                        AIDS NEWS SERVICE
                   Michael Howe, MSLS, Editor
                     AIDS Information Center
                VA Medical Center, San Francisco
                     (415) 221-4810 ext 3305
                          July 8, 1994

                       Safer Sex (Part II)

         Current Trends: Sexual Behavior and Condom Use
         -- District of Columbia, January-February 1992

     From 1980 through 1990, the cumulative incidence of acquired
immunodeficiency syndrome (AIDS) in the District of Columbia (DC)
(2713 cases per 100,000 persons) was approximately eight times that
of the surrounding metropolitan area (340 per 100,000) (1). From
1980 through 1986, the AIDS epidemic primarily involved men who had
sex with men; since 1986, the incidence of AIDS has been increasing
among injecting-drug users (IDUs) and their sex partners (1).
Although AIDS incidence in DC has been projected to increase by 34%
from 1990 to 1994 (1), patterns of sexual behavior and condom use
are unknown among homosexual/bisexual men, IDUs, and other
heterosexuals in DC and other urban areas with a high incidence of
AIDS. To obtain current data on human immunodeficiency virus
(HIV)-related knowledge and behavior, the DC Commission of Public
Health (CPH) conducted a telephone survey of DC residents regarding
HIV-related knowledge, number of sex partners, and condom use
during the 1-year period preceding the survey. This report
summarizes results of the survey. 
     During January-February 1992, the DC CPH conducted a telephone
survey of residents aged 18-45 years who were contacted through 
randomly selected telephone numbers. Excluded were government/
business telephone numbers, numbers not answered after three
attempts, and respondents aged greater than 45 years. Of 1300
persons eligible for interview, 795 (61%) responded. The interviews
included questions on number of sex partners, relationship to
primary sex partner, sex of sex partner, and condom use (2).
Results are reported for 578 non-Hispanic sexually active persons
(defined as respondents who were married or who reported having a
sex partner during the preceding 12 months); the sample size for
Hispanics was too small to include in the analysis. To adjust for
unequal sampling probabilities and nonresponse, estimates were
weighted by race, sex, and age to the 1990 census population of DC.
Statistical comparisons of proportions and logistic regression
modeling were used to characterize these data.
     Overall, 25% of respondents reported having had two or more
sex partners during the previous 12 months. The mean number of
partners among all respondents was 1.5 (Table 1, page 397);
respondents with two or more partners had an average of 3.2
partners during the preceding year. Respondents who were not in a
steady relationship (55%) and respondents who self-rated their HIV
risk as "high" or "medium" (55%) were most likely to report
multiple partners (Table 1). Men were more likely than women (35%
versus 15% (p less than 0.001)), and blacks were more likely than
whites (28% versus 20% (p less than 0.001)) to report having had
two or more partners. 
     Overall, 40% of respondents reported always using condoms, and
34% reported never using condoms (Table 1). Among sexually active
persons not in a steady relationship, 65% reported always using
condoms, and 11% reported never using condoms. Of those who
reported having had two or more sex partners, 59% reported always
using condoms, and 9% reported never using condoms. Seventy percent
of men who had two or more sex partners reported always using
condoms, compared with 37% of women.
     Based on stepwise multiple logistic regression, which removed
variables that did not contribute substantially to the model, the
number of sex partners was the strongest predictor of always using
condoms (odds ratio (OR)=2.5 for two or more versus one sex
partner; 95% confidence interval (CI)=1.7-3.0] (3). Men were almost
twice as likely as women (OR=1.9; 95% CI=1.3-2.7) and blacks were
almost twice as likely as whites (OR=1.9; 95% CI=1.2-2.8) to report
always using condoms. Men who had reported two or more sex partners
were substantially more likely to always use condoms than were men
with one partner (OR=3.5; 95% CI=2.1-5.9), but women who reported
two or more partners were not significantly more likely to use
condoms than were women with one sex partner (OR=1.3; 95% CI=0.6-
2.5). College graduates (OR=1.6 for college graduates versus all
others; 95% CI=1.0-2.4) and 18-29-year-olds (OR=1.5 for 18-
29-year-olds versus 30-45-year-olds; 95% CI=1.0-2.1) were also
independent although marginal predictors of reporting always using
condoms.

REPORTED BY: 

     V Kofie, MD, Preventive Health Svcs Administration, District
of Columbia Commission of Public Health. A Peruga, MD, AIDS
Program, Pan American Health Organization. Behavioral Surveillance
Br, Office of Surveillance and Analysis, National Center for
Chronic Disease Prevention and Health Promotion, CDC.

EDITORIAL NOTE: 

     When compared with a 1988 nationwide sample of 18-45-year-old
sexually active men (4), a higher percentage of DC men in 1992
reported having had two or more sex partners during the year (25%
versus 35%, respectively). The same survey indicated that the
percentage of women nationwide who reported having had two or more
sex partners differed little from the percentage of DC women (13%
versus 15%, respectively). The findings in the DC study indicate
that sexually active men in an urban area such as DC may be more
likely to report having had sexual contact with two or more sex
partners in the recent past.
     The findings in this report also indicate that, in DC, the
percentage of persons with multiple partners who reported always
using condoms was higher than that reported from a national sample
(59% versus 17%, respectively) (5). Although the findings reported
here and the national sample measured different age ranges and
obtained the same information with different questions, the
difference between the results of the two surveys may reflect the
higher percentage of college graduates among DC residents in this
sample compared with persons nationwide. In addition, because
findings in this sample were not weighted for education level, this
group may overrepresent college graduates in DC.
     This survey is subject to at least three limitations. First,
with a sample based on randomly selected telephone numbers,
households without telephones (i.e., poorer residents) were not
included. Second, persons who are often away from home would have
been less likely to have been contacted. Third, this survey was not
designed to determine condom use of specific partners. However, use
of global measures of condom use such as "always" or "never" should
offset recall bias for condom use in regard to different sex
partners. 
     The findings in this report can be used to determine target
groups for public health education messages encouraging consistent
use of condoms. These messages should be appropriate for the target
groups with risk behaviors for HIV infection. 

REFERENCES

1. Rosenberg PS, Levy ME, Brundage JF, et al. Population-based
monitoring of an urban HIV/AIDS epidemic. JAMA 1992;268:495-503.

2. Kanouse D, Berry SH, Gorman EM, et al. AIDS-related knowledge,
attitudes, beliefs, and behaviors in Los Angeles County. Santa
Monica, California: RAND, 1991. 

3. SAS Institute, Inc. Statistical Analysis System (SAS), version

4. CDC. Number of sex partners and potential risk of sexual
exposure to human immunodeficiency virus. MMWR 1988;37:565-8. 

5. Catania JA, Coates TJ, Stall R, et al. Prevalence of
AIDS-related risk factors and condom use in the United States.
Science 1992;258:1101-6.

6. Cary, North Carolina: SAS Institute, Inc, 1990.

*    29 CFR section 1910.1025.

**   29 CFR section 1926.

(Centers for Disease Control and Prevention. Morbidity and 
Mortality Weekly Report. 1993 May 28;42(20):390-91,397-98.)

        Update: Barrier Protection Against HIV Infection
             and Other Sexually Transmitted Diseases

     Although refraining from intercourse with infected partners
remains the most effective strategy for preventing human
immunodeficiency virus (HIV) infection and other sexually
transmitted diseases (STDs), the Public Health Service also has
recommended condom use as part of its strategy.  Since CDC
summarized the effectiveness of condom use in preventing HIV
infection and other STDs in 1988 (1), additional information has
become available, and the Food and Drug Administration has approved
a polyurethane "female condom."  This report updates laboratory and
epidemiologic information regarding the effectiveness of condoms
in preventing HIV infection and other STDs and the role of
spermicides used adjunctively with condoms.*
     Two reviews summarizing the use of latex condoms among
serodiscordant heterosexual couples (i.e., in which one partner is
HIV positive and the other HIV negative) indicated that using latex
condoms substantially reduces the risk for HIV transmission (2,3).
In addition, two subsequent studies of serodiscordant couples
confirmed this finding and emphasized the importance of consistent
(i.e., use of a condom with each act of intercourse) and correct
condom use (4,5).  In one study of serodiscordant couples, none of
123 partners who used condoms consistently seroconverted; in
comparison, 12 (10%) of 122 seronegative partners who used condoms
inconsistently became infected (4).  In another study of
serodiscordant couples (with seronegative female partners of
HIV-infected men), three (2%) of 171 consistent condom users
seroconverted, compared with eight (15%) of 55 inconsistent condom
users. When person-years at risk were considered, the rate for HIV
transmission among couples reporting consistent condom use was 1.1
per 100 person-years of observation, compared with 9.7 among
inconsistent users (5).
     Condom use reduces the risk for gonorrhea, herpes simplex
virus (HSV) infection, genital ulcers, and pelvic inflammatory
disease (2).  In addition, intact latex condoms provide a
continuous mechanical barrier to HIV, HSV, hepatitis B virus (HBV),
Chlamydia trachomatis, and Neisseria gonorrhoeae (2).  A recent
laboratory study (6) indicated that latex condoms are an effective
mechanical barrier to fluid containing HIV-sized particles.
     Three prospective studies in developed countries indicated
that condoms are unlikely to break or slip during proper use.
Reported breakage rates in the studies were 2% or less for vaginal
or anal intercourse (2).  One study reported complete slippage off
the penis during intercourse for one (0.4%) of 237 condoms and
complete slippage off the penis during withdrawal for one (0.4%)
of 237 condoms (7).
     Laboratory studies indicate that the female condom (Reality
(trademark)**)--a lubricated polyurethane sheath with a ring on
each end that is inserted into the vagina--is an effective
mechanical barrier to viruses, including HIV.  No clinical studies
have been completed to define protection from HIV infection or
other STDs.  However, an evaluation of the female condom's
effectiveness in pregnancy prevention was conducted during a
6-month period for 147 women in the United States.  The estimated
12-month failure rate for pregnancy prevention among the 147 women
was 26%.  Of the 86 women who used this condom consistently and
correctly, the estimated 12-month failure rate was 11%.
     Laboratory studies indicate that nonoxynol-9, a nonionic
surfactant used as a spermicide, inactivates HIV and other sexually
transmitted pathogens.  In a cohort study among women, vaginal use
of nonoxynol-9 without condoms reduced risk for gonorrhea by 89%;
in another cohort study among women, vaginal use of nonoxynol-9
without condoms reduced risk for gonorrhea by 24% and chlamydial
infection by 22% (2).  No reports indicate that nonoxynol-9 used
alone without condoms is effective for preventing sexual
transmission of HIV.  Furthermore, one randomized controlled trial
among prostitutes in Kenya found no protection against HIV
infection with use of a vaginal sponge containing a high dose of
nonoxynol-9 (2).  No studies have shown that nonoxynol-9 used with
a condom increases the protection provided by condom use alone
against HIV infection.

REPORTED BY:

     Food and Drug Administration. Center for Population
Research, National Institute of Child Health and Human Development,
National Institutes of Health. Office of the Associate Director for
HIV/AIDS; Div of Reproductive Health, National Center for Chronic
Disease Prevention and Health Promotion; Div of Sexually
Transmitted Diseases and HIV Prevention, National Center for
Prevention Svcs; Div of HIV/AIDS, National Center for Infectious
Diseases, CDC.

EDITORIAL NOTE:

     This report indicates that latex condoms are highly
effective for preventing HIV infection and other STDs when used
consistently and correctly.  Condom availability is essential in
assuring consistent use.  Men and women relying on condoms for
prevention of HIV infection or other STDs should carry condoms or
have them readily available.
     Correct use of a latex condom requires 1) using a new condom
with each act of intercourse; 2) carefully handling the condom to
avoid damaging it with fingernails, teeth, or other sharp objects;
3) putting on the condom after the penis is erect and before any
genital contact with the partner; 4) ensuring no air is trapped in
the tip of the condom; 5) ensuring adequate lubrication during
intercourse, possibly requiring use of exogenous lubricants; 6)
using only water-based lubricants (e.g., K-Y jelly (trademark) or
glycerine) with latex condoms (oil-based lubricants (e.g.,
petroleum jelly, shortening, mineral oil, massage oils, body
lotions, or cooking oil) that can weaken latex should never be
used); and 7) holding the condom firmly against the base of the
penis during withdrawal and withdrawing while the penis is still
erect to prevent slippage.
     Condoms should be stored in a cool, dry place out of direct
sunlight and should not be used after the expiration date.  Condoms
in damaged packages or condoms that show obvious signs of
deterioration (e.g., brittleness, stickiness, or discoloration)
should not be used regardless of their expiration date.
     Natural-membrane condoms may not offer the same level of
protection against sexually transmitted viruses as latex condoms.
Unlike latex, natural-membrane condoms have naturally occurring
pores that are small enough to prevent passage of sperm but large
enough to allow passage of viruses in laboratory studies (2).
     The effectiveness of spermicides in preventing HIV
transmission is unknown.  Spermicides used in the vagina may offer
some protection against cervical gonorrhea and chlamydia.  No data
exist to indicate that condoms lubricated with spermicides are more
effective than other lubricated condoms in protecting against the
transmission of HIV infection and other STDs.  Therefore, latex
condoms with or without spermicides are recommended.
     The most effective way to prevent sexual transmission of HIV
infection and other STDs is to avoid sexual intercourse with an
infected partner.  If a person chooses to have sexual intercourse
with a partner whose infection status is unknown or who is infected
with HIV or other STDs, men should use a new latex condom with each
act of intercourse.  When a male condom cannot be used, couples
should consider using a female condom.
     Data from the 1988 National Survey of Family Growth underscore
the importance of consistent and correct use of contraceptive
methods in pregnancy prevention (8).  For example, the typical
failure rate during the first year of use was 8% for oral
contraceptives, 15% for male condoms, and 26% for periodic
abstinence.  In comparison, persons who always abstain will have
a zero failure rate, women who always use oral contraceptives will
have a near-zero (0.1%) failure rate, and consistent male condom
users will have a 2% failure rate (9).  For prevention of HIV
infection and STDs, as with pregnancy prevention, consistent and
correct use is crucial.
     The determinants of proper condom use are complex and
incompletely understood.  Better understanding of both individual
and societal factors will contribute to prevention efforts that
support persons in reducing their risks for infection.  Prevention
messages must highlight the importance of consistent and correct
condom use (10).

REFERENCES

1. CDC. Condoms for prevention of sexually transmitted diseases.
MMWR 1988;37:133-7.

2. Cates W, Stone KM. Family planning, sexually transmitted
diseases, and contraceptive choice: a literature update. Fam Plann
Perspect 1992;24:75-84.

3. Weller SC. A meta-analysis of condom effectiveness in reducing
sexually transmitted HIV. Soc Sci Med 1993;1635-44.

4. DeVincenzi I, European Study Group on Heterosexual Transmission
of HIV. Heterosexual transmission of HIV in a European cohort of
couples (Abstract no. WS-CO2-1). Vol 1. IXth International
Conference on AIDS/IVth STD World Congress. Berlin, June 9,
1993:83.

5. Saracco A, Musicco M, Nicolosi A, et al. Man-to-woman sexual
transmission of HIV: longitudinal study of 343 steady partners of
infected men. J Acquir Immune Defic Syndr 1993;6:497-502.

6. Carey RF, Herman WA, Retta SM, Rinaldi JE, Herman BA, Athey TW.
Effectiveness of latex condoms as a barrier to human
immunodeficiency virus-sized particles under conditions of
simulated use. Sex Transm Dis 1992;19:230-4.

7. Trussell JE, Warner DL, Hatcher R. Condom performance during
vaginal intercourse: comparison of Trojan-Enz (trademark) and
Tactylon (trademark) condoms. Contraception 1992;45:11-9.

8. Jones EF, Forrest JD. Contraceptive failure rates based on the
1988 NSFG. Fam Plann Perspect 1992;24:12-9.

9. Trussell J, Hatcher RA, Cates W, Stewart FH, Kost K.
Contraceptive failure in the United States: an update. Stud Fam
Plann 1990;21:51-4.

10. Roper WL, Peterson HB, Curran JW. Commentary: condoms and
HIV/STD prevention--clarifying the message. Am J Public Health
1993;83:501-3.

**Use of trade names is for identification only and does not imply
endorsement by the Public Health Service or the U.S. Department of
Health and Human Services.

(Centers for Disease Control and Prevention. Morbidity and
Mortality Weekly Report. 1993 Aug 6;42(30):589-591,597.)
