Female condom and male condom failure among women at high risk of sexually transmitted diseases

OBJECTIVE: The objective of this study was to study the frequency and determinants of breakage and slippage during female and male condom use. GOAL: The goal of this study was to determine condom breakage and slippage rate. STUDY: We conducted a 6-month prospective follow-up study of women attending 2 sexually transmitted disease clinics. Breakage and slippage rates were computed. Logistic regression was used to evaluate baseline characteristics and time-dependent behaviors. RESULTS: A total of 869 women used condoms in 20,148 acts of intercourse. Breakage was less common for female condoms (0.1%; 95% confidence interval [CI], 0.05-0.21) than for male condoms (3.1%; 95% CI, 2.80-3.42). Slippage was more common for female condoms (5.6%; 95% CI, 5.10-6.13) than for male condoms (1.1%; 95% CI, 0.90-1.28). Rates significantly decreased with use and increased with number of previous failures. From first use to >15 uses, combined failure rate fell from 20% to 1.2% for female condoms (P < 0.0001) and 9% to 2.3% for male condoms (P < 0.01). CONCLUSIONS: Both condoms may provide good protection against sexually transmitted diseases. Experience determines success with either condom.     

Predicting pregnancy risk in women attending an STD clinic

BACKGROUND: Although sexually transmitted disease (STD) clinics focus mainly on STD treatment and prevention, women attending these clinics are also at high risk for pregnancy. GOAL: To evaluate the relationship between certain demographic and behavioral characteristics and the probability of pregnancy in women attending an urban STD clinic. STUDY DESIGN: Non-contraceptive-using women in an STD clinic-initiated randomized controlled contraception study (n = 877) were interviewed at baseline, and incident pregnancies within 1 year of enrollment were measured. Association between baseline demographic and behavioral characteristics with incident pregnancy was assessed by chi-square analysis, and logistic regression was used to assess factors associated with an incident pregnancy. RESULTS: Among the 673 women (76.7%) for whom follow-up pregnancy information was available, 220 (32.7%) incident pregnancies occurred within 1 year. By logistic regression controlling for study assignment, incident pregnancy was associated with age < or =19 years (odds ratio [OR], 2.8; 95% CI: 1.5-5.2), previous abortion (OR, 3.1; 95% CI: 1.7-5.4), frequency of sexual encounters of at least once a week (OR, 1.8; 95% CI: 1.2-2.6), and having a chlamydial infection at the time of enrollment (OR, 1.8; 95% CI: 1.0-3.2). With a combination of demographic and behavioral characteristics correlated by univariate analysis with incident pregnancy (i.e., age < or =19 years, nonwhite race, high school/general equivalency diploma or less education, previous pregnancy, no use of birth control with last intercourse, sex at least once a week, previous abortion, > or =3 partners within the past month, and <17 years of age at first pregnancy), the cumulative risk of pregnancy with 6 or more of the 9 characteristics was 51%, compared with 25.6% for women with < or =5 characteristics. CONCLUSION: For this STD clinic population, a combination of demographic and behavioral characteristics was useful when combined for identifying a subgroup of women at higher risk for subsequent pregnancy. Targeted intervention by STD care providers should include the provision for both pregnancy and STD prevention counseling.     

Baseline STD prevalence in a community intervention trial of the female condom in Kenya

OBJECTIVE: We present baseline sexually transmitted disease (STD) prevalence rates from an ongoing intervention trial at Kenyan agricultural sites. METHODS: After gaining the cooperation of management, we identified six matched pairs of tea, coffee, and flower plantations and enrolled approximately 160 women at each site. Six intervention sites received an information programme and distributed female and male condoms, while six control sites received male condoms only and similar information about them. At clinic visits, we tested participants for cervical gonorrhoea (GC) and Chlamydia trachomatis (CT) by ligase chain reaction on urine specimens, and Trichomonas vaginalis (TV) by culture. The study has 80% power to detect a 10% prevalence difference during follow up, assuming a combined STD prevalence of 20%, 25% loss to follow up and intracluster correlation coefficient (ICC) of 0.03. RESULTS: Participants at intervention and control sites (total 1929) were similar at baseline. Mean age was 33 years, the majority were married, more than half currently used family planning, 78% had never used male condoms, and 9% reported more than one sexual partner in the 3 months before the study. Prevalences of GC, CT, and TV were 2.6%, 3.2%, and 20.4% respectively (23.9% overall), and were similar at intervention and control sites. The ICC for STD prevalence was 0.0011. Baseline STD was associated with unmarried status, non-use of family planning, alcohol use, and more than one recent sexual partner, but the highest odds ratio was 1.5. CONCLUSIONS: Baseline results confirm a high prevalence of trichomoniasis and bacterial STD at these Kenyan rural sites. Improved STD management is urgently needed there. Our ongoing female condom intervention trial is feasible as designed.     

Consistent condom use in married Zimbabwean women after a condom intervention

OBJECTIVES: Condom use to prevent HIV in Africa has increased in nonmarital sexual encounters but remains low within marriage. Married women of reproductive age, however, are at high risk of HIV. GOAL: This study investigated factors associated with consistent condom use after a brief intervention. STUDY DESIGN: We conducted an HIV prevention condom intervention with a cohort of 394 married women, aged 17 to 47, recruited from clinics in Zimbabwe. Consistent condom users were ineligible. At enrollment, participants received education and were offered free male and female condoms and HIV testing. Women completed a follow-up questionnaire at 2-months. We used logistic regression analysis to measure the association of protected sex (i.e., 100% use of male or female condoms) at follow-up with condom attitudes, negotiation skills, HIV risk perception and testing. RESULTS: At follow-up, 179 (48.5%) women reported consistent condom use throughout the study, and 318 (87%) reported condom use at last sexual episode; 72 women tested HIV-positive, only 4 of whom reported at enrollment that it was likely that they were infected. Results showed that women who tested positive were more likely to report consistent condom use (OR 2.9, 95% CI 1.7-5.2). HIV risk perceptions and condom negotiation self-efficacy increased postintervention, and were significantly associated with consistent condom use. Hormonal contraception was negatively associated with consistent condom use (OR 0.3, 95% CI 0.19-0.65). CONCLUSIONS: Married women reported significant increases in consistent condom use in response to a brief intervention, especially if HIV-positive.     

Decreasing STD incidence and increasing condom use among Chinese sex workers following a short term intervention: a prospective cohort study

OBJECTIVE: To describe the impact of a repeating behavioural intervention focused on preventive education and provision of STD testing and treatment services to female sex workers. METHODS: A prospective cohort study of 966 sex workers (first of its kind in China) was conducted in Guangzhou from March 1998 to October 1999. At each visit information was collected on sexual behaviour, condom use and knowledge about HIV transmission and condom use, education was given, STD were diagnosed, and treatment was provided free of charge. We evaluated trends in condom use, knowledge about HIV transmission and condom use, and STD incidences. Generalised estimating equations were applied to control for repeated measurements. RESULTS: The proportion of consistent condom use increased from the intake through the third follow up visit (from 30% to 81%), as well as the proportion of having good knowledge on HIV transmission (4.3% to 98.6%) and condom use (23.6% to 79.3%). The incidence of gonorrhoea, trichomoniasis, and chlamydia decreased over each follow up visit; from 17.5/100 person years (PY), 22.4/100PY, 65.9/100PY at the first follow up visit to 5.1/100PY, 3.0/100PY, 16.1/100PY at the third follow up visit, for each STD respectively. CONCLUSIONS: STD care and prevention programmes targeting sex workers are feasible in China and, more importantly, intervention consisting of prevention education and STD care is likely to reduce unprotected sexual behaviour and STD incidence in this group at high risk for HIV and other STD infection.     

Casual sexual experience abroad in patients attending an STD clinic and at high risk for HIV infection.

OBJECTIVE--To study possible "import" routes of HIV infection to Norway (by obtaining information on casual sexual contacts abroad from patients attending an STD clinic), and to assess their behavioural risk factors (such as alcohol intake, use of condom) for HIV infection. DESIGN AND SETTING--Patients visiting the clinic for sexually transmitted diseases (STD), April-June 1989, received a questionnaire. SUBJECTS--606 consecutive persons of whom 599 agreed (98.8%) to participate. We grouped the patients in four categories. 1: Sex with a prostitute during the last 5 years, 2: Homosexuals/bisexuals, 3: prostitutes/intravenous drug abusers (IVDUs) and 4: Other heterosexuals. RESULTS--245 patients (41%) reported having a casual sex partner abroad (M: 182, F: 63), mainly in Europe, particularly in Spain, Denmark and Greece. Outside Europe such contacts were most frequently reported from USA, Brazil and Thailand. Among men who had had sex with a prostitute, 93.5% reported such sex abroad (homosexuals/bisexuals: 63.6%, prostitutes/IVDUs: 66.7%, "other heterosexuals: 32.1%). Homosexual/bisexual men with casual partner(s) abroad used a condom more frequently than did others. CONCLUSION--245 of 599 persons reported casual sex abroad during 1985-1989, and the different "risk groups" reported countries where most HIV infected persons belonged to their own "risk group". We have reason to believe that alcohol intake increased the likelihood of casual sexual activity and decreased the use of condom. Norwegian travellers need more information on the risks of casual sex abroad, the use of condoms and the combination of alcohol intake and casual sex.     

Reversible contraception for women at high risk of fetal anomalies

Women at risk of pregnancy who are taking potentially teratogenic drugs need to use highly effective contraception. The choice of contraception should reflect the woman's feelings about induced abortion as a backup in case of contraceptive failure. If abortion is acceptable, use of any contraceptive seems reasonable. If abortion is not acceptable, depomedroxyprogesterone acetate, oral contraceptives, and intrauterine devices (each used with a condom) should provide the greatest protection against pregnancy. For most young women, the contraceptive of choice will be a low-dose oral contraceptive.     

Urethritis in women attending an STD clinic.

Of an unselected group of 159 women attending a sexually transmitted diseases (STD) clinic 20% (32) had symptoms of urethritis. A positive correlation existed between the finding of more than 10 polymorphonuclear leucocytes (PMNL) per high-power field in the Gram-stained urethral smear and the presence of Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis. Conversely, these organisms were rarely isolated if no PMNL were present. Fewer cultures gave positive results for these organisms if micturition had occurred less than four hours before examination. C trachomatis was recovered from the urethra or endocervix in 29/150 (19 . 3%) and from the urethra alone in six women. In contrast, N gonorrhoea was never recovered from the urethra in the absence of endocervical infection. Of the 159 women 10% had bacteriuria due to non-sexually transmissible agents; 50% had asymptomatic bacteriuria. All, however, had other urethral pathogens isolated as well. Thus, sexually transmitted disease agents are highly prevalent in women attending an STD clinic who have signs and symptoms of urethritis. As in non-gonococcal urethritis in men, C trachomatis may be an important cause of urethritis in women.     

Psoriasis and risk of nonfatal cardiovascular disease in U.S. women: a cohort study

Background Psoriasis has been linked to cardiovascular comorbidities in cross‐sectional studies, but evidence regarding the association between psoriasis and incident cardiovascular disease (CVD) is limited. Objectives To make a prospective evaluation of the association between psoriasis and risk of incident nonfatal CVD. Methods Participants (n = 96 008) were included from the Nurses’ Health Study II, and followed for 18 years. Information on physician‐diagnosed psoriasis was obtained by self‐report and diagnosis was confirmed by supplementary questionnaires. We included 2463 individuals with self‐reported psoriasis and a subsample of 1242 with validated psoriasis. The main outcome was incident nonfatal CVD events [nonfatal myocardial infarction (MI) and nonfatal stroke], ascertained by biennial questionnaires and confirmed. Results During 1 709 069 person‐years of follow‐up, 713 incident nonfatal CVD events were confirmed. Psoriasis was associated with a significantly increased multivariate‐adjusted hazard ratio (HR) of nonfatal CVD, 1·55 [95% confidence interval (CI): 1·04–2·31]. HRs for nonfatal MI and stroke were 1·70 (95% CI: 1·01–2·84) and 1·45 (95% CI: 0·80–2·65), respectively. The association remained consistent in a sensitivity analysis of confirmed psoriasis (HR: 2·06, 95% CI: 1·31–3·26). For individuals with concomitant psoriatic arthritis, the risk of nonfatal CVD was even higher (HR: 3·47; 95% CI: 1·85–6·51). Women diagnosed with psoriasis at < 40 years of age or with duration of psoriasis ≥ 9 years had substantial elevations in CVD risk: HR: 3·26 (95% CI: 1·21–8·75) and 3·09 (95% CI: 1·15–8·29), respectively. Conclusions Psoriasis is an independent predictor for nonfatal CVD among women, with particularly high risk for those with longer duration of psoriasis and concomitant psoriatic arthritis.     

Evaluation of the virus permeability of a new condom for women

The authors tested a polyurethane women's condom for permeability to the human immunodeficiency virus (HIV) and cytomegalovirus (CMV) using an artificial intercourse model. They did not detect viral leakage in three trials for each virus. Use of this device, which can be controlled by the woman, may reduce HIV and CMV infection.     

Sexual behavior among adolescent women at high risk for sexually transmitted infections

BACKGROUND: The temporal pattern of partners and sexual encounters may be key factors in the acquisition and transmission of sexually transmitted diseases (STDs). Behavior among adolescent women is of particular interest because they frequently have the highest prevalence and incidence of infection. GOAL: To examine coital diary data collected during a 7-month longitudinal study of young women at high risk of STDs and to describe their sexual behaviors, with particular attention to issues of partner sequence and overlap. STUDY DESIGN: A 7-month longitudinal study of young women infected with or having a sexual contact infected with Neisseria gonorrhoeae, Chlamydia trachomatis, or Trichomonas vaginalis attending the STD clinic or one of four neighborhood adolescent health clinics. Data were collected at enrollment and at 1, 3, 5, and 7-month follow-up visits. Coital diaries were kept between visits. RESULTS: The average frequency of coital events was 0.94 per week. The median number of sexual partners during the follow-up period was one, and overlapping of partnerships was an uncommon occurrence. The number of days between the last coital event of a current relationship and the first encounter of a new relationship differed for those choosing a new partner (mean, 20.6 days) and those who returned to a previous partner (mean, 7.9 days; P < 0.001). CONCLUSION: Although at high risk for STDs, high-risk behavior was not common among the study population. Partner choice and the behavior of these partners may be more important elements than personal high-risk behavior in accounting for the high prevalence of sexually transmitted infections among inner-city adolescent women.     

Risk factors for bacterial vaginosis in women at high risk for sexually transmitted diseases

OBJECTIVE AND GOAL: Bacterial vaginosis (BV) is extremely common and is associated with adverse obstetrical and gynecological outcomes. The etiology of the microbiologic changes is unknown. The objective of this study was to determine risk factors associated with incident BV. STUDY: 96 women without BV were followed prospectively for 1 year for the development of BV. Thirty-seven of their male partners were also studied. RESULTS: The incidence rate of BV was 2.33/person-year (95% CI, 1.63-2.50). Median time to development of BV was 81 days. Incident BV was significantly associated with exposure to a new sexual partner (RR, 1.13; 95% CI, 1.02-1.25; P = 0.02) and frequency of vaginal sex since last visit (RR, 1.07; 95% CI, 1.01-1.15; P = 0.03). Use of condoms with occasional partners was protective (RR, 0.80; 95% CI, 0.67-0.98; P = 0.003). In multivariate analysis, sex with a new partner since the prior visit was the only behavior found to be significantly associated with incident BV (RR, 1.74; 95% CI, 1.05-2.87; P = 0.03). CONCLUSION: These data support the sexual transmission of BV.     

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.