Epidemiology & Social
Partner type and condom use
Macaluso, Maurizioa; Demand, Michael J.a; Artz, Lynn M.a; Hook, Edward W. IIIb,c
From the aDepartment of Epidemiology and International Health, School of Public Health and the bDivision of Infectious Diseases, School of Medicine, University of Alabama at Birmingham and the cJefferson County Department of Health, Birmingham, Alabama, USA.
Sponsorship: This project was carried out under contract with the National Institute of Child Health and Human Development (Contract N01-HD-1-3135).
Note: The content of this publication does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the US Government.
Requests for reprints to: Dr M. Macaluso, MJH 108, 1530 3rd Avenue S, Birmingham, Alabama 35294-2010, USA.
Received: 25 May 1999;
revised: 9 November 1999; accepted: 22 November 1999.
Objectives: To examine the association between type of sexual partnership and condom use consistency.
Design: A prospective follow-up study of women attending two urban clinics for sexually transmitted diseases (STD).
Methods: Sexual diaries recording barrier method, partner initials and partner type for each act of intercourse were kept by 869 women. Condom use by partner type was evaluated in three ways in the entire group: among women who encountered multiple partners, during months in which women encountered multiple partners, and within sexual partnerships that changed status during the study.
Results: Consistency of condom use was higher with new and casual partners than with regular partners in the entire group and among women who encountered multiple partners. In months in which partners of different types were encountered, condom-use consistency was higher with new and casual partners than with regular partners. Consistent condom use decreased in partnerships that changed status from new to regular. The female condom was used more often with regular partners than with new or casual partners in the entire study group, among women who encountered multiple partners, and during months in which a woman achieved consistent use with her regular partner.
Conclusions: This study provides strong evidence that condom use behavior is modified by partner type. Observations about condom use and partner type made in cross-sectional or retrospective surveys also hold in the present longitudinal analyses of individual women and of partnerships that change status. The female condom may be an important option for achieving consistent protection within stable partnerships.
When used correctly and consistently, the male latex condom is a powerful barrier against the spread of sexually transmitted disease (STD) and HIV . Since the 1970s, the prophylactic efficacy of the male condom against a variety of microorganisms has been evaluated in cross-sectional, case-control, and follow-up studies [2–18].
Three recent large-scale trials have demonstrated that it is possible to reduce the incidence of STD and HIV in high-risk groups through structured behavioral interventions that include consistent condom use as a central component of safer sexual behavior [19–21].
Although male condoms are widely available, effective, and a recognized means of preventing STD and HIV, many at-risk women still fail to achieve consistent protection against STD. The use characteristics of the male condom and the social norms associated with male condom use are thought to create a dynamic in which the male partner has a disproportionate amount of control over the decision of whether or not to use the product. This situation has prompted the call for safe and reliable female-controlled methods of STD and HIV prevention [22–25]. Approved for sale by the Food and Drug Administration in 1992, the female condom has been described as the best female-controlled prophylactic to come onto the market . The modest body of information available about the efficacy of the female condom indicates that it may provide a viable alternative to the male condom [26–31].
Although the availability of options such as the female condom may improve the gender dynamics of condom-use behavior, it is likely that interaction within partnerships will continue to play an important role in the decision to use barrier contraceptives and in the ability of a couple to maintain consistent use over time. Condom use appears to vary systematically according to the type of sexual partnership. Cross-sectional examinations of monogamous heterosexuals reveal that the willingness to propose and the ability to achieve condom use are greater within new and casual relationships than within long-term or primary relationships [32–38]. Surveys of a variety of population groups ranging from college students to commercial sex workers, and including representative samples of European and United States populations, have evaluated condom use by partner type [37,39–48]. These studies systematically show that consistent condom use is reported more frequently with casual or new partners than with primary partners. It has also been hypothesized that as sexual relationships grow more stable and intimate over time, condom use decreases . With the exception of one longitudinal study of commercial sex workers in Cameroon , however, most of the evidence available is based on retrospective recall rather than on prospective recording of condom use. Furthermore, we are not aware of any study of the longitudinal changes of condom use within relationships as the nature of the relationship changes (e.g., from a new partnership to a primary partnership).
The purpose of the present study was to examine the association between partner type and condom use in a group of women of childbearing age who were at risk of STD and HIV infection. Unlike previous studies, which relied on the retrospective recall of condom-use behavior, this study used detailed prospective diary reports of sexual behavior and condom use over a 6-month period. Thus, it was possible to investigate the association between partner type and condom use for each act of intercourse during follow up for the entire study group and within the subgroup of women who had intercourse with multiple partners. It was also possible to evaluate the influence of partner type on condom-use consistency during months in which women encountered multiple partners, and within couples that experienced a relationship status change during the follow-up period.
Materials and methods
Study design and procedures
Data for this study come from a prospective follow-up investigation of the prophylactic efficacy of the female condom. All participants were women recruited from two urban STD clinics in Alabama between 14 July 1995 and 28 February 1998. Approximately 30 000 men and women visit the two clinics each year to receive STD diagnosis and treatment. Five eligibility criteria were employed to recruit participants. Eligible individuals were required to be between 18 and 35 years of age, not to be currently pregnant or planning to become pregnant in the next 6 months, not to have had a hysterectomy, not to be taking antibiotics on a regular basis, and to have no plans to be out of town for any prolonged duration during the 6-month follow-up period. Women meeting these criteria who agreed to participate were scheduled to return approximately 10 days later for an initial study visit.
At the initial study visit, women provided written informed consent, were interviewed by female research assistants, received an intensive behavioral intervention promoting barrier contraception and female condom use, and were taught to complete a detailed sexual diary. A licensed nurse-clinician or nurse practitioner performed a pelvic examination on each woman and collected physical specimens following health department guidelines. The nurse also assessed each woman's ability to insert the female condom correctly. Upon completion of the physical examination, women were provided with a free 6-week supply of male and female condoms and compensated $25.
Participants returned at monthly intervals until they either completed six visits or withdrew from the study. At each follow-up visit, a series of questions was asked in order to assess whether individuals continued to meet eligibility criteria and to record general information about sexual activity and contraceptive behavior since the previous visit. Sexual diaries were also returned at each follow-up visit for data abstraction and coding; diaries were reviewed with research assistants to verify the completeness and accuracy of the information reported. Participants were re-examined at each visit and received additional supplies of male and female condoms as needed. Women were compensated $25 for each follow-up visit attended and $50 upon completion of the study.
Of importance for this analysis is the sexual diary, which was designed to gather information on sexual activity and barrier use during each month of follow-up. Each participant was instructed to use the diary for taking personal notes in addition to recording sexual activity, male and female condom use, the initials of sexual partners, and partner type. Partner type consisted of three categories: new, regular, and casual. A new partner was a partner first encountered during that month. A regular partner was a partner she had met before the current month with whom she had an established relationship, such as her husband or boyfriend. A casual partner was a partner she had met before the current month but whom she did not consider as regular.
The analytic plan consisted of four components. First, the association between condom use and partner type was evaluated for every act of vaginal intercourse reported during the 6-month follow-up period. Second, the association between condom use and partner type was evaluated for every act of intercourse reported by the subgroup of women who encountered multiple partners during follow-up. Third, condom-use consistency was assessed by partner type during all months in which women encountered multiple partners of different types. Fourth, changes in condom-use consistency were evaluated within couples that experienced a transition in relationship status during the follow-up period (i.e., a partner who was classified into two different categories in different months of follow-up, such as a new partner who became regular, or a regular partner who became casual).
Logistic regression models for repeated measurements were used to assess the association between partner type and condom use for the entire study group and for those who encountered multiple partners. Because two condom types were used in the study, two nested analyses were conducted. The first logistic regression analysis examined the association between partner type and the use of any condom (i.e., either male or female condom use) at each act. The second logistic regression analysis examined the association between partner type and the specific condom used, conditional on having used a condom (i.e., restricted to acts in which either the female or the male condom was used). The possible correlation of outcomes within subjects was assumed to be autoregressive of order 1 and was taken into account using generalized estimating equations . Baseline characteristics of the woman (age, race, marital status, education, employment status, income, age at sexual debut, number of lifetime sexual partners, pregnancy history, STD history, STD diagnosis at baseline) were considered as potential confounders of the association between partner type and condom use and were included in the models.
To further clarify whether the behavior of the same woman varied systematically with the type of partner, we examined condom-use consistency (i.e., use of the male or female condom during each act of vaginal intercourse) by partner type during each month in which a woman encountered multiple partners. The partner initials and corresponding partner classification reported in the sexual diary were used to identify the number and type of partners encountered during each month of follow-up. Consideration was given to the possibility that women might encounter partners with the same initials. In such instances, participants were instructed to provide unique initials for each partner. Condom-use consistency within the follow-up interval was calculated separately by partner type for each woman, and follow-up intervals were classified according to whether consistent condom use was achieved with each partner type encountered. Conditional logistic regression was used to assess the influence of partner type on condom use, taking into account the potential correlation among repeated measures (i.e., multiple months of follow-up in which the same woman encountered different types of partner). Control of confounding was obtained implicitly, since the conditional logistic regression analysis evaluated effects within months of follow up of the same woman.
The final analysis evaluated condom use within couples that experienced a relationship status change during the study. The partner type associated with a set of initials during one month was compared with the partner type associated with the same set of initials in other months to determine partner status changes during the follow-up interval. Consistency of condom use was calculated for each relationship before and after the relationship status change and was evaluated using conditional logistic regression models similar to those used in the analysis of condom-use consistency among women who encountered multiple partners during one month.
A total of 3531 potentially eligible women received recruitment interviews, 2702 women (77%) agreed to participate, and 1159 women (33%) attended the initial visit. Of the 1159 women who attended the initial visit, 869 (75%) came to at least one follow-up visit, returned at least one sexual diary, and reported at least one act of vaginal intercourse during the follow-up period. All six follow-up visits were attended by 525 women (45%). The mean number of visits attended by a woman was four. Regression analyses comparing study participants with women who refused to participate indicated that the refusers were slightly older, less often African-American, more educated, had fewer lifetime partners, less often had a history of STD, and were more often hormonal contraceptive users (data not shown). Women who agreed to participate but did not attend the initial visit were not significantly different from study participants.
The 869 women who returned for follow-up were typically young, African-American and of low socioeconomic status. The mean age of participants was 24 years. The racial/ethnic distribution of the group was 85% African-American, and 15% non-African-American. Seventy-five percent reported being single and 22% were living with a male sexual partner. On average, participants had completed 12 years of formal education and 56% were employed at the time of recruitment. Monthly income from all sources was for the most part low: 39% made less than $300, 29% made between $301 and $600, and 32% made over $600. All participants stated that they did not plan to become pregnant during the 6-month observation period and renewed their statement at each follow-up visit as a condition for continued eligibility. In fact, a majority used a method of birth control: 20% of the initial study group was surgically sterilized, 30% used hormonal methods of contraception, and 50% (non-mutually exclusive with previous choices) used condoms. Only 17% stated that they did not use any form of birth control. Participants were at high risk of contracting an STD. The mean age of sexual debut was 16 years, and the mean number of lifetime sexual partners was 7.5. Two thirds (68%) reported having had a past STD. At entry into the study, 55% were diagnosed with an STD. The judgment that the group was at high risk for STD was also based on the knowledge that approximately 25% of the STD clinic patients return to the clinic with a new complaint within 6 months.
Condom use by partner type
During the 6-month follow-up interval, 865 (99%) participants reported having intercourse with a regular partner, 284 (33%) encountered a casual partner, and 235 (27%) encountered a new partner. A total of 29 312 acts of vaginal intercourse were reported during the study. The male condom was used in 42% of these acts and the female condom in 27%. No barrier was used in 31% (Table 1). In a logistic regression model evaluating use of any condom as the outcome of each act of intercourse, the probability of using a condom was significantly higher with new partners [odds ratio (OR) 1.7; 95% confidence interval (CI) 1.3–2.2] and casual partners (OR 1.6; 95% CI 1.3–2.1) than with regular partners. In the same model, non-African-American women (OR 0.6; 95% CI 0.4–0.9) and women who reported engaging in intercourse before age 16 years (OR 0.6; 95% CI 0.4–0.9) were less likely to use condoms. In a logistic regression model evaluating use of the female condom as the outcome of each protected act of intercourse, the probability of using the female condom was lower with new (OR 0.5; 95% CI 0.4–0.6) and casual partners (OR 0.4; 95% CI 0.4–0.6) than with regular partners. In the same model, women who were 25 years or younger were significantly less likely to use the female condom (18–20 years of age OR 0.7; 95% CI 0.5–0.9; 21–25 years of age OR 0.8; 95% CI 0.7–0.9) than women who were 26 years or older. Non-African-American women were more likely to use a female condom than African-American women (OR 1.5; 95% CI 1.1–2.1).
Condom use by partner type among women who encountered multiple partners
The aggregate data presented above represent a comparison among subgroups of women who were heterogeneous with respect to the type of partner encountered during the follow-up interval. For example, the rate of male condom use with a regular partner reported in Table 1 is calculated on the basis of a large number of women who had sex with only one partner during the study. By contrast, the rate of male condom use among women who encountered a new partner is calculated primarily on the basis of the experience of women who changed partners during the study. The observed difference in condom-use consistency by partner type could result, therefore, from confounding by characteristics of the woman, rather than from the type of partner.
Intercourse with multiple partners during the study was reported by 461 women (51%), and accounted for 15 549 (53%) of the 29 312 reported acts of vaginal intercourse. The pattern of barrier use in this subgroup of women was similar to that of the entire study group (Table 2). Throughout the follow-up period, women who encountered multiple partners used condoms more frequently with new (OR 1.6; 95% CI 1.2–2.1) and casual (OR 1.5; 95% CI 1.1–1.9) partners than with regular partners. Female condom use was again less frequent with new (OR 0.5; 95% CI 0.4–0.6) and casual (OR 0.5; 95% CI 0.4–0.6) partners than with regular partners.
Condom-use consistency during months in which multiple partners were encountered
Women had intercourse with multiple partners of different type during a total of 639 months of follow-up. Both a new and a regular partner were encountered during 189 months, a new and a casual partner during 117 months, and a casual and a regular partner during 333 months (Table 3). For those women who encountered new and regular partners, condom-use practices were concordant (i.e., condoms were used consistently with both partner types or inconsistently with both partner types) during 113 follow-up intervals. Condom use was consistent with the new partner and inconsistent with the regular partner during 55 intervals, and the reverse was true during the remaining 21 intervals. Condom use was, therefore, less consistent with regular partners than with new partners within the same month (P < 0.001). Similarly, during the 333 months in which a woman encountered a casual and a regular partner, condom use was systematically less consistent with the regular partner than with the casual partner (P < 0.001). In contrast, there was no significant difference in condom use consistency by partner type when a woman encountered both a new and a casual partner during the same month.
In this analysis, the female condom appeared to be an important means of achieving consistent protection with a regular partner. In the 65 months of follow-up during which a woman achieved consistent use both with a new partner and with a regular partner, the proportion of the acts of intercourse protected by the female condom was 26% with a new partner and 33% with a regular partner. In the months of follow-up in which consistent protection was achieved only with the new partner, the proportion of acts of intercourse protected by the female condom was 14%, while in the months of follow-up in which consistency was achieved only with the regular partner, the proportion of acts protected by the female condom was 24%. Women also used the female condom more often with a regular partner and more often to achieve consistent protection with a regular partner in months in which a woman encountered both a regular and a casual partner. Finally, women used the female condom more often with a casual partner and more often to achieve consistent protection with a casual partner, in months in which both a casual and a new partner were encountered (results not shown in detail).
Relationship status change and condom-use consistency
The study also offered a limited opportunity to examine changes in condom-use consistency following transitions in relationship status. There were four possible relationship status changes: from new to regular, from casual to regular, from new to casual, and from regular to casual. Twenty eight relationships experienced a counterintuitive status change (e.g., regular to new, casual to new) (n = 4) or shifted back and forth between casual and regular status from month to month (n = 24). These relationships were excluded from the analysis. Altogether, 185 relationship status changes occurred during follow-up: 121 women had one relationship that changed status, 19 women had two relationships that changed status, six women had three relationships that changed status, and two women had four relationships that changed status. Women who experienced clear relationship status changes with multiple partners (n = 27) were included in the analyses as many times as there were relationships that changed status during their follow-up.
In all, 49 relationships changed from new to regular, 47 changed from casual to regular, 37 changed from new to casual, and 52 changed from regular to casual. Although the number of discordant partnerships for each type of change in relationship status was small and the power of this analysis was limited, there was a clear and statistically significant excess of relationships in which consistency of use decreased after the relationship status changed from new to regular (P < 0.03) (Table 4). The data available for this analysis were too sparse to evaluate whether the likelihood of using the female condom changed with partnership status.
Our findings provide persuasive evidence that the type of sexual partnership plays an important role in determining consistency of condom use. The findings are compatible with the hypothesis that the greater the affective distance between partners the less frequently condoms are used . Women who were in regular partnerships were less likely to use condoms consistently than women who were in new or casual relationships, which presumably are less stable and intimate than regular partnerships. The findings also provide support for the notion that condom use decreases as a relationship grows more stable and intimate over time. In this study, as relationship status changed from new to regular a significant decrease in condom-use consistency was observed.
Female condom use was significantly less common with new and casual partners than with regular partners. This association was evident for the entire study group and remained strong when analysis was restricted to women who encountered multiple partners. Although consistent condom use was less frequent with a regular partner than with a new or casual partner, the female condom was used more often to achieve consistent protection with a regular partner and the male condom was used more often to achieve consistent protection with a new or casual partner. It is possible, therefore, that the difference in overall protection by partner type would have been more extreme had the male condom been the only device promoted in this study. If this finding is confirmed, the female condom may provide an important supplement to the male condom for promoting barrier methods within regular partnerships.
Other explanations of the observed differences in condom use by partner type should be taken into consideration. Cultural, psychosocial, and contextual factors may also influence the decision about whether or not to use a condom with a particular type of partner. For example, cultural norms may encourage condom use for casual sex and within new relationships and discourage condom use within stable long-term relationships and marriage. Further, individual perceived need for condoms may vary by partner type based on the belief that there is less risk of STD or HIV infection with intimate and long-term monogamous partners than with new and casual partners. Finally, when sex is combined with drugs and alcohol, when there are large disparities in age between partners, and in the context of sexual coercion and paid sex, high-risk unprotected intercourse is more common . The information gathered in this study did not allow an analysis of the causal relation between these variables and consistency of condom use by partner type.
Several potential limitations should be kept in mind in interpreting the findings of this study. First, the study group was drawn from at-risk women attending two urban STD clinics in Alabama. Preliminary analyses suggest that women at higher risk of STD tended to select themselves into the study. Furthermore, a substantial proportion of the participants withdrew before completing follow-up. No major demographic or baseline differences existed between women who completed the study and women who withdrew. However, if withdrawal from follow-up occurred as a function of the characteristics of the partnership or condom-use consistency, the association described in this paper could be biased. Although selection bias weakens our ability to generalize to the entire population, the study group consisted of women whose risk profile is highly relevant for the study of STD and HIV epidemiology and represents an important target for public health interventions. Internal validity, rather than sample-to-population representativeness, is the basis for generalizing the associations found in this study to a larger population of women at high risk of STD. The amount and quality of data collected in this study, its prospective design, and the strength of the within-month and within-partnership analyses lead us to believe that important generalizations can be made from the results of this study.
Second, classification of partnerships was determined on the basis of the woman's subjective report. While a woman may have regarded a man as her regular partner, we have no way of determining whether she was regarded as his regular partner. Thus, differences in the way sexual partners classified their relationship may have had a bearing on the decision to use condoms. Although it is unlikely that participants did not accurately represent new partnerships, a woman could have incorrectly classified a partner as regular, while his perception was that the relationship was casual. As a result, the comparison between regular and casual partners may be biased, most likely toward the null.
Third, consistency of condom use increased sharply at entry into follow-up as a consequence of the behavioral intervention and declined gradually over the course of the study . The decrease in condom-use consistency observed among couples that changed status from new to regular may have resulted, in part, from the overall decline in condom use observed in the cohort at large. This interpretation of the findings is unlikely, however, as the observed low consistency of condom use with a regular partner is present in longitudinal analyses of condom use by act of intercourse, in analyses of the behavior of the same woman with different partners, and in longitudinal analyses of partnership status change. The consistency of these findings is a strong indication that the reported association between partner type and condom use is real. Additionally, it is important to note that the intervention encouraged consistent condom use with every partner during every sex act and discouraged women from believing that having only one partner at a time would keep them safe from infection. As such, it is quite possible that the intervention diminished the differences in condom use by partner type that would have been observed had the study not had an intervention component.
Fourth, because only a few women were able to maintain consistent protection by using the female condom exclusively, it was difficult to assess the association between partner type and condom choice during months in which women encountered multiple partners of different types. Similarly, the number of partnerships that changed status during follow-up was small, limiting the ability to study less common or alternating status changes. Power limitations also made it impossible to evaluate specific patterns of barrier use, such as use of the female condom versus use of the male condom, following relationship status changes. These limitations are not severe, however, as even the low-power longitudinal analysis of partnerships achieved statistical significance.
The limitations discussed above are compensated by several important strengths of this study. First, to our knowledge, this is the only report from a large-scale study of women who are not commercial sex workers in which sexual behavior and condom use are evaluated prospectively by partner type. We found that observations commonly made in cross-sectional or retrospective surveys also hold in longitudinal analyses of the experience of individual women and within specific partnerships over time. Participant characteristics did not appear to confound the association between partner type and condom use in the models predicting condom use at each act of intercourse for the entire study group or in those for women with multiple partners during the study. The characteristics of participants were implicitly controlled for in the conditional logistic regression analyses of individual months of follow-up and of partnerships that changed status.
Additionally, all partner-related and condom-use data employed in the present study come from the prospective sexual diaries kept by participants. Prospective diary report of behavior is thought to have two important advantages over retrospective data collection. First, since behaviors are recorded on a daily basis, diary reporting reduces the risk that participants will suffer memory lapses or experience confusion about dates. The analytical problems associated with the inaccurate estimation of behavioral frequencies and the reporting of events that take place outside the reference period are minimized by this [52,53]. Second, prospective diary report of behavior is done privately and, therefore, reduces the likelihood that individuals will give socially desirable answers [54–56]. Face-to-face retrospective reporting of sexual and contraceptive behavior may be particularly vulnerable to self-presentation bias of this sort .
In summary, the results of this study support the hypothesis that condom use varies with the type of sexual partnership and tends to be less consistent as sexual relationships grow more stable and intimate over time. This problem may represent an important challenge to STD and HIV intervention programs aimed at achieving consistent condom use unconditionally with all partners. Offering the female condom as a supplemental form of protection may improve the effectiveness of such programs by facilitating maintenance of consistent barrier use among individuals who are in regular partnerships. It is possible that, to optimize such interventions, research will have to identify the circumstances in which unprotected sex within a regular partnership can be considered as safe.
1. Warner DL, Hatcher RA. Male condoms.
In Contraceptive Technology,
17th revised edn. Edited by Hatcher RA, Trussell J, Stewart F et al.
New York: Irvington;. 1998, 325– 355.
2. McCormack W, Yhe-hsiung L, Zinner S. Sexual experience and urethral colonization with genital mycoplasmas.
Ann Intern Med. 1973, 78: 696 –698.
3. Barlow D. The condom and gonorrhoea.
Lancet 1977, ii: 811 –812.
4. Kelaghan J, Rubin GL, Ory HW, Lyde PM. Barrier-method contraceptives and pelvic inflammatory disease.
JAMA 1982, 248: 184 –187.
5. Austin H, Louv WC, Alexander J. A case-control study of spermicide and gonorrhoea.
JAMA 1984, 251: 2822. 2822.
6. Katznelson S, Drew L, Mintz, Mintz, L. Efficacy of the condom as a barrier to the transmission of cytomegalovirus.
J Infect Dis. 1984, 150: 155 –157.
7. Quinn RW, O'Reilley KR. Contraceptive practices of women attending the sexually transmitted disease clinic in Nashville, Tennessee.
Sex Transm Dis 1985, 12: 99. 99.
8. Mann J, Quinn TC, Piot P. et al
. Condom use and HIV infection among prostitutes in Zaire.
Lancet 1986, 316: 345. 345.
9. Minuk G, Bohme T, Bowen T. et al
. Efficacy of commercial condoms in the prevention of hepatitis B virus infection.
Gastroenterology. 1987, 93: 710 –714.
10. Cameron DW, Ngugi EN, Ronald AR. et al
. Condom use prevents genital ulcers in women working as prostitues.
N Engl J Med 1988, 319: 274 –278.
11. Oberle MW, Rosero-Bixby L, Lee FK, Sanchez-Braverman M, Nahmais J, Guinan ME. Herpes simplex virus type 2 antibodies: high prevalence in monogamous women in Costa Rica.
Am J Trop Med Hygiene 1989, 41: 224 –229.
12. Plummer FA, Cameron DW, Ngugi EN. et al
. Cofactors in male-female sexual transmission of human immunodeficiency virus type I.
J Infect Dis 1991, 163: 233 –239.
13. Rosenberg MJ, Davidson AJ, Chen JH, Judson FN, Douglas MD. Barrier contraceptives and sexually transmitted diseases in women: a comparison of female-dependent methods and condoms.
Am J Public Health 1992, 82: 669 –674.
14. Saracco A, Musicco M, Nicolosi A. et al
. Man-to-woman sexual transmission of HIV: longitudinal study of 343 steady partners of infected men.
J Acquir Immune Def Syndr 1993, 6: 497 –502.
15. de Vincenzi I. A longitudinal study of human immunodeficiency virus transmission by heterosexual partners.
N Engl J Med 1994, 331: 341 –346.
16. Zenilman JM, Weisman CS, Rompalo AM. et al
. Condom use to prevent incident STDs: the validity of self-reported condom use.
Sex Transm Dis 1995, 22: 15 –21.
17. Deschamps MM, Pape JW, Hafner A, Johnson WD Jr. Heterosexual transmission of HIV in Haiti.
Ann Intern Med 1996, 125: 324 –330.
18. Buchbinder SP, Douglas JM, McKirnan DJ, Judson FN, Katz MH, MacQueen KM. Feasibility of human immunodeficiency virus vaccine trials in homosexual men in the United States: risk behavior, seroincidence, and willingness to participate.
J Infect Dis 1996, 174: 954 –961.
19. NIMH Multisite HIV Prevention Trial Group . A randomized clinical trial of small group counseling to reduce risk for HIV. Science
20. Kamb ML, Fishbein M, Douglas JM. et al
. Efficacy of risk-reduction counseling to prevent human immunodeficiency virus and sexual transmitted diseases.
JAMA 1998, 280: 1161 –1167.
21. Shain RN, Piper J, Newton E. et al
. A randomized, controlled trial of a behavioral intervention to prevent sexually transmitted diseases.
N Eng J Med 1999, 340: 93 –100.
22. Stein ZA. HIV prevention: the need for methods women can use.
Am J Public Health 1990, 80: 460 –4462
23. Cates W, Stewart FH, Trussell J. Commentary: the quest for women's prophylactic methods – hopes vs science.
Am J Public Health 1992, 82: 1479 –1483.
24. Rosenberg MJ, Gollub EL. Commentary: methods women can use that may prevent sexually transmitted disease, including HIV.
Am J Public Health 1992, 82: 1473 –1478.
25. Gollub EL, Stein Z. Commentary: the new female condom – item 1 on a women's AIDS prevention agenda.
Am J Public Health 1993, 83: 498 –500.
26. Bounds W. Male and female condoms.
Br J Fam Plann 1989, 15: 14 –17.
27. Soper DE, Shoupe D, Shangold . et al
. Prevention of vaginal trichomoniasis by compliant use of the female condom.
Sex Transm Dis 1993, 20: 137 –139.
28. Farr G, Gabelnick H, Sturgen K, Dorflinger L. Contraceptive efficacy and acceptability of the female condom.
Am J Public Health 1994, 84: 1960 –1964.
29. Soper DE, Brockwell NJ, Dalton HP. Evaluation to the effects of a female condom on the female lower genital tract.
Contraception 1991, 44: 21 –29.
30. Cecil H, Perry MJ, Seal DW, Pinkerton SD. The female condom: what we have learned thus far.
AIDS Behav 1998, 2: 241 -256.
31. Fontanet AL, Saba J, Chandelying V. et al
. Protection against sexually transmitted diseases by granting sex workers in Thailand the choice of using the male or female condom: results from a randomized controlled trial.
AIDS 1998, 12: 1851 –1859.
32. Bajos N, Ducot B, Spencer B, Spira A. Sexual risk-taking, socio-sexual biographies and sexual interaction: elements of the French national survey on sexual behavior.
Soc Sci Med 1997, 44: 25 –40.
33. Catania JA, Stone V, Binson D, Dolcini MM. Changes in condom use among heterosexuals in wave 3 of the AMEN survey.
J Sex Res 1995, 32: 193 –200.
34. Walter HJ, Vaughan RD, Gladis MM, Ragin DF, Kasen S, Cohall AT. Factors associated with AIDS risk behaviors among high school students in an AIDS epicenter.
Am J Public Health 1992, 82: 528 –532.
35. Gold RS, Karmiloff-Smith A, Skinner MJ, Morton J. Situational factors and thought processes associated with unprotected intercourse in heterosexual students.
AIDS Care 1992, 4: 305 –323.
36. Kline A, van Landingham M. HIV-infected women and sexual risk reduction: the relevance of existing models of behavior change.
AIDS Educ Prevent 1994, 6: 390 –402.
37. Lansky A, Thomas JC, Earp JA. Partner-specific sexual behaviors among persons with both main and other partners.
Fam Plann Perspect 1998, 30: 39 –96.
38. Raj A. Identification of social cognitive variables as predictors of safer sex behavior and intent in heterosexual college students.
J Sex Marital Ther 1996, 22: 247 –258.
39. Hooykaas C, van der Linden MM, van Doornum GJJ, van der Velde FW, van der Pligt J, Coutinho RA. Limited changes in sexual behaviour of heterosexual men and women with multiple partners in the Netherlands.
AIDS Care 1991, 3: 21 –30.
40. Podhisita C, Wawer MJ, Pramualratana A, Kanungsukkasem U, McNamara R. Multiple sexual partners and condom use among long-distance truck drivers in Thailand.
AIDS Educ Prevent 1996, 8: 490 –498.
41. Castilla J, Barrio G, de la Fuente L, Belza MJ. Sexual behaviour and condom use in the general population of Spain, 1996.
AIDS Care 1998, 10: 667 –676.
42. Anderson JE, Wilson R, Doll L, Jones TS, Barker P. Condom use and HIV risk behaviors among US adults: data from a national survey.
Fam Plann Perspect 1999, 31: 24 –28.
43. Weir SS, Roddy RE, Zekeng L, Ryan KA, Wong EL. Measuring condom use: asking `do you or don't you' isn't enough.
AIDS Educ Prev 1998, 10: 293 –302.
44. Norris AE, Ford K. Sexual experiences and condom use of heterosexual, low-income African American and Hispanic youth practicing relative monogamy, serial monogamy, and nonmonogamy.
Sex Transm Dis 1999, 26: 17 –25.
45. Weinberg MS, Lottes IL, Aveline D. AIDS risk reduction strategies among United States and Swedish heterosexual university students.
Arch Sex Behav 1998, 27: 385 –401.
46. Dubois-Arber F, Jeannin A, Konings E, Paccaud F. Increased condom use without other major changes in sexual behavior among the general population in Switzerland.
Am J Publ Health 1997, 87: 558 –566.
47. Scheidt DM, Windle M. Individual and situational markers of condom use and sex with nonprimary partners among alcoholic inpatients: findings from the ATRISK Study.
Health Psychol 1996, 15: 185 –192.
48. Catania JA, Binson D, Dolcini MM. et al
. Risk factors for HIV and other sexually transmitted diseases and prevention practices among US heterosexual adults: changes from 1990 to 1992.
Am J Public Health 1995, 85: 1492 –1499.
49. McCullagh P, Nelder JA. Generalized Lineal Models
. New York: Chapman & Hall; 1989.
50. Caceres CF, Marin BV, Hudes ES, Reingold AL, Rosasco AM. Young people and the structure of sexual risks in Lima.
AIDS 1997, 11 (Suppl 1) : S67 –S77.
51. Artz L, Macaluso M, Kelaghan J. et al
. Effectiveness of an intervention promoting the female condom to STD clinic patients.
Am J Public Health 2000, 90: 237 –244.
52. Verbrugge L. Health diarting the female condom to STD clinic patients.
Am J Public Health 2000, 90: 237 –244.
53. Verbrugge L. Health diaries.
Med Care 1980, 18: 73 –94.
54. Bradburn NM, Rips L, Shevell S. Answering autobiographical questions: the impact of memory and inference on surveys.
Science 1987, 236: 157 –161.
55. Hynie M, John L. Sexual attitudes and contraceptive behavior revisited: can there be too much of a good thing?
J Sex Res 1996, 33: 127 –135.
56. McLaws M, Oldenburg D, Ross MW, Cooper D. Sexual behaviour in AIDS-related research: reliability and validity of recall and diary measures.
J Sex Res 1990, 27: 265 –281.
57. Rosner T, Tarler K, Namazi H, Wykle ML. Health diaries interviews: consistency in reporting by older adults.
Res Aging 1992, 14: 248 –266.
This article has been cited 90 time(s).
Journal of Sexual MedicinePrevalence and Factors Associated with Condom Use among Chinese Monogamous Female Patients with Sexually Transmitted Infection in Hong KongJournal of Sexual Medicine
Janac-Journal of the Association of Nurses in AIDS CareVariations in Young Men's and Women's Attitudes and Intentions to Use Condoms With Different Types of Sexual PartnersJanac-Journal of the Association of Nurses in AIDS Care
Journal of Black PsychologyMotivations for Secondary Abstinence Among African American Females at Risk for HIV/Sexually Transmitted InfectionsJournal of Black Psychology
Bmc Womens Health"A man's gonna do what a man wants to do": African American and Hispanic women's perceptions about heterosexual relationships: a qualitative studyBmc Womens Health
Archives of Sexual BehaviorSexual Risk Behaviors by Relationship Type and Trauma History Among HIV-Positive Men Who Have Sex with MenArchives of Sexual Behavior
Journal of Womens Health & Gender-Based Medicine
Acceptability research on female-controlled barrier methods to prevent heterosexual transmission of HIV: Where have we been? Where are we going?
Journal of Womens Health & Gender-Based Medicine, 10(2):
International Journal of Std & AIDS
All STDs are not created equal: an analysis of the differential effects of sexual behaviour changes on different STDs
International Journal of Std & AIDS, 14(5):
AIDS Care-Psychological and Socio-Medical Aspects of AIDS/HivNegotiating safe sex among women of Afro-Surinamese and Dutch Antillean descent in the NetherlandsAIDS Care-Psychological and Socio-Medical Aspects of AIDS/Hiv
Archives of Sexual BehaviorAn Assessment of HIV/STI Vulnerability and Related Sexual Risk-Taking in a Nationally Representative Sample of Young Croatian AdultsArchives of Sexual Behavior
Educational level is associated with condom use within non-spousal partnerships in four cities of sub-Saharan Africa
Samj South African Medical Journal
Barriers to accessing free condoms at public health facilities across South Africa
Samj South African Medical Journal, 92(3):
Annals of Behavioral Medicine
Methodological challenges in research on sexual risk behavior: I. Item content, scaling, and data analytical options
Annals of Behavioral Medicine, 26(2):
American Journal of EpidemiologyCondom effectiveness for reducing transmission of gonorrhea and chlamydia: The importance of assessing partner infection statusAmerican Journal of Epidemiology
Canadian Journal of Public Health-Revue Canadienne De Sante Publique
Usage of condom by adolescents advising for the oral contraception in the region of Montreal
Canadian Journal of Public Health-Revue Canadienne De Sante Publique, 96(6):
Archives of Sexual BehaviorSafe sex versus safe love? Relationship context and condom use among male adolescents in the favelas of Recife, BrazilArchives of Sexual Behavior
VaccineThe epidemiology of genital human papillomavirus infectionVaccine
Prevention ScienceRegression Mixture Models of Alcohol Use and Risky Sexual Behavior Among Criminally-Involved AdolescentsPrevention Science
Journal of Psychosomatic ResearchViral load and HIV treatment attitudes as correlates of sexual risk behavior among HIV-positive gay menJournal of Psychosomatic Research
Sexually Transmitted InfectionsA comparison of four condom-use measures in predicting pregnancy, cervical STI and HIV incidence among Zimbabwean womenSexually Transmitted Infections
International Family Planning Perspectives
Covert use of topical microbicides: Implications for acceptability and use
International Family Planning Perspectives, 30(2):
Womens Health IssuesThe association between history of violence and HIV risk - A cross-sectional study of HIV-negative incarcerated women in ConnecticutWomens Health Issues
Journal of Womens HealthComparison of Sexual Partnership Characteristics and Associations with Inconsistent Condom Use among a Sample of Adolescents and Adult Women Diagnosed with Chlamydia trachomatisJournal of Womens Health
Social Science & MedicineMobilizing collective identity to reduce HIV risk among sex workers in Sonagachi, India: The boundaries, consciousness, negotiation frameworkSocial Science & Medicine
AIDS Care-Psychological and Socio-Medical Aspects of AIDS/HivDifferences between Internet and community samples of MSM: implications for behavioral surveillance among MSM in ChinaAIDS Care-Psychological and Socio-Medical Aspects of AIDS/Hiv
International Journal of Std & AIDSCondom use among high-risk heterosexual women with concurrent sexual partnerships, Houston, Texas, USAInternational Journal of Std & AIDS
Challenges and processes of selecting outcome measures for the NIMH Collaborative HIV/STD Prevention Trial - NIMH Collaborative HIV/STD Prevention Trial Group
Revue D Epidemiologie Et De Sante PubliqueDeterminants of condom use and heterosexual multiple sexual partnership in French Antilles and French GuianaRevue D Epidemiologie Et De Sante Publique
AIDS and BehaviorMultiple Sexual Partnerships in a Sample of African-American Crack SmokersAIDS and Behavior
Social Indicators ResearchCongruency of the cognitive and affective components of the attitude as a moderator on intention of condom use predictorsSocial Indicators Research
American Journal of Public HealthCondom use and hip hop culture: The case of urban young men in New York CityAmerican Journal of Public Health
Clinical Infectious Diseases
Drug-using women need comprehensive sexual risk reduction interventions
Clinical Infectious Diseases, 37():
American Journal of EpidemiologyApplication of the case-crossover design to reduce unmeasured confounding in studies of condom effectivenessAmerican Journal of Epidemiology
International Journal of Std & AIDSCondom use in the year following a sexually transmitted disease clinic visitInternational Journal of Std & AIDS
AIDS Education and Prevention
HIV-infected persons' knowledge of their sexual partners' HIV status
AIDS Education and Prevention, 14(3):
Sexually Transmitted Diseases
Do condoms prevent genital HPV infection, external genital warts, or cervical neoplasia?
Sexually Transmitted Diseases, 29():
American Journal of Obstetrics and GynecologyPregnant adolescents at risk: Sexual behaviors and sexually transmitted disease prevalenceAmerican Journal of Obstetrics and Gynecology
International Journal of Std & AIDS
Repeated human papillomavirus DNA findings among female university students
International Journal of Std & AIDS, 18():
American Journal of Public Health
Condom use and HIV risk among US adults
American Journal of Public Health, 93(6):
Behavior ModificationAn intervention to promote the female condom to sexually transmitted disease clinic patientsBehavior Modification
Annals of EpidemiologyWeighting condom use data to account for nonignorable cluster sizeAnnals of Epidemiology
Family Planning Perspectives
Female condom use among women at high risk of sexually transmitted disease
Family Planning Perspectives, 32(3):
Health PsychologyAlcohol use and high-risk sexual behavior among men who have sex with men: The effects of consumption level and partner typeHealth Psychology
Addictive BehaviorsAlcohol use, partner type, and risky sexual behavior among college students: Findings from an event-level studyAddictive Behaviors
AIDS and BehaviorDrinking and condom use: Results from an event-based daily diaryAIDS and Behavior
Sexually Transmitted InfectionsSexual partner concurrency among STI clinic patients with a steady partner: correlates and associations with condom useSexually Transmitted Infections
Psychology of Addictive BehaviorsApplication of the Social Action Theory to Understand Factors Associated With Risky Sexual Behavior Among Individuals in Residential Substance Abuse TreatmentPsychology of Addictive Behaviors
Women & HealthHigh-risk women's willingness to try a simulated vaginal microbicide: Results from a pilot studyWomen & Health
Journal of Personality and Social PsychologyToward a Person X Situation Model of Sexual Risk-Taking Behaviors: Illuminating the Conditional Effects of Traits Across Sexual Situations and Relationship ContextsJournal of Personality and Social Psychology
Social Science & MedicineUnderstanding the association between condom use at first and most recent sexual intercourse: An assessment of normative, calculative, and habitual explanationsSocial Science & Medicine
Contraceptive use patterns across teens' sexual relationships: The role of relationships, partners, and sexual histories
AIDS Care-Psychological and Socio-Medical Aspects of AIDS/HivCondom use and self-efficacy among female sex workers with steady partners in ChinaAIDS Care-Psychological and Socio-Medical Aspects of AIDS/Hiv
International Journal of EpidemiologyA case-crossover analysis of predictors of condom use by female bar and hotel workers in Moshi, TanzaniaInternational Journal of Epidemiology
Journal of Urban Health-Bulletin of the New York Academy of Medicine
Transmission of STIs/HIV at the partnership level: Beyond individual-level analyses
Journal of Urban Health-Bulletin of the New York Academy of Medicine, 80(4):
Psychology & HealthRisk drinking and contraception effectiveness among college womenPsychology & Health
Family Planning Perspectives
Characteristics of adolescents' sexual partners and their association with use of condoms and other contraceptive methods
Family Planning Perspectives, 33(3):
AIDS Care-Psychological and Socio-Medical Aspects of AIDS/HivIneffective use of condoms among young women in managed careAIDS Care-Psychological and Socio-Medical Aspects of AIDS/Hiv
Sexually Transmitted InfectionsGender differences in sexual behaviours in response to genitourinary symptomsSexually Transmitted Infections
Romance and Sex in Adolescence and Emerging Adulthood: Risks and Opportunites
Adolescent sexual relationships and reproductive health outcomes: Theoretical and methodological challenges
Romance and Sex in Adolescence and Emerging Adulthood: Risks and Opportunites, ():
Back to behavior: prevention priorities in countries with low HIV prevalence
International Journal of Clinical and Health Psychology
A qualitative study of the viability of usage of the female condom among university students
International Journal of Clinical and Health Psychology, 6(1):
AIDS and BehaviorContextual determinants of condom use among female sex exchangers in East Harlem, NYC: An event analysisAIDS and Behavior
International Journal of Std & AIDS
A review of female-condom effectiveness: patterns of use and impact on protected sex acts and STI incidence
International Journal of Std & AIDS, 17():
Journal of Studies on Alcohol and Drugs
Predictors of Risky Sexual Behavior With New and Regular Partners in a Sample of Women Bar Drinkers
Journal of Studies on Alcohol and Drugs, 70(2):
Sexually Transmitted Infections
Reasons for not using condoms among the Hong Kong Chinese population: implications for HIV and STD prevention
Sexually Transmitted Infections, 78(3):
Perspectives on Sexual and Reproductive Health
Covert use of topical microbicides: Implications for acceptability and use
Perspectives on Sexual and Reproductive Health, 36(3):
Social Science & MedicineMicrobicide acceptability research: current approaches and future directionsSocial Science & Medicine
AIDS and BehaviorAdolescent relationships and condom use: Trust, love and commitmentAIDS and Behavior
Journal of Sex Research
Longitudinal test of a multiple domain model of adolescent condom use
Journal of Sex Research, 44(4):
Culture Health & SexualityManaging men: women's dilemmas about overt and covert use of barrier methods for HIV preventionCulture Health & Sexuality
Journal of Studies on Alcohol and Drugs
Alcohol Consumption, Drug Use, and Condom Use Among STD Clinic Patients
Journal of Studies on Alcohol and Drugs, 70(5):
Journal of Infectious DiseasesCondom Use and Human Papillomavirus in MenJournal of Infectious Diseases
Psychology of Addictive BehaviorsThe Influence of Marijuana and Alcohol Use on Condom Use Behavior: Findings From a Sample of Young Adult Female Bar DrinkersPsychology of Addictive Behaviors
Bmc Womens HealthAn assessment of the likely acceptability of vaginal microbicides for HIV prevention among women in rural GhanaBmc Womens Health
Plos OneTransactional Sex Risk across a Typology of Rural and Urban Female Sex Workers in Indonesia: A Mixed Methods StudyPlos One
AIDS Education and Prevention
Who Are the Preferential Targets for Intervention Programs Related to the Female Condom Among Sex Workers in Southern China?
AIDS Education and Prevention, 25(4):
JAIDS Journal of Acquired Immune Deficiency SyndromesChanges in HIV-Related Preventive Behavior in the US Population: Data From National Surveys, 1987-2002JAIDS Journal of Acquired Immune Deficiency Syndromes
prospective studies; sexual behavior; sexually transmitted diseases; epidemiologic methods; barrier contraception; female condom
© 2000 Lippincott Williams & Wilkins, Inc.
Highlight selected keywords in the article text.