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Another is that the HIV-positive partner will be chronically infected and so will not have the very high viral load characteristic of acute HIV infection.Thirdly, in long-term serodiscordant relationships, studies have shown that the HIV-negative partner can acquire a degree of immunity to their partner’s HIV.

One disadvantage is that condom use in long-term relationships, even in serodiscordant couples, is relatively rare.Laboratory studies and product testing have shown that reputable condoms tested in the laboratory are completely impermeable to micro-organisms as small as viruses.However, the same studies show that condoms come off the penis altogether 3 to 5% of the time but may slip down (but not off) up to 13% of the time.Studies of condom efficacy have therefore largely contrasted HIV and STI incidence or prevalence in people who claim 100% consistent use against people who use them inconsistently or not at all.Because these studies involve private behaviours that investigators cannot observe directly, it is difficult to determine accurately whether an individual is a condom user and whether condoms are used consistently and correctly.These margins of uncertainty...should represent an obligation on the part of the health ministries and all these campaigns to act in the same way as they do with regard to cigarettes, which they state to be a danger." Finding out the degree to which condoms protect against HIV is important both for HIV-negative people who want to protect themselves against HIV, and HIV-positive people who want to avoid transmitting it.

Knowing how well they protect against other STIs is important for sexual health in general and may be particularly important for people with HIV, who may be more vulnerable to the effects of certain STIs.

For these reasons, HIV transmission within long-term serodiscordant relationships, especially heterosexual ones, may be rarer than it is between casual sex partners.

For all these reasons, large studies may be needed to establish differences in HIV (and HSV and HPV) incidence between condom users and non-users.

The next problem is deciding what kind of study provides truly reliable evidence.

It would be unethical to mount a randomised trial of condom use because the control group would have to stop using them altogether.

The evidence we have is based on three types of trials, and each has potential weaknesses.