reflected inadequacies of the evidence available and should not be interpreted as proof of the adequacy or inadequacy of the condom to reduce the risk of STDs other than HIV transmission in men and women and gonorrhea in men. To definitively answer the remaining questions about condom effectiveness for preventing STD infections will require well-designed and ethically sound clinical studies.” So basically, the report concludes that it [i]can[/i] conclude only that condoms reduce rates for HIV and gonorrhea, but not much beyond that. Again (as I actually had an argument on this point with someone, which is why I say it) this doesn't say that condoms don't do wonderful things with STDs -- only that the evidence is insufficient to make scientifically airtight statements in most cases.

This report also very specificially (and unusually, for such a report, which I think makes it significant) cautions that it is not intended to make public health policy recommendations regarding the role of condoms in HIV/STD prevention policy and programs, which is rather similar to what you're trying to use it to do here.

In addition, it should be noted that these newly available tests only claim to screen for HIV-1, not HIV-2, so effectiveness of the test will vary somewhat depending on who you're dealing with and where they're from. Admittedly, HIV-2 is less prevalent in most parts of the world and appears to be less easily transmitted, but that's not necessarily much comfort if you guess wrong. I sure wouldn't want to be use your approach in Africa, that's for sure.

So I find it inaccurate to say, "seven covered encounters carry the risk of one uncovered encounter" particularly if you're coming up with a number that looks at transmission rates between those who are regular condom users and those who are not. It's very much worth noting that a number of the cited studies hedged their bets on those who were infected who said they were regular condom users, in some cases openly doubting the veracity of the reporting.

Don't misunderstand me -- I am a full believer that screening tests work -- I worked in a Red Cross blood bank when HIV testing was first introduced, and part of my job was tracking blood and reasons why donors were screened out. There's no question such testing essentially cleaned up the blood supply. But I'm not particularly comfortable with making a risk analysis that depends on a figure come up with using "meta-analysis of several studies," comparing it to concrete FDA and industry test results, and then using that as a recommendation for behavior. And that's not even dealing with the fact, as has been brought up here repeatedly, that there are practical problems with your scenario in real life.

joe_zop

Many thanks for your detailed and informed post (coffee seems to work well for you :) ). I am glad you took the time to go through the NIH report, and I will comment on your observations.

[quote][i]
That said, months back I read the entire NIH review cited in your link, and I disagree that it conclusively shows a one in seven rate. In fact, this review stated that the vast majority of the studies out there were so poorly constructed that it was basically impossible to draw any decent scientific conclusions on condom effectiveness, period.[/quote][/i]
The inconclusive part was about STDs other than HIV (as you correctly state later in your post). The 85% figure about HIV is conclusive.

[quote][i]
That 85% decrease rate was simply not a hard and fast number, most certainly not one that was consistent across studies, so drawing probability conclusions from it is rather dicey.[/i][/quote]
What the panel did is use established statistical methods to fit the studies it found reliable. If the fit was not good enough, it was considered inconclusive (which happened in the case of other STDs). The fit to the 85% figure was statistically reliable in the case of HIV, as the panel concluded.

[quote][i]
To quote from the study's executive summary, 'The Panel stressed that the absence of definitive conclusions reflected inadequacies of the evidence available and should not be interpreted as proof of the adequacy or inadequacy of the condom to reduce the risk of STDs other than HIV transmission in men and women and gonorrhea in men. To definitively answer the remaining questions about condom effectiveness for preventing STD infections will require well-designed and ethically sound clinical studies.' So basically, the report concludes that it [i]can[/i] conclude only that condoms reduce rates for HIV and gonorrhea, but not much beyond that.[/i][/quote]
Hear, hear. HIV is the main infection that test kits are concerned with, and as you say, the study does establish the 85% figure in the case of HIV. I extrapolated to herpes-2 (generously, I think, as herpes-2 can be transmitted through areas outside the condom), but I am all ears if people have other information.

[quote][i]
Again (as I actually had an argument on this point with someone, which is why I say it) this doesn't say that condoms don't do wonderful things with STDs -- only that the evidence is insufficient to make scientifically airtight statements in most cases.[/i][/quote]
My point. So the 85% for HIV, which the panel found the evidence sufficient for, is by implication a "scientifically airtight statement"

[quote][i]
This report also very specificially (and unusually, for such a report, which I think makes it significant) cautions that it is not intended to make public health policy recommendations regarding the role of condoms in HIV/STD prevention policy and programs, which is rather similar to what you're trying to use it to do here.[/i][/quote]
Me? public health policy? I'll take this as a compliment :) . Let me repeat what I said in a previous post about the public health issue. It is completely legitimate, even prudent, for public health officials to advocate condoms vigorously even if their effectiveness was just 50%, let alone 85%. We are talking about saving lives, dangers to sociaty, and enormous expenses, using a cheap, simple, and universally recognized tool. If I were a health official, I would not advocate test kits since I need to worry about teen agers who can barely afford a pizza and about morons who may try to fit the test kit on their penis. I wouldn't even publicize the 85% number in order not to discourage the use of condoms. Well, I am not a public health official and I am addressing a constituency of sophisticated traveled adults like yourself who can read the literature and draw their own conclusions.

[quote][i]
In addition, it should be noted that these newly available tests only claim to screen for HIV-1, not HIV-2, so effectiveness of the test will vary somewhat depending on who you're dealing with and where they're from. Admittedly, HIV-2 is less prevalent in most parts of the world and appears to be less easily transmitted, but that's not necessarily much comfort if you guess wrong. I sure wouldn't want to be use your approach in Africa, that's for sure.
[/i][/quote]
The companies sought FDA approval for HIV-1 only (marketing in the US where HIV-2 is very rare), but MedMira Reveal (the 3-minute kit) works for both HIV-1 and HIV-2 (see the comprehensive reference on test kits in a previous post of mine).

[quote][i]
Don't misunderstand me -- I am a full believer that screening tests work -- I worked in a Red Cross blood bank when HIV testing was first introduced, and part of my job was tracking blood and reasons why donors were screened out. There's no question such testing essentially cleaned up the blood supply. But I'm not particularly comfortable with making a risk analysis that depends on a figure come up with using "meta-analysis of several studies," comparing it to concrete FDA and industry test results, and then using that as a recommendation for behavior. [/i][/quote]
I am glad you have a technically related background. Let me just mention that (1) I trust NIH more than the industry as NIH is a research entity with no biased agenda, and (2) [b]I am not making any recommendation for behaviour[/b]. Just giving information and opinions that adults can read and draw their own conclusions.

[quote][i]
And that's not even dealing with the fact, as has been brought up here repeatedly, that there are practical problems with your scenario in real life. [/i][/QUOTE]
I keep saying this is a valid point worth discussing, but it is a separate issue from the safety. I plan to get into it after the current discussion winds down.

Thanks again, joe_zip.

Ok, since we've gotten into this I went back and actually read the NIH thing again to refresh my memory. I pulled the quotes I used previously from an old newspaper letter exchange I had with someone who was using the study to argue against teaching condom usage in schools -- a position that this particular report has often been used to bolster, unfortunately, which is why I read it in the first place. (I don't do the editorial letter thing a lot, but the letter writer pissed me off with her right-wing christian crapola, and it bugged me to have a corrective study used to distort things.) Hence my comment about the public policy health issue, as the truth is that what we're talking about here -- with adults who presumably can read and follow research, but who also, based on postings in various places on this board, are sometimes folks who go bareback without any testing at all -- is a policy of how to approach mongering with some degree of safety and confidence. So this really rather [i]is[/i] a policy discussion in a public place, even if it's not public policy.

I see that the 85% figure is in the review, but I also see that the NIH simply evaluated the meta-analysis done by someone else as opposed to did one themselves, so they do not really provide that 85% reduction rate -- they simply find it's the level they can confidently say is credible, and let's keep in mind that the purpose of this literature review was to basically throw cold water on everything except what could be said for certain (and to call for more studies!) So they've taken the worst-case number here. According to Planned Parenthood's summation of the same study (Davis & Weller, 1999, which I've tried without success to track down on the net) the "meta-analysis of 25 studies on HIV transmission and condoms found that efficacy rates ranged from 87 percent to 96 percent against HIV infection." That's a little different story, isn't it? It's why I say it's not a hard and fast number -- it's scientifically airtight to the degree that the literature review can say for certainty that it's [i]at least[/i] that rate -- it may actually be higher. So the disparity between testing and condoms may well not be what you're describing.

The other problem I see is this -- even if you're testing someone for HIV and Herpes, you're not testing them for a host of other bad things such as gonorrhea, syph, chlamydia, trichomoniasis, any of the various strains of hepatitis, etc. So if you're going bareback with the idea that after you've tested them and they've come up negative you're reasonably safe you're still rolling the dice, since many of these other goodies are far more prevalent than HIV. The test you screen for assures you that they don't have that particular gremlin -- not others. And as the NIH report makes clear, just because there's not sufficient scientific evidence to be conclusive doesn't mean that condoms don't work on these other things. My take is still that a condom is the best overall protection for a monger, even if the test is moderately more effective on a single disease or two. (Not to mention the condom is far cheaper and more likely to reassure your temporary partner.)

joe_zop

Points well taken. I am not treating the one in seven as cast in stone, but it is the best scientific estimate available. That's what we have. The conclusion is that test kits are three times safer than condoms. That's our best objective estimate at this point.

Anything that goes against the [i]status quo[/i] causes discomfort, and test kits are no exception. Most people have come to terms with condoms, and they don't like to rock the boat. Some may decide that even with the x3 benefit of test kits, they will continue to use condoms only. Some may choose otherwise.

As for the other diseases, please notice that a lot of people on this board do DFK, BBBJ, and/or DATY quite regularly. For them, the reward justifies the risk, whether this is wise or not. Their highest priority is not to catch HIV or herpes, and it is not the end of the world if they risk catching another curable disease.

Having said that, there is a correlation between having different STDs, and one may argue that a provider who passes both your tests is safer for other STDs than an untested provider. One may even argue that the self selection will make providers who know or suspect they have STDs not agree to testing, hence get eliminated. All of this is argumentative. The only fact is the safety level of test kits versus condoms for HIV and herpes. What to do with that is for individuals to decide.

Sabio,
I too reread that study or rather the review of other studies and it repeatedly warns about inadequate data and methods. The Davis and Weller part specificly states that all 12 studies they used had replied upon self-reporting of condom usage and breakage. It would be difficult to do otherwise. And the 85% is a summary estimate. The part that addresses the risk of condom breakage and leakage shows very low numbers for risk of infection due to breakage namely 1 in 167 for breakage infection, 1 in 125,000 for non-visable defect leakage and 1 in 250,000 for non-leakage transfer of a virus. The conclusion: mechanically, condoms are VERY effective in stopping a virus. So how do you get from 99.4% to 85% effective? Not addressed. But logically not all of the "always use" were always using. Not surprising. Also drug use or other transmission routes are possible. Your statement that the NIH would have thought about and addressed these concerns is only partly true. They mentioned many possible flaws -especially self-reporting, but didn't design any of the studies. But to the panel the summary of those studies that were usable proved that condoms are at least 85% effective against HIV and they consider it a positive outcome. With better designed studies the number could be much higher but not any lower.

And the overall theme of the report is that condom usage is highly effective and that even these flawed studies made this apparent. I think these scientists would be horrified to learn that you are taking the 85% effective conclusion as a hard and negative fact and then using it to calculate that non-condom usage with a prostitute could be justified.

Yet I don't really argue with your conclusion that testing a woman, staying with her exclusively for a period of time, first with condom usage and later without is dangerous compared to the alternatives, especially if the time period is more than a couple of days. Just not very practical . . .

I'm a newbie, be gentle. Where can I get OraQuick?

Prokofiev

Thank you for your commentary.

[quote][i] But to the panel the summary of those studies that were usable proved that condoms are at least 85% effective against HIV and they consider it a positive outcome. With better designed studies the number could be much higher but not any lower.
[/i][/quote]
Please point out the page of the report in which the qualification [b]at least[/b] is mentioned in connection with the 85% figure, and also the part where it mentions that with better designed studies the number could be much higher but not any lower.

[QUOTE][i] I think these scientists would be horrified to learn that you are taking the 85% effective conclusion as a hard and negative fact and then using it to calculate that non-condom usage with a prostitute could be justified.
[/i][/QUOTE]
I never said that. Non-condom use with a prostitute is one of the riskiest behaviours a person can engage in. The subject of my posts is [b]testing[/b]. Imagine if I told you for a fact that the provider you are about to sleep with has AIDS. Would you sleep with her, even with a condom, or would you try someone else? That's what testing allows you to do.

Here's where "at least" enters.
You have a group of "always use" that are self-reporting, a flaw pointed out repeatedly in the study. They can't report more than 100%. But it could be 95%, 90% or less, depending on the participants. Therefore the 85% effective number which is predicated on 100% usage would be higher depending on the true number. And since the real number of infections are very small - just a couple of HIV infections that resulted from lying could make a huge difference. But it can't be lower since virtually every posibility(lying, slipage, breakage, drugs, homosexual activity) would make it higher. I suppose the "never use" group could also be lying and actually use condoms, making their infection rate artifically low . . . but I doubt it.

You also ignore the calculated .006 infection risk number (=1 in 167) for condom usage including breakage (which they say can be as high as 3.2%). How do you go from 1 in 167 to 1 in 7 actual? What is the mechanism? Do you really believe that 7 covered exposures (especially without breaking) equals 1 unprotected exposure? When they calculate exposure without breakage is more like 1 in 125,000? That's crazy.

You seem to want that 1 in 7 number so badly that you refuse to consider any other possibility. But I'm NOT against testing. That is clearly a good idea . . .

Prokofiev

Well, we are about to fill a page of the safe sex section in 24 hours, which should be a record for this section of the board :)

I perfectly understand that the one in seven figure puzzles you. It puzzled me, too. I bought into it because of the credibility of the NIH. If there was an agenda to be had, it would be in favor of getting a bigger number than seven to support public health policy.

I found numbers that are even less than seven on the web, but I didn't "want" them as they came from non-credible sources (for example religious organizations with an obvious agenda).

Perhaps it will make things a bit easier to swallow if you look at the pregnancy numbers. If condoms are used [b]consistently and correctly[/b], they reduce pregnancy by a factor between one in ten and one in twenty. Do you agree that a sperm is bigger than a virus? What is the "mechanism" for it to reach the egg if condoms are as astronomically effective as you project them to be?

Here is another test, more like a lottery but isn´t odds for you anyway? Nice read on stats and info as well, that is if you "get lucky". Would be interesting to see others results.

http://www.ministryofsound.com/music/radio/
Click on the scratch off lottery banner on the left.

Oops, here is a better link for the STD lottery. Seems that the other link always comes up with chlamydia and a 1:1 chance would be too odd and scary!

http://www.playingsafely.co.uk/games/sex_lottery.asp

hysteromania

I'll take your posts as a break to loosen up in the middle of a serious discussion :) .

Of course, all of us are playing the STD lottery except those who choose abstinence. What makes one game of lottery safer than another is ........, you guessed it, the PROBABILITY of catching a particular STD.

Whether you will be lucky or unlucky is beyond your control. What is under your control is choosing a method that has better odds. That's why I am comparing the odds of different methods.

Good luck ;) .