Comparison of STD Prevalence by Reported Condom Use Errors in 100% Condom Users of an Urban STD Clinic Judith C. Shlay, MD, MSPH Jennifer Landrigan, MHS John M. Douglas Jr., MD Denver Public Health Denver, Colorado

Background Consistent and correct condom usage considered the most effective practical means of reducing STD But, there is controversy about the protective effect of condom usage due to limited data Most studies evaluating the effectiveness of condom use do not consider the importance of correct use

Objective To assess the association between any error in condom use in patients reporting 100% condom use for vaginal or anal intercourse over the past 4 months and prevalence of various STD among women, heterosexual men (MSW), and gay men (MSM) attending an urban STD clinic

Methods Computerized medical record review of visits by men and women seen for a new problem Prevalence rates: –non-viral STD: gonorrhea by culture, chlamydia by SDA, or trichomonas by wet prep –viral STD: recent onset symptomatic genital warts, 1 st episode herpes, or molluscum contagiosum Stratified by any reported errors in condom usage over the past 4 months

Methods Errors elicited: breakage, leakage, slippage, turned inside out, re-use, initiation of sex prior to using condom or removal of condom before finishing sex (Warren et al. Sex Transm Dis 1998) Associations between error vs no error in condom usage and STD rates were assessed by chi square analysis Logistic regression was performed using variables found to be significant in the bivariate analysis

Study Population Time Period: January-December 2001 Total seen 100% condom 100% use with use by history error questions Total12,283 1,591 (13%) 904 (57%) Women (12%) 280 (56%) MSW (12%) 483 (59%) MSM (26%) 141 (52%)

Reported Error Type Women MSW MSM (N=280) (n=483) (n=141) Any error61% 53% 36% Break38% 35% 20% Leak 5% 6% 4% Slip22% 14% 12% Inside out 5% 6% 10% Re-use 1% 1% 1% Sex before15% 11% 9% Sex after 6% 3% 4%

Baseline Characteristics: Total Sex Acts Over Past 4 Months** Women MSW MSM % error % error % error <5 51% 39%21% % 56%41% > 15 69%* 63% 56% **Refers to vaginal or anal sex *P=0.05 for trend P<0.01 for trend

Multivariate Analysis of Predictors of any Error MSWMSMFemale Race/ethnicity Black2.3 ( )0.9 ( ) Hispanic1.5 ( )2.7 ( ) White New sex partners ** None 1.0 >1 1.7 ( ) Number sex partners ** 11.0 >12.0 ( ) Total sex acts ( )2.7 ( )1.4 ( ) >152.8 ( )4.3 ( )2.1 ( ) **over the past 4 months

STD Among 100% Condom Users with/without Errors: Non-viral STD Total GC CT TV Non-viral (N) N(%) N(%) N(%) N(%) Women error171 6 (3.5) 15 (8.8) 13 (7.6) 30 (17.5) no error109 0 (0)* 14 (12.8) 5 (4.6) 18 (16.5) MSW error (8.2) 36 (14.1)- 50 (19.6) no error228 1 (0.4) 11 (4.8) - 11 (4.8) MSM error 50 4 (8.0) 4 (8.0) - 8 (16.0) no error 91 9 (9.9) 4 (4.4)- 11 (12.1) *P=0.05 P<0.01

STD Among 100% Condom Users with/without Errors: Viral STD Total Warts HSV MCV Viral (N) N(%) N(%) N(%) N(%) Women error171 5 (2.9) 7 (4.1) 0 (0) 12 (7.0) no error1091 (0.9) 0 (0) 0 (0) 1 (0.9) MSW error255 6 (2.4) 6 (2.4) 1 (0.4) 12 (4.7) no error2281 (0.4) 1 (0.4) 1 (0.4) 3 (1.3) MSM error 501 (2.0) 0 (0) 0 (0) 1 (2.0) no error912 (2.2) 0 (0) 1(1.1) 3 (3.3) P<0.05 P=0.08

Relative Reduction in STD Among Female and MSW 100% Condom Users with vs without Errors ErrorNo error% reduction (N=426)(N=337) Non-viral 80 (18.8)24 (7.1)62.2% GC 27 (6.3) 1 (0.3)95.2% Viral 24 (5.6) 4 (1.2)78.6% HSV 13 (3.1) 1 (0.3)90.3%

Multivariate Analysis of Predictors of Non-Viral and Viral STD for Women Non-viralViral Women Error0.9 ( )9.8 ( ) Race/ethnicity Whites Blacks 4.2 ( )0.6 ( ) Hispanics 1.6 ( )1.6 ( )

Multivariate Analysis of Predictors of Non- Viral and Viral STD for MSW Non-viralViral MSW Error3.5 ( )4.1 ( ) Race/ethnicity Whites Blacks 10.2 ( ) 0.9 ( ) Hispanics6.4 ( )1.4 ( ) Sex acts** ( )0.2 ( ) > ( )0.5 ( ) **total sex acts (vaginal or anal) over past 4 months

Limitations Condom use was self-reported with the potential for recall bias Survey represented a sample of 100% condom users seen at an STD clinic and may not be representative of all consistent condom users Information not available on partner types or length of relationship(s) Lack of information on infected partners

Conclusion - 1 Most common errors for all groups were breakage, slippage, and having sex before use of condom For MSW, error rates higher among people of color, among those with a higher number of sex partners, and with increased number of sex acts For MSM, error rates higher among Hispanics and with increased number of sex acts For all risk groups, error rates were consistently higher with increasing number of sex acts

Condom errors were associated with viral STD for both females and MSW Condom errors were associated with non-viral STD for MSW only Lack of reported errors with GC in MSM may be due to oral-genital transmission Absence of effect for chlamydia and trichomonas in women may be due to longstanding prevalent infection Conclusion - 2

Implications Correct condom use appears to be protective for viral STD among MSWs and females, as well as for non-viral STD among MSWs Interventions need to focus on enhancing correct as well as consistent condom use Emphasis should be placed on demonstrating techniques to avoid condom use error Further research should focus on implementing strategies to improve consistent and correct condom usage