Anderson, John E. PhD; Warner, Lee MPH, PhD; Macaluso, Maurizio MD, DrPH
From the Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, GA
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
Correspondence: John E. Anderson, PhD, Division of Reproductive Health, 4770 Buford Highway NE, Mailstop E-34, Atlanta, GA 30341. E-mail: Jea1@cdc.gov.
Received for publication January 26, 2011, and accepted May 10, 2011.
The prevalence of condom use at last intercourse, estimated from questions added to a national survey, was estimated to be 20.2%. Use of condom was significantly higher for sex outside ongoing relationships and among those with 2 or more past-year sex partners and its use increased slightly but significantly from 1996 to 2008.
Condom use is a contraceptive method that also provides protection against sexually transmitted diseases (STDs), including HIV.1 Public health programs seek to increase the condom use among persons at risk for transmitting or acquiring infection.2 Data from health surveys have indicated increases in condom use after 1980s.3,4 National data on trends and variation in condom use based on health surveys have been reported periodically.4 We present data on condom use trends from a nationally representative survey of adults living in the United States—the General Social Survey (GSS)—from 1996 to 2008 to measure recent trends and to estimate the degree to which persons at increased risk for HIV or other STDs report using condoms. This analysis updates results reported for earlier years of this survey through 2002,5,6 with the most recent data available through 2008.
Since 1972, the GSS is a national household probability survey of adults aged ≥18 years conducted by the National Opinion Research Center at the University of Chicago that has collected information on a variety of topics of social importance annually or semiannually.7 Questions on sexual behavior and condom use have been asked in alternating years from 1996 to 2008 as part of a self-administered questionnaire; questions on drug use behaviors were added in 2000.
The GSS uses a probability sampling method designed to give each household in the United States an equal probability of being included. One adult aged ≥18 years is selected from each household to respond the survey. With the use of weighting factors estimates from the survey are designed to be nationally representative. The overall response rates for the main interview of the GSSs in this period have averaged 72%,7 and since 1996, an estimated 84.1% of the respondents completed the self-administered questionnaire. The analysis presented here is based on the data for 12,280 total respondents aged 18 years and older interviewed in 1996, 1998, 2000, 2002, 2004, 2006, or 2008 who had at least one sex partner in the past year; more detailed analysis is reported for 3095 sexually active respondents from the 2006 and 2008 GSSs.
The measure of condom use is based on a question on condom use at last sexual intercourse (“The last time you had sex, was a condom used? By sex we mean vaginal, oral, or anal sex.”), similar to questions used on other national surveys.3,8 Condom use at last intercourse is assessed separately depending on the relationship with the last sexual partner based on the following question: “The last time you had sex, was it with someone you were in an ongoing relationship with, or was it with someone else? Remember that by “sex” we mean only vaginal, oral, or anal sex.” We compared condom use with regular partners to use with partners outside of ongoing relationships, and we present condom use by major population subgroups defined by demographic and socioeconomic factors as well as by sex- and drug-related HIV/STD risk factors. Risk factor measures were based on a series of questions about recent behavior. We defined having sex with someone not well known as having sexual intercourse with a “casual date or pickup” or having paid for or having been paid for sex in the past year. Sex-related HIV/STD risk factors were defined for the past year and included having had 5 or more sex partners, male-to-male sex, or having paid for or having been paid for sex. Drug-related HIV/STD risk factors were defined for the past 3 years and included having injected drugs or used crack cocaine during this time. Finally, an overall drug- or sex-related HIV/STD risk category was defined as anyone in the sex- or drug-risk categories defined earlier. Percentages have been computed for population groups with t tests of differences between categories. We have assessed trends in condom use using linear logistic regression models with condom use as a dichotomous outcome measure and year of survey as a continuous predictor; this method allows us to check whether the average use of condoms is moving upward or downward during the period covered. We also used a t test of difference to test significance of change in condom use between the first and second half of the 1996–2008 period. All estimates were computed using SAS software and are based on survey weighting factors7 and have been adjusted with an assumed design effect of 1.3.
Between 1996 and 2008, 20.2% of GSS respondents reported using condoms during their most recent sexual intercourse (Table 1). Use of condom was much higher overall outside of ongoing relationships compared to within ongoing relationships (46.4% vs. 18.1%, respectively) and among those with 2 or more past-year sex partners compared with those with 1 partner (44.7% vs. 15.6%). Assessment of trends during the 1996–2008 period by comparing the 1996–2002 period with 2004–2008, and by using linear logistic regression models for 1996–2008 period indicates that only the trend for the total sample was statistically significant using the regression method (Table 1). For the 1996–2002 and 2004–2008 intervals, the average percentage of respondent using condoms was 19.8 to 20.8. There were no statistically significant trends in condom use for the subgroups defined by relationship type or number of partners.
For the period between 2006 and 2008 (Table 2), condom use was substantially higher among those whose most recent intercourse was outside of an ongoing relationship, 50.5% compared with 19.8% for those whose most recent sex was in an ongoing relationship. Among all respondents, condom use was greater for those who were 18 to 24 years of age, nonwhite, unmarried and who had multiple past-year sex partners, and engaged in other behaviors that might place them at increased risk for HIV or STDs. Of those with some degree of sex- or drug-related HIV risk (based on a composite category), 37.4% reported condom use at most recent intercourse.
Among persons whose last sexual intercourse was within an ongoing relationship, condom use was higher among those who were unmarried, were younger, were nonwhite, lived outside of the Midwest region or in metropolitan areas, or had sex-related risk behavior (Table 2); among those who had some degree of HIV risk, 30.0% reported using condoms during last intercourse (Table 2). Among those whose last sexual intercourse was not within an ongoing relationship, 50.5% used condoms, and its use was higher among those with increased sexual risk; 53.9% of those at risk reported condom use compared with 49.5% of others, a difference that was not statistically significant.
Using the definitions discussed earlier, the GSS indicates that 2.2% of the US population more than 18 years of age is at risk through drug injection or crack use (equivalent to 3.5–6.5 million persons); 3.8% were at risk because of sexual behavior (6.8–10.5 million), and 5.6% were at risk through either drug or sex behavior (10.6–15.1 million). On the basis of the reported condom usage, an estimated 6.9 to 9.2 million of those at risk were potentially exposed to risks of acquiring or transmitting disease, and possibly to the risk of unintended pregnancy, through nonuse of condoms at their most recent intercourse.
Public health programs seek to increase consistent and correct condom use among those at increased risk.2 Previous analysis of GSS data examined condom use at last intercourse through 2002.6 The present analysis adds data collected in 2004, 2006, and 2008 and examines correlates of recent condom use. Although we detected a significant (albeit slight) trend of increasing condom use among all adults between 1996 and 2008, the degree of change from 19.8% use in 1996–2002 to 20.8% use in 2004–2008 would be unlikely to have major public health effect. We did not detect a significant increase in use among subgroups defined by partner type or number of partners. These results can be compared with data indicating the contraceptive use of condoms increased from the 1980 through the mid-1990s, but not afterward.3,4 Similar to earlier GSS results, and other studies, we found that condoms are more likely to be used by persons most at risk5,6,8–10; however, even among those at increased risk, fewer than half used condoms during most recent sexual intercourse.
Measuring condom use at last intercourse with the help of GSSs provides information on levels, differences, and trends in condom use, but cannot evaluate whether condoms were used consistently or correctly.11 Asking about last intercourse requires fewer questions, and is more easily added to general purpose surveys3,8 and is less likely to result in recall bias.12 Self-reported condom use may contain reporting errors, but self-administered questionnaires as used here have been found to yield accurate reporting of sensitive topics.13
Regarding condom use among adults, the GSS data indicate that overall there was a trend toward greater condom use in the United States between 1996 and 2008, but it was much smaller than increases observed between 1980s and 1990s.4 As in previous studies,5,6 persons at increased risk for HIV or STDs due to sex- or drug-related behaviors and those having sex outside of regular relationships were more likely than others to use condoms; however, most of them did not use condoms with their regular partners.
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2. Centers for Disease Control and Prevention. Goals and objectives of the CDC HIV prevention strategic plan: Extended through 2010. Atlanta, GA: Centers for Disease Control and Prevention, October 2007.
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12. Anderson J, Rietmeijer C, Wilson R, et al. Asking about condom use: Is there a standard approach that should be adopted across surveys? In: 1998 Proceedings, American Statistical Association, Section on Survey Research Methods. Alexandria, VA: American Statistical Association, 1998:873–877.
13. Turner CF, Lessler J, Devore J. Effects of mode of administration and wording on reporting of drug use. In: Turner C, Lessler J, Gfroerer J, eds. Survey Measurement of Drug Use: Methodological Studies. Washington, DC: Government Printing Office, 1992:177–220. DHHS publication ADM-92–1929.