Prevalence and patterns of condom use among patients attending a sexually transmitted disease clinic

The purpose of this study is to evaluate prevalence and patterns of condom use among patients attending a sexually transmitted disease (STD) clinic, who are at increased risk of developing STDs. Interviews of 800 patients attending a Baltimore STD clinic were conducted. The prevalence of condom use was dependent on the measure of use employed. For example, 9 out of 10 patients reported ever having used condoms, slightly less than one-third of the patients reported having used condoms in the past 30 days, and only 17% of the patients reported using a condom at last sex. Use also varied somewhat by type of sexual partner, and within any given relationship, from first to last sexual encounter. The most significant factor corresponding to condom use in the 30 days prior to the interview was number of sexual partners (lifetime and in the last month). Multivariate analyses revealed number of lifetime partners to be the most significant predictor of condom use for men, whereas age was the most significant variable for women. These findings suggest that interventions should focus not only on the individual, but the couple.

Helping patients to reduce their risk of acquiring sexually transmitted disease

This monthly series was developed from the AOA Task Force on AIDS Writers' Workshop, held August 16 to 18, 1991, in New York. The workshop was sponsored by an education grant from Burroughs Wellcome. It will provide brief clinical updates and perspectives on the human immunodeficiency virus (HIV). Readers may request tear sheets from the AOA editorial offices.

Introductory small cash incentives to promote child spacing in India

The Ammanpettai Family Welfare Program began in 1985 as a pilot program to determine whether offering small monthly cash incentives for a limited period would be a cost-effective way to increase the use of modern temporary methods of contraception among rural Indian women who do not want to become pregnant but are not ready to adopt sterilization. The program has demonstrated that a modest cash incentive for 3-5 months attracts very large numbers of women to a clinic where they learn about and are provided with the pill, condoms, or the IUD. In catchment areas where official government reports showed temporary-methods prevalence rates of 3-5 percent at best, the Ammanpettai incentive program has attracted up to 70 percent of eligible women to join the program and try the method of their choice. By requiring that participants bring their youngest child to the clinic, the program provides for mother and child health surveillance, including immunizations. The great majority of rural women who join the program work as field laborers, have little or no schooling, and have little knowledge of or experience with modern contraceptive methods. Continuation rates are 25-50 percent at one year if follow-up is maintained by village resident women distributors. The program has been extended to several rural primary health centers in Thanjavur District, to 14 government health posts in the city of Madras, and to a semiurban area and several rural areas in Bihar. The cost-effectiveness of this program compares favorably with that of the current government family welfare program.

Patterns and predictors of high-risk sexual behavior in female partners of HIV-infected men with hemophilia

OBJECTIVE

To characterize and quantify high-risk heterosexual activity in HIV-discordant couples.

DESIGN

Analysis of cross-sectional and longitudinal questionnaire data from 217 HIV-negative female sexual partners of HIV-infected hemophilic men.

METHODS

Comparison of prevalence rates of anal sex, oral sex, vaginal intercourse with or without condoms, and use of other contraceptives between 1985 and 1991. Logistic regression analysis of demographic, sexual and clinical variables to predict unprotected vaginal sex. Actuarial estimates of semi-annual relapse rates to unsafe sex.

RESULTS

The proportion of women at low risk increased from 7 to 69% between 1985 and 1991, mainly because more women were using condoms during all acts of vaginal intercourse. Other contraceptive practices did not change during this time. The proportion engaging in oral or anal sex decreased (from 26 to 13% and 13 to 4%, respectively). Unprotected vaginal sex was more common among women who enrolled earlier, had less education, engaged in oral or anal sex, and among those whose partners had not had AIDS. Unprotected vaginal sex before enrollment was the strongest predictor of this high-risk activity during follow-up. Two-year rates of relapse to high-risk behavior were significantly higher among women who enrolled at high risk compared with those who enrolled at low risk (39 versus 8%, P = 0.005).

CONCLUSIONS

Although high-risk sexual behavior became much less prevalent in this population between 1985 and 1991, many continued to have unprotected vaginal sex occasionally. Counseling efforts should target couples who have been the most sexually active or have less education, and should emphasize not only initial risk reduction but also maintenance of low-risk behavior.

Surprising success in Kenya's FP programme

Mrs. Margaret Gachara, Deputy Director of the Ministry's Family Health Division, explained that the strengths and weaknesses of the program have recently been examined using a new operations research approach, known as situation analysis. "If family planning was not working in Kenya, we had to know why in order to decide what to do about it. We began the study to find out where our weaknesses lay. To our surprise, we found that we were not weak, but moderately successful," she said. The Kenya Situation Analysis Study, conducted by the Health Ministry and the Population Council, revealed that contraceptive prevalence increased by 2%/year between 1984-89, from 17% to 27%. "That is quite acceptable by World Bank and WHO standards. Our total fertility rate has dropped from 7.9% to 6.7%, and in urban areas is down to 3.8%. We are now continuing with in-depth studies, but we expect to be able to say next year that our family planning program should have a moderately high rating, especially in terms of quality of care." Since the 1st results of the Analysis Study were published, family planning agencies in several other African, Asian and Latin American countries have requested similar studies. The Kenyan study showed that the Pill is the most popular method of contraception, used by about 80% of family planning acceptors. However, the use of injectable contraceptives has risen about 4-fold in recent years, from 0.5 to 1.8 million doses a year, Mrs. Gachara said. When the study was conducted, availability of injectable contraceptives was very poor and did not have strong logistical support. This has now been changed, and its use is going up very fast in rural areas. 1 of the reasons is that women who want to use contraception, but do not have support from their husbands, can have injection without their husbands knowing. Although the 3 monthly injectable initially had a very bad press and little Parliamentary support, research has shown that many of the fears were unfounded. Kenyan policy is to make the injectable available to women with 4 children and to those over 35. Guidelines have recently been changed, to require 1 live birth before injectables are offered, rather than 2. The government is also making efforts to promote the use of Noristerat, and a pilot program is currently underway to study implants. The situation analysis did reveal problems in a number of areas, and a list of recommendations has now been drawn up to improve the quality of care. The recommendations include improved supply of information on permanent contraceptive methods and on the side-effects of other contraceptives, a reduction in waiting times for family planning services and an increase in follow-up. "The future looks good for family planning in Kenya, but we have to match our services to contraceptive health benefits and to focus more on maternal health in its totality," Mrs. Gachara said.

Agreement between oral contraceptive users and prescribers: implications for case-control studies

Case-control studies examining the effects of oral contraceptives (OC) are prone to misclassification bias due to errors in assessment of OC use. Concern about inaccurate exposure histories has increased since current studies require women to recall OC use over prolonged periods of time. In preparation for a case-control study of breast cancer and OC use, an investigation was carried out to assess agreement between women's lifetime histories of OC use (covering a period of up to 20 years) and prescribers' records. OC histories were obtained during personal interview with 218 women who had used OC at some point in their lives (127 breast cancer patients, 91 controls). Recall was aided by an album with color photographs of all OC marketed in the Netherlands from 1962 onwards (n = 65), and a calendar that covered the women's life span from date of birth to menopause. The participants were asked for the names of all physicians who prescribed OC for them. The rate of response from the prescribers was high (94%), but only half of the forms provided useful information. Patient-prescriber agreement on brand names (including dosage) was 70%. About half of the women agreed with their prescribers on starting dates to within less than a year's difference. Approximately the same percentage of agreement was found for stopping dates. Multiple linear regression indicated that agreement on brand names and dates of usage was lower for women of low socioeconomic status, for healthy women (as compared to breast cancer patients) and for periods of pill use that had to be recalled from the more distant past. Agreement on total duration of use was high enough to permit testing of a moderately strong duration-response relationship in a case-control study.

Comparison of condom breakage during human use with performance in laboratory testing

This paper combines results from a study of the determinants of condom quality and use conducted by The Population Council in two countries in the Caribbean with results from a condom breakage study conducted by Family Health International (FHI) in the United States. The studies, conducted two years apart, compared the breakage rates of condoms from the same lot during human use to their performance in laboratory test results. Breakage rates of 12.9% for Barbados, 10.1% for St. Lucia and 6.7% for the United States compared to passing ASTM laboratory tests suggest that existing laboratory tests as used with the current pass/fail standards are either not sufficiently sensitive or not well-defined to reliably predict condom performance during human use. The study also suggests that user behaviors and practices may be a factor in condom breakage. If the condom is to be an effective method against unplanned pregnancy and STD/HIV infection, and if consumer confidence is to be retained, condom breakage during sexual intercourse must be reduced.

Family planning for women with bipolar disorder

Women with bipolar disorder often ask their treating clinician for information about family planning, as they are concerned about the impact of their illness on offspring. Three areas that should be included in discussions with patients and their partners are heritability of the disorder, risks during pregnancy, and risks during the postpartum period. The author summarizes information about genetic transmission of bipolar disorder, effects on bipolar patients of stress associated with pregnancy and childrearing, and effects of medication on the fetus and newborn. Discussion of these issues is most relevant for a women patient who is planning a pregnancy, but may also be useful for couples before marriage, for a women patient who finds that she is pregnant, and for men with bipolar disorder who want to become fathers.