The Effect of Correct and Consistent Condom Use on Chlamydial and Gonococcal Infection Among Urban Adolescents

Barrier Protection Use by Adolescents During Sexual Activity

Rates of sexual activity, pregnancies, and births among adolescents have continued to decline during the past decade to historic lows. Despite these positive trends, many adolescents remain at risk for unintended pregnancy and sexually transmitted infections (STIs). This technical report discusses the new data and trends in adolescent sexual behavior and barrier protection use. Since 2017, STI rates have increased and use of barrier methods, specifically external condom use, has declined among adolescents and young adults. Interventions that increase availability of or accessibility to barrier methods are most efficacious when combined with additional individual, small-group, or community-level activities that include messages about safer sex. Continued research informs public health interventions for adolescents that increase the consistent and correct use of barrier methods and promote dual protection of barrier methods for STI prevention together with other effective methods of contraception.

Sexual Behaviors, Referral to Sexual Health Services, and Use of Sexual Health Services Among Transgender High School Students

BACKGROUND

Transgender adolescents are at increased risk for negative sexual health outcomes compared to their cisgender peers.

METHODS

Using data from 10,231 students from 7 high schools in a large, urban school district, our analysis compared sexual behaviors, referral to sexual health services by school staff, and use of sexual health services between transgender and cisgender students. We used propensity score matching to create a comparable sample of transgender and cisgender students and logistic regression models to examine how gender identity was associated with aforementioned outcomes.

RESULTS

Transgender students were more likely to have ever had sex, less likely to have used a condom at last sex, and more likely to have been referred for human immunodeficiency virus (HIV) testing, sexually transmitted disease (STD) testing, and other sexual health services than cisgender students. Transgender students were no more likely than cisgender students to have tested for HIV or STDs.

CONCLUSIONS

These findings underscore the need for understanding the risk perceptions held by transgender students and for prevention efforts that are inclusive for all gender identities. Research is needed to understand if school-based sexual health interventions such as staff referrals for sexual health services are effective for transgender students.

Condom Availability Programs in Schools: A Review of the Literature

OBJECTIVE

This review synthesizes findings from the peer-reviewed evaluation literature on condom availability programs (CAPs) in secondary schools.

DATA SOURCE

Peer-reviewed evaluation literature indexed in MEDLINE, EMBASE, PsychINFO, ERIC, CINAHL, Sociological Abstracts, SCOPUS, and POPLINE.

STUDY INCLUSION AND EXCLUSION CRITERIA

Manuscripts had to be, written in English, and report evaluation data from a US school-based CAP.

DATA EXTRACTION

Articles were coded independently by 2 authors. Discrepancies were resolved through open discussion.

DATA SYNTHESIS

We grouped findings into outcome evaluation and process evaluation findings. Outcome evaluation findings included sexually transmitted infections (STIs), pregnancy rates, condom use, contraception use, sexual risk, and substance use. Process evaluation findings included awareness of CAPs, attitudes toward CAPs, attitudes toward condoms, and receipt of education and instruction.

RESULTS

Of the 138 citations reviewed, 12 articles published between 1995 and 2012 met the inclusion criteria, representing 8 programs. Evaluations indicate CAPs yield condom acquisition rates between 23% and 48%, have mixed results related to condom use, and are not associated with increases in sexual and other risk behaviors. One program found CAPs were associated with a decrease in a combined rate of chlamydia and gonorrhea. One program found no association between CAPs and unintended pregnancy. Students' attitudes toward CAPs were favorable and awareness was high.

CONCLUSIONS

Condom availability programs are accepted by students and can be an appropriate and relevant school-based intervention for teens. Condom availability programs can increase condom use, but more evaluations are needed on CAP impact on rates of HIV, STIs, and unintended pregnancy.

Population-based study of chlamydial and gonococcal infections among women in Shenzhen, China: Implications for programme planning

This study was aimed to estimate the prevalences of chlamydia (CT) and gonococcal (NG) infections and explore risk factors associated with the CT infection among women in Shenzhen, China. We collected socio-demographic and clinical data from women (aged 20–60) and determined positivity of CT or NG by nucleic acid amplification test (NAAT) with self-collected urine specimens. We estimated prevalence of CT and NG and determined risk factors associated with CT infection. Among 9,207 participants, 4.12% (95% confidence interval [CI], 3.71%-4.53%) tested positive for CT and 0.17% (95% CIs, 0.09%-0.25%) for NG. Factors significantly associated with CT infection included being an ethnic minority (ethnicity other than Han China) (Adjusted odds ratio [AOR], 1.9; 95% CI, 1.2–3.0), using methods other than condom for contraception (AOR, 1.5; 95% CI, 1.2–1.8), having a history of adverse pregnancy outcomes (AOR, 1.4; 95% CI, 1.1–1.8), and experiencing reproductive tract symptoms in the past three months (AOR, 1.3; 95% CI, 1.0–1.7). we found that CT infection is prevalent among women in Shenzhen, China and associated with both demographic and behavioral factors. A comprehensive CT screening, surveillance and treatment programme targeting this population is warranted.

A Daily Diary Analysis of Condom Breakage and Slippage During Vaginal Sex or Anal Sex Among Adolescent Women

BACKGROUND

Adolescent women are disproportionately impacted by the adverse outcomes associated with sexual activity, including sexually transmitted infections (STI). Condoms as a means of prevention relies on use that is free of usage failure, including breakage and/or slippage. This study examined the daily prevalence of and predictors of condom breakage and/or slippage during vaginal sex and during anal sex among adolescent women.

METHODS

Adolescent women (N = 387; 14 to 17 years) were recruited from primary care clinics for a longitudinal cohort study of STIs and sexual behavior. Data were daily partner-specific sexual diaries. Random intercept mixed-effects logistic regression was used to estimate the fixed effect of each predictor on condom breakage/slippage during vaginal or during anal sex (Stata, 13.0), adjusting model coefficients for the correlation between repeated within-participant diary entries.

RESULTS

Condom slippage and/or breakage varied across sexual behaviors and was associated with individual-specific (eg, age and sexual interest) and partner-specific factors (eg, negativity). Recent behavioral factors (eg, experiencing slippage and/or breakage in the past week) were the strongest predictors of current condom slippage and/or breakage during vaginal or anal sex.

CONCLUSIONS

Factors associated with young women's condom breakage/slippage during vaginal or during anal sex should be integrated as part of STI prevention efforts and should be assessed as part of ongoing routine clinical care.

Condom Availability in Schools: A Practical Approach to the Prevention of Sexually Transmitted Infection/HIV and Unintended Pregnancy

Adolescents and young adults are highly impacted by sexually transmitted infections (STIs) and unplanned pregnancy in the United States and globally. Consistent and correct use of male latex condoms is associated with protection against both STIs and pregnancy. Providing adolescents and young adults with access to free condoms in schools may increase the use of condoms by improving condom availability, eliminating cost, and decreasing embarrassment associated with purchasing condoms. Studies demonstrate that condom availability in schools is associated with the increased use of condoms and improved overall sexual health. The Society for Adolescent Health and Medicine encourages schools to make condoms available to students as part of efforts to decrease rates of STIs and unplanned pregnancy in adolescents and young adults. The Society for Adolescent Health and Medicine also encourages health care providers to advocate for and support the availability of condoms in local schools.

Estimating the Prevalence and Predictors of Incorrect Condom Use Among Sexually Active Adults in Kenya: Results From a Nationally Representative Survey

BACKGROUND

Condom use continues to be an important primary prevention tool to reduce the acquisition and transmission of HIV and other sexually transmitted infections. However, incorrect use of condoms can reduce their effectiveness.

METHODS

Using data from a 2012 nationally representative cross-sectional household survey conducted in Kenya, we analyzed a subpopulation of sexually active adults and estimated the percent that used condoms incorrectly during sex, and the type of condom errors. We used multivariable logistic regression to determine variables to be independently associated with incorrect condom use.

RESULTS

Among 13,720 adolescents and adults, 8014 were sexually active in the previous 3 months (60.3%; 95% confidence interval [CI], 59.0-61.7). Among those who used a condom with a sex partner, 20% (95% CI, 17.4-22.6) experienced at least one instance of incorrect condom use in the previous 3 months. Of incorrect condom users, condom breakage or leakage was the most common error (52%; 95% CI, 44.5-59.6). Factors found to be associated with incorrect condom use were multiple sexual partnerships in the past 12 months (2 partners: adjusted odds ratio [aOR], 1.5; 95% CI, 1.0-2.0; P = 0.03; ≥3: aOR, 2.3; 95% CI, 1.5-3.5; P < 0.01) and reporting symptoms of a sexually transmitted infection (aOR, 2.8; 95% CI, 1.8-4.3; P < 0.01).

CONCLUSIONS

Incorrect condom use is frequent among sexually active Kenyans and this may translate into substantial HIV transmission. Further understanding of the dynamics of condom use and misuse, in the broader context of other prevention strategies, will aid program planners in the delivery of appropriate interventions aimed at limiting such errors.

2015 UK national guideline for the management of infection with Chlamydia trachomatis

This guideline offers recommendations on the diagnostic tests, treatment regimens and health promotion principles needed for the effective management of Chlamydia trachomatis genital infection. It covers the management of the initial presentation, as well the prevention of transmission and future infection. The guideline is aimed at individuals aged 16 years and older presenting to healthcare professionals working in departments offering Level 3 care in sexually transmitted infections management within the UK. However, the principles of the recommendations should be adopted across all levels, using local care pathways where appropriate.

Contraception for adolescents

Contraception is a pillar in reducing adolescent pregnancy rates. The American Academy of Pediatrics recommends that pediatricians develop a working knowledge of contraception to help adolescents reduce risks of and negative health consequences related to unintended pregnancy. Over the past 10 years, a number of new contraceptive methods have become available to adolescents, newer guidance has been issued on existing contraceptive methods, and the evidence base for contraception for special populations (adolescents who have disabilities, are obese, are recipients of solid organ transplants, or are HIV infected) has expanded. The Academy has addressed contraception since 1980, and this policy statement updates the 2007 statement on contraception and adolescents. It provides the pediatrician with a description and rationale for best practices in counseling and prescribing contraception for adolescents. It is supported by an accompanying technical report.

Contraception for adolescents

A working knowledge of contraception will assist the pediatrician in both sexual health promotion as well as treatment of common adolescent gynecologic problems. Best practices in adolescent anticipatory guidance and screening include a sexual health history, screening for pregnancy and sexually transmitted infections, counseling, and if indicated, providing access to contraceptives. Pediatricians' long-term relationships with adolescents and families allow them to help promote healthy sexual decision-making, including abstinence and contraceptive use. Additionally, medical indications for contraception, such as acne, dysmenorrhea, and heavy menstrual bleeding, are frequently uncovered during adolescent visits. This technical report provides an evidence base for the accompanying policy statement and addresses key aspects of adolescent contraceptive use, including the following: (1) sexual history taking, confidentiality, and counseling; (2) adolescent data on the use and side effects of newer contraceptive methods; (3) new data on older contraceptive methods; and (4) evidence supporting the use of contraceptives in adolescent patients with complex medical conditions.

Asking only "Did you use a condom?" underestimates the prevalence of unprotected sex among perinatally HIV infected and perinatally exposed but uninfected youth

Among young adults who use condoms, incomplete condom use (putting a condom on after beginning or taking a condom off before finishing sex) and condom failure (condom breaking or slipping off during sex) are common. Therefore, sexual behavior surveys that ask only if a condom was used are likely to underestimate the actual prevalence of unprotected sex. This study examined data from 135 sexually active perinatally HIV-infected (PHIV+) youth and perinatally exposed but uninfected (PHIV-) youth, ages 13 to 24. Participants were asked whether they used a condom on their first and their most recent occasion of vaginal sex. Youth who reported using a condom were asked a follow-up question about whether there was any time during that occasion when sex was not protected by a condom. This follow-up question identified additional participants--almost double the proportions who initially said they did not use a condom--who had unprotected sex. Incomplete condom use was similar among PHIV+ and PHIV-youth, boys and girls, Latinos and African Americans, and younger and older youth. These findings illustrate the importance of asking specifically about whether any unprotected behavior occurred from start to finish of sex to achieve more valid estimates of sexual risk behavior.

Condom Use by Adolescents

Rates of sexual activity, pregnancies, and births among adolescents have continued to decline during the past decade to historic lows. Despite these positive trends, many adolescents remain at risk for unintended pregnancy and sexually transmitted infections (STIs). This policy statement has been developed to assist the pediatrician in understanding and supporting the use of condoms by their patients to prevent unintended pregnancies and STIs and address barriers to their use. When used consistently and correctly, male latex condoms reduce the risk of pregnancy and many STIs, including HIV. Since the last policy statement published 12 years ago, there is an increased evidence base supporting the protection provided by condoms against STIs. Rates of acquisition of STIs/HIV among adolescents remain unacceptably high. Interventions that increase availability or accessibility to condoms are most efficacious when combined with additional individual, small-group, or community-level activities that include messages about safer sex. Continued research is needed to inform public health interventions for adolescents that increase the consistent and correct use of condoms and promote dual protection of condoms for STI prevention with other effective methods of contraception.

A Longitudinal Examination of Risk and Protective Factors Associated with Drug Use and Unsafe Sex among Young African American Females

This study prospectively examined associations among multiple theoretically informed risk (e.g., depression, sexual sensation seeking, and risky peers norms) and protective factors (e.g., social support, STI knowledge, and refusal to have sex self efficacy) on unsafe sex among 715 African American adolescent females aged 15-21 who participated in an STI/HIV prevention intervention. Generalized estimating equation models were used to assess associations between baseline characteristics and sexual risk over a 12-month follow up period. Overall risk in this population was high: at baseline, nearly a third of women reported sex under the influence of alcohol or substances; ≥ 2 partners for vaginal sex, and casual sex partners in the 60 days prior to baseline, and nearly 75% of those reporting vaginal sex used condoms inconsistently. In multivariable analysis, when risk and protective factors were simultaneously considered, higher levels of sexual sensation seeking were associated with having multiple sex partners and inconsistent condom use. Greater perception of risky peer norms was associated with a higher risk of having sex under the influence of alcohol or drugs. In addition, higher sex refusal self-efficacy was protective against having multiple; casual; and concurrent sex partners. Incorporating these salient factors into prevention programs may be critical to the development of targeted interventions for this population.

Factors associated with condom use problems during vaginal sex with main and non-main partners

BACKGROUND

Incorrect condom use is a common problem that can undermine their prevention impact. We assessed the prevalence of 2 condom use problems, breakage/slippage and partial use, compared problems by partnership type, and examined associations with respondent, partner, and partnership characteristics.

METHODS

Data were collected at 3-month intervals during a 12-month period (1999-2000) among urban sexually transmitted disease (STD) clinic users. Condom use problems were compared between partnership types using z tests for equality of proportions. Logistic generalized estimating equations modeling accounted for within-participant correlation of repeated measures.

RESULTS

Overall 3297 respondents reported 9304 main and 6793 non-main partnerships; condoms were used at least once in 4942 (53.0%) and 4523 (66.6%) of these partnerships, respectively. Condom breakage/slippage was reported during 6.0% of uses (5.1% main, 9.4% non-main) and partial use during 12.5% of uses (12.8% main, 11.5% non-main). The proportion of respondents experiencing any condom use problem in the prior 3 months was higher among main compared with non-main partnerships: 39.1% versus 29.9% had either problem; 22.5% versus 19.0% had breakage/slippage only; 21.8% versus 18.7% had partial use; and 8.7% versus 7.1% had both use problems. In multivariable analysis, factors associated with condom use problems varied by partnership type and respondent sex. The most common predictors of problems across models were sex while high and inconsistent condom use.

CONCLUSIONS

This study highlights the diverse set of risk factors for condom use problems at the individual, partner, and partnerships levels.

Gender-specific relationships between depressive symptoms, marijuana use, parental communication and risky sexual behavior in adolescence

A large body of research has identified correlates of risky sexual behavior, with depressive symptoms and marijuana use among the most consistent psychosocial predictors of sexual risk. However, substantially less research has examined the relationship between these risk variables and adolescent risky sexual behavior over time as well as the interaction of these individual-level predictors with family-level variables such as parenting factors. Additionally, most studies have been restricted to one index of risky sexual behavior, have not taken into account the complex role of gender, and have not controlled for several of the factors that independently confer risk for risky sexual behavior. Therefore, the current study investigated the association between depressive symptoms and parameters of parenting on marijuana use, number of sexual partners and condom usage measured 9 months later for both boys and girls. Participants were 9th and 10th grade adolescents (N = 1,145; 57.7% female). We found that depressive symptoms may be a gender-specific risk factor for certain indices of risky sexual behavior. For boys only, marijuana use at Time 2 accounted for the variance in the relationship between depressive symptoms at Time 1 and number of partners at Time 2. Additionally, strictness of family rules at Time 1 was associated with the number of partners with whom girls engaged in sex at Time 2, but only among those with lower levels of depressive symptoms at Time 1. Results from the current investigation speak to the utility of examining the complex, gender-specific pathways to sexual risk in adolescents. Findings suggest that treatment of mental health and substance use problems may have important implications in rates of risky sexual behavior and, conceivably, controlling the high rates of serious individual and public health repercussions.

Condom type may influence sexual behavior and ejaculation and complicate the assessment of condom functionality

BACKGROUND

Studies that evaluate condom effectiveness are affected by factors related to how the condom was used, and these factors may not be consistent between different types of condoms. Also, subjective assessments of the sexual act may be unreliable.

STUDY DESIGN

We performed a secondary data analysis of a randomized crossover trial of male and female condoms among 108 couples.

RESULTS

Self-reported duration and activeness of coital acts were significantly different for uses of the male condom compared to uses of the female condom. Fewer individuals reported ejaculation occurring with the female condom. Reliability of self-reports of ejaculation compared to a biological marker of semen detected inside the used male and female condoms was not strong.

CONCLUSIONS

We found that sexual behaviors appear to differ by the type of condom used for the coital act. Studies should consider sexual behavior when evaluating condom effectiveness. Furthermore, studies would be strengthened by the use of a biological marker of semen to determine whether ejaculation, and therefore a true risk of exposure, occurred.

Condom effectiveness: where are we now?

After performing a review of prospective cohort evaluations, a focussed assessment of the current knowledge base and methodology pertaining to condom effectiveness against sexually transmissible infections, including HIV, was also conducted. Key observations included the point that studies of condom effectiveness are inherently complex and the potential forms of study bias all generally favour the null hypothesis. Perhaps the most challenging obstacle to rigor in these studies lies in determining which events of condom-protected sex occurred before infection as opposed to after infection when, in fact, infection occurs. This problem leads to misclassification bias; however, other sources of misclassification bias are common. Greater attention to the selection of a recall period, improved precision of self-reported measures, and accounting for condom use errors and problems are critical steps that must occur to promote rigor in these studies. Despite multiple shortcomings, prospective studies of condom effectiveness provide a reasonably favourable evaluation. Subsequent studies, however, should be designed to greatly reduce the error variance that predisposes condom effectiveness studies to type 2 errors that mask the potential value of condoms.

Condom use errors and problems: a global view

Background Significantly more research attention has been devoted to the consistency of condom use, with far fewer studies investigating condom use errors and problems. The purpose of this review was to present the frequency of various condom use errors and problems reported worldwide. Methods: A systematic literature search was conducted for peer-reviewed articles, published in English-language journals between 1995 and 2011. Results: Fifty articles representing 14 countries met criteria for inclusion. The most common errors included not using condoms throughout sex, not leaving space at the tip, not squeezing air from the tip, putting the condom on upside down, not using water-based lubricants and incorrect withdrawal. Frequent problems included breakage, slippage, leakage, condom-associated erection problems, and difficulties with fit and feel. Prevalence estimates showed great variation across studies. Prevalence varied as a function of the population studied and the period assessed. Conclusion: Condom use errors and problems are common worldwide, occurring across a wide spectrum of populations. Although breakage and slippage were most commonly investigated, the prevalence of other condom use errors and problems found in this review were substantially higher. As a framework for understanding the role of condom errors and problems in inadequate protection, we put forward a new model: the Condom Use Experience model. This model can be used to generate testable hypotheses for future research. Addressing condom use errors and problems in research and interventions is crucial to closing the gap between the perfect use and typical use of condoms.

Condom use around the globe: how can we fulfil the prevention potential of male condoms?

Despite a global epidemic of sexually transmissible infections and the availability and endorsement of condoms as an effective intervention, the overall use of condoms remains low. This review explores various challenges and opportunities to fully realizing the prevention potential for condoms.

Determinants of condom breakage among female sex workers in Karnataka, India

Background

Condoms are effective in preventing the transmission of HIV and other sexually transmitted infections, when properly used. However, recent data from surveys of female sex workers (FSWs) in Karnataka in south India, suggest that condom breakage rates may be quite high. It is important therefore to quantify condom breakage rates, and examine what factors might precipitate condom breakage, so that programmers can identify those at risk, and develop appropriate interventions.

Methods

We explored determinants of reported condom breakage in the previous month among 1,928 female sex workers in four districts of Karnataka using data from cross-sectional surveys undertaken from July 2008 to February 2009. Using stepwise multivariate logistic regression, we examined the possible determinants of condom breakage, controlling for several independent variables including the district and client load.

Results

Overall, 11.4% of FSWs reported at least one condom break in the previous month. FSWs were much more likely to report breakage if under 20 years of age (AOR 3.43, p = 0.005); if divorced/ separated/widowed (AOR 1.52, p = 0.012); if they were regular alcohol users (AOR 1.63, p = 0.005); if they mostly entertained clients in lodges/rented rooms (AOR 2.99, p = 0.029) or brothels (AOR 4.77, p = 0.003), compared to street based sex workers; if they had ever had anal sex (AOR 2.03, p = 0.006); if the sex worker herself (as opposed to the client) applied the condom at last use (AOR 1.90, p < 0.001); if they were inconsistent condom users (AOR 2.77, p < 0.001); and if they had never seen a condom demonstration (AOR 2.37, p < 0.001).

Conclusions

The reported incidence of condom breakage was high in this study, and this is a major concern for HIV/STI prevention programs, for which condom use is a key prevention tool. Younger and more marginalized female sex workers were most vulnerable to condom breakage. Special effort is therefore required to seek out such women and to provide information and skills on correct condom use. More research is also needed on what specific situational parameters might be important in predisposing women to condom breakage.

Male adolescent sexual and reproductive health care

Male adolescents' sexual and reproductive health needs often go unmet in the primary care setting. This report discusses specific issues related to male adolescents' sexual and reproductive health care in the context of primary care, including pubertal and sexual development, sexual behavior, consequences of sexual behavior, and methods of preventing sexually transmitted infections (including HIV) and pregnancy. Pediatricians are encouraged to address male adolescent sexual and reproductive health on a regular basis, including taking a sexual history, performing an appropriate examination, providing patient-centered and age-appropriate anticipatory guidance, and delivering appropriate vaccinations. Pediatricians should provide these services to male adolescent patients in a confidential and culturally appropriate manner, promote healthy sexual relationships and responsibility, and involve parents in age-appropriate discussions about sexual health with their sons.

Interventions to prevent sexually transmitted infections, including HIV infection

The Centers for Disease Control and Prevention (CDC) Sexually Transmitted Disease (STD) Treatment Guidelines were last updated in 2006. To update the "Clinical Guide to Prevention Services" section of the 2010 CDC STD Treatment Guidelines, we reviewed the recent science with reference to interventions designed to prevent acquisition of STDs, including human immunodeficiency virus (HIV) infection. Major interval developments include (1) licensure and uptake of immunization against genital human papillomavirus, (2) validation of male circumcision as a potent prevention tool against acquisition of HIV and some other sexually transmitted infections (STIs), (3) failure of a promising HIV vaccine candidate to afford protection against HIV acquisition, (4) encouragement about the use of antiretroviral agents as preexposure prophylaxis to reduce risk of HIV and herpes simplex virus acquisition, (5) enhanced emphasis on expedited partner management and rescreening for persons infected with Chlamydia trachomatis and Neisseria gonorrhoeae, (6) recognition that behavioral interventions will be needed to address a new trend of sexually transmitted hepatitis C among men who have sex with men, and (7) the availability of a modified female condom. A range of preventive interventions is needed to reduce the risks of acquiring STI, including HIV infection, among sexually active people, and a flexible approach targeted to specific populations should integrate combinations of biomedical, behavioral, and structural interventions. These would ideally involve an array of prevention contexts, including (1) communications and practices among sexual partners, (2) transactions between individual clients and their healthcare providers, and (3) comprehensive population-level strategies for prioritizing prevention research, ensuring accurate outcome assessment, and formulating health policy.

Interventions to reduce sexual risk for human immunodeficiency virus in adolescents: a meta-analysis of trials, 1985-2008

OBJECTIVE

To provide an updated review of the efficacy of behavioral interventions to reduce sexual risk of human immunodeficiency virus (HIV) among adolescents.

DESIGN

We searched electronic databases, leading public health journals, and the document depository held by the Synthesis of HIV/AIDS Risk Reduction Project. Studies that fulfilled the selection criteria and were available as of December 31, 2008, were included.

SETTING

Studies that investigated any behavioral intervention advocating sexual risk reduction for HIV prevention, sampled adolescents (age range, 11-19 years), measured a behavioral outcome relevant to sexual risk, and provided sufficient information to calculate effect sizes.

PARTICIPANTS

Data from 98 interventions (51,240 participants) were derived from 67 studies, dividing for qualitatively different interventions and gender when reports permitted it.

MAIN OUTCOME MEASURES

Condom use, sexual frequency, condom use skills, interpersonal communication skills, condom acquisition, and incident sexually transmitted infections (STIs).

RESULTS

Relative to controls, interventions succeeded at reducing incident STIs, increasing condom use, reducing or delaying penetrative sex, and increasing skills to negotiate safer sex and to acquire prophylactic protection. Initial risk reduction varied depending on sample and intervention characteristics but did not decay over time.

CONCLUSIONS

Comprehensive behavioral interventions reduce risky sexual behavior and prevent transmission of STIs. Interventions are most successful to the extent that they deliver intensive content.

Correlates of incorrect condom use among depressed young women: an event-level analysis

STUDY OBJECTIVE

Depressed young women are at particularly high risk of sexually transmitted infections (STIs), yet little is known about their condom use practices. This study sought (1) to describe condom use errors among depressed adolescent and young adult women and (2) to identify event- and individual-level correlates of incorrect use.

DESIGN

Depressed, sexually active outpatients ages 15-22 responded to a computer-based questionnaire, then reported on penile-vaginal sex events on a handheld computer several times a day for two weeks. For each sex event with a condom, incorrect condom use was defined as a response indicating incorrect use on at least one of five questions. Event- and individual-level correlates of incorrect use were analyzed using logistic regression adjusted for age and within-individual clustering.

SETTING

Participants were recruited from two adolescent clinics, a psychiatric clinic, and a young parents' program of an urban children's hospital and collected data in the settings of their everyday lives.

PARTICIPANTS

Thirty-one young women contributed 143 condom use events to these analyses.

INTERVENTIONS

None.

MAIN OUTCOME MEASURE

Incorrect condom use.

RESULTS

Incorrect condom use was reported for 51% of condom use events. The most common error was not holding the condom on withdrawal (31%). Having sex to change mood, to relax, or for physical pleasure increased the odds of incorrect condom use, but was no longer significant when individual-level variables were included in the model. In the multiple logistic regression model, impulsiveness increased and stronger belief that mood affects sexual behaviors decreased the odds of incorrect condom use (adjusted OR 1.3 and 0.81, respectively).

CONCLUSIONS

Even if they use condoms, depressed adolescent and young adult women are at increased risk of STIs because they frequently use condoms incorrectly. Psychological factors may help identify depressed young women who are at particularly high risk of incorrect condom use.

Psychometric properties of a pictorial scale measuring correct condom use

This study was designed to assess the psychometric properties of a pictorial scale of correct condom use (PSCCU) using data from female sex workers (FSWs) in China. The psychometric properties assessed in this study include construct validity by correlations and known-group validation. The study sample included 396 FSWs in Guangxi, China. The results demonstrate adequate validity of the PSCCU among the study population. FSWs with a higher level of education scored significantly higher on the PSCCU than those with a lower level of education. FSWs who self-reported appropriate condom use with stable partners scored significantly higher on PSCCU than their counterparts. The PSCCU should provide HIV/STI prevention researchers and practitioners with a valid alternative assessment tool among high-risk populations, especially in resource-limited settings.

Trichomonas vaginalis prevalence, incidence, risk factors and antibiotic-resistance in an adolescent population

OBJECTIVE

To determine the prevalence and incidence of trichomoniasis, risk factors for infection, and the prevalence of metronidazole and tinidazole-resistant Trichomonas vaginalis (T. vaginalis) in female adolescents.

METHODS

Nonpregnant, HIV-seronegative, sexually active females (13-19 years) visiting an inner city public primary care clinic were tested for T. vaginalis by wet mount and culture, and interviewed about risk-taking behavior every 6 months. Infected patients were treated with a 2 g oral dose of metronidazole. Isolates from positive T. vaginalis cultures were tested for in vitro resistance to metronidazole and tinidazole.

RESULTS

Among 467 study participants, 67 (14.4%; 95% confidence interval, 11.3-17.5) were diagnosed with trichomoniasis at first T. vaginalis culture. Significant risk factors for T. vaginalis infection were having an older sex partner and concurrent Neisseria gonorrhoeae infection. The incidence was 22.1 cases per 100 person-years. Among 42 participants who had a prevalent infection and returned for followup, 13 (31.0%) had at least 1 more episode of trichomoniasis. Resistance testing was completed for 78 isolates: 37 at first visit and 41 during follow-up. One (2.7%; 95% confidence interval, 0.07-14.2) of the 37 first-visit isolates was moderately resistant to metronidazole (minimal lethal concentration = 200 microg/mL). Of the 41 follow-up visit isolates, 1 was moderately resistant to metronidazole and 2 had borderline resistance (minimal lethal concentration = 50 microg/mL). The prevalence of tinidazole resistance was 0% (0.0%-9.5%).

CONCLUSION

The study population had high prevalence and incidence of trichomoniasis. The prevalence of antibiotic-resistant T. vaginalis among female adolescents was low.

Condom use in the year following a sexually transmitted disease clinic visit

Consistent condom use can prevent sexually transmitted infections (STIs), but few studies have measured how the prevalence of consistent use changes over time. We measured the prevalence and correlates of consistent condom use over the course of a year. We did a secondary analysis of data from an HIV prevention trial in three sexually transmitted disease clinics. We assessed condom use during four three-month intervals for subjects and across their partnerships using unconditional logistic regression. Condom use was also assessed for subjects during all three-month intervals combined. The 2125 subjects reported on 5364 three-month intervals including 7249 partnership intervals. Condoms were always used by 24.1% of subjects and 33.2% of partnerships during a three-month interval. Over the year, 82% used condoms at least once but only 5.1% always used condoms. Always use of condom was more likely for subjects who had sex only once (66.5%) compared with >30 times (6.4%); one-time partnerships (64.1%) compared with main partnerships (22.2%); and in new partnerships (44.0%) compared with partnerships that were not new (24.5%). Although consistent condom use may prevent STIs, condoms were rarely used consistently during the year of follow-up.

Screening asymptomatic adolescent men for Chlamydia trachomatis in school-based health centers using urine-based nucleic acid amplification tests

BACKGROUND

Urine-based screening for Chlamydia trachomatis using highly sensitive and specific nucleic acid amplification tests offers a unique opportunity to screen men attending school-based health centers.

METHODS

As part of a large multicenter chlamydia screening project in men, 1434 students were enrolled; 1090 in high schools in Baltimore and 344 middle and high-school students in Denver. Students were screened for chlamydia using urine-based nucleic acid amplification tests at well adolescent visits, acute care visits, or visits for other reasons, such as sports physicals. A self-administered survey to ascertain sexual risk behaviors was used. Data were analyzed separately for Baltimore and Denver, with univariate and multivariate logistic regression analysis.

RESULTS

The overall prevalence in asymptomatic adolescent men was 6.8% (7.5% in Baltimore and 4.7% in Denver, P = n.s.). Students in Denver were older, more racially diverse, and more likely to have had intercourse in the previous 2 months than students in Baltimore. Students in Baltimore were more likely than those in Denver to have used a condom at last intercourse with casual and main partners. Among men in Denver but not Baltimore, condom use at last intercourse with both casual (OR 0.15, 95% CI, 0.03, 0.78) and main partners (OR 0.30, 95% CI, 0.10, 0.91) was protective against infection. The only risk factor for CT infection in Baltimore students was age (OR 1.47, 95% CI, 1.23, 1.75). In multivariate analysis that included age (as a continuous variable), race, history of an STI, any sex partner in the last 2 months, >1 sex partner in the past 12 months, a new partner in the last 2 months, and condom use with last main and last casual partner, age (adjusted odds ratio 1.34, 95% CI, 1.11, 1.62) and black race (adjusted odds ratio 2.37, 95% CI, 1.21, 4.63) were the only variables associated with testing chlamydia positive.

CONCLUSIONS

School-based health centers are important venues in which to perform urine-based screening for chlamydia in sexually active, asymptomatic males, especially in high prevalence communities, and such screening provides the opportunity to identify and treat substantial numbers of chlamydia infections.

Measure of HIV/STD risk-reduction: strategies for enhancing the utility of behavioral and biological outcome measures for African American couples

OBJECTIVE

Numerous studies have discussed the value of including biological outcome measures as a complement to behavioral outcome measures to assess the efficacy of HIV risk-reduction interventions. This article highlights strategies used to minimize the limitations of including both self-reported sexual behaviors and biologically confirmed sexually transmitted diseases as primary outcome measures in an HIV/sexually transmitted disease (STD) prevention program for African American serodiscordant couples (Eban).

DESIGN

Couples receiving an HIV intervention condition (Eban) were compared with couples receiving a time-equivalent General Health Promotion condition on behavioral and biological outcomes. Both behavioral and biological data were collected at baseline, immediately postintervention, and at 6 and 12 months postintervention.

METHODS

Literature reviews, consulting other researchers who conducted couples studies, our investigative team's experience in previous HIV interventions, and formative work were used to develop procedures to minimize potential limitations associated with the inclusion of behavioral and biological outcome measures for Eban.

RESULTS

Given the strengths of including behavioral and biological outcome measures, the Eban study chose to have both measures serve as primary outcomes. The primary behavioral outcome for the trial is the proportion of protected vaginal and anal intercourse episodes that occurred within the index couple in 90 days before each follow-up assessment and over the 12-month postintervention follow-up period. The primary biological outcome is the proportion of participants (male or female study partners) with an incident STD (Chlamydia, gonorrhea, or trichomoniasis) over the 12-month postintervention follow-up period.

CONCLUSIONS

Employing procedures to minimize limitations of using self-reported sexual behaviors and STDs as complementary primary outcomes enhances their utility as measures of the efficacy of HIV/STD prevention interventions.

Sexually transmitted infections in adolescent women

Adolescent women possess physiologic and, frequently, behavioral characteristics that place them at an increased risk for contracting sexually transmitted infections. Diagnosis and prompt treatment of sexually transmitted infections is of paramount importance for an adolescent's future fertility and prevention of transmission to future partners. Diagnosis and treatment is often hindered by lack of symptoms, concern for screening and treatment confidentiality, and lack of knowledge about community medical resources.

Slips, breaks and ‘falls’: condom errors and problems reported by men attending an STD clinic

Summary

The objective was to comprehensively assess the prevalence of condom-use errors and problems among male clients attending a public sexually transmitted disease (STD) clinic. Men ( n = 278) attending an STD clinic completed an anonymous questionnaire. Seven errors and six problems were assessed. Summative scores were tested for associations with three key variables. Of 834 condom-protected events: 19% were associated with ‘fit and feel’ problems, 15% involved breakage, 14% involved lost erection, 9% were associated with lost erection while applying condoms, 8% involved slippage during withdrawal and 7% involved slippage during sex. A mean of 6.4 errors/problems were observed. None of these summative variables (total errors, total problems or total of errors and problems) were significantly associated with age, minority status or whether men indicated they had ever been taught how to use condoms. Multiple types of condom-use errors and problems may be highly prevalent among high-risk men attending public STD clinics.

Decreased condom breakage and slippage rates after counseling men at a sexually transmitted infection clinic in Jamaica

PURPOSE

Our objective was to evaluate condom failure (breakage and slippage) rates before and those during a trial that provided instructions on correct condom use.

METHOD

Our analysis was based on 314 men who presented with urethral discharge at Jamaica's largest sexually transmitted infection clinic and were enrolled into our 6-month trial.

RESULTS

Participants reported breaking 18.5% (95% confidence interval=12.8-24.1%) of their condoms during the 7 days prior to the screening visit and having 3.5% (95% confidence interval=1.2-5.7%) of their condoms slip off completely. After the condom counseling provided during the screening visit, breakage rates decreased (p<.05) and remained below 10% throughout the trial. During in-depth interviews, the men who reported frequent condom failures cited (1) improper storage/exposure to heat, (2) improper handling while putting on condoms and (3) use of lubricants/improper lubricants as the possible reasons for their high failure rates.

CONCLUSION

Although the rates of reported condom breakage and slippage decreased significantly after counseling, we need to improve the quality of condom counseling to further reduce failure rates.

Men with broken condoms: who and why?

OBJECTIVES

To identify (1) the prevalence of condom breakage, and demographic and sexuality-related differences among young men who have sex with women reporting and not reporting this event; (2) condom-specific behaviours associated with breakage.

METHODS

Young men (n = 278) attending a clinic for treatment of sexually transmitted infections (STIs) responded to an anonymous questionnaire aided by a CD recording of the questions. The samples were screened to include only men who had used a condom during penile-vaginal sex at least three times in the past 3 months. Condom-specific behaviours (including breakage) were assessed using these last three acts of condom use as the recall period. Correlates achieving bivariate significance were subjected to multivariate analysis.

RESULTS

Nearly one third (31.3%) of the men reported recent breakage. The breakage rate was 15%. Three correlates significantly distinguished between men who did and did not report breakage. Men who had past STIs were more likely to report breakage (adjusted odds ratio (AOR) 2.08), as were men who also reported condom slippage (AOR 2.72). Less self-efficacy for correct condom use was also significantly associated with breakage (AOR 1.07). Further, three condom-specific behaviours were significantly associated with breakage: allowing condoms to contact sharp objects (AOR 2.6), experiencing problems with the "fit or feel" of condoms (AOR 2.3) and not squeezing air from the receptacle tip (AOR 2.0).

CONCLUSIONS

Breakage may be common and may occur in a larger context of difficulties with condoms. STI clinics could potentially benefit some men by providing instructions on the correct use of condoms.

Relationship of condom use with other sexual risk behaviors among selected Japanese adolescents

This study examines relationships between condom use and age at initiation of sex, the number of sexual partners, and alcohol or drug use before sex among a convenience sample of 2852 Japanese adolescents. We found that nonuse of condoms is related to early initiation of sex, having multiple sexual partners and alcohol or drug use before sex.

Condom use with steady and casual partners in inner city African-American communities

OBJECTIVES

This study examined rates of and factors associated with consistent condom use with steady partner and with casual partners in inner city African-American communities with high sexually transmitted infection (STI) prevalence.

METHODS

Structured interviews were conducted using street intercept methods and venue based sampling with 997 African-American residents of inner city neighbourhoods in Houston and Dallas, Texas; of which data were analysed for the 736 that reported having sex in past 2 months. Condom use was measured as a proportion of use in last five sex acts with steady and casual partners.

RESULTS

Reported rates of consistent condom use were high-31.4% with steady partner and 29.5% with casual partner. Multivariate logistic models differed by type of partner. Married people and those with history of STI were less likely to use condoms with the main partner, while older people were less likely and males, and those visiting a doctor more likely to use condoms with casual partners.

CONCLUSIONS

The proportion of condom use with both partner types was relatively high reflecting a general trend towards increased condom use in the United States. The finding of lower reported rates with casual partners has been discussed. Factors associated with condom use differ according to type of partner. Precise measurement of actual condom use continues to be an elusive task but is required for the design of appropriate messages and evaluation of STI programmes.

Condom use and the risk of genital human papillomavirus infection in young women

BACKGROUND

To evaluate whether the use of male condoms reduces the risk of male-to-female transmission of human papillomavirus (HPV) infection, longitudinal studies explicitly designed to evaluate the temporal relationship between condom use and HPV infection are needed.

METHODS

We followed 82 female university students who reported their first intercourse with a male partner either during the study period or within two weeks before enrollment. Cervical and vulvovaginal samples for HPV DNA testing and Papanicolaou testing were collected at gynecologic examinations every four months. Every two weeks, women used electronic diaries to record information about their daily sexual behavior. Cox proportional-hazards models were used to evaluate risk factors for HPV infection.

RESULTS

The incidence of genital HPV infection was 37.8 per 100 patient-years at risk among women whose partners used condoms for all instances of intercourse during the eight months before testing, as compared with 89.3 per 100 patient-years at risk in women whose partners used condoms less than 5 percent of the time (adjusted hazard ratio, 0.3; 95 percent confidence interval, 0.1 to 0.6, adjusted for the number of new partners and the number of previous partners of the male partner). Similar associations were observed when the analysis was restricted to high-risk and low-risk types of HPV and HPV types 6, 11, 16, and 18. In women reporting 100 percent condom use by their partners, no cervical squamous intraepithelial lesions were detected in 32 patient-years at risk, whereas 14 incident lesions were detected during 97 patient-years at risk among women whose partners did not use condoms or used them less consistently.

CONCLUSIONS

Among newly sexually active women, consistent condom use by their partners appears to reduce the risk of cervical and vulvovaginal HPV infection.

Condom use and risk of gonorrhea and Chlamydia: a systematic review of design and measurement factors assessed in epidemiologic studies

BACKGROUND

Studies of condom use to reduce risk of most sexually transmitted infection provide inconsistent results. This inconsistency is often attributed to methodologic limitations yet has not been assessed systematically.

OBJECTIVES

The objectives of this study were to review studies of condom use and risk of gonorrhea and chlamydia, and to evaluate the importance of 4 key design and measurement factors on condom effectiveness estimates.

DESIGN

We reviewed studies published 1966-2004 to assess risk reduction for gonorrhea and/or chlamydia associated with male condom use.

RESULTS

Of 45 studies identified, most found reduced risk of infection associated with condom use. All studies reviewed had methodologic limitations: only 28 (62%) distinguished consistent from inconsistent use; 2 (4%) reported on correct use or use problems; 13 (29%) distinguished incident from prevalent infection; and one (2%) included a population with documented exposure to infection. Eight of 10 studies with 2 or more of these attributes reported statistically significant protective effects for condom use versus 15 of 35 studies with zero or one attribute (80% vs. 43%, P = 0.04).

CONCLUSIONS

Condom use was associated with reduced risk of gonorrhea and chlamydia in men and women in most studies, despite methodologic limitations that likely underestimate condom effectiveness. Epidemiologic studies that better address these factors are needed to provide more accurate assessment of condom effectiveness.

Chlamydia in gynecologic practice

The focus on Chlamydia trachomatis in gynecologic practice 20 years ago was in treating its potential consequences: pelvic inflammatory disease, infertility and ectopic pregnancy. Although these conditions are still important, the current focus of C. trachomatis management for the obstetrician and gynecologist is early detection and treatment. The majority of women with C. trachomatis are asymptomatic, therefore, screening programs are being devised so that C. trachomatis can be treated prior to the occurence of any adverse consequences. Novel tests have allowed the use of urine samples and self-collected vulvovaginal swabs in the detection of C. trachomatis. This article will review the consequences of C. trachomatis infection in women, methods of identification of the organism, the prevalence in various populations, and treatment and screening strategies.