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One widely quoted remark of this nature came from Ugandan President Yoweri Museveni who, at the Fifteenth International AIDS Conference in Bangkok in 2004, advocated for HIV prevention based on “optimal relationships based on love and trust instead of institutionalised mistrust, which is what the condom is all about…I think of condoms as an improvisation, not a solution”.

(See the text of Museveni’s speech.) Museveni later complained of being misunderstood and signed an article in The Lancet saying that condoms formed a valuable part of HIV prevention.

In these circumstances, it is easy to see why condoms sometimes fail, even in consistent users.

In addition, however, people are not consistent in their use of condoms, and may not even be consistent when they claim to be, or think they are.

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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.

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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.

Research early on in the epidemic showed that 40 to 70% of men who claimed they use condoms 100% of the time in fact did not use them for every act of intercourse.

Twenty years later, 51 to 66% of women taking part in a microbicide study reported 100% condom usage at different time points during the trial, but the researchers calculated from inconsistency in their answers that the actual proportion who maintained 100% condom use was 25%.

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