dmcanzi@watserv1.waterloo.edu (David Canzi) (01/04/91)
Medical News for December 10th to December 23rd, 1990
Copyright 1990: USA TODAY/Gannett National Information Network
Reproduced with Permission
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Dec. 19, 1990
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HIV TEST BANNED OVERTURNED:
A 1987 ban on insurance firms from using HIV tests to decide insurance
eligibility was overturned by the New York Court of Appeals. State insurance
officials, who supported the ban, had argued that tests are unreliable. New
York has had 33,674 AIDS cases - the highest total in USA.
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Center for Disease Control Reports
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Morbidity and Mortality Weekly Report
Thursday October 4, 1990
Notices to Readers
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Current Trends
Heterosexual Behaviors and Factors that Influence Condom Use among
Patients Attending a Sexually Transmitted Disease Clinic -- San
Francisco
Because the incidence of human immunodeficiency virus (HIV) infection and
other sexually transmitted diseases (STDs) is lower among persons who use
condoms regularly, the Public Health Service has promoted the consistent and
proper use of condoms by sexually active persons (1). In San Francisco, rates
of HIV infection and other STDs among white homosexual men have decreased
dramatically since 1982 (2,3); this decrease has been attributed to the use of
condoms and the adoption of other sex practices that reduce the risk for
transmitting and acquiring these infections. At the same time, however, the
incidence of syphilis and other STDs has increased among heterosexuals,
especially among minorities (2). This report summarizes findings from a study
of heterosexual behaviors and factors that influence condom use among men and
women attending an STD clinic in San Francisco.
From October 1 through December 31, 1989, every 10th man and every second
woman entering the clinic for care was asked to participate in the study.
After obtaining informed consent, an interviewer administered a standardized
questionnaire. Patients asked to enroll in the study were 18-65 years of age
and reported having had sexual intercourse with a member of the opposite sex
within the previous 12 months; 341 were enrolled, including eight men and 11
women who reported having had sexual intercourse with members of both sexes.
Persons who reported exchanging sex for money or drugs were also included in
the survey. To minimize recall bias, data from those who had not had sexual
intercourse with a member of the opposite sex within the previous 2 months
were excluded from the final analysis (n=41).
The 341 patients (162 men and 179 women) enrolled in the study ranged in
age from 18 to 64 years (mean: 28 years); 88 (54%) of the men and 90 (50%) of
the women were either black or Hispanic (Table 1). One hundred fifty-six (46%)
reported annual incomes less than $5000. Overall, 149 (46%) of 325 patients
were newly diagnosed with an STD on the day of the interview (61 (39%) of 155
men and 88 (52%) of 170 women); diagnoses for the remaining 16 were unknown.
Of the 341 patients, 133 (82%) men and 142 (79%) women knew that HIV could
be transmitted through vaginal and anal intercourse and by sharing needles
during intravenous (IV)-drug administration; 157 (97%) men and 171 (96%) women
knew that regular condom use could reduce the likelihood of acquiring HIV
infection.
In the final analysis, nearly all (292 (97%) of 300) patients reported
they had used a condom sometime in the past (Figure 1): 245 (82%) at least
once in the previous 12 months and 180 (60%) at least once during the 2 months
before the interview. Seventy-six (25%) reported they had used a condom when
they last had intercourse; these patients were less likely to be diagnosed
with an STD on the day of the interview (relative risk (RR)=0.6; 95%
confidence interval (CI)=0.4-0.9, Mantel-Haenszel chi-square test). This
association did not vary by their reasons for the clinic visit. Condom use at
last intercourse was reported by five (14%) of 36 Hispanics, 20 (16%) of 126
blacks, and 41 (37%) of 112 whites (p less than 0.001, chi-square test).
Among men, the likelihood of using a condom at last intercourse was lower
for those who reported 1) they had used alcohol or other drugs at last
intercourse (RR=1.3; 95% CI=1.1-1.5); 2) they would not use a condom if they
were "in love" with their partners (RR=1.2; 95% CI=1.1-1.5); 3) they
experienced difficulty in communicating with their partners about condoms
(RR=1.3; 95% CI=1.1-1.5); and 4) their partners did not want to use condoms
(RR=1.4; 95% CI=1.1-1.8).
Among women, condom use at last intercourse was lower for those who 1)
were black (RR=1.3; 95% CI=1.1-1.6); 2) reported that condoms decrease sexual
pleasure (RR=1.5; 95% CI=1.2-1.8); 3) reported that they would not use a
condom if they were "in love" with their partner (RR=1.3; 95% CI=1.1-1.5); and
4) reported that their partners were unwilling to use condoms (RR=1.5; 95%
CI=1.1-2.0).
Several variables were not statistically associated with condom use,
including patients' prior STD history, age, income, education, total number of
sex partners, perceived risk for HIV infection, knowledge about HIV
transmission and condom effectiveness, peer endorsement of condoms, and
acquaintance with someone with acquired immunodeficiency syndrome (AIDS);
whether patients engaged in vaginal or anal intercourse; and whether patients
exchanged sex for money or drugs.
Based on multivariate analysis controlled for age, race, income, number of
sex partners, and other variables (Table 2), condom use was lowest among men
who had used alcohol or other drugs at their most recent sexual intercourse
and men who stated that their partners did not want to use condoms. Condom use
was lowest among women who reported that their partners did not want to use
condoms, believed condoms reduce sexual pleasure, reported having had sex with
a steady partner, or were black.
Overall, 30 (27%) of 113 men and 41 (31%) of 132 women who had used
condoms during the previous 12 months reported at least one episode of condom
breakage. Rates of condom breakage in the previous 2 months were calculated as
the proportion of times condoms broke while being used during vaginal or anal
intercourse. The breakage rates for condoms during vaginal and anal
intercourse were 4.3% and 4.2%, respectively. However, condom use was
reported for only 24 episodes of anal intercourse.
Reported by: C Lindan, MD, S Kegeles, PhD, N Hearst, MD, P Grant, D Johnson,
Center for AIDS Prevention Studies, Univ of California, San Francisco; G
Bolan, MD, San Francisco Dept of Public Health; GW Rutherford, III, MD, State
Epidemiologist, California Dept of Health Svcs. Div of Sexually Transmitted
Diseases and HIV Prevention, Center for Prevention Svcs, CDC.
Editorial Note: Because the San Francisco STD clinic emphasizes health
education and distributes condoms free of charge, the participants in this
study may have overstated their use of condoms despite being assured of
confidentiality. This study focused on patients' last episode of sexual
intercourse because less recall was required and because patients who used
condoms at that time were less likely to be diagnosed with an STD on the day
of the interview. Nonetheless, the interpretation of these findings may be
limited by recall and reporting bias.
In this study population, overall reported condom use was low. Although
infrequent use of condoms can be expected in an STD-patient population,
substantial differences were reported in condom use between whites and
minorities. These data also indicate lower condom use among women who had sex
with "steady" partners than among those with casual partners--a finding
consistent with studies among homosexual male partners (4), female prostitutes
(5), and women attending reproductive health clinics (6).
Patient reports of condom use decreasing sexual pleasure are consistent
with other reports among homosexual men and IV-drug users (7,8), although in
this study the association of this variable with not using a condom was
statistically significant only among women. Other factors associated with
lower condom use reported in this study included lack of partner endorsement
of condoms and use of alcohol or other drugs at the time of sexual
intercourse, which are consistent with findings in other population groups (7-
9).
Condom breakage generally has been reported in association with anal
intercourse among homosexual men. In the STD-patient population in this
report, a large proportion of heterosexual men and women reported condom
breakage during vaginal intercourse; this finding is consistent with a
previous study of heterosexual men and women attending a genitourinary
medicine clinic in London (10). In San Francisco, however, the breakage rates
were higher than those reported by prostitutes in a prospective study in
Australia (0.5% breakage during anal intercourse; 0.8%, vaginal intercourse)
(11). Factors related to condom breakage may include improper use, improper
storage, or poor manufacture.
Data from this study and another ongoing study of patients' sex partners
will be used by the San Francisco Department of Public Health and
collaborating organizations to develop and evaluate interventions to increase
condom use.
References
1. CDC. Condoms for prevention of sexually transmitted diseases. MMWR
1988;37:133-7.
2. San Francisco Department of Public Health. Syphilis and congenital
syphilis in San Francisco. San Francisco Epidemiol Bull 1990;6:1-6.
3. Winkelstein WW, Wiley JA, Padian NS, et al. The San Francisco men's health
study: continued decline in HIV seroconversion rates among homosexual/bisexual
men. Am J Public Health 1988;78:1472-4.
4. van Griensven GJ, de Vroome EM, Tielman RA, et al. Effect of human
immunodeficiency virus (HIV) antibody knowledge on high-risk sexual behavior
with steady and nonsteady sexual partners among homosexual men. Am J Epidemiol
1989;129:596-603.
5. Hooykaas C, van der Pligt J, van Doornum GJ, van der Linden MM, Coutinho
RA. Heterosexuals at risk for HIV: differences between private and commercial
partners in sexual behaviour and condom use. AIDS 1989;3:525-32.
6. Aral SO, Soskolne V, Magder LS, Bowen GS. Condom use by women seeking
family planning services (Abstract). Vol 2. VI International Conference on
AIDS. San Francisco, June 20-24, 1990:267.
7. Magura S, Shapiro JL, Siddiqi Q, Lipton DS. Variables influencing condom
use among intravenous drug users. Am J Public Health 1990;80:82-4.
8. Valdiserri RO, Lyter D, Leviton LC, Callahan CM, Kingsley LA, Rinaldo CR.
Variables influencing condom use in a cohort of gay and bisexual men. Am J
Public Health 1988;78:801-5.
9. Hingson RW, Strunin L, Berlin BM, Hereen T. Beliefs about AIDS, use of
alcohol and drugs, and unprotected sex among Massachusetts adolescents. Am J
Public Health 1990;80:295-9.
10. Sonnex C, Hart GJ, Williams P, Adler MW. Condom use by heterosexuals
attending a department of GUM: attitudes and behaviour in the light of HIV
infection. Genitourin Med 1989;65:248-51.
11. Richters J, Donovan B, Gerofi J, Watson L. Low condom breakage rate in
commercial sex (Letter). Lancet 1988;2:1487-8.
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Volume 3, Number 38 December 28, 1990
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--
David Canzi "Silencing the racists protects free speech"
Kitchener-Waterloo Record, editorial, Dec. 18, 1990