Variability in Condom Use Trends by Sexual Risk Behaviors: Findings from the 2003-2015 National Youth Risk Behavior Surveys

Condom non-use among adolescents: Prevalence and associated factors among school-going adolescents from 58 countries

OBJECTIVES

Studies in several resource-limited settings have investigated the prevalence and potential factors associated with condom non-use among adolescents, showing inconsistent and varied findings, owing to methodological inconsistencies. Thus, this study aimed to investigate the prevalence and associated factors of condom non-use among a global sample of adolescents and their differences based on sex and region.

METHODS

We conducted a cross-sectional study using the 2009-2018 Global School-based Health Survey data from 58 countries which included 183,100 adolescents aged 12-15 years. Random-effects meta-analysis was used to estimate the overall and regional pooled prevalence of condom non-use. Multilevel mixed-effect logistic regressions were used to investigate the correlates of condom non-use.

RESULTS

Overall, 26.2% of the total sample reported being sexually active and of these, 27.6% did not use condoms during last intercourse, with boys reporting higher than girls (27.9% vs. 25.6%). The prevalence of condom non-use was the highest in the African region (29.2%) and the lowest in the South-East Asia region (21.1%). There were variations in prevalence across countries, regions, and sex. Female gender, older age, loneliness, suicidal ideation, being bullied, parental support and supervision, truancy, smoking, illicit drug use, early sexual initiation, and having multiple sex partners were associated with condom non-use. There was evidence of heterogeneity of correlates across regions and sex.

CONCLUSIONS

In this analysis, we found variations in the prevalence and associated factors of condom non-use among adolescents by sex and region. These findings can shape effective sexual health initiatives and improve resource distribution across regions.

Condom Use Beliefs Differ According to Regulatory Focus: A Mixed-Methods Study in Portugal and Spain

Reports worldwide have been showing increasing rates of sexually transmitted infections (STIs) and condomless sex in recent years. Research has identified several individual and situational variables that can determine the decision to use condoms or forgo their use. We argue that such a decision can also be shaped by motives related to pleasure and safety (i.e., regulatory focus in sexuality). Using open ended questions, we asked 742 Portuguese and Spanish adults to indicate situations and reasons that could inform the decision making process with casual partners and the functions/attributes related to condoms. Using thematic analyses, we coded the drivers of condomless sex and condom use into themes and subthemes, and computed their frequencies. Using quantitative measures, we also asked participants to indicate their condom use expectancies and perceived barriers. Comparing participants according to regulatory focus revealed some differences. Pleasure promotion participants were more likely to consider that condom use decision making is driven by unexpectedness, pleasure, and intimacy pursuit, attached more pleasure reduction functions to condoms, expected more negative outcomes in condom use, and endorsed more sensation and partner barriers in condom use. In contrast, disease prevention participants were more likely to consider that condom use decision making is driven by adequate sexual education, responsibility, and behavioral control, and attached more health protective functions to condoms. These differences can inform the development of tailored intervention and awareness campaigns aimed at helping people to use condoms more consistently with casual partners and to avoid behaviors that put them at risk of STI transmission.

Prevalence and Trends of Sexual Behaviors Among Young Adolescents Aged 12 Years to 15 Years in Low and Middle-Income Countries: Population-Based Study

BACKGROUND

Risky sexual behaviors remain significant public health challenges among adolescents. Nearly 90% of adolescents live in low and middle-income countries (LMICs), but few studies have used standardized methodology to monitor the prevalence and trends of sexual behaviors among adolescents in LMICs.

OBJECTIVE

This study aimed to assess the prevalence of sexual behaviors (ever had sexual intercourse, multiple sexual partners, and condom use) among adolescents aged 12 years to 15 years as well as the trends in prevalence between 2003 and 2017.

METHODS

For this population-based study, we used recent data from the Global School-based Student Health Survey conducted in 69 LMICs from 2003 to 2017 to assess the recent prevalence of sexual behaviors by using complex analysis and a random effects meta-analyses method. Using the chi-square trend test, we also assessed the trends in the prevalence of sexual behaviors in 17 countries that had conducted ≥1 round of surveys from 2003 to 2017.

RESULTS

We included 145,277 adolescents aged 12 years to 15 years (64,719/145,277, 44.5% boys) from the 69 LMICs that had conducted ≥1 survey and 80,646 adolescents aged 12 years to 15 years (34,725/80,646, 43.1% boys) from the 17 LMICs that had conducted ≥1 round of surveys. The recent global prevalence of ever had sexual intercourse was 6.9% (95% CI 6.2%-7.6%) and was higher among boys (10.0%, 95% CI 9.1%-11.1%) than girls (4.2%, 95% CI 3.7%-4.7%) and among those aged 14 years to 15 years (8.5%, 95% CI 7.7%-9.3%) than those aged 12 years to 13 years (4%, 95% CI 3.4%-4.7%). Among adolescents who had ever had sex, the recent global prevalence of having multiple sexual partners was 52% (95% CI 50.4%-53.6%) and was higher among boys (58%, 95% CI 56.1%-59.9%) than girls (41.4%, 95% CI 38.9%-43.9%) and among those aged 14 years to 15 years (53.5%, 95% CI 51.6%-55.4%) than those aged 12 years to 13 years (49.7%, 95% CI 45.9%-53.5%). Among adolescents who had ever had sex, the recent global prevalence of condom use was 58.1% (95% CI 56.2%-59.9%) and was higher among girls (59.2%, 95% CI 56.4%-61.9%) than boys (57.7%, 95% CI 55.7%-59.7%) and among those aged 14 years to 15 years (59.9%, 95% CI 58.0%-61.8%) than those aged 12 years to 13 years (51.6%, 95% CI 47.5%-55.7%). Between the earliest and latest surveys, the overall prevalence of ever had sexual intercourse (3.1% decrease) and condom use (2.0% decrease) showed downward trends. The overall prevalence of having multiple sexual partners increased by 2.6%.

CONCLUSIONS

We provide evidence and important implication for policymakers to develop targeted policy support systems to prevent and reduce risky sexual behaviors among young adolescents in LMICs with a high prevalence of risky sexual behaviors.

Is There Risk Compensation among HIV Infected Youth and Adults 15 Years and Older on Antiretroviral Treatment in South Africa? Findings from the 2017 National HIV Prevalence, Incidence, Behaviour and Communication Survey

In this paper, risk compensation among individuals on antiretroviral therapy (ART), using the 2017 South African national survey on HIV, is explored. A multi-stage stratified cluster random sampling approach was used to realize 11,130 participants 15 years and older. Logistic regression analysis assessed the association between multiple sexual partners, condom use at last sexual encounter, consistency of condom usage and potential explanatory variables using HIV status and ART exposure as a mediator variable. HIV positive participants who were aware and on ART were less likely to have multiple sexual partners, and less likely not to use a condom at last sex compared to HIV positive participants who were aware but not on ART. The odds of reporting multiple sexual partners were significantly lower among older age groups, females, non-Black Africans, and rural settings, and higher among those with tertiary level education, and risky alcohol users. The odds of no condom use at last sexual encounter were more likely among older age groups, females, other race groups, and less likely among those with secondary level education. The odds of inconsistent condom use were more likely among older age groups, females, and other race groups, and less likely among those with tertiary level education, high risk and hazardous alcohol users. Risk compensation is not apparent among HIV infected adults who are on ART. Risk groups that should receive tailored interventions to reduced risky sexual behaviours were identified.

Factors Influencing Contraceptive Use Among Sexually Active U.S. Middle and High School Students, 2015 to 2019

Objective The objective of this study is to see whether factors including the age of first sexual intercourse, sexual orientation, age at the time of survey administration, race/ethnicity, and sex affect condom and other types of contraceptive usage among United States middle and high school students. Methods We analyzed data from the Centers for Disease Control's Youth Risk Behavior Surveys from the years 2015 to 2019. Students were asked questions about condom and specific type of contraceptive use (e.g. birth control pills, intrauterine device/implant, shot/patch/ring, withdrawal), age of first sexual intercourse, and sexual orientation, as well as demographic questions. Using a logistic regression model, we tested the linear effects on condom and contraception investigated variables. Results Differing sexual orientations had a significant relationship with both condom and contraceptive usage, with those who identified as lesbian or gay being least likely to use contraception as opposed to those who identified as straight, bisexual, or unsure. Female participants were 31.6% less likely to use contraception overall and 41.7% less likely to use condoms in comparison to male participants. With a one-year increase in the age of first sexual intercourse, contraceptive use overall increased by 23% and condom use specifically increased by 17%. With a one-year increase in a participant's age at the time of survey administration, contraceptive use decreased by 7.4% and condom use decreased by 21%. Between the years 2015 to 2019, there was an average decrease of 5.3% in the usage of condoms. Conclusion We found significant differences in contraceptive and/or condom usage between students of different sexual orientations, sex, age of first sexual intercourse, age at the time of survey administration, and between different years studied. These differences could be attributed to differences in sex education, cultural background, and availability of resources. Further investigations should be conducted to delineate these differences.

Reported Chlamydia and Gonorrhea Are Decreasing Among Young Black Women: Good News or Bad News? A Narrative Review

ABSTRACT

Since 2010, reported chlamydia and gonorrhea rates decreased among Black women aged 15 to 19 years and were stable for Black women aged 20 to 24 years in the United States. Rates increased for older Black women aged 25 to 39 years and all White women. The Black/White rate ratio decreased across age groups. We examined whether trends in reported rates reflected changing prevalence or changing screening. We analyzed trends in reported chlamydia and gonorrhea rates from 2010 to 2018 among women in the United States aged 15 to 39 years by age and race/ethnicity subgroup, state, and reporting source. Most jurisdictions reported decreased chlamydia and gonorrhea rates among Black teens and increased rates among White teens and older women. Between 2010 and 2018, public clinics reported fewer cases, especially among young Black women, that were not restored by increases elsewhere. We reviewed literature on trends in screening, prevalence, and sequelae. Family planning clinics annual reports showed chlamydia tests among women younger than 25 years decreased by 541,573 tests (-38%) in 2018 compared with 2010 and the number of women visiting sexually transmitted disease clinics had decreased 50% by 2016 compared with 2010. Prevalence of chlamydia in a sentinel population (Job Corps) was unchanged for Black women younger than 25 years and increased for Whites aged 20 to 24 years. Sequelae trends using data from a large all-payer emergency department database were mixed: pelvic inflammatory disease decreased, whereas ectopic pregnancy increased. Decreases in testing at public clinics likely missed diagnoses among young Black women, a group traditionally at highest risk and in need of more testing. Innovative approaches to screening are needed.

Association between First Sexual Intercourse and Sexual Violence Victimization, Symptoms of Depression, and Suicidal Behaviors among Adolescents in the United States: Findings from 2017 and 2019 National Youth Risk Behavior Survey

The objective of this study was to investigate the association between first sexual intercourse and sexual violence victimization, symptoms of depression, and suicidal ideation among sexually active adolescents in the United States. Data for this study came from the U.S. 2017 and 2019 iterations of the National Youth Risk Behavior Survey. An analytic sample of 6252 adolescents aged 14–18 years old (49.5% female) who reported ever having sexual intercourse was analyzed using Poisson regression. The outcome variables investigated in this study were sexual violence victimization, symptoms of depression, suicidal ideation, a suicide plan, and suicide attempts, and the main explanatory variables were age at first sexual intercourse and forced sexual intercourse. We also analyzed differences by gender and race. Of the 6252 adolescents who reported ever having sexual intercourse, 7.1% had their first sexual intercourse before age 13, and 14.8% experienced forced sexual intercourse. About 16% of adolescents experienced sexual violence during the past year, 42.6% reported symptoms of depression, 23.9% experienced suicidal ideation, 19.3% made a suicide plan, and 11.1% attempted suicide during the past year. In the regression analysis, early sexual intercourse was significantly and positively associated with suicidal ideation (relative risk (RR) = 1.15, 95% Confidence Interval (CI) = 1.02–1.30), suicide plan (RR = 1.18, 95% CI = 1.00–1.38), and suicide attempts (RR = 1.36, 95% CI = 1.15–1.61). Controlling for the effects of covariates, history of forced sexual intercourse was positively associated with the five outcomes examined with the relative risk ranging between 1.59 and 6.01. Findings of this study suggest that history of early or forced sexual intercourse is associated with poor mental health outcomes among adolescents and underscores the importance of developing interventions that offer psychological support in reducing the adverse impact of early sexual intercourse and forced sexual intercourse on adolescent health.

Impact of viral suppression among persons with HIV upon estimated HIV incidence between 2010 and 2015 in the United States

BACKGROUND

The suppression of viremia among persons with HIV (PWH) using antiretroviral therapy has been hypothesized to reduce HIV incidence at the population level. We investigated the impact of state level viral suppression among PWH in the United States on estimated HIV incidence between 2010 and 2015.

METHODS

Viral suppression data and HIV incidence estimates from the National HIV Surveillance System were available from 29 states and the District of Columbia. We assumed a one year delay for viral suppression to impact incidence. Poisson regression models were used to calculate the estimated annual percent change (EAPC) in incidence rate. We employed a multivariable mixed-effects Poisson regression model to assess the effects of state level race/ethnicity, socioeconomic status, percent men who have sex with men (MSM) and hepatitis C virus prevalence as a proxy for injection drug use on HIV incidence.

FINDINGS

Fitted HIV incidence for 30 jurisdictions declined from 11.5 in 2010 to 10.0 per 100,000 population by 2015 corresponding with an EAPC of -2.67 (95% confidence interval [95%CI] -2.95, -2.38). Southern states experienced the highest estimated incidence by far throughout this period but upon adjustment for viral suppression and demographics there was a 36% lower incidence rate than Northeast states (adjusted rate ratio [aRR] 0.64; 95%CI 0.42, 0.99). For every 10 percentage point (pp) increase in viral suppression there was an adjusted 4% decline in HIV incidence rate in the subsequent year (aRR 0.96; 95%CI 0.93, 0.99). While controlling for viral suppression, HIV incidence rate increased by 42% (aRR 1.42 95%CI 1.31, 1.54) for every 5 pp increase in percent Black race and by 27% (aRR 1.27 95%CI 1.10, 1.48) for every 1 pp increase in percent MSM in states.

INTERPRETATION

A decline in estimated HIV incidence from 2010 to 2015 was associated with increasing viral suppression in the United States. Race and sexual orientation were important HIV acquisition risk factors.

Associated factors and sex differences in condom non-use among adolescents: Brazilian National School Health Survey (PeNSE)

Background

Condom non-use among sexually active adolescents is a major cause of unintended pregnancy and sexually transmitted infections. In order to promote condom use, it is essential to understand factors associated with condom non-use.

Aim

Our aim was to evaluate sex differences and associated factors of condom non-use based on the nationally representative Brazilian National School Health Survey.

Methods

The study participants were 100,962 adolescents 13–18 years old, 9th graders from both public and private schools throughout Brazil. The following factors were considered as explanatory group variables for the outcome of condom non-use among adolescents: school and health service, sexual behavior, substance use, and self-reported body and health perception. Poisson regression model was performed.

Results

Of the total students, 28% (n = 28,157) had had sexual intercourse at least once. (boys, 37.1%; girls, 19.5%). Of these, 69.2% had used condoms the last time they had intercourse (girls: 68%; boys: 69.9%). The variables associated with condom non-use for both sexes were not having accessed a health service or approached a health professional for health-related care; not having received pregnancy prevention counseling or guidance on AIDS or STI prevention at school; early sexual initiation; no additional contraception method; substance use; feeling alone; not being satisfied with their own body; feeling fat or thin; and poor self-reported health. The number of sexual partners was also associated with condom non-use; however, contrasting behavior was indicated between sexes. A higher number of sexual partners indicated less use of condoms among girls, while for boys, a higher number of sexual partners indicated higher condom use.

Conclusion

High condom non-use appears to be associated with lack of health care access and sexual health education, poor sexual practices, substance use, and poor self-perception, indicating areas for health promotion programs.

Sexually Transmitted Infection Risk Reduction Strategies Among US Adolescents and Adults With Multiple Opposite-Sex Sex Partners or Perceived Partner Nonmonogamy, 2011-2017

BACKGROUND

This study examined condom use and sexually transmitted infection (STI) testing among unmarried, non-cohabiting women and men who had multiple past-year partnerships or perceived their partner's involvement in another sexual relationship.

METHODS

We identified 5868 and 5330 unmarried, non-cohabiting sexually active women and men aged 15 to 44 years using National Survey of Family Growth data for 2011 to 2017. To measure multiple partnerships, we created 4 dichotomous variables that included both past-year number of opposite-sex sex partners (1, 2 or more) and perceived partner nonmonogamy (PPNM) (yes, no). Results were stratified by relationship type at last sex ("steady" vs "casual").

RESULTS

Overall, 39.4% of women and 48.3% of men reported multiple partnerships and 23.4% and 24.0% reported PPNM. Lower condom use was seen for women and men who had 2 or more partners in the past year and PPNM than those with only 1 partner and no PPNM (women, 28.5%; 95% confidence interval [CI], 24.1-32.9 vs 39.3%; 95% CI, 36.6-41.9) (men, 37.7%; 33.5-41.8 vs 54.9%; 51.9-57.9). STI testing was higher for groups with PPNM. Men with a steady sex partner had higher prevalence of past-year STI testing if they reported PPNM than not (adjusted prevalence ratio, 2.00; 95% CI, 1.63-2.45).

CONCLUSIONS

Screening practices that include a standardized sexual risk assessment could identify those with multiple sex partners or PPNM and improve linkage to STI services. Availability of point-of-care tests and expedited partner therapy could provide targeted strategies that prioritize rapid diagnosis and effective partner treatment which may prevent further STI spread.

The Association Between State Physical Education Laws and Student Physical Activity

INTRODUCTION

This study examined the association between state physical education time requirements and physical activity and physical education outcomes among high school students.

METHODS

State physical education time requirement laws for 2004-2016 from the Classification of Laws Associated with School Students database were linked with 2005-2017 national Youth Risk Behavior Survey data using state and year identifiers. Analyses were conducted between 2018 and 2019 to assess associations between physical education time requirement laws and physical activity or physical education outcomes using multinomial logistic regressions, while controlling for sociodemographic characteristics, year-fixed effects, and state confounders.

RESULTS

State laws requiring ≥90 minutes of physical education per week were associated with 3.1 percentage points lower probability of no days of physical activity ≥60 minutes (95% CI= -5.0, -1.1), 3.7 percentage points lower probability of no days of moderate exercise ≥30 minutes (95% CI= -6.2, -1.3), 4.2 percentage points lower probability of no days of vigorous exercise ≥20 minutes (95% CI= -5.2, -3.3), and 19.3 percentage points lower probability of not attending physical education class (95% CI= -34.4, -4.2). The laws were associated with a 2.4 percentage point higher probability of daily moderate exercise ≥30 minutes in male students (95% CI=0.6, 4.2) and a 3.4 percentage point higher probability in female students (95% CI=1.9, 4.9), with larger associations for female students (p<0.01).

CONCLUSIONS

Findings from this study help support the role that physical education state requirements can play in enhancing adolescents' ability to meet recommended amounts of daily physical activity and the related public health benefits.

Making a Case for Integrating Evidence-Based Sexual Risk Reduction and Mental Health Interventions for Adolescent Girls

Recently identified as the top concern of teens, mental health issues now compete with sexual health risks as major threats to the well-being of adolescent females. Depression and anxiety can lead to or compound the negative repercussions of sexual behavior choices that result in disproportionately high rates of sexually-transmitted infections (STIs), hetero-sexually acquired HIV, and unplanned pregnancy rates in girls ages 15-19. There are a limited number of CDC- and DHHS-recognized HIV/STI and teen pregnancy evidence-based interventions (EBIs) targeted to adolescent girls of diverse races/ethnicities and none that simultaneously address common mental health disorders. The Health Improvement Project for Teens (HIPTeens), a manualized gender-specific sexual risk reduction intervention, and the Creating Opportunities for Personal Empowerment (COPE) Program, a manualized cognitive-behavioral skills intervention that reduces depression and anxiety, are recognized by national agencies as strong EBIs that have successfully improved their targeted outcomes. Baseline data from the HIPTeens clinical trial revealed that a substantial portion of the more than 700 girls enrolled had moderate to high levels of depressive symptoms as well as other mental health challenges (e.g., binge drinking and eating, cannabis use). Thus, there is an urgent need to combine EBIs, such as HIPTeens and COPE, to curtail these leading public health problems confronting today's adolescents.

Being on the Safe Side: A Qualitative Study of Condom Use Motivations According to Contraceptive Type among Adolescents in Atlanta, Georgia

STUDY OBJECTIVE

Quantitative data suggest that adolescent users of long-acting reversible contraception (LARC), compared with short-acting methods (pill, patch, ring, depot medroxyprogesterone acetate [DMPA]), might be less likely to use condoms. We qualitatively describe and explain adolescent contraceptive users' motivations for condom use, including variation according to contraceptive type.

DESIGN

Individual, in-depth qualitative interviews, analyzed thematically.

SETTING

Participants were recruited from public family planning clinics and an adolescent medicine clinic, as well as university and other community settings in Atlanta, Georgia.

PARTICIPANTS

Sexually active contraceptive users aged 17-19 years old (n = 30), including LARC (n = 10), DMPA (n = 10), and oral contraceptive (n = 10) users.

RESULTS

Of the 30 participants, most (n = 25; 83%) used condoms with their more effective contraceptive method, although 11 of 25 used them inconsistently (44%). Oral contraceptive users were particularly motivated to use condoms for pregnancy prevention, because of concerns about contraceptive method efficacy and a desire to be on "the safe side." In contrast, LARC users were primarily motivated by sexually transmitted infection (STI) prevention. DMPA users' motivations were more mixed. Across contraceptive type, factors influencing condom use motivations included sexual health education, personal awareness and/or experience, and perceived consequences and risk.

CONCLUSION

Because all participants were using an effective contraceptive method, it is notable that pregnancy prevention was a prominent motivator for using condoms, although LARC users reported STI prevention to be a more important motivation. Parental and school-based sexual health education that clearly addresses STI prevention in addition to pregnancy prevention has the potential to influence condom use motivations and behavior.

Sexually Transmitted Diseases Among US Adolescents and Young Adults: Patterns, Clinical Considerations, and Prevention

This article describes prevalence and recent trends in the most common sexually transmitted diseases (STD) among young people in the United States. Common clinical presentations and best practices related to screening and treatment of these conditions are summarized. Clinical considerations for working with adolescents and young adults in the area of sexual and reproductive health are highlighted. Key approaches for sexually transmitted disease prevention with adolescents and young adults are presented.

Condom Availability Programs in Schools: A Review of the Literature

OBJECTIVE

This review synthesizes findings from the peer-reviewed evaluation literature on condom availability programs (CAPs) in secondary schools.

DATA SOURCE

Peer-reviewed evaluation literature indexed in MEDLINE, EMBASE, PsychINFO, ERIC, CINAHL, Sociological Abstracts, SCOPUS, and POPLINE.

STUDY INCLUSION AND EXCLUSION CRITERIA

Manuscripts had to be, written in English, and report evaluation data from a US school-based CAP.

DATA EXTRACTION

Articles were coded independently by 2 authors. Discrepancies were resolved through open discussion.

DATA SYNTHESIS

We grouped findings into outcome evaluation and process evaluation findings. Outcome evaluation findings included sexually transmitted infections (STIs), pregnancy rates, condom use, contraception use, sexual risk, and substance use. Process evaluation findings included awareness of CAPs, attitudes toward CAPs, attitudes toward condoms, and receipt of education and instruction.

RESULTS

Of the 138 citations reviewed, 12 articles published between 1995 and 2012 met the inclusion criteria, representing 8 programs. Evaluations indicate CAPs yield condom acquisition rates between 23% and 48%, have mixed results related to condom use, and are not associated with increases in sexual and other risk behaviors. One program found CAPs were associated with a decrease in a combined rate of chlamydia and gonorrhea. One program found no association between CAPs and unintended pregnancy. Students' attitudes toward CAPs were favorable and awareness was high.

CONCLUSIONS

Condom availability programs are accepted by students and can be an appropriate and relevant school-based intervention for teens. Condom availability programs can increase condom use, but more evaluations are needed on CAP impact on rates of HIV, STIs, and unintended pregnancy.