HIV, sexually transmitted infections, and risk behaviours in male sex workers in London over a 10 year period

OBJECTIVES: To describe changing characteristics of men who sold sex in London between 1994 and 2003. METHODS: A baseline survey of 823 male sex workers attending a specialist clinic, plus follow up of 628 men for 1379 person years. RESULTS: Men recruited earlier (1994 to 1996) were more likely than those recruited later (2000 to 2003) to be UK born and to self define as homosexual. Later recruits included more men from South/Central America and eastern Europe and a higher proportion reported regular female partners. Baseline prevalence of HIV was 9% (59/636), and multivariate analysis showed an associated with injecting drug use and unprotected sex with a casual partner. During follow up there were 49 incident cases of HIV. Survival analysis showed earlier recruitment (1994-6) to be associated with a higher incidence of HIV. The prevalence of gonorrhoea increased over time. CONCLUSIONS: Men who sell sex are at risk of HIV and other STIs, but these risks do not appear to be directly linked to sex work. The changing demographics of these men is associated with different patterns of infection and poses challenges for service delivery.     

Clients of female sex workers in Lima, Peru: a bridge population for sexually transmitted disease/HIV transmission?

OBJECTIVES: The objectives of this study were to determine the prevalence of risk behaviors, gonorrhea, and chlamydia in clients of female sex workers, and to compare them with men selected from the general population. STUDY DESIGN: We conducted a cross-sectional study of men recruited from commercial sex venues in Lima, Peru from January to February 2002. Subjects answered a survey and provided a urine sample. RESULTS: Men reported that in the recently concluded commercial sex encounter, 95.8% used condoms, and 85.8% always used condoms with female sex workers. Only 16% reported always using condoms with their stable partners; 50.8% always used condoms with casual, noncommercial partners; and 59.6% always used condoms for homosexual anal sex. There were 8 (2%) cases of chlamydia and no cases of gonorrhea. CONCLUSIONS: Clients of female sex workers report high rates of condom use with sex workers and a low prevalence of chlamydia and gonorrhea. It is unlikely that they constitute a bridging population.     

Male clients of brothel prostitutes as a bridge for HIV infection between high risk and low risk groups of women in Senegal

OBJECTIVE: To explore the extent to which male clients of prostitutes have a role as a bridge in the spread of HIV into the general population of Dakar, Senegal. METHODS: A sexual behaviour HIV prevalence survey was carried out among clients of female prostitutes working in brothels recruited outside the prostitutes' rooms after the encounter. All men entering the house and leaving the women's rooms were asked to answer the questions and to donate saliva for HIV-1 and HIV-2 testing. RESULTS: Findings suggest that a proportion of clients form a potential bridge for HIV transmission between prostitutes and partners from the general population. They have unprotected sexual contacts with both brothel prostitutes, and steady and casual partners, and expose both unmarried and married women to HIV infection. Findings also indicate that wives are more exposed to HIV than other categories of women in the population. CONCLUSIONS: Clients of brothels' prostitutes have a significant potential for spreading HIV beyond the initial high risk behaviour groups in Senegal. Efforts should be provided to target specific groups at higher risk for HIV infection, such as young men from the densely populated working class neighbourhoods of Dakar, and women outside the commercial sex networks for HIV education and prevention.     

Basing policy on evidence: low HIV, STIs, and risk behaviour in Dili, East Timor argue for more focused interventions

BACKGROUND: East Timor is a newly independent, poor nation with many internally displaced people and foreign peace keeping forces. Similarities with Cambodia, which now has Asia's worst HIV epidemic, caused donors to earmark money for HIV prevention in East Timor, but no data were available to plan appropriate programmes. OBJECTIVES: To determine levels of infection with HIV and other sexually transmitted infections (STIs) and associated risk behaviours in Dili, East Timor, in order to guide resource allocation and appropriate prevention and care strategies. METHODS: In mid-2003, a cross sectional survey of female sex workers, men who have sex with men (MSM), taxi drivers, and soldiers was conducted. Participants provided biological specimens and all answered structured questionnaires. RESULTS: HIV prevalence was 3% among female sex workers (3/100), 0.9% among MSM (1/110), and zero in the other groups. All the HIV infected sex workers reported sex with foreign clients. Partner turnover reported by all groups was among the lowest in Asia, so was condom use. Access to basic HIV prevention services, including condoms and STI services, was extremely low in all groups. CONCLUSIONS: A few sex workers are infected with HIV in East Timor, but the virus is not circulating widely among their clients, and sexual networking is limited. The risk of a generalised HIV epidemic in East Timor is minimal. HIV can be contained by the provision of basic services to the small minority of the population at highest risk, preserving resources for other health and development needs.     

HIV, syphilis infection, and sexual practices among transgenders, male sex workers, and other men who have sex with men in Jakarta, Indonesia

OBJECTIVES: To establish the prevalence of HIV, syphilis, and sexual risk behaviour among three groups of men who have sex with men in Jakarta, Indonesia, and to investigate sexual links between these men and broader heterosexual populations. METHODS: Anonymous, cross sectional surveys among community recruited transgender and male sex workers and self recognised men who have sex with men (MSM) were undertaken in mid-2002 in Jakarta, Indonesia. Places where transgender and male sex workers sell sex and where men go to meet non-commercial male sex partners were mapped. Probability samples were selected for the sex worker populations, while a mixed probability and convenience sample was drawn for self recognised MSM. Blood was drawn for HIV and syphilis serology and community interviewers administered a standardised questionnaire. RESULTS: HIV prevalence was 22% among transgender sex workers, 3.6% among male sex workers, and 2.5% among self recognised MSM, and syphilis prevalence was 19.3%, 2.0% and 1.1% respectively. 59.3% of transgender sex workers and 64.8% of male sex workers reported recent unprotected anal intercourse with clients, and 53.1% of other MSM reported unprotected anal sex with male partners. Some 54.4% of male sex workers and 18.3% of other MSM reported female partners in the preceding year. CONCLUSION: HIV has reached substantial levels among transgender sex workers, and is not negligible in other MSM groups. Risk behaviour is high in all subpopulations, and bisexual behaviour is common, meaning the threat of a wider epidemic is substantial. Prevention programmes targeting male-male sex are needed to reduce this threat.     

Vaginal douching, condom use, and sexually transmitted infections among Chinese female sex workers

BACKGROUND AND OBJECTIVE: Vaginal douching has been hypothesized to increase a woman's risk for human immunodeficiency virus (HIV) infection. However, data on the prevalence of this practice and its association with condom use and sexually transmitted infections (STIs) are limited. STUDY: A cross-sectional survey among 454 female sex workers (FSWs) in a Chinese county. RESULTS: Vaginal douching was reported by 64.7% of the women. The prevalence of self-reported history of STI and that of current STI was 19.4% and 41.5%, respectively. Fifteen percent of the women reported consistent use of condoms with their clients and 8.4% with their regular partners. Vaginal douching was significantly associated with decreased use of condoms (with clients: OR = 0.31; with regular partner(s): OR = 0.22) and increased rate of self-reported STI history (OR = 1.95). However, there was no direct relation between douching and current STI. Over one third of the women believed that douching can prevent STI/HIV. CONCLUSION: Vaginal douching exposes FSWs to a high risk of STI/HIV. Medical professional and public health workers should correct women's misconception about the effectiveness of douching and discourage women from douching through educational activities.     

Sexual patterning and condom use among a group of HIV vulnerable men in Thika, Kenya

Background/aim: A composite sample of 37 peer educators and 215 members of self help groups of male informal sector workers in Thika, Kenya, targeting HIV/AIDS prevention, were interviewed about their sexual behaviour, using a customised template, as part of a broader survey on gender attitudes and peer pressure. METHOD: Details on each sexual partner reported by each man over a 12 month recall period included type of partner, months during which sexual relations took place, and condom use. RESULTS: The men reported 471 sexual partners over the recall period, with a range of 0-16 partners, and an average of just under two partners. 8% of men had had no sexual partner, half were monogamous, and 3% had multiple partners with whom they used condoms exclusively, leaving 39% at varying degrees of risk. Condom use increased significantly with reduced intimacy of partner. 16% of men reported having at least one liaison with a female sex worker and two thirds of such liaisons were exclusively protected by condom use. Younger, single men had significantly more partners, but were more likely to use condoms. Duration of membership in self help groups was strongly associated with exclusive use of condoms with casual or FSW partners. Recorded attitudes corresponded somewhat with practice, but the data showed large gaps between the two, and low levels of gender sensitivity. CONCLUSION: There is some evidence that group membership has resulted in increased condom use and partner reduction, but there are doubts as to the extent to which the "ABC" strategy can be successful in stemming the HIV/AIDS epidemic. It may be necessary for interventions to target contextual issues, particularly gender relations, if the approach is to be more successful.     

Association between 'safer sex fatigue' and rectal gonorrhea is mediated by unsafe sex with casual partners among HIV-positive homosexual men

OBJECTIVE: The objective of this study was to investigate whether and what sexual risk behavior is a mediator of associations between rectal gonorrhea (RG) and highly active antiretroviral therapy-related beliefs, safer sex fatigue, or sexual sensation-seeking among homosexual men. STUDY DESIGN: This study consisted of a cross-sectional survey between March 2002 and December 2003 among homosexual visitors of the Amsterdam sexually transmitted disease clinic. METHODS: In total, 1568 men answered a written questionnaire. Associations were determined using logistic regression corrected for repeated measurements. RESULTS: The RG infection rate was high among homosexual men who were HIV-positive (16%) compared with those with negative or unknown HIV status. Mediation could be confirmed among HIV-positive men only. Those who experienced higher levels of safer sex fatigue were more likely to be positive for RG. This association was mediated by unprotected anal intercourse (UAI) with casual partners. CONCLUSION: Addressing safer sex fatigue might help prevent UAI with casual partners and possibly also RG among HIV-positive homosexual men.     

HIV and STIs in clients and female sex workers in mining regions of Gejiu City, China

OBJECTIVE: To investigate HIV/sexually transmitted infections (STIs) among female sex workers (FSWs) and clients in a mining region of China. GOAL: To estimate HIV/STI prevalence and to identify HIV risk factors among FSWs and miner clients. STUDY DESIGN: A cross-sectional study of 96 FSWs and 339 miner clients. RESULTS: In FSWs, prevalence of HIV was 8.3%, herpes simplex virus-2 70.8%, syphilis 12.5%, Neisseria gonorrhoeae 36.8%, Chlamydia trachomatis 46.3%, Trichomonas vaginalis 22.1%, and 90.6% were infected with any STI. Illegal drug use was associated with HIV [adjusted odds ratio (OR) = 45.1, 95% confidence interval, 6.4-317.9] in FSWs, and 45.8% reported no condom use with the last client. In miner clients, HIV prevalence was 1.8%, herpes simplex virus-2 14.9%, syphilis 2.4%, N. gonorrhoeae 2.1%, C. trachomatis 6.5%, and 23.2% were infected with any STI. Never using condoms with FSWs and regular partners were reported in 61.2% and 84.1%, respectively. Independent risk factors for HIV in miner clients were illegal drug use (OR 190.2), symptoms of urethral discharge or frequent urination (OR 32.9), early sexual debut (OR 7.1), and visiting 4 or more FSWs in the last 12 months (OR 11.5). CONCLUSIONS: HIV/STI prevalence is high among FSWs and moderate among clients in mining regions of Gejiu City. Drug use is the most important factor placing FSWs and miner clients at risk for HIV in Gejiu City; risky sexual characteristics such as early sexual debut, frequent visits to FSWs, and STI symptoms are also important factors for miner clients. FSWs and miner clients may constitute bridging groups for HIV to low-risk populations.     

Prevalence of sexually transmitted infections among clients of female commercial sex workers in Thailand

BACKGROUND: Clients of commercial sex workers are considered at high risk for the acquisition and transmission of sexually transmitted diseases (STDs). Identification and treatment of infections in this group could help to reduce the transmission of STDs. GOAL: To ascertain the prevalence of sexually transmitted organisms in male clients of female sex workers in Thailand by analysis of seminal fluid collected after intercourse. STUDY DESIGN: Used condoms were collected from 291 male clients attending a brothel in Hat Yai, Thailand during a 7-day period. Nucleic acid was extracted from seminal fluid and tested by polymerase chain reaction for the presence of Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, herpes simplex virus (HSV) and HIV sequences. RESULTS: Overall, 17 (6%), 47 (16%), and 2 (1%) of specimens were positive for C trachomatis, N gonorrhoeae and T vaginalis respectively. HSV sequences were found in 24 (8%) of the specimens: 14 specimens (5%) with HSV type 1, and 11 specimens (4%) with HSV type 2. HIV RNA was detected in two samples (1%). Overall, 75 specimens (26%) were positive for one or more infections, and more than one pathogen was detected in 16 specimens (5%). CONCLUSION: This study reports a high rate of STDs among clients of female sex workers in Thailand. Consequently, this population is a significant risk for transmitting STDs to commercial sex workers and to other noncommercial partners. Strategies that target this population of men are needed to reduce STD and HIV transmission.     

Role of core and bridging groups in the transmission dynamics of HIV and STIs in Cotonou,Benin, West Africa

The potential for exposure of low and high risk women to HIV and sexually transmitted infections (STI) through unprotected sex with male clients of female sex workers in Cotonou could account for most if not all of the estimated yearly numbers of HIV infections in Cotonou women (approximately 1000). As ongoing transmission of HIV, and also of the most predominant STIs such as gonorrhoea and HSV-2, appears to be largely fuelled by transmission within core and bridging groups in Cotonou, interventions targeted at both female sex workers and their male clients remain of the utmost importance and could have a significant effect on the evolution of HIV/STI epidemics in Benin.     

Behavioral surveillance surveys of the male clients of female sex workers in Hong Kong: results of three population-based surveys

BACKGROUND: Male clients of female sex workers (FSWs) are an important group vulnerable to HIV infection. GOALS: The goal was to administer and assess behavioral surveillance surveys of male clients of FSWs in Hong Kong. STUDY DESIGN: Three population-based telephone surveys of males aged 18 to 60 were conducted from 1998 to 2001 (n=5159). RESULTS: Of all respondents, about 10.8% to 14% had patronized FSWs in the previous 6 months. Among male clients of FSWs, about 25% did not always use condoms, 4% to 6% had contracted a sexually transmitted disease, 16% had undergone HIV antibody testing, and 20% or more reported having four or more sex partners in the previous 6 months. There was no improvement in condom use over time. Cross-border (from Hong Kong to mainland China) commercial sex was common. CONCLUSION: The level of risk behaviors associated with male clients of FSWs remained substantial. The overall effectiveness and coverage of relevant prevention programs were questioned.     

A prospective study assessing the effects of introducing the female condom in a sex worker population in Mombasa, Kenya

OBJECTIVE: To assess the impact and costs of adding female condoms to a male condom promotion and distribution peer education programme for sex workers in Mombasa, Kenya. DESIGN: A 12 month, prospective study of 210 female sex workers. METHODS: We interviewed participants about their sexual behaviour every 2 months for a total of seven times and introduced female condoms after the third interview. We also collected cost data and calculated the cost and cost effectiveness of adding the female condom component to the existing programme. RESULTS: Introduction of the female condom in an HIV/AIDS prevention project targeting sex workers led to small, but significant, increases in consistent condom use with all sexual partners. However, there was a high degree of substitution of the female condom for male condoms. The cost per additional consistent condom user at a programme level is estimated to be 2160 dollars (1169 pounds sterling, 1711 euros) (95% CI: 1338 to 11 179). CONCLUSIONS: The female condom has some potential for reducing unprotected sex among sex workers. However, given its high cost, and the marginal improvements seen here, governments should limit promotion of the female condom in populations that are already successfully using the male condom. More research is needed to identify effective methods of encouraging sex workers to practise safer sex with their boyfriends.     

A survey of female prostitutes at risk of HIV infection and other sexually transmissible diseases.

OBJECTIVE--To determine risk factors for the transmission of human immunodeficiency virus (HIV), including injecting drug use (IDU), sexual behaviour and other sexually transmissible diseases (STDs), in female prostitutes who attended the Sydney Sexual Health (previously STD) Centre. DESIGN--We surveyed by questionnaire 231 (47%) of 491 female prostitutes who visited the Centre over a 19 month period from 1986 to 1988. All were tested for HIV antibody. MAIN OUTCOME--All the women were seronegative for HIV but a number of major risk factors for infection were identified. RESULTS--Seventeen of 26 (65%) current injecting drug users had shared needles in the previous 6 months. Nineteen per cent of those surveyed had bisexual non-paying partners and 21% had partners who injected drugs. Sixty nine per cent always used condoms for vaginal intercourse with paying clients, but they were rarely used with non-paying partners. Condom use was also rare for anal intercourse with clients and/or partners by those (18%) who practised it. Seventeen per cent used condoms alone for contraception and 48% relied on oral contraceptives. We found a reduction in gonorrhoea, herpes and trichomoniasis when compared with a 1985 study conducted at the same Centre. However, there was an increase in reported abnormal cervical cytology. CONCLUSION--In spite of behaviour change by some, there are still many women working as prostitutes in Sydney who remain seriously at risk of HIV infection. We recommend more widespread use of barrier methods of contraception, intensified efforts to prevent the sharing of intravenous needles, closer monitoring of the health of prostitutes, and scientific study of their paying and non-paying sexual partners.     

青岛市男男性行为人群艾滋病高危性行为调查

目的:了解男男性行为人群(MSM)的高危性行为,为制定预防控制策略提供依据。方法:采用同伴推动抽样法对MSM人群进行问卷调查。结果:累计调查1849人,年龄中位数26岁,与男性发生过肛交者占98.37%;最近3个月男性性伴在2人以上者占46.29%,有女性性伴者占11.14%;最近一次与男性肛交时安全套使用率为57.92%,最近3个月与男性肛交时每次都使用安全套的比例为35.37%。结论:MSM人群普遍存在多性伴、无保护的性行为,传播性病艾滋病的风险较大。     

年轻男男性行为者首次同性性行为及其意愿的关联因素分析

目的 了解年轻男男性行为者(YMSM)首次同性性行为状况,分析首次同性性行为意愿的关联因素.方法 采用"滚雪球"抽样法于2016年9月至2019年9月在绵阳市招募YMSM作为调查对象,对其进行首次同性性行为状况及关联因素等的问卷调查.结果 共收取有效问卷344份,YMSM发生首次同性性行为时的年龄为(18.1±2.0)...     

Prevalence of Chlamydia trachomatis and Neisseria gonorrhoeae in Turkey among men With urethritis.

BACKGROUND: Chlamydia trachomatis and Neisseria gonorrhoeae are known to cause urethritis. However, only a small number of studies in Eastern European countries have investigated the causes of urethritis. GOALS: To determine the prevalence of C trachomatis and N gonorrhoeae among men with symptomatic urethritis in Istanbul, Turkey, and to determine whether contact with a commercial sex worker increased the likelihood of chlamydial infections. STUDY DESIGN: Men with a diagnosis of urethritis at the Istanbul Faculty of Medicine were screened for C trachomatis and N gonorrhoeae by Abbott's ligase chain reaction (LCR) using either urethral swabs or first-void urine. N gonorrhoeae cultures were done on a subset of these patients. RESULTS: The study enrolled 813 men. All of the men denied condom use during their previous sexual exposures. The overall prevalence of C trachomatis, as determined by LCR, was 15.7%. Only 192 patients were screened for both organisms. N gonorrhoeae prevalence was 9.4%. There was no difference in the chlamydia prevalence between men who had contact with commercial sex workers (CSWs) and men who had no such contact (15.3% versus 17.2%). However, clients of foreign CSWs were more likely to have chlamydia than clients of registered Turkish CSWs. CONCLUSIONS: C trachomatis and N gonorrhoeae are commonly found in Turkish men with urethritis. The findings did not show more chlamydial infection among men who had contact with CSWs than among men who had no such contact. The failure to use condoms among these men must be addressed.     

The association between abuse in childhood and STD/HIV risk behaviours in female genitourinary (GU) clinic attendees

OBJECTIVES: To compare and contrast women with a history of child abuse with those who have no history of child abuse on STI/HIV risk behaviours and safer sex beliefs in an inner city UK sample. DESIGN: Cross sectional sample survey. METHODS: Routine female clinic attendees were invited to complete an anonymous self report questionnaire which included background information, sexual and drug risk behaviour, self reported sexually transmitted infections (STIs), psychological distress (Hospital and Anxiety Depression Scale; HADS), Sexual Risk Cognitions Questionnaire (SRCQ), and history of child sexual, physical, and emotional abuse. RESULTS: 137 (45%) of 303 women reported a history of child abuse; all three forms of child abuse--sexual (26%), physical (20%), and emotional (27%) abuse--overlapped. The majority of women reported one sexual partner in the past month, and the majority did not use condoms. Women reporting a history of child abuse were more likely to have had previous STIs (p = 0.007) and to have had more than one STI (p = 0.04) compared with women who had not experienced child abuse. Injecting drug use and commercial sex work were of low prevalence across the whole sample and no group differences were found. Women reporting a history of child abuse had higher HADS anxiety (p = 0.03) compared with women with no history of child abuse. Confidence in using condoms with a sexual partner was not related to child abuse. Women with a history of child abuse reported significantly higher frequency of thoughts reflecting anticipated negative reactions from partners to suggesting condom use (p = 0.02) and judging a partner's risk by their appearance (p = 0.05) compared with women with no history of child abuse. CONCLUSIONS: Comparable rates of child sexual abuse with US studies were found in this UK inner city population of women attending sexual health services. Women who had experienced child abuse were more likely to report ever having had an STI and having had more than one STI. Complex psychological and social factors contribute to difficulties for women in negotiating safer sex including emotional distress, abuse histories, and anticipating a negative reaction from partners. Multifaceted prevention models are needed.     

Homosexual men's HIV related sexual risk behaviour in Scotland

OBJECTIVE: To date, the epidemic of HIV infection in Scotland has been primarily associated with injecting drug use. However, the epidemiology of HIV in Scotland changed in the late 1980s, with homosexual men becoming the largest group at risk of HIV infection and AIDS. Our aim was to describe homosexual men's sexual risk behaviours for HIV infection in a sample of men in Scotland's two largest cities. DESIGN/SETTING: Trained sessional research staff administered a short self completed questionnaire, to homosexual men present in all of Glasgow's and Edinburgh's "gay bars," during a 1 month period. SUBJECTS: A total of 2276 homosexual men participated, with a response rate of 78.5%. Of these, 1245 were contacted in Glasgow and 1031 in Edinburgh. MAIN OUTCOME MEASURES: Sociodemographic data, recent (past year) sexual behaviour, information on last occasion of anal intercourse with and without condoms, and sexual health service use. RESULTS: Anal intercourse is a common behaviour; 75% of men have had anal intercourse in the past year. A third of our sample report anal intercourse with one partner in the past year, but 42% have had anal intercourse with multiple partners. Over two thirds of the total population have not had any unprotected anal intercourse (UAI) in the past year and a quarter of the sample have had UAI with one partner only. 8% report UAI with two or more partners. More men in Edinburgh (17% v 10%) reported unprotected sex with casual partners only, but more men in Glasgow (29% v 20%) reported UAI with both casual and regular partners (chi 2 = 12.183 p < 0.02). Multiple logistical regression found that odds of UAI are 30% lower for men with degree level education and 40% lower for men who claim to know their own HIV status, whereas they are 40% higher for those who have been tested for HIV and 48% higher for infrequent visitors to the "gay scene". Men who have had an STI in the past year are 2.4 times more likely to report UAI than those who have not. Men with a regular partner were significantly more likely to report UAI, as were those who had known their partner for longer, and who claimed to know their partner's antibody status. CONCLUSION: On the basis of current sexual risk taking, the epidemic of HIV among homosexual men in Scotland will continue in future years. The data reported here will prove useful both for surveillance of sexual risk taking, and the effectiveness of Scotland-wide and UK-wide HIV prevention efforts among homosexual men.     

Determinants of inconsistent condom use with female sex workers among men attending the STD clinic in Singapore

BACKGROUND/ OBJECTIVES: Female sex workers and their male clients have been identified as risk groups for the transmission of STDs and HIV. Behavioural interventions targeting clients need to address inconsistent condom use among them. The aim of the study is to assess the sociodemographic, behavioural, and psychological factors associated with inconsistent condom use among clients of sex workers. METHODS: 229 male patients attending the STD clinic in Singapore who reported paying for sex in the previous 6 months were interviewed. Response rate was 91%. RESULTS: Overall, 45% used condoms inconsistently; these clients were more likely to have poor STD knowledge, visit sex workers five or more times in the past 6 months, have lower self efficacy, less favourable social norms for condom use, and more likely to forget condom use when intoxicated (alcohol impaired decision making). CONCLUSIONS: Behavioural interventions for clients need to improve STD/HIV transmission knowledge and focus on improving client's self efficacy in using condoms.