# Presentation: 486196

## 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, 1st 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**
**Total****	****	****12,283         1,591 (13%)****	****  904 (57%)**
**Women****	****  4285****	****	****502 (12%)****	****  280 (56%)**
**MSW****	****	****  6951****	****	****819 (12%)****	****  483 (59%)**
**MSM****	****	****  1047****	****	****270 (26%)****	****  141 (52%)**

## Reported Error Type

**	****	****	****Women****	****  ****MSW****	****	****     ****MSM****	**
**	****	****   ****	****(N=280)****	**** (n=483)  ****	****     (n=141)**
**Any error****	****61%****	****	****  53%****	****	****      36%****	**
**Break****	****	****38%****	****	****  35%****	****	****      20%**
**Leak****	****	****  5%****	****	****    6%****	****	****        4%**
**Slip****	****	****22%****	****	****  14%****	****	****      12%**
**Inside out****	****  5%****	****	****    6%****	****	****      10%**
**Re-use****	****  1%****	****	****    1%****	****	****        1%**
**Sex before****	****15%****	****	****  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%****	**** **
**  ****5-14****	****       60%****	****          ****	****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

**	****	****	****	**** ****MSW****	****	****MSM****	****	****Female**
**Race/ethnicity****	****	****	**
**  ****Black****	****	****	****2.3 (1.4-3.8)****	****0.9 (0.2-4.2)**
**  ****Hispanic****	****	****1.5 (0.9-2.4)****	****2.7 (1.1-6.7)**
**  ****White****	****	****	****1.0****	****	****1.0**
**New sex partners**********	****	**
**  ****None****	****  ****	****	****1.0**
**  **_**>**_**1****	****	****	****1.7 (1.0-2.7)**
**Number sex partners********
**  ****1****	****	****	****	****1.0**
**  ****>1****	****	****	****2.0 (1.3-3.0)**
**Total sex acts**
**  ****1-4****	****	****	****1.0****	****	****1.0****	****	****1.0**
**  ****5-14****	****	****	****2.1 (1.3-3.4)****	****2.7 (1.1-6.9)****	****1.4 (0.7-2.6)**
**  **_**>**_**15****	****	****	****2.8 (1.7-4.7)****	****4.3 (1.6-11.6)****	****2.1 (1.1-3.9)**
** ******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**
**  ****error****	****	****171 ****	**** 6 (3.5)     15 (8.8)      13 (7.6)    ****	**** 30 (17.5)**
**  ****no error****	****109****	**** 0 (0)*****	****   14 (12.8)     5 (4.6)     ****	**** 18 (16.5)**
**MSW**
**  ****error****	****	****255 ****	****21 (8.2)    36 (14.1)****	****-        ****	**** 50 (19.6)**
**  ****no error****	****228****	**** 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**
**  ****error****	****	****171 ****	****5 (2.9)      7 (4.1)        0 (0)    ****	**** 12 (7.0)**
**  ****no error****	****109****	****1 (0.9)****	****    0 (0)****‡****         0 (0)     ****	**** 1  (0.9)****‡**
**MSW**
**  ****error****	****	****255 ****	****6  (2.4)     6 (2.4)       1 (0.4)     ****	****12 (4.7)**
**  ****no error****	****228****	****1 (0.4)****††     ****1 (0.4)****††****    1 (0.4)        ****	****  3 (1.3)****‡**
**MSM**
**  ****error ****	****	****50****	****1 (2.0)****	****     0 (0)          0 (0)****	****  1 (2.0)**
**  ****no error****	****91****	****2 (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

- 			  Error		No 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-viral****	****	****Viral**
**Women  **
**Error****	****	****	****0.9 (0.5-1.9)****	****	****9.8 (1.2-80.2)**
**Race/ethnicity****	**
**   ****Whites****	****	**** 1.0****	****	****	****1.0**
**   ****Blacks****	****	**** 4.2 (1.9-9.1)****	****	****0.6 (0.1-3.0)**
**   ****Hispanics****	****	**** 1.6 (0.6-3.0)****	****	****1.6 (0.4-6.5)**
**    **

## Multivariate Analysis of Predictors of Non-Viral and Viral STD for MSW

**	****	****	****	****Non-viral****	****	****Viral**
**MSW**
**Error****	****	****	****3.5 (1.7-7.4)****	****	****4.1 (1.1-15.8)**
**Race/ethnicity**
**    ****Whites****	****	****1.0****	****	****	****1.0**
**    ****Blacks****	****             10.2 (4.0-26.1) ****	****	****0.9 (0.2-3.4)**
**    ****Hispanics****	****	****6.4 (2.4-16.8)****	****	****1.4 (0.4-4.9)**
**Sex acts****
**     ****1-4****	****	****	****1.0****	****	****	****1.0**
**     ****5-14****	****	****	****0.9 (0.4-1.9)****	****	****0.2 (0.03-0.9)**
**	**_**>**_** ****15****	****	****	****0.8 (0.4-1.7)****	****	****0.5 (0.1-1.7)**
****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

- 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