Condoms and HIV in adolescents:a medical assessment

Raul Alessandri, M. D., Zelig Friedman, M. D., Liliana Trivelli, M.D.
Linacre Quarterly 1994 (August); 61: 62-74.
Dr. Alessandri has been a pathologist at Long Beach Memorial Hospital since 1986. Dr. Friedman, an allergist, is also an orthodox rabbi. Dr. Trivelli is Inspector of the American Blood Bank association .
English translation: Antonio Pardo.

I. Mechanical failure of the condom
II. Failure attributable to Username
III. Condoms for Protection Against HIV Seroconversion
IV. Sexually Transmitted Diseases (STDs)
V. Education sexual contraceptives and sexual activity
VI. Alternatives to condoms/ Education HIV sexual
VII. Conclusion
Notes

The widely publicised sexual revolution, as with many issues, has involved unexpected strata of society: neglected young people have become sexually active at younger and younger ages, with a cohort of promiscuity, sexually transmitted diseases, ectopic pregnancies and exponentially increasing issue pregnancies and children born out of wedlock, growing up in an environment full of psycho-affective deprivation. To this we have to add the risk that HIV/AIDS may become very prevalent in this group, despite the political decision that AIDS is not a sexually transmitted disease.

Condoms, virtually shelved as effective contraceptives because of their high failure rate, reduced pleasure and employment unpleasantness, have been resurrected and chosen as a means of "safer sex" to protect our young people from this epidemic.

There are major flaws in this approach which, with a little honesty and goodwill, does not claim to be "the '100%' solution, just the best we can offer to those who will become sexually active". Not only is it no solution at all, but it can actually multiply the problem. Dr. Noble, an infectious disease specialist, puts it this way: "submit condoms to adolescents is like giving them water pistols for a general fire alarm"1.

Mechanical failure of the condom 

A) It is well known that condoms break and slip, even in the best of hands, so to speak. There are two recent controlled programs of study by Trussel et al. that report breakage and slippage frequencies of 14.6%. In the first study, the authors summary: "A prospective study using two brands of condoms found that, of 405 condoms used for sexual intercourse, 7.9% either broke during intercourse or upon withdrawal, or slipped off during intercourse; neither of these events is related to the condom subject . 7.2% slipped on withdrawal; no relationship was found between condom slippage and condom brand or previous condom use, but it was significantly higher when any additional lubricant was used"2. In the second study, a commentary in the journal Family Planning Perspectives,b reads: "The researchers note that the high frequency of condom slippage and fall off upon removal - 17% of condoms that had not broken or fallen off during intercourse - indicates a high level of inappropriate use. They indicate that a better employment may be difficult to achieve, as all women who participated had received written and verbal instructions on proper employment "3.

B) FDA Quality Controlc. In the spring of 1987, the FDA began using a water loss test , in which "the condom is filled with 300 ml of water and checked for leakage" .... "They are accepted as having an acceptable level of quality when, in any given batch, the water permeation failure rate does not exceed 4 condoms per 1000. Batches that exceed this specific rejection criterion are withdrawn or excluded from sale. Among batches of condoms that had an acceptable quality level, the observed failure rate was 2.3/1000". In the February 1988 study there was an overall failure rate for all batches of 12%, and there were 16 rejections of defective condoms4. Relatively recent rejections include "Ramses Extra Strength" (March 1991) due to "unacceptable number of holes and ring cracks"5, "Saxon Wet Lubricated" (May 1991) for failing FDA quality control6, and another large rejection was cited by The New York Times in November 1991.

The test of permeation has shown that latex is not impermeable to human immunodeficiency virus (HIV) particles7 . Latex surgical gloves, necessary for infection control, are often permeable: it is not uncommon to find blood on hands, and the solution internship is to wear two pairs of gloves. This technique does not appear to be internship acceptable with condoms.

C) Anal sex. Despite our concern about the issue, we are not aware of condoms for anal sex being widely available. Manufacturers may be reluctant to advertise such products. "Because of the increased friction during anal intercourse, condoms need to be stronger than normal," says a study on condom safety and acceptability by gay men. The safer (thicker) the condom, the lower its acceptability8. And the failure rate in anal sex is much higher than in vaginal sex because, for anatomical and physiological reasons, the rectum and vagina are not homologous. Given the figures provided by the AIDS Section of the New York City Health department , because of the subject and mode of transmission, anal sex is particularly dangerous among young people: before the age of 30, it involves infection at an early age. In December 1992, there were 4587 AIDS cases in men in New York. The probable mode of transmission had been determined in 4,352 cases. Of these, 2687 had sex with men in risk groups, 261 had used intravenous drugs and had sex with men, and 2 had sex with women in risk groups. The problem is quite different in women: . issue of the total number of cases under 29 years of age was 1454, of which 1298 had good information, and of these, 511, almost 40%, had had sex with men in risk groups9. It is important to look at these figures, because it seems that the reported increase in "heterosexual AIDS" is basically a women's problem. The figures are not as extreme in the data collected by the CDCd, but there is a clear and huge difference between the risk posed by heterosexual sex for women and men.

Failure attributable to Username 

It has been reported that the failure of condoms used as contraceptives in the adolescent population can be as high as 50%10. While it is true that a very high percentage of these failures are due to non-use, we must acknowledge that there are numerous scientific publications that state that Education sexual/HIV has consistently failed to bring about significant changes in adolescent behaviour, especially in terms of behaviour that reduces the risk of transmission11 12 13 14 15 16.

The data are well summarized by A. R. Shiffman, who states the following: "The knowledge about AIDS or HIV infection and prevention was not associated with any change in risk behaviors, nor was it associated with issue of sources of information about the epidemic, nor with knowledge direct contact with infected patients, nor with estimation of risk staff, nor with committee undergoing an HIV test test . In fact, the young people whose risk behaviours increased the most were those who were most likely to know someone who had died of AIDS and who estimated their own risk as high. Most young people said they did not use condoms regularly, did not like them, and had little confidence in their ability to protect themselves"17.

A serious obstacle to adolescent condom use is that adolescents often have sex because of a sudden impulse. A well-known survey by Harris, commissioned by Planned Parenthoode in 1986, recorded that 83% of 14-15 year olds reported that their first sexual experience was unexpected18. Dr. D. Kirby wrote in Family Planning Perspectives that, in controlled programs of study conducted in school clinics, no impact on their use as contraceptives had been obtained. He found that the two most common reasons given by young women were that they "didn't expect to have sex" and that "I just didn't think I could get pregnant". Most of the reasons, she continues, "were not related to access to contraceptives. "19 A more recent study, in the same publication, found no decrease in the birth rate among those who came to the clinic20.

Several authors who have studied psychosocial factors and predictors of condom use among students found that inappropriate condom use was highly prevalent, and was associated with high-risk behaviours (promiscuity, drugs) which, in turn, were associated with adverse life circumstances: poor parental financial aid , medication abuse, academic problems.

For example, Anderson found that inappropriate employment or no employment use of condoms affected 65.6% of children who had been told about AIDS and 66.6% of those who had never been told. Condom employment "always" was 34.4% and 33.4% respectively. It also found that teaching about HIV/AIDS is not associated with less risky sexual behaviour21.

Weisman has recorded that the frequency average of correct condom use among adolescents was 16%, somewhat higher for "monogamous relationships" and leave for non-stable relationships22. H. Walter found, in a study in New York City and Rockland County schools, that of the 36% of 10th graders Degree who were sexually active, 25.2% used condoms incorrectly, and this misuse was associated with promiscuity and drug abuse23. and DiClemente found that the issue number of lifetime sexual partners was inversely proportional to the frequency of condom use24.

D. Orr found that only 22% of the girls in her study had used a condom the last time they had sex. Fifty-five of the group "always" had not used a condom the last time. Of these, 23% had already been pregnant and 19% had both an STDf (Chlamydia)25. And, according to the January 92 Morbidity and Mortality Review, less than 50% of students used a condom during their last sexual intercourse26. A previous report by D. Orr on "Premature sexual activity as an indicator of psychosocial risk" states that his data "supports the idea that sexual activity is significantly associated with other health risk behaviours and that, with increasing age, sexual intercourse is more frequently associated with alcohol or marijuana employment , and this association is greater in girls. "27 Gillmore et al. reported that risky sexual behaviour is associated with drug and alcohol abuse, smoking and delinquency. In contrast, in their study, adolescents committed to conventional values, activities and institutions, such as family and church, were less likely to engage in risky sexual behaviour "presumably because they think more about the future".28 A recent commentary in Family Planning Perspectives graduate "Teen sex and other risky behaviours" states that adolescents rarely engage in a single problem behaviour (drugs, violence, theft, school failure or expulsion from school). Instead, they tend to engage in multiple problem behaviours29.

Condoms "can help reduce the danger" but they must be used correctly and consistently. This is not most likely to be the case among adolescents, nor is it the case in the adult population, on the contrary: recent programs of study among university students has shown that, although they are concerned about the risk of acquiring an STI, and know the techniques for "safer sex", few follow them. Only 23% "always" usecondoms30. Even among young gay men, as Klepinger et al. point out, their perceptions of the severity of the disease appear to have little impact on their sexual behaviour, and there is no clear relationship between their knowledge of AIDS, their issue of recent sex, their condom use or their engagement in anal or casual sex"31. Haemophiliacs and their spouses constitute a special group : most of the patients were infected by the use of contaminated blood products before the development HIV testing. A large group of these couples, usually in stable, monogamous relationships, were counselled on "safer sex" techniques. Despite the obvious risk, non-compliance was a common problem, reaching a frequency of 45% - 55%32 33.

The condom employment requires skill, maturity, self-discipline, planning, motivation. Teenagers, immature, impulsive and risk-taking, seeking immediate gratification, do not seem good candidates for acquiring and practising these qualities. And if we could teach them, we would not have the current educational crisis, with the high frequency of failures we experience.

The bottom line is that adolescents engage in sexual activity because of deeper problems, and no amount of sexual Education will persuade them to use condoms correctly and properly.

Condoms for protection against HIV seroconversion 

Our detailed search of the recent literature has failed to reveal any medical literature showing a strong positive correlation between reliance on condoms and prevention of sexual transmission of HIV32 33 34 35 36 37 38 39.(In fact, we have been unable to find any recent controlled studies of condom use that provide protection against any sexually transmitted diseases. If anything, there appears to be a positive correlation between the availability easier availability of condoms, as manifested, for example, in laws requiring free distribution of condoms in pharmacies, and the current STD epidemic).

Most of the programs of study have been conducted over short periods of time, do not have satisfactory control groups, or are conducted on groups that are not representative of our young population. For example, some of these programs of study have been carried out with married haemophiliacs, whose sexual activity is hardly comparable to that of young people. Moreover, something different seems to be at play in these groups, because there were several pregnancies that were not accompanied by seroconversion33. The prevalence of seroconversion in this group is only about 10%32 33 38 40, and this leave figure has been confirmed by gPCR and viral cultures41 42. This leads to question all programs of study of "condom prevention" in couples with haemophiliacs. programs of study documented on prostitutes in an African country revealed high levels of seroconversion, which led to the discontinuation of the study. This study also included the use of Nonoxynol 9, which had been recommended for protection because it appears to have "in vitro" antiviral activity. At the time the study was stopped, prostitutes using Nonoxynol had a higher issue seroconversion rate, although the difference was not statistically significant43.

Hearst et al. have attempted to estimate the risk of seroconversion. Their conclusion: "Using a condom with a Username intravenous drug user, a bisexual man, or a prostitute is much more dangerous than having sex without a condom with someone who does not belong to a high-risk group "44.

Similar findings have been obtained by studying the frequency of reinfection in patients treated for STDs who had been instructed to use condoms. According to Cohen et al. 19.9% of men and 12.6% of women were reinfected after a period of only 9 months45.

Finally, a detailed and statistically comprehensive study by Susan C. Weller of School Galveston Medical School, University of Texas, recently published in Social Science and Medicine, after reviewing 87 scientific papers, concludes that careful selection of sexual partners reduces risk by a factor of two to four orders of magnitude. Condoms, on the other hand, assuming 90% effectiveness, would reduce risk by only one order of magnitude and, according to their analysis of the empirical data , their protective effect must be estimated at only 69%46.

Many of the authors previously mentioned stressed that the false sense of security provided by "protected sex", when in fact the Degree of protection is so low, can lead to a real increase in the issue of cases, which seems to have occurred with teenage pregnancies, following the establishment of school clinics distributing condoms.

Sexually transmitted diseases (STDs)  

Adolescents suffer from STDs very frequently. A recent report by high school Alan Guttmacher, reproduced in The New York Times (31 March 93) states that the incidence of STDs in the United States is 12 million new cases per year and, of these, 3 million, 25%, occur in people under the age of 25. STDs disproportionately affect women, leading to pelvic inflammatory disease (PID), infertility and ectopic pregnancies, and making these women much more susceptible to AIDS. According to William R. Archer, "one in three sexually active teenagers will acquire an STD before they graduate from high school"47. And McCray states: "People with an STD that causes genital or anal ulceration (syphilis, chancroid, herpes simplex) may, for biological reasons, be at increased risk of acquiring and transmitting HIV infection. "48 To complicate matters, 80% of these patients do not know they have an STD, and may transmit it without realising it49. And adolescents who use drugs, are sexually promiscuous or engage in anal intercourse are especially susceptible to STDs and HIV50.

Condoms do not offer good protection against STDs. The CDC's official publication, Morbidity and Mortality Weekly Review (MMWR) states: "Abstinence and sex with an uninfected, mutually faithful partner are the only fully effective prevention strategies. Proper use of condoms during all sexual intercourse can reduce, but not eliminate, the risk of STDs. People who are likely to be infected or know they are infected with HIV should be aware that condom use cannot completely eliminate the risk of transmission for themselves or others ... condoms may offer less protection because there are areas of skin not covered by the condom that may be infectious or vulnerable to infection. The actual effectiveness of condom use in STD prevention is more difficult to assess. Condoms are not always effective in preventing STDs."4 And Cates, in Family Practice Perspectives, puts things even more difficult to assess: "programs of study controlled studies of condom protection against STDs conducted with women provide less convincing evidence than corresponding research conducted with men. In the same study, he finds no difference in the prevalence of Chlamydia infection between group who used condoms and those who did not51. and Samuels found that condom-using university students had an infection rate of 35.7% and non-users 37%, a difference that is not statistically significant52.

Condoms provide particularly poor protection against transmission of human papillomavirus (HPV), some strains of which are associated with cervical cancer. Recently, disseminated cervical cancer has been added to the definition of AIDS. Cates quotation a Finnish study in which condoms were of no use in protecting against HPV51 cervical infections, and Dr. Richart, director of Gynecologic Pathology at Columbia Presbyterian Medical Center, in an interview in Oncology Times, stated that 20% of infected men have HPV lesions at sites other than the penis, many of them extremely difficult to see, but nonetheless infectious. It appears that 20% of women aged 14-18 are already infected with HPV, and three out of four have strains of the virus associated with cervical cancer53. And Dr. Dervin, in the annual review of Family Medicine, sponsored by the San Francisco Medical School, School , University of California, stressed that HPV infection is a regional rather than a localised disease, and is not amenable to control by local measures such as condoms54.

Condoms and STIs are problematic not only because of their own pathology, as summarised above, but also because STIs facilitate sexual transmission of HIV. This occurs not only through skin or mucosal lesions, but also through the cellular inflammatory response, which includes cells heavily infected with the virus.

Education sexuality on contraceptives and sexual activity 

Since the early 1950s there has been a slow increase in teenage sexual activity and out-of-wedlock pregnancies. The figures at that time were in the order of 3-5%, always higher among poor minorities. By the mid-1960s, the frequency of single motherhood had risen to a staggering 16%, prompting Prof. Moynihan (now Senator Moynihan) to institute powerful measures to help re-establish the two-parent family. Planned Parenthood and the Sex Information and Education Council of the United States (SIECUS), noting the same problem, successfully advocated for development sex Education curricula with an emphasis on contraception, and the establishment of school-based clinics from which parents were excluded. Aspirin and throat cultures cannot be provided secretly to minors, but these restrictions did not apply to contraceptives or to committee on how to use them. Following the idea of Roe v. Wade, abortion counselling has also been a frequent element in the armoury of these clinics. The striking parallel between the development of sexually explicit Education curricula, availability of contraceptives, and the explosion of youth pregnancies has been well documented by S. Roylance, J. A. Ford and J. Kasun in their testimony before the Senate committee on work and Human Resources in March 1981. Their data showed that pregnancies increased as these new programmes were introduced, and the rate of pregnancies increased in parallel with expenditures on these programmes: States with the highest expenditures showed the highest levels of pregnancies and abortions. In California, one of the pioneer states, the pregnancy rate grew 20 times faster from 1970 to 1976 than in the rest of the nation, and in Humboldt County, this increase was 40 times faster after the introduction of the sexual Education programmes55.

These findings should be contrasted with the results of a law passed in Utah in 1980 requiring parental consent for the distribution of contraceptives to minors; there was a substantial decrease in clinical attendance , teenage pregnancy and abortion rates55. A similar result was observed in Minnesota following a 1981 law requiring parental notification56.

In 1982, Dr. H. H. Newman, director a physician at department of New Haven Health, wrote that, under the guise of reducing teenage pregnancy, Education sexual programmes attempted to teach children to achieve sexual adjustment, to explore issues such as masturbation, sexual techniques, homosexuality and rape. In her words: "Instead of teaching young people how to avoid unwanted pregnancy and its consequences, we teach them that the joy of sex is their human inheritance". He goes on to say that there is no scientific evidence that such courses have a positive impact on teenage pregnancies. His own experience suggests the opposite, and quotation the case of Sweden which experienced an increase in what was then called "illegitimate births", except among those who were quite old, or among those who did not receive sexual Education . In New Haven there were three similar schools. One of them had instituted a comprehensive sexual Education programme 11 years earlier, which led to a disturbing increase in issue pregnancies, compared to the other two schools that did not offer such a programme. He concluded that more research and statistical evidence was needed before adopting such programmes, which, in his opinion, "may be contributing to the problem.

Numerous published programs of study reinforce this view. Reports by Marsiglio and Mott, and Dawson found that children who received early sexual Education were between 1.2 and 1.5 times more likely to engage in early sexual activity58 59. One by Harris and his team, commissioned by Planned Parenthood, confirmed these findings18 . And, more recently, the daily press has reported similar experiences in Los Angeles and Colorado.60 61.

The CDC has reported an increase in sexual activity among 15-year-old girls, from 4.6% in 1970 to 25.6% in 198862. Analysis of these data, published in Family Planning Perspectives, revealed an increase in promiscuity and little internship contraception63. Given the nature of the evidence, and the pro-contraception stance of the survey implementers, the true figures for condom non-use may be even higher than the 30-50% acknowledged by boys and girls. The data is reconfirmed in a September 1992 CDC report on adolescent promiscuity, AIDS and condoms64.

For society at large, it seems clear that Education sexuality has failed. But to assess success or failure, we have to look at the objectives. Given the information available in the preceding paragraphs, it might seem that the stated goal of reducing teenage pregnancies has not been achieved, and the insistence on these programmes leads to the inevitable conclusion that the real goal has been to change social attitudes towards sex, abolishing traditional restrictions on sex and encouraging acceptance of practices that many parents consider deviant. Such goals may be difficult to defend in a public discussion , so the myth of AIDS and pregnancy prevention has to be perpetuated.

A recent article in Parents Magazine openly states that the goal of the Sex Information and Education Council of the United States (SIECUS) and Planned Parenthood is "promote healthy sexuality in young people, providing them with the skills they need to help them make responsible sexual decisions"65, but they will take no responsibility for the disasters they leave behind, affecting our children, when their attempts at social engineering fail, and immature young human beings are taught as factual ideas based on unproven but fashionable opinions, utterly rejecting the wisdom of centuries of civilisation. The universal perception of marriage as the proper environment for the enjoyment of a healthy sex life and the growth of the family cannot be attributed to particular religious or moral beliefs, but must be recognised as the result of countless attempts at essay and error. Any modification of established mores would require scientific evidence that modern advocates of rampant sexual activity have been unable to provide. The New York City public school system provides a select opportunity to develop a carefully controlled scientific study comparing the traditional, abstinence-based techniques that have worked for previous generations and the new, protected promiscuity so enthusiastically advocated.

Alternatives to condoms/ Education sexuality on HIV 

Kirby has analysed the different approaches to sexual Education and the prevention of pregnancy and STDs. He concludes that the Study program oriented knowledge has failed, finding which belatedly confirms the conclusion of the ancient Greek philosophers, that knowledge and internship virtue do not require each other. What Kirby calls the "second generation" ones, which attempt to clarify values and inform decision-making, he also considers to have failed. And, without analysis, he also dismisses "third generation" abstinence-based programmes. There seems to be a superior knowledge among experts, which allows them to eliminate from their consideration this approach, without even looking at the results of experiments that have employee such methods. He then proceeds to defend a "fourth generation" programme, a mixture of abstinence and contraception, which he calls "Reducing the risk". According to his analysis, this programme did not reduce sexual activity, and appeared to be successful in increasing the internship of contraception among women and "low-risk youth"66.

As we have already stated, statistics from the CDC and the New York City Health committee reveal a striking disparity in the frequencies of heterosexual HIV transmission between male and female partners, a disparity that, for unknown reasons, is much more B in whites than in blacks or Hispanics. Contraceptive methods well received by women but not by men, assuming the young people had answered correctly, can only be of types that have no effect on HIV transmission, and methods that benefit low-risk groups while leaving high-risk ones the same do not seem worth much effort. If, on the other hand, we could develop programmes that convert high risk to low risk, and low risk to no risk, our authorities should explore and evaluate them carefully by means of controlled comparative programs of study .

degree scroll XX of the Public Health Service Act of 1981 attempted to do exactly that. It helped develop and evaluate abstinence-based methods. The first programme of this subject, called "Postponing Sex" began in Atlanta in 1983, in inner city schools. "At the end of the 8th grade Degree, students who had not participated in the programme were five times more likely to have become sexually active than those who had followed the programme"67.

A large issue of similar programmes have been developed, and while many of them are often the work of spiritually oriented individuals, all those that have received some funding from federal sources have remained strictly non-religious. These include the Joseph Kennedy Foundation's "Community of Caring"68, "Teen Aid"69, "Sex Respect"70, "Teen Choice"71 and "Free Teens"72. The common denominator of all these programmes is that abstinence is the healthiest option for adolescents, that sexual activity should be reserved for a mature and committed relationship and that character education is a desirable part of any system educational. All of these programmes have shown B to be effective in reducing the rate of sexual activity and pregnancy, results that none of the contraceptive or drug-based programmes can boast. Similar or better results are expected in HIV transmission: if the risk of a new life acts as a deterrent, given positive reinforcement, it is logical to expect the same or more when the risk is death. And, based on anecdotal experience, programmes that emphasise abstinence, but give condoms as a kind of lifeline, have not been as effective as those that rely exclusively on abstinence73.

Conclusion 

The sexual revolution of recent decades has led to a profound shift in the thoughts and perspectives of many experts, especially among those without children of their own. Behaviours that have become acceptable for adults in private are now advocated for children. Those who think this way tend to forget that it takes time to make a child an adult, and that doctrinaire ideas that do not have obvious tragic consequences for adults can be misunderstood and taken to internship irresponsibly by immature youngsters. In our schools we are confronted with another problem: murderous violence. No expert, at least as yet, has suggested that all young people should attend come to school wearing a bulletproof vest, or that we should provide them with proper instruction in the correct handling of firearms to prevent deaths due to stray bullets, as if every bullet must hit the target. We also know the problems caused by irresponsible drinking, perhaps in combination with irresponsible driving. We all feel the same in these areas, but we have not been able to find reliable ways of teaching responsibility to young people, except to try to ban particularly dangerous activities, and hope that they survive until life itself teaches them more behaviour manager, with traditional marriage being one of the most successful schools for achieving this goal.

Notes 

(1) Noble RC. The Myth of "Safe sex". Newsweek, April 1, 1991.

(2) Trussel J, Warner DL, Hatcher R, et al. Condom Slippage and Breakage Rates. Fam Plann Perspect 1992; 24: 20-23.

(3) Digest. Study Finds Low Condom Breakage Rate, Ties Most Slippage to Improper Use. Fam Plann Perspect 1992; 24: 191.

(4) CDC. Condoms for Prevention of Sexually Transmitted Diseases. MMWR 1988; 37: 133-134.

(5) National Recall Alert center. Recall warning Alert #842 (Condoms). March 26, 1991 p. 8.

(6) Recalls, an Update List. Good Housekeeping May 1991, p. 121.

(7) Carey RF, Herman WA, Retta SM, et al. Effectiveness of Latex Condom As a Barrier to HIV Sized Particles under Conditions of Simulated use. Sex Transm Dis 1992; 718: 230-234.

(8) Wigersma L, Oud R. Safety and Acceptability of Condoms for use by Homosexual Men as a Prophylactic against Transmission of HIV During Anogenital Sexual Intercourse, Br Med J 1987; 295: 94.

(9) AIDS Surveillance Update, New York, NY: New York City Department of Health; January 1993.

(10) Jones EE, Forest JD. Contraceptive Failure Rates Based on the 1988 NSFG. Fam Plann Perspect 1992; 24:12-19.

(11) Strunin L, Hingson R. Acquired Immunodeficiency Syndrome and Adolescents: Knowledge, Beliefs, Attitudes and Behaviors. Pediatrics 1987; 79: 825-828.

(12) Kegeles SM, Adler NE, Irwin ChE. Sexually Active Adolescents and Condoms: Changes over one Year Knowledge, Attitudes and Use. Am J Public Health 1988; 78: 460-461.

(13) Stout JW, Rivara FP. Schools and Sex Education: Does it Work? Pediatrics 1989; 83: 375-379.

(14) Goodman E, Cohall AT. Acquired Immunodeficiency Syndrome and Adolescents: Knowledge, Attitudes, Beliefs, and Behaviors in a New York City Adolescent Minority Population. Pediatrics 1989; 36-42.

(15) Kann L, Anderson JE, Holtzman D, et al. HIV Knowledge, Beliefs, and Behaviors among High School Students in the United States: Results from a National Survey. J School Health 1991; 61: 397-401.

(16) Millstein SG, Irwin ChE, Adler NE, et al. Health Risk Behaviors and Health Concerns Among Young Adolescents. Pediatrics 1992; 89: 422-428.

(17) Stiffman AR, Earl SF, Dore P, et al. Changes in Acquired Immunodeficiency Syndrome-Related Risk Behavior After Adolescence: Relationships to Knowledge and Experience Concerning Human Immunodeficiency Virus Infection. Pediatrics 1992; 89: 950-956.

(18) Harris and Associates Survey "American Teens Speak: Sex, Myths, TV and Birth Control", conducted for Planned Parenthood, 1986.

(19) Kirby D, Warza KC, Ziegler J. Six School Based Clinics: Their Reproductive Health Services and Impact on Sexual Behavior. Fam Plann Perspect 1991; 23: 6-16.

(20) Kirby D, Resnik MD, Downes B, et al. The Effects of School Based Health Clinics in St. Paul on School Wide Birth Rates. Fam Plann Perspect 1993; 25: 12-16.

(21) Anderson JE, Kann L, Holtzman D, et al. HIV/AIDS Knowledge and Sexual Behavior Among High School Students. Fam Plann Perspect 1990; 22: 252-255.

(22) Weisman C, Plichta S, Nathanson CA, et al. Consistency of Condom Use for Disease Prevention Among Adolescent Users of oral Contraceptives. Fam Plann Perspect 1991; 23: 71-74.

(23) Walter HJ, Vaughan RD, Cohall AT. Psychosocial Influence on Acquired Immunodeficiency Syndrome - Risk Behaviors Among High School Students. Pediatrics 1991; 88: 846-852.

(24) DiClemente RJ, Dubin M, Siegel D, et al: Determinants of Condom Use Among Junior High School Students in a Minority, Inner City School District. Pediatrics 1992; 89:197-202.

(25) Orr DP, Langefeld CD, Katz BP, et al. Factors Associated with Condom Use Among Sexually Active Female Adolescents. J Pediatrics 1992; 120: 311-317.

(26) CDC. Sexual Behavior Among High School Students - United States, 1990. MMWR 1992; 40: 885-887.

(27) Orr DP, Beiler M, Ingersoll G. Premature Sexual Activity as an Indicator of Psychological Risk. Pediatrics 1991; 87: 141-147.

(28) Gillmore MR, Butler SS, Lohr MJ, et al. Substance Use and other Factors Associated with Risky Sexual Behavior Among Pregnant Adolescents. Fam Plann Perspect 1992; 24: 255-268.

(29) Digest. Teenage Sex and Other Risky Acts. Fam Plann Perspect 1993; 25:3.

(30) Joffe GP, Foxman B, Schmidt A, et al: Multiple Partners and Partner Choice as Risk Factors for Sexually Transmitted Disease Among Female College Students. Sex Transm Dis 1992;19: 272-278.

(31) Klepinger DH, Billy J, Tanfer K, Grady WR. Perceptions of AIDS Risk and Severity and Their Association With Risk Related Behavior Among US Men. Fam Plann Perspect 1993; 25: 74-82.

(32) Laurian Y, Peynet J, Verroust F. HIV Infection in Sexual Partners of HIV Seropositive Patients with Hemophilia. N Engl J Med 1989; 320: 183.

(33) Lusher JM, Operskalski EA, Alerdot LM, et al. Risk of Human Immunodeficiency Virus Type I Infection Among Sexual/non Sexual Household Contacts of Persons With Congenital Clotting Disorders. Pediatrics 1991; 88: 242-249.

(34) Fischl MA, Dickinson G, Scott GB, et al. Evaluation of Household Partners, Children and Household Contacts of Adults with AIDS. JAMA 1987; 257:640-644.

(35) Padian N, Marquis L, Francis DP. Male to Female Transmission of Human Immunodeficiency Virus. JAMA 1987; 253: 788-790.

(36) Detels R, English P, Visscher BR, et al. Seroconversion, Sexual Activity, and Condom Use Among 2915 HIV Seronegative Men Followed For Up to 2 Years. J Acquired Immun Def Syn 1989; 2: 77-83.

(37) Frosner GG. How Efficient is "Safer Sex" in Preventing HIV Infection? Infection 1989; 17:3-5.

(38) Kreiss JK, Kitchen LW, Prince HE, et al. Antibody to Human T Lymphotropic Virus Type III in Wives of Hemophiliacs. Ann Intern Med 1988;148:1299-1301.

(39) Brettler DB, Forsberg AD, Levine PH, et al. Human Immunodeficiency Virus Isolation Studies and Antibody Testing. Arch Intern Med 1988;148:1299-1301.

(40) CDC. HIV Infection and Pregnancies in Sexual Partners of HIV Seropositive Hemophilic Men-United States. MMWR 1987; 36: 593-595.

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(a) Human immunodeficiency virus.

(b) Perspectives on Family Planning.

(c) Food and Drug Administration: US government agency responsible for the approval of medicines, prostheses, food additives, etc.

(d) Committee for Disease Control: committee Atlanta Infectious Disease Control.

(e) Planned Parenthood Federation: association , a non-state, US-based organisation whose programmatic purpose is the dissemination of contraceptive methods, both in the United States and worldwide.

(f) Sexually transmitted disease.

(g) Polymerase Chain Reaction: analysis to determine whether a biological sample contains the genes sought, even if they are present in very small quantities leave.

(h) committee on Education and sexual information.