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The condom conundrum: barriers to condom use among commercial sex workers in Durban, South Africa.

We examined socio-cultural and economic determinants of condom use among 100 female South African commercial sex workers. The symbolism and dynamics of condom use between sex workers and their clientele were explored. These issues were also investigated when sex workers negotiated sex with their personal partners. An additional focus was the extent to which HIV/AIDS influences women's condom use in these situations. Results demonstrate considerable contrast between factors influencing condom use in professional versus private sex situations. With clients, practical issues such as financial strain were the major obstacles to condom use. With personal sex partners, sex workers avoided condoms due to their negative symbolism. Condoms were seen as suggestive of filth, disease, infidelity, and mistrust. HIV/AIDS awareness had minimal impact on condom use. HIV/AIDS was viewed as a remote threat, overridden by immediate practical and emotional concerns. The intervention implications of condom symbolism and differential barriers to condom use are discussed.

Adult↗

Can condom users likely to experience condom failure be identified?

A study based on a convenience sample of 177 couples who each used 11 condoms found that 103 condoms (5.3%) broke before or during intercourse and 67 condoms (3.5%) slipped off during sex. Couples who had not used a condom in the past year were almost twice as likely to experience condom failure as were couples who had used at least one during that period (p < .001). Of the couples who had used a condom in the previous year, the failure rate among those who reported at least one condom break during that period was more than twice the failure rate among those who reported no breaks (p < .001). Among couples who had used condoms in the past year without breaking any, those who did not live with their partner and those who had a high school education or less were at increased risk of condom failure (adjusted odds ratios of 3.2 and 2.7, respectively).

Adolescent↗

Incorporating adolescent females' perceptions of their partners' attitudes toward condoms into a model of female adolescent condom use.

The highest rates of sexually transmitted infections in the U.S. occur among adolescent females. One prevention strategy promoted for sexually active adolescents is condom use: therefore, influences on correct and consistent condom use are worth examining. Because interventions and observational research into predicting and increasing condom use have yielded mixed results, we hypothesized that a theoretically driven model incorporating female adolescents' perceptions about partner sentiments along with their own perceptions, intentions, and behaviours would improve condom use predictions. We also measured condom use errors and consistency for a more precise estimate of effective use than is common in the literature. In three structural equation models tested on a sample of 519 female adolescents, we found that intentions were associated with both correct and consistent condom use; that females' expectancy beliefs about condom use were associated with intentions; and that females' expectancy beliefs about partners' sentiments reduced the impact of their expectancy beliefs about condom use. The implications of these relations upon condom use correctness and consistency are discussed with respect to informing interventions, among other future research.

Adolescent↗

Condom carrying is not associated with condom use and lower prevalence of sexually transmitted diseases among minority adolescent females.

BACKGROUND: Most of the studies associated with condom carrying and use have been conducted with adults. Because minority teenage females are particularly at risk for STD/HIV infection, further investigations specifically focusing on this population are warranted. GOAL: To determine whether observed condom carrying among adolescent females was associated with multiple measures of self-reported condom use, self-reported history of sexually transmitted diseases, and prevalence of biologically confirmed sexually transmitted diseases. METHODS: For this study, 522 sexually active African American adolescent females were recruited from low-income neighborhoods in Birmingham, Alabama. Measures of self-reported condom use, STD history, and condom carrying were collected. Adolescents were also tested for three prevalent sexually transmitted diseases. RESULTS: At the time of the assessment, 8% of the adolescents were observed to have a condom with them. Condom carrying was not found to be significantly associated with condom use and prevalence of sexually transmitted diseases. CONCLUSION: Condom carrying may not be an important outcome of sexually transmitted disease/HIV prevention programs designed to reduce HIV/sexually transmitted disease risk among adolescent females.

Adolescent↗

Reported condom use and condom use difficulties in street outreach samples of men of four racial and ethnic backgrounds.

The epidemiology of the HIV/AIDS epidemic in the United States has focused research attention on lesbian, gay, bisexual and transgendered communities as well as on racial and ethnic minorities. Much of that attention has, however, been focused on specific racial and ethnic groups, and specific sexual minorities. We report on the results of a study that examined the association between condom use and partnership types among men from four major racial/ethnic groups. Self-reported data on sexual identity (homosexual, bisexual, and heterosexual) and condom use in the past three months were collected from 806 African Americans, Hispanic, Asian, and white men intercepted in public places in Houston, TX. Data indicated that condom use was lowest in African Americans and Hispanic men, bisexual men reported the highest levels of use, with heterosexual men reporting the lowest use. African Americans and Hispanic men reported generally that it was very difficult to use a condom during sexual contact, although the patterns for self-identified homosexual, heterosexual, and bisexual men varied across race/ethnicity. Homosexual African American men reported the least difficulty, and white homosexual men the most difficulty compared with heterosexual and bisexual peers. For homosexually identified men, there were considerable differences across race/ethnicity in the proportion of partners who never or rarely disagreed to use condoms, with Asians disagreeing least, and African Americans most. Within racial/ethnic groups, the levels of condom use and difficulty were similar for male and female partners, suggesting that it is sexual identity, rather than partner gender, that has impacted condom-use messages. These data suggest that racial/ethnic targeting of condom use is likely to be most efficacious in increasing condom use in men.

Adolescent↗

Estimated condom failure and frequency of condom use among gay men.

OBJECTIVES: Condoms are designed to bar transmission of the human immunodeficiency virus (HIV), but they sometimes fail. This paper explores the effect of experience with condoms on condom failure among gay men. METHODS: Risk of condom failure (breakage or slippage) on a single occasion is estimated for four sexual acts reported over 12 months by a sample of gay New York City men (n = 741). The estimation procedure assumes that each episode in which a condom is used is an independent event. Evidence is offered to support this assumption. RESULTS: Risk of condom failure in a single episode was fairly high, particularly in anal intercourse, for men who had engaged in each act only a few times in the previous year. It declined rapidly with experience (e.g., to below 1% for receptive anal intercourse after about 10 episodes in the previous year). Condoms failed less often in oral than anal sex, but estimated risk of failure also decreased with experience. CONCLUSIONS: Gay men should be especially cautious the first few times they use a condom; after moderate experience, however, they may expect a low risk of condom failure.

Adolescent↗

Condom use to prevent incident STDs: the validity of self-reported condom use.

BACKGROUND: Studies of sexual behavior and of interventions designed to reduce human immunodeficiency virus risk usually depend on self-report. Validation of self-reported condom use measures has not been previously reported in an urban population at high risk for sexually transmitted diseases and human immunodeficiency virus. METHODS: A prospective cohort study was performed in subjects recruited from sexually transmitted disease clinics in Baltimore. At enrollment, a questionnaire was administered that assessed human immunodeficiency virus risk factors and sexually transmitted disease history, and used a retrospective calendar to assess sexual events and condom use over the previous 30 days. Clinical evaluation was performed for sexually transmitted diseases. At follow-up 3 months later, the same procedures were repeated. Incident sexually transmitted diseases at follow-up were defined as new culture or serologically documented diagnoses of gonorrhea, chlamydia, syphilis, or trichomoniasis. RESULTS: In the 323 male and 275 female (total = 598) subjects who completed a follow-up visit, 21% reported using condoms for every act of sexual intercourse over the previous 30 days, 21% reported occasionally using condoms, and 59% reported not using condoms. At follow-up, 21% of subjects had new incident gonorrhea, chlamydia, syphilis, or trichomoniasis. Fifteen percent of the men who were "always" condom users had incident sexually transmitted diseases compared with 15.3% of "never users;" 23.5% of women who were "always" users had incident sexually transmitted diseases compared with 26.8% of "never" users. CONCLUSIONS: In this high-risk population, self-reported condom use is not associated with lower sexually transmitted disease incidence. This finding suggests that self-reported condom use measures, even in a research setting, may be subject to substantial reporting bias.

Adult↗

Preliminary comparison of the polyurethane female condom with the latex male condom in Kenya.

This paper summarizes acceptability data published to date on the innovative female condom, and presents an additional study comparing the acceptability of the female condom and the latex male condom in a sample of low risk women attending private obstetrician/ gynaecologists' clinics in Nairobi, Kenya. Eighty-four percent of all subjects who completed interviewer-assisted questionnaires reported that they liked using the female condom, and more than two-thirds of all the women liked the female condom as much or better than the male condom. Fifty-five percent of the women would use the device in future if it were available. The least liked features were that the device was too large for easy insertion, messy to handle, and reduced sensation. Use became easier and more comfortable with experience. The most liked features were that the device made sex more enjoyable, protected against sexually transmitted diseases and pregnancy, and was under the woman's control. Male partner response was slightly less favourable, and sometimes resulted in women's noncompliance or discontinuation of use, despite the fact that such a device is supposed to empower women. This study provides preliminary data indicating that the female condom is a fairly acceptable method for some Kenyan couples, but recommends further research into safety, cost-effectiveness and hindrances to acceptability.

Adult↗

Condom performance during vaginal intercourse: comparison of Trojan-Enz and Tactylon condoms.

Forty-nine mutually monogamous couples used a total of 478 condoms during vaginal intercourse in a prospective trial whose purpose was to discover whether the performance of a new non-latex hypoallergenic condom was substantially equivalent to that of a leading condom brand already being marketed. Of these 478 condoms, seven (1.46%) either broke or fell off the penis during intercourse. Two (0.42%) of the 471 condoms that did not break or fall off during intercourse fell off the penis when it was being withdrawn from the vagina. Altogether, 469 (98.1%) of the 478 condoms used for intercourse survived intact throughout intercourse and withdrawal. Differences in breakage and slippage rates for the two condom brands were statistically insignificant. The overall 98.1% success rate is much higher than the rate of success found in a previous condom trial with nearly identical research protocol. The reason for the difference is attributed to much more precise questioning of subjects in the current trial.

Adult↗

Cost as a barrier to condom use: the evidence for condom subsidies in the United States.

OBJECTIVES: This study sought to determine the impact of price on condom use. METHODS: A program based on distribution of condoms at no charge was replaced with one providing low-cost condoms (25 cents). Pretest and posttest surveys asked about condom use among persons reporting 2 or more sex partners. RESULTS: At pretest, 57% of respondents had obtained free condoms, and 77% had used a condom during their most recent sexual encounter. When the price was raised to 25 cents, the respective percentages decreased to 30% and 64%. CONCLUSIONS: Cost is a barrier to condom use. Free condoms should be distributed to encourage their use by persons at risk for HIV and other sexually transmitted diseases.

Adolescent↗

Condom availability programs in Massachusetts high schools: relationships with condom use and sexual behavior.

OBJECTIVES: This study assessed relationships between condom availability programs accompanied by community discussion and involvement and adolescent sexual practices. METHODS: Sexual practice and condom use differences were assessed in a representative sample of 4166 adolescents enrolled in high schools with and without condom availability programs. RESULTS: Adolescents in schools where condoms were available were more likely to receive condom use instruction and less likely to report lifetime or recent sexual intercourse. Sexually active adolescents in those schools were twice as likely to use condoms, but less likely to use other contraceptive methods, during their most recent sexual encounter. CONCLUSIONS: The strategy of making condoms available, an indication of socioenvironmental support for condom use, may improve HIV prevention practices.

Adolescent↗

Examination of the relationship between African American adolescents' condom use at sexual onset and later sexual behavior: implications for condom distribution programs.

School-based condom distribution programs have generated considerable controversy across the country. In the present study 249 sexually active African American adolescents who did (n = 119) and did not (n = 130) use a condom during their initial sexual experience were compared to assess whether condom use at the onset of sexual activity was associated with later differences in sexual behavior. The results indicated that youths who used a condom from the onset of sexual activity were more likely to have used a condom in the most recent intercourse occasion, less likely to be diagnosed with a sexually transmitted disease (STD) or to combine substance use with sexual activity, endorsed more positive attitudes toward condoms, and were older when they initiated sexual activity. The findings have implications for condom availability programs and indicate that initial condom use was not associated with earlier onset of sexual activity and was associated with higher rates of precautionary behavior among sexually active minority adolescents.

Adolescent↗

Recent use of condoms and emergency contraception by women who selected condoms as their contraceptive method.

OBJECTIVE: This study was undertaken to determine how consistently indigent, predominantly Hispanic women who had previously selected male condoms as their contraceptive method had used condoms and emergency contraception (EC) during the 2 weeks before their family planning clinic visit and reasons for any nonuse. STUDY DESIGN: Cross-sectional survey with no personal identifiers collected. RESULTS: Two hundred forty-eight women were surveyed. Overall, 43.8% of sexually active women reported inconsistent condom use during the prior 14 days. Only 39% of women who had not used condoms consistently used EC at least once. The most common reason for nonuse of both condoms (44%) and EC (41%) was that the woman did not perceive that she was at risk. CONCLUSION: Inconsistent use of condoms and low use of EC are very frequent, even in a short-time frame. Patients may be reluctant to volunteer to clinicians their real contraceptive choices. Risk taking occurs at high rates, even among couples provided ready and free access to male condoms and EC.

Adult↗

Correlates of condom use and reasons for condom non-use among drug users.

Two hundred and seventy-seven drug using adults were interviewed regarding details of their most recent sexual encounter. Demographic, attitudinal, and context variables were associated with condom use and non-use. Greater perceived risk of STDs/HIV and positive attitudes toward condoms' effect on sexual pleasure were associated with greater likelihood of reporting condom use. Common reasons for not using condoms included lower perceived risk of contracting HIV/STDs, negative attitudes toward condoms' effect on pleasure, and lack of condom availability. Tailoring messages to modifiable perceptions of risk and condom attitudes may be useful in reducing sexual risk among drug-using individuals.

Adolescent↗

Condom use and sexual behaviors among individuals procuring free male condoms in South Africa: a prospective study.

BACKGROUND: Although the South African government has increased the number of male condoms distributed free to the public, there is no understanding of whether these are being used effectively to prevent the spread of sexually transmitted diseases, including HIV infection. GOAL: The study goal was to determine sexual behaviors and barriers to condom use among individuals procuring condoms distributed free to the public sector. STUDY DESIGN: In a prospective study, individuals who procured condoms from 12 public health facilities across South Africa were recruited and observed for the next 5 weeks. RESULTS: The 384 successfully observed subjects reported 3262 sexual contacts, of which 2637 (81%) involved protection with a condom. In multivariate analysis, alcohol consumption and use of other contraceptives were associated with unprotected sexual intercourse. CONCLUSION: The levels of condom use are relatively high in this population, but these data highlight several important barriers to condom use that may be targeted by future interventions.

Adult↗

Correlates of condom use and attitudes to condoms and AIDS in a group of Darwin women.

This study investigated the use of condoms, attitudes to condoms and correlates of these in women in Darwin, Northern Territory, Australia. A survey using a Condom Attitudes Scale was administered to a convenience sample of 160 women. With regular partners, these women had a low level of use of condoms, with a somewhat higher level of use with casual partners. Their perceived risk of Human Immunodeficiency Virus and other sexually transmitted diseases was not strong. These women's attitude towards the condom was reasonably positive. The major factor that correlated with attitudes to condoms was the type of relationship with a partner. This paper demonstrates the need for health professionals to continue to promote condom use among women.

Acquired Immunodeficiency Syndrome↗

Association between condom use and HIV infection: a randomised study of self reported condom use measures.

STUDY OBJECTIVE: To compare the association between different measures of condom use and prevalent HIV infection. DESIGN: Randomised cross sectional study to assess association between HIV infection and different measures of self reported condom use. Female sex workers were randomised to one of five different face to face questionnaires on condom use. Three questionnaires used always to never scales to measure use but differed in the reference period for use; a fourth asked about use in the last 10 coital acts; and the fifth was a retrospective log of coital acts in the past two weeks. Use was assessed with new clients, repeat clients, and non-clients. SETTING: Yaoundé and Douala, Cameroon. PARTICIPANTS: 2266 female sex workers. MAIN RESULTS: The association between condom use and prevalent HIV infection varied for different measures of condom use. None of the five level measures showed a dose response protective effect of condom use. Measures aimed at reducing recall bias (measures based on the past 10 coital acts or a coital log) showed little or no association with prevalent infection. Measures based on the past month or six months had a stronger association with prevalent infection. Regardless of the type of measure or reference period, the strongest association between use and infection was for use with partners who were not clients. CONCLUSION: These findings underscore challenges described by others of measuring condom use and interpreting the association between use and prevalent infection.

Adolescent↗

A randomized controlled trial comparing nonoxynol-9 lubricated condoms with silicone lubricated condoms for prophylaxis.

OBJECTIVE: We tested the effect of nonoxynol-9 (N-9) in condom lubrication on the risk of acquiring STD and genital discomfort. METHODS: The study was a triple masked, randomised controlled trial comparing N-9 lubricated condoms with plain silicone lubricated condoms among Dominican female sex workers. RESULTS: Randomisation provided two groups (313 for N-9 and 322 for plain) similar in baseline characteristics, but extensive loss to follow up occurred (56 women in each group completed the 24 week follow up). Most vaginal acts with clients were protected with condoms (99% of vaginal sex) but fewer acts with non-clients were protected (43% of vaginal sex). No significant differences occurred in rates of cervical infections (N-9 = 3.4 per 100 person months v plain = 2.8), trichomoniasis (N-9 = 2.8 v plain = 3.6), or discomfort rates (N-9 = 0.82 v plain = 0.92). CONCLUSIONS: Plain silicone lubricated condoms are as effective as N-9 lubricated condoms, cost less, have longer expected shelf life, and therefore may be the better condom to provide.

Adolescent↗