Why is there a condom (or, more properly, a virtual, male condom) on Philadelphia’s City Hall tower?

The truth is, in redesigning my web site, I couldn’t think of a better image to evoke the controversy that has raged during the AIDS epidemic and that could be connected with a local Philadelphia landmark. And need I say it: a condom wouldn’t have looked good on the Liberty Bell.

It also gives me this opportunity to provide a brief overview of condom controversies and issues in the context of HIV/AIDS.

From Private Matter to Public Issue

One of the remarkable features of the AIDS epidemic has been the way it has forced what traditionally has been private – things that were simply not talked about, like condoms – into public discourse. The condom on the tower symbolizes the idea of this issue moving from private to public.

And just to be clear, it wasn’t so much the epidemic that forced this change. This change was largely driven by an activist community, including many people with HIV/AIDS.

People who don’t care much about the public health challenges posed by HIV/AIDS resist these changes. There’s no better example than President Ronald Reagan’s failure to speak publicly about the epidemic during its first five years. He finally mentioned the epidemic in a press conference in 1986, but even then he failed to say “AIDS.”

Putting a condom on City Hall tower wasn’t my idea, however. As Nick Ifft, M.D., one of the early advocates on HIV/AIDS issues in Philadelphia confirmed recently, the Philadelphia AIDS Task Force developed a poster about 25 years ago that had the City Hall tower covered by a condom. But they decided that the poster would alienate more people than it would attract to their cause. Instead, they used their limited resources for a more focused campaign of condom distribution in gay bars.

More recently, in what’s probably the most celebrated image of a condom on a building, AIDS activists put a condom on Senator Jesse Helms’s house in 1991 (after making sure that he wasn’t home) to make the point that Helms was “more dangerous than a virus,” as recounted on Peter Staley’s POZ blog. The blog entry includes a video of the condom installation. Watching this video of this event recently, I couldn’t help but think that using a virtual condom has its advantages – no need, for example, to climb up on any roofs.

It’s easy to see why some people would resist the way private matters that have become more public. We’re moving references to sexuality, including sexual pleasure and desire, into public discourse. Recently, as detailed in a New York Times story, “Pigs With Cellphones, but No Condoms,” an advertisement for Trojan condoms was rejected by Fox Broadcasting and CBS. The precise reasons for this rejection are not clear to me, but perhaps discomfort with the publicly expressing the idea of sexual pleasure was a significant factor.

Although we like to think we’ve abandoned prudery and have been much more knowledgeable in these matters, some of us still don’t know how to talk about condoms or fully understand what they’re for. Presidential candidate Senator John McCain, for example, in an interview with reporters in March 2007 was uncertain whether condoms prevent HIV transmission. Yet Senator McCain’s confusion, while inexcusable, was probably induced in part by the reporter’s inept choice of words. The reporter repeatedly asked about “contraceptives” – not “condoms” specifically – as preventing HIV. McCain should have known that a condom is a contraceptive, and that condoms prevent HIV transmission, but that not all contraceptives prevent HIV transmission. But apparently he didn’t.

Pennsylvania General Assembly and Condom Invisibility

Here’s a good example of ignoring the importance of condoms in preventing HIV infection: one of the few times the Pennsylvania General Assembly addressed the AIDS epidemic, it passed a law that increases criminal sentences for people with HIV who are convicted of prostitution. Prostitution was already a crime in Pennsylvania when this law was enacted, so it’s questionable whether enhancing penalties for those with HIV who are convicted of prostitution offenses would have much deterrent effect. But even worse, this statute enhances penalties without regard to whether the sexual activity posed any risk of HIV transmission. It’s as though the legislature didn’t know that condoms can prevent HIV transmission. (Or, perhaps more accurately, they knew, but didn’t know how or weren’t about to write a condom or safer sex exception into the law.) It’s enough under the statute to show that the defendant is aware of being HIV positive, not that he posed a risk of transmission – in effect, a crime based not on risk of harm, but merely on the status of the defendant.

The Normalization of Condoms

There’s no question that if condom use was far more widespread – if we would “normalize” condom use – we’d have much less of an AIDS epidemic, and much less of other sexually transmitted diseases that increase the risk of HIV infection, and far fewer teen pregnancies.

An example of this approach in normalizing condoms is New York City’s “New York Condom” initiative, and New York State has a program as well. Sadly, neither Philadelphia nor Pennsylvania at the state level has a similar program.

The Current Problem

The evidence of our need to normalize condoms is as clear as it is appalling.

In 2008, the U.S. Centers for Disease Control and Prevention announced the results of the first national study of four common sexually transmitted diseases – human papillomavirus (HPV), chlamydia, genital herpes, and trichomoniasis – among girls and women. They found that one in four is infected with at least one of the diseases. Among the women with these diseases, 15 percent had more than one disease.

The CDC has recently released reports on high school student HIV risk behavior and HIV prevention education programs in secondary schools. First, trends in HIV risk behaviors during 1991-2007 among high school students show, not surprisingly, an overall decline in behavior such having sex, failing to use condoms, having multiple (four or more) partners. But during that time period:

• Nearly half (47.8%) high school students had sex
• Of those sexually active students, more than a third (39.5%) didn’t use condoms
• Many students (14.9%) had sex with multiple (four or more) partners

Then in 2005-2007, there was no change in risk behaviors. That means that condom use had not increased during those two most recent years.

In August 2008, as President Bush signed the PEPFAR reauthorization into law, the Black AIDS Institute pointed out that more black Americans are infected with HIV than the total populations of people living with HIV in seven of the 15 countries served by PEPFAR. As Phill Wilson, the CEO of the Black AIDS Institute commented, “Were Black America a separate country, it would elicit major concern and extensive assistance from the U.S. government. Instead, the national response to AIDS among Black Americans has been lethargic and often neglectful.”

CDC Condom Censorship

In 2001, the CDC removed its 1999 condom factsheet from its web site, a move perhaps intended to lessen attention to condoms, but which seems to have had the opposite result. The original 1999 factsheet included this instruction on how to use a condom:

Put on the condom after the penis is erect and before intimate contact. Place the condom on the head of the penis and unroll it all the way to the base. Leave an empty space at the end of the condom to collect semen. Remove any air remaining in the tip by gently pressing the air out toward the base of the penis.

When the CDC replaced the factsheet with another one in 2002, this instruction was gone. As an Advocates for Youth analysis of the two condom factsheets shows, the CDC’s revised factsheet demonstrates a willingness to censor life-saving information and to reduce public confidence regarding condoms.

Whether the CDC change has had much of an impact is unknown, but it is certainly symbolic. Information about condoms and how to use them can be found easily enough elsewhere on the Internet, and instructions similar to those removed from the CDC’s site are available on the FDA’s web site, which reprints a 1990 brochure on the topic of condoms as preventing HIV transmission.

FDA Condom Label Controversy

In 2000 Congress enacted a provision in Public Law 106-554 requiring that the Food and Drug Administration to determine whether condom package labels were medically accurate regarding the overall effectiveness or lack of effectiveness of condoms in preventing sexually transmitted diseases. Of course, to the extent that condom efficacy could be disparaged or called into doubt, the use of condoms would be discouraged, and, without a “safer” way to engage in sex, more people would decline to do so. Overlooking, of course, the risk that such an approach will result in an increase in the number of people who don’t bother with condoms because they don’t believe they’re effective.

Actually, a stated concern behind Public Law 106-554 was that condoms did not prevent transmission of human papilloma virus (HPV). This concern was seen as a way of discrediting condoms generally as a means of preventing disease transmission. More recently, however, a study in the New England Journal of Medicine concluded that condoms were indeed effective in reducing, but not eliminating, the risk of HPV transmission.

Compare the label proposed by the FDA

When used correctly every time you have sex, latex condoms greatly reduce, but do not eliminate the risk of pregnancy and the risk of catching or spreading HIV, the virus that causes AIDS

with the CDC’s condom recommendation on its web site:

When used consistently and correctly, [condoms] are highly effective in preventing transmission of HIV, the virus that causes AIDS

Which one promotes condom use? Researchers at the Annenberg Public Policy Center found that among unmarried persons the CDC language was more effective in promoting condom use because it stresses “efficacy versus risk.”

Condoms and Comprehensive Sex Education in Public Schools

Another 2008 CDC report shows why we haven’t made better progress: schools simply are not teaching HIV prevention or, when they teach it at all, they do so inadequately and ineffectively. Although Pennsylvania’s State Board of Education requires by regulation that HIV prevention be taught in all public schools, the CDC survey results show that only 92.8% of Pennsylvania secondary schools actually comply with this requirement. And less than a third (29.7%) of Pennsylvania school districts teach all 11 HIV prevention topics as recommended by the CDC (two of the 11 topics are “how to correctly use a condom” and “condom efficacy”).

In 2005, the Pennsylvania State Board of Education sought to include a recommendation in its regulation that school HIV prevention programs conform to the CDC recommendations, but it withdrew this proposal in early 2008. School districts in Pennsylvania are thus free to teach abstinence only until marriage and not even mention condoms as a means of preventing HIV transmission.

The administration of Governor Edward Rendell surprised many people by applying for federal abstinence-only funding for the 2009 fiscal year. By now, the case against abstinence-only education has been established as a result of two comprehensive studies, a 2007 Congressionally mandated study and a survey of 11 state evaluations, including Pennsylvania.

Almost two decades ago, the Philadelphia School District commenced a pilot program of providing condoms to high school students. (Technically, the condoms are made available from the Family Planning Council.) The program, which included an opt-out provision for parents who didn’t want their kids to have access to condoms, was upheld by the U.S. Court of Appeals for the Third Circuit in Parents United for Better Schools v. School District. Nevertheless, today the condom availability program is limited to only 11 of the Philadelphia’s public high schools (not to mention middle schools, or the 21 public charter schools), and in June 2008 ACT-UP Philadelphia held a demonstration at the School District building to demand expansion of the program. The issue has been the subject of favorable editorials in both the Philadelphia Inquirer and Daily News.

All this is my way of explaining why there’s a condom on City Hall. In future essays, I’ll address specific, current issues relating to condom availability and enhancing HIV prevention.