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

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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