Judith C. Shlay, MD, MSPH Jennifer Landrigan, MHS John M. Douglas Jr., MD Denver Public Health

1. 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

2. 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

3. 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

4. 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

5. 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

6. 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%)

7. Reported Error Type WomenMSW 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%

8. 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

9. 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

10. 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

11. 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

12. Relative Reduction in STD Among Female and MSW 100% Condom Users with vs without Errors Error No error % reduction (N=426) (N=337) • Non-viral80 (18.8) 24 (7.1) 62.2% • GC 27 (6.3) 1 (0.3) 95.2% • Viral24 (5.6) 4 (1.2) 78.6% • HSV 13 (3.1) 1 (0.3) 90.3%

13. 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)

14. 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

15. 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

16. 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

17. Conclusion - 2 • 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

18. 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