of the World Health Organization Global Programme on AIDS
Year 1992 No 3, pp.15-16
An Interview with Zbigniew Halat
Dr Zbigniew Halat, an outspoken epidemiologist of 42, grew up
in the city of Wroclaw, close to Poland's border with Germany. Involved
in the local organization of Solidarity in 1980-81, he left Poland
the declaration of martial law to study venereal and skin diseases in
From 1982 to 1984 he organized a free clinic to treat sexually
diseases - STDs) in Nyeri, capital of Kenya's Central Province, where
saw patients with what he now believes were early symptoms of AIDS.
martial law was lifted in 1984, he returned to Poland to work in the
health system on allergies, skin disease and immunization. In the
of 1987 he launched one of Eastern Europe's first AIDS hotline
services, and since April 1991 he has been responsible for
health, disease prevention and control and the national health
in Poland as a Deputy
of Health and Social Welfare.(*)
Despite considerable opposition, Dr Halat
advocates condoms - not just abstinence - to prevent AIDS, and he is
an army of midwifery and nursing students to spread the message of safe
sex to boys, girls and fellow teenagers of both sexes, partly through
use of educational materials from GPA. (WHO also assisted Poland in
up its short-term plan on AIDS in 1990, and it is helping to prepare a
conference to reach a national consensus on AIDS.) Dr Halat spoke to
AIDSnews while on a recent visit to Geneva.
Dr Halat, how prevalent are AIDS and HIV infection in your country?
Officially there are said to be
2200 people infected
HIV, and 100 cases of AIDS. In both cases, about 70 per cent of them
attributed to drug abuse. I think all these figures are wrong. This is
partly because male and female sex workers, and men who have sex with
tend to get help in private clinics which have no procedures of
And there is a lot of misconduct in such places - people taking blood
for example, throwing it away and telling people they are uninfected.
need to strengthen our medical system and open it as much as possible
all groups in society. The true incidence of HIV and AIDS in Poland
bc seen only when we can fund a proper study and can organize a
unit. We do not have what is needed to make proper diagnoses. We don't
have the equipment to conduct a bronchoscopy, for example, to look for
PCP. (Editor's note: Pneumocistis carinii pneumonia, a common
illness.) In my opinion, most transmission of HIV in Poland
If so, Poland would differ in this from other European countries. How do you believe this has come about?
It goes back to the 1970s, when the then communist government first allowed Polish citizens to travel to the West freely. Differences in the economic levels of neighbouring countries lead to prostitution and infection. And cheap sex brings with it an enormous danger of HIV. Living in Poland is like living in the Caribbean and being close to the USA. When Poles got the freedom to travel in the 1970s - I was earning $ 10 a month at the time - many of my fellow citizens went to Germany and sold sex to get money. Now, many people come here for sex. They pay girls and boys for unprotected sex. Young boys of 10 or 12 hang around outside buses from Germany offering sex for very little money. Unfortunately, there are men and women who find sex boring unless it is unsafe. And there are parts of western Poland where many young people go to Berlin to be prostitutes. Male prostitution is quite common, but not as common as female prostitution. Also, the spread of bloodborne diseases in our country is very dynamic.
One in 1600 Polish women between
the ages of 20 and
get the hepatitis B virus (HBV) in hospital or outpatient clinics
their pregnancies. So HBV in Poland is more common in women than men,
in most countries, the reverse is the case.
Poland is heavily Roman Catholic. Does this pose problems for you in spreading the message of safe sex?
Religious problems are a real
obstacle, a real
fact. According to Catholicism, a man should not deposit his semen
other than in his wife's vagina, so sexual fondling and masturbation to
ejaculation are out of the question. But we need to adjust our advice
to reality. Promiscuity exists in Poland as it does in other countries,
and you have to admit that sexuality is an issue for young people and
be seen only as a sin.
So have you run into problems with the Catholic Church?
If you say plainly that something
if you repeat it enough times, thc Church has no objection. I say, let
a priest be a priest, let a doctor be a doctor. But priests are not the
only people who pose problems. In 1991, one of my fellow deputy health
ministers said that condoms were only for deviants. He was fired by the
prime minister of the time, Mr Bielecki, who was a liberal. And an
minister said recently that there was no need for AIDS education. I
his comment was "very exotic".
What is the position on AIDS education?
The older generation does not
want to talk to
generation about sex. There are some things which most mums and dads
it impossible to say. Doctors are not good at AIDS education because
tend to medicalize the issue and use words of Greek and Latin origin.
teachers get red faces about condoms. In any case, in this time of
from communism, when there has been a swing to the authoritarian right,
it is not possible to incorporate AIDS education into the official
In my opinion the best way is to use peer educators.
Who will these peer educators be?
We have an army of young women -
13 000 secondary
students, 3000 of them doing midwifery - who could be health educators.
We started a peer training programme in 1988 in Wroclaw with the
of the local midwifery school. The midwife peer educators, who are
19 or 20 years old, go into local schools and talk to the pupils from
ages of 11 up, usually separating the sexes until they are 15. The
is now very well-known in the area. Other schools are asking for it,
parents too. We find that young women can talk about sex much more
than young men with their peers, male and female. The educators tell
group that it is natural for young people to have sexual urges, to
and to fantasize. This gets them all relaxed. And then the educators
in with the message: "But when it comes to intercourse, use a condom
a virucide". And they tell the girls it is important to know someone
more than one day, and that they should check whether the boyfriend can
fulfil his role not just as a sex partner, but as someone they can talk
to and enjoy other leisure activities with. One aim is to delay first
I follow the idea of abstinence as an ideal, but at the same time
that it can be too demanding.
How do you plan to mobilize the whole army of nursing and midwife students?
We have set up a programme called
Sobie - "Ourselves for Ourselves". It is headed by Dorothy
Ivonne Mackiewicz, who were in the first group of peer educators. We
to make a short-cut to a new generation of Poles using self made
materials based on WHO and Red Cross models. Fifteen girls from Warsaw
and Wroclaw went to Bristol in June to learn of British experiences,
with WHO support we organized summer camps for 60 midwifery students
60 nursing students in August to train them as trainers to go into the
schools. They will go into the schools and show how to use condoms by
them on their fingers, and so on. (I do that whenever I go on
The girls will also talk about general health promotion, including what
tobacco can do to you, not just about AIDS and sex. The Polish
is dying from smoking and drinking and lack of physical exercise.
What about condom supply in Poland?
For many years, there was a
factory in Poland which
condoms with holes and measured their elasticity with rulers. Now we
founded a new Polish-German joint venture with quality technology
after by German specialists. We make all kinds of condoms, even
ones, for oral, vaginal and anal sex. And they cost the equivalent of
US cents for three.
If your plans for peer education come to fruition, the younger generation will be well educated on AIDS issues. What about the generation of people who came before them?<> People are shy of picking up leaflets. It is easier for them to pick up a phone. That is why I think hotlines are very important. I first set up a counselling service for pre- and post-HIV diagnosis in the autumn of 1987. We were the first in central and eastern Europe to have dialled automatic information on AIDS. There are now about 10 or 11 hotlines in Poland. Recorded messages directed at housewives, drug users or other groups supply other numbers to phone if the callers feel they are in danger. They then reach an operator from their own social group whom they can talk to. Usually people say they are ringing on behalf of a friend, but gradually we gain their confidence and they come to visit a doctor, who is usually attached to an STD clinic. In my country, a typical problem might involve a young married mother who suddenly fears she might be infected after having a single sexual encounter with someone who has been abroad - her first love, perhaps, unexpectedly met in the street. She wants to have another child, she doesn't want to infect her husband, so she feels she needs condoms, or support. She worries, she gets psychosomatic symptoms. ... For such cases, I think it is inhuman not to create an anonymous counselling unit. The same goes for homosexuals: why not invite them to a place with a gay doctor for pre- and post-test counselling? I think we will soon set up that kind of facility.
(*) "the quixotic and controversial deputy minister of health, government sanitary inspector, and chief environmental health officer, Zbigniew Halat MD is engaged in a personal crusade to shake the health service out of the spiritual atrophy induced by 45 years of communism. Hard working, self reliant, aggressive, and abrasively masculine, this man of Promethean energies put me in mind of a nineteenth century northern mill owner" (Karin Chopin, Letters from Poland, British Medical Journal, May 30, June 6, and June13, 1992)
Condoms always have and always will pose a great use-effectiveness problem. In fact, the FDA requires the manufacturer to list the ideal use-effectiveness rates of approved contraceptives in the package inserts for oral contraceptives, which are even more easily controlled in use. Combining the ideal and the use-effectiveness rates, condoms are listed at 90-70 percent, which translates to a failure rate of 10-30 percent. These rates are based on birth prevention, not disease prevention.
This distinction is critical when safety and protection are honestly considered and evaluated. For example, a woman's window of fertility is 7 days out of an average 28-day cycle. Infections such as AIDS, however, can occur every day at any given minute, depending on the immune system. This means that there are at least four times as many days during which disease can be transmitted as opposed to the occurrence of fertilization - the simple transmission of a sperm into an egg.(1, 2, 3) Some claim that condoms will cut down on the spread of many sexually transmitted diseases, including AIDS.
However, a study published in Sexually Transmitted Diseases fails to show any reduction in newly acquired STDs among those who are described as "always users" of condoms. (4) S. duBose Ravenel, M.D., comments that "the obvious possibility that condoms do not provide significant protection was not even discussed by the authors." (5) According to Joe S. McIlhaney, Jr., M.D., there is clinical evidence to show that "the same rate of chlamydial infection occurs in those who use condoms and those who do not." We can conclude that the condom also fails to protect women from chlamydia trachomatis, "the most common bacterial sexually transmitted disease in the United States." (6) Doctors Zelig Friedman and Liliana Trivelli of the HIV/AIDS Advisory Council of New York City's Board of Education express grave concerns about condom effectiveness and write:
Although no one would argue that condoms may help reduce the risk of pregancy and of some diseases if used perfectly, a closer look at the circumstances of failure renders this option unacceptable. Condoms have a poor track record as contraceptives (15% failure for youngsters in the first year of use), offer no protection for chlamydia or HPV [human papiloma virus] and have a 2Đ4% rate of tearing, breakage and slippage. With regard to HIV they are not impermeable. (7)
THE SPERM VS. THE AIDS VIRUS
A paper in the February 1992 issue of Applied and Environmental Microbiology reports that filtration techniques show the HIV-1 virus to be 0.1 micron (4 millionths of an inch) in diameter. It is three times smaller than the herpes virus, 60 times smaller than the syphilis spirochete, and 50 to 450 times smaller than sperm. (8)
THE FLAWED CONDOM
Naval Research Laboratory (NRL) researchers, using powerful electron microscopes, have found that new latex, from which condoms are fabricated, contains "maximum inherent flaw[s]" (that is, holes) 70 microns in diameter. (9) These holes are 700 times larger than the HIV-1 virus. There are pores in latex, and some of the pores are large enough to pass sperm-sized particles. Carey, et al., observed leakage of HIV-sized particles through 33%+ of the latex condoms tested. In addition, as Gordon points out in his review, the testing procedures for condoms are less than desirable. United States condom manufacturers are allowed 0.4% leaky condoms (AQL). Gordon states, "The fluctuations in sampling permits many batches not meeting AQL to be sold." In the United States, 12% of domestic and 21% of imported batches of condoms have failed to meet the 0.4% AQL. (10)
CONDOMS FAIL TESTING
In a 1988 study sponsored by the National Institutes of Health, Bruce Voeller of the Mariposa Foundation in Topanga, California, a non-profit organization dedicated to preventing the spread of sexually transmitted diseases, ranked 31 brands of latex condoms according to how well they met the U.S. and international quality assurance standards designed to ensure that condoms provide an effective barrier against human sperm. "Many of the condoms now on the market would not get FDA approval if they were required to meet today's standards," says Voeller. Although all condoms sold in the U.S.are supposed to pass quality assurance tests, those marketed before 1976 need not meet the more stringent requirements necessary to win FDA marketing approval. (11)
Dr. Collart reports that "Gotszche and Hording in their study of in vivo [real life] condom failure rates concluded 'Condoms to prevent HIV transmission do not imply truly safe sex.' In addition Steiner, et al., observed newer lots of condoms had actual breakage rates of 3.5-8.8%, while actual breakage rates for older lots ranged from 9.8-18.6%. In a study conducted by Ahmed, et al., 29%-42% of those who had used condoms experienced at least one breakage. In a survey conducted by the University of Manchester, 52% of those who had obtained condoms from their family planning clinic had one or more either burst or slip off in the 3 months before the survey. In studies by Albert, et al., and by Wright, et al., 36% and 38% of their respondents reported condom failures respectively." (12)
CONDOM + SPERMICIDE
Some have advocated the use of spermicide containing nonoxynol-9 in the prevention of HIV infection. However, the protective effects of nonoxynol-9 have not been established in vivo for any of the viral STDs. Some reports suggest that spermicides (including nonoxynol-9) may be associated with irritation and ulceration of genital and rectal epithelia, side-effects that may actually facilitate HIV infection. In a study with Nairobi prostitutes, a higher rate of new HIV infections was found among women using nonoxynol-9 than among those not using it. Additionally, in a study of rhesus monkeys who were exposed to a high dose of simian immunodeficiency virus following vaginally inserted nonoxynol-9 foam, half the monkeys developed an infection. (13, 14, 15, 16)
CONDOM CLIMATE CONTROL
Condoms are sensitive to heat and cold, yet they are not normally transported in climate-controlled vehicles. Vesey, in his study of condoms,checked 72,000 trucks and has actual photographs of eggs frying in the backs of trucks used for condom distribution. Partly due to Vesy's study, Burlington County, NJ, banned the distribution of condoms at the county's AIDS counselling center, because they concluded that the risk of liability for condom failures was too great. (17)
In a 1990 review article by April and Schreiner, the authors summarize recent studies on HIV infection and conclude, "Recent studies on HIV prevention show the assumption that condoms provide reliable protection against HIV to be a dangerous illusion." The studies reviewed by the authors showed that the rate of seroconversion (HIV infection) associated with condom use ranged from 13% to 27% and more. (18) Frosner concludes that "Available data now indicate that efficacy of condoms has been largely overestimated." (19) In a study in Florida, where heterosexual couples used condoms, 17% of partners of AIDS patients became infected within 18 months, (20) despite the frequency of sexual relations being lower if one partner is HIV-positive.(21) Detels, et al., (22) observed a risk reduction of only 3.3:1 for those who used condoms with all of their partners, and a 1.8:1 increase in risk for those who used condoms for some of their partners as opposed to using condoms for none of their partners.
This would indicate that condoms are ineffective for prolonged or lifelong protection from AIDS. (23) In addition, since 100% condom use is difficult if not impossible to obtain, the realistic number to look at would be the risk while using condoms some of the time. It is more realistic to expect teens to be abstinent (which is 100% effective in preventing sexual transmission of HIV) than it is to expect them to use condoms 100% of the time (which has an HIV failure rate approaching 100% with life-long use.) Joffe, et al., (24) state: "The association between categories of condom use and history of an STD were not statistically significant at conventional levels after adjustment for number of partners." Cohen, et al., (25) conducted a study in which patients who had contracted an STD were given a condom education course. Within nine months "19.9% of the men and 12.6% of the women returned with new STD," some multiple times. The STD reinfection rate actually increased for women. Frosner states the U.S. government has withdrawn a $2.6 million grant to study condoms because "An unacceptably high number of condom users probably would have been infected in such a study."
PANACEA OR PLACEBO?
In conclusion, Herbert Ratner, M.D., offers the best summary of all when he says, Actually, the major accomplishment of the condom campaign to prevent AIDS is to impress the promoters, politicians and the public at large that something is being done; and although well-intentioned, it offers more of a placebo than a panacea. Publicizing the condom to the four winds is, for the most part, the bravura of a puritan who is trying to prove to the world that he is not a puritan. To concentrate on the mechanical aspects of the sex act to the exclusion of the emotional and psychological aspects (which the condom campaign ignores) is the essence of Puritanism. The only difference between the new and the old is that whereas the traditional puritans were alleged to believe that sex was something to be isolated and repressed, neo-puritans accept sex as something to be isolated and exercised. (28) Reviewed by Joel McIlhaney, M.D., of the Medical Institute for Sexual Health
1.Weller, Susan C., "A Meta-Analysis of Condom Effectiveness in Reducing Sexually Transmitted HIV," Social Science and Medicine, Vol. 36, #12, June 1993, pp. 1635-1644.
2.Smith, Richard W., The Condom: Is It Really Safe Sex? (unpublished, October 1990) pp. 8-9.
3.Collart, David G., M.D., Condom Failure for Protection From Sexual Transmission of the HIV: A Review of the Medical Literature, Feb. 16 1993.
4.Zenilman, Jonathan, et al., "Condom Use to Prevent Incident STDs: The Validity of Self-Reported Condom Use," Sexually Transmitted Diseases, Jan.-Feb. 1995, pp.15-21;
5.Ravenel S. duBose, M.D., "Comments and Observations," Aug. 5, 1995.
6.Joel McIlhaney, Jr., M.D., "Chlamydia Trachomatis; The Most Common Bacterial Sexually Transmitted Disease in the United States," Medical Institute for Sexual Health Sexual Health Update, Vol. 3, #3, Fall, 1995.
7.Friedman and Trivelli, "Condom Availability for Youth: A High Risk Alternative," Pediatrics, 2/97, p. 285.
8.Lytle, C. D., et al., "Filtration Sizes of Human Immunodeficiency Virus Type 1 and Surrogate Viruses Used to Test Barrier Materials," Applied and Environmental Microbiology, Vol. 58, #2, Feb. 1992.
9."Anomalous Fatigue Behavior in Polysoprene," Rubber Chemistry and Technology, Vol. 62, #4, Sep.-Oct. 1989.
10.Collart, David G., M.D., loc. cit.
11.Nowak, Rachel, "Research Reveals Condom Conundrums," The Journal of NIH Research, Vol. 5, Jan. 1993, pp. 32, 33.
12.Collart, David G., M.D., op. cit.
13.Bird, K.D., AIDS, Vol. 5, pp. 791-796, 1991.
14.Voeller, B., AIDS, Vol. 6, pp. 341-342, 1992.
15.Kreiss, J.; Ruminjo, I.; Ngugi, E.; Roberts, P.; Ndinya-Achola, J.; and Plummer, F., 1989 V International Conference on AIDS, Montreal.
16.Miller, C.J.; Alexander, N.J.; Sutjipto, S.; et al., J. Med. Primatol, Vol. 19, pp. 401-409, 1990.
17.Vesey, W.B., HLI Reports, Vol. 9, pp. 1-4, 1991.
18.April, K., and Schreiner, W., Schweiz. med. Wschr., Vol. 120, pp. 972-978, 1990.
19.Frosner, G.G., 1989, Infection, Vol. 17, pp. 1-3.
20.Fischl, M.A.; Dickinson, G.M.; Segsl, A.; Flanagan, S.; and Rodriguez, M.; Presentation THP. 92, III International Conference on AIDS in Washington D.C., 1-5 June, p. 178, 1987.
21.Klimes, I., et al., AIDS Care, Vol. 4, p. 151, 1992.
22.Detels, R.; English, P.; Visscher, B.R.; Jacobson, L.; Kingsley, L.A.; Chmiel, J.S.; Dudley, J.P.; Eldred, L.J.; and Ginzburg, H.M.;Journal of Acquired Immune Deficiency Syndromes, Vol. 2, pp. 77-83, 1989.
23.Gordon, R., loc. cit.
24.Joffe, G.P.; Foxman, B.; Schmidt, A.J.; Farris, K.B.; Carter, R.J.; Neumann, S.; Tolo, K.-A.; and Walters, A.M.; 1992, Sexually Transmitted Diseases, Vol. 19, pp. 272-278.
25.Cohen, D.A.; Dent, C.; MacKinnon, D.; and Hahn, G.; Sexually Transmitted Diseases, Vol. 19, pp. 245-251, 1992.
26.Fršsner, G.G., loc. cit.
27.Byer, C.O., and Shainberg, L.W., Dimensions of Human Sexuality, Wm. C. Brown Publishers, 1991.
28.Ratner, Herbert, M.D., "Condoms and AIDS," ALL About Issues, Feb. 1989, p. 36
ENVIRONMENTAL HEALTH NEWS
Tanzania - Ten million condoms fail checks
Thursday, May 16 2002
The Tanzanian government has announced
that it is to
destroy a shipment of 10 million condoms imported by the United Nations
for free distribution, after tests revealed that they were defective.
After testing samples from three containers of Singaporean condoms – worth approximately $800,000 – officials from the Tanzanian Bureau of Standards claimed that the prophylactics had failed “the water test” and should be destroyed.
The government has issued public assurances that the quality of condoms would not be compromised in its fight against Aids and that it was investigating how the consignment could be destroyed in an environmentally friendly way.
But, according to UN officials, the test applied by the bureau was too rigorous. World Health Organisation specifications state that condoms should be filled with water, while hanging vertically, to check for leaks. None of the consignment would have failed this test, claims the UN. But the condoms did fail when filled with water to check for visual defects, suggesting weak points.
The United Nations Fund for Population Activities imported the condoms in a bid to reduce the spread of Aids.The UN estimates that one in 10 Tanzanians are living with HIV/Aids. In some areas, rates of 44 per cent have been recorded among pregnant women. Unofficially, the rate is thought to be far higher.
BBC News, 20 January, 2004
Durex withdraws condom lubricant
The makers of Durex have ceased production of condoms containing a controversial lubricant amid doubts about its ability to prevent infection.
The lubricant, nonoxynol-9 (N-9), was originally thought to provide a high level of protection against infections such as HIV.
However, recent studies have shown that it may actually increase the risk.
Concerns had been raised by the World Health Organization, UNAIDS and the US Centres for Disease Control.
The UK National Aids Trust, which has campaigned for the removal of N-9 from condoms, applauded the decision.
Keith Winestein, campaigns manager, said: "This is a very welcome decision.
"A raft of agencies and organisations agree that N-9 is harmful and it needs to be removed from any products that might put the consumer at risk."
Call on the government
Mr Winestein said the government should re-double its efforts to ensure N-9 is removed from all condoms manufactured in the UK, as well as those sent overseas.
N-9, originally developed as a detergent, has been used for nearly 50 years as a vaginal cream that rapidly kills sperm cells.
Research indicated that N-9 can act to break up or irritate the cell lining, or epithelium, of the rectum and the vagina - the first line of defence against HIV and other diseases.
Such irritation can make it easier for a virus or other infective organism to invade.
The danger in anal sex is especially significant because the rectum has only a single-cell wall. The vagina has a wall that is about 40 cells thick.
When it comes to condoms, many of which are treated with N-9 inside and out, there is more HIV risk if the condom slips, breaks or is misused.
But there is also possible danger of N-9 breakdown of the anal or vaginal epithelium whether the condom breaks or not.
Durex condoms are manufactured by SSL International Plc.
In a statement, the company said: "SSL is anticipating a material reduction in demand for spermicidally-lubricated condoms following a recent WHO report which questioned the level of additional protection provided by such condoms when compared to non-spermicidally lubricated condoms.
"In light of this, SSL decided to discontinue using the spermicide N9 in our condom manufacturing process.
"As a result of this action, SSL will stop offering spermicidally lubricated condoms for sale and distribution."
Other companies, such as Johnson and Johnson, have already
products containing N-9.