**IL 10-2001-012**

In Reply Refer To: 13B

**August 16, 2001**

**UNDER SECRETARY FOR HEALTH'S INFORMATION LETTER**

# 

# ACCESS TO CONDOMS AS HIV PREVENTION

**1.** This Information Letter provides information on the use of
condoms in the prevention of human immunodeficiency virus (HIV);
provides guidance and further information on the Veterans Health
Administration (VHA) existing policy on providing male and female
condoms through the National Formulary; and provides recommendations on
the prescribing of condoms.

**2. Background**

a\. In the absence of a cure or preventive vaccine, consistent use of
barrier methods, such as the condom, remains the single best method of
preventing transmission of HIV. Multiple cohort studies, including those
of serodiscordant couples, have demonstrated a strong protective effect
of condom use against HIV infection. Consistent use of condoms has been
found to reduce the risk of HIV transmission by 87 to 95 percent.
Condoms also play an important role in the prevention of transmission of
sexually transmitted diseases that are transmitted through genital
secretions or genital ulcerative diseases when the ulcers or lesions
occur in areas covered or protected by the condom. Finally, as the most
recent data from the Centers of Disease Control and Prevention have
suggested that 10 to 15 percent of cases of hepatitis C may be secondary
to sexual transmission, condoms may also play a role in preventing
transmission of hepatitis C.

b\. Thus, education about risk reduction and access to condoms for male
and female veterans is a key component of VHA's program to prevent HIV,
hepatitis C and sexually transmitted diseases (STDs) and their impact on
veterans and VHA. As the nation's largest single provider of HIV care,
it is important that the Department of Veterans Affairs (VA) be a leader
in the integration of HIV prevention into clinical care.

c\. Findings from a recent national survey conducted by the Pharmacy
Benefits Management Strategic Health Care Group suggest that while many
pharmacies in the VA health care system routinely stock the male latex
condom and the female polyurethane condom, they may be underutilized and
are not routinely being prescribed to veterans with HIV, or those at
high-risk for HIV.

**3. A Reminder of VA Policy on the National Formulary**

a\. Both male latex and the female polyurethane condoms are currently
available on the VHA National Formulary and are classified as a medical
supply (VA CLASS XA900). Male and female veterans can be prescribed any
type of condom, as best suits their individual prevention needs.

b\. As stated in VHA Directive 2001-044, "Items listed in the FORMULARY
must be made available throughout the VA health care system and cannot
be made non-formulary at the Veterans Integrated Service Network (VISN),
or local level. Restrictions can be established at the national, VISN or
local level for formulary items that require close monitoring to ensure
appropriate use. Restrictions may include evidence-based guidelines
and/or prescribing privileges for providers with certain expertise.
Restrictions will not be based solely on economic issues and will not be
so limited as to prevent patients with legitimate needs from receiving
FORMULARY medications."

### 4. Recommendations 

a\. The Public Health Strategic Health Care Group (PHSHG) and the
Pharmacy Benefits Management (PMB) Strategic Health Care Group recommend
that patients with HIV [routinely]{.underline} be asked if they wish to
receive a prescription for condoms in order to help prevent transmission
of HIV to others through sexual contact. Condom use is to be strongly
encouraged for veterans with HIV, as part of their routine care.

b\. It is strongly recommended that condom use and the potential need
for prescriptions be routinely discussed with patients who:

\(1\) Are not HIV positive, but who report high-risk activities such as
unprotected sex with multiple sexual partners.

\(2\) Have been diagnosed with an STD.

\(3\) Have a history or current diagnosis of injection drug use or
substance abuse.

\(4\) Have tested positive for hepatitis C or hepatitis B.

**NOTE:** It is also recommended that the potential need for condoms be
discussed with veterans who are being evaluated or treated for impotence
or erectile dysfunction if they also report high-risk sexual behaviors
or multiple sexual partners.

c\. VA Pharmacy staff are encouraged to work closely with local
providers to ensure that condoms are readily available to patients who
require them. To help offset the cost of increased condom dispensing,
the PBM and PHSHGs have arranged for the availability of male condoms
through the Pharmaceutical Prime Vendor (PPV) at a greatly reduced cost.
Lubricated male condoms are available through the VA PPV for \$43.75 per
1,008. **NOTE:** The PPV Item Number for the reduced price condoms is
4190914.

**5. References**

a\. Centers for Disease Control and Prevention. "Sexually Transmitted
Disease Treatment Guidelines," [Morbidity and Mortality Weekly
Report]{.underline} ([MMWR).]{.underline} 1993; 42 (No. RR-14).

b\. Centers for Disease Control and Prevention. Latex Condoms and STDs
Prevention Messages, July 2001.

c\. Wald, A., Langenberg, A.G.M., Link, K., Izu, A.E., Ashley, R.,
Warran, T., Tyring, S., Douglas, J.M., and Corey. L. Effect of Condoms
Reducing the Transmission of Herpes Simplex Virus Type 2 from Men to
Women," [Journal of the American Medical Association]{.underline}
([JAMA)]{.underline}, 2001; 285:3100-3106.

d\. Centers for Disease Control and Prevention. "Recommendations for
Prevention and Control of Hepatitis C Virus (HCV) Infection and
HCV-Related Chronic Disease" [MMWR]{.underline} 1998; 47 (No. RR-19).

**6.** Questions may be referred to Kim Hamlett-Berry, Ph.D., Director
of HIV and Hepatitis C Prevention Service, Public Health Strategic
Health Care Group (13B), at (202) 273-8929, or Michael Valentino, R.
Ph., MHSA, Associate Chief Consultant, Pharmacy Benefits Management
Strategic Health Care Group, at (708) 786-7886.

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                                  S/ Tom Sanders for

                                  Thomas L. Garthwaite, M.D.

                                  Under Secretary for Health
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  DISTRIBUTION:   CO:     E-mailed 8/17/2001

                  FLD:    VISN, MA, DO, OC, OCRO, and 200 -- E-mailed
                          8/17/2001
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