Effective Condom Use: The Key to HIV/STD Prevention 

According to conventional wisdom, condoms are a reasonably effective means to prevent unwanted pregnancy and sexually transmitted diseases (STDs), including human immunodeficiency virus (HIV). Recent findings by research teams in Seattle, Washington, and Durham, North Carolina, however, show that many couples may not use condoms correctly. Consequently, these people may not be adequately protected against either pregnancy or disease.

Most studies of condom use have looked at whether and how often couples used condoms. A recent study of condom use among young women, published in the journal AIDS Care, has gone a step further and looked instead at factors that correlate with ineffective condom use. Dr. Diane Civic, of the Group Health Cooperative in Seattle, and her colleagues assessed two types of ineffective use: delayed condom use (waiting until some penetration has occurred or just before ejaculation) and condom failure (involving slippage and/or breakage). Their study focused on young women at risk of contracting STDs. Almost half of the women in the study who had used condoms in the last three months reported delayed condom use during that time. About one-fifth of respondents experienced condom slippage, breakage, or both.

The study was done at the Group Health Cooperative in Washington State and the Duke Health System in North Carolina, both managed care organizations. A set of potential study participants was initially generated from computer databases. These were women between the age of 18 and 24 who had visited their health plan practitioners for any reason within a recent six-month period. Introductory letters were sent to 8,994 women. Of these, 1218 were eligible according the study criteria and 1210 actually agreed to participate.

Participants were chosen based on a set of criteria that determined their risk of contracting STDs. Eligible women were unmarried, not in a monogamous relationship for one year or more, sexually active with a male partner in the past six months, and not pregnant. These women then answered questions in a 20- to 30-minute telephone survey. The survey covered such topics as sexual, reproductive and STD history; perceptions of STD risk; and behaviors involving condom use.

The researchers found that a number of characteristics were correlated with ineffective condom use. For example, delayed condom use was most likely among women who were younger than 21, had a primary partner, or used condoms frequently.

Women who relied on condoms as their primary means of contraception also reported delayed condom use. Although seemingly paradoxical, this finding might reflect the greater concern that young adults have about preventing pregnancy rather than disease. Under these circumstances, condom use may be postponed until near ejaculation. The researchers note, however, that since women may be exposed to pre-ejaculate that contains sperm, the effectiveness of the condom for contraception is reduced. Also, delayed condom use reduces protection against such pathogens as human papillomavirus and herpes simplex virus, which are spread by skin-to-skin contact.

Higher reported rates of slippage and/or breakage of condoms were associated with other factors. Women of color were more likely to have experienced condom failure than white women. Women with a history of STDs were also more likely to report slipped and/or broken condoms, possibly because condom failure increases risk of exposure to pathogens.

Though having a primary partner did correlate with delayed condom use, it did not increase the incidence of condom slippage and/or breakage. Women who reported using condoms more than 15 times in the past three months were three times more likely to have had slippage and/or breakage than women who used condoms just one to three times in the same period.

The characteristics of women's sexual partners were more significant in delayed condom use than in condom failure. Women with primary partners were more likely to delay condom use, but women whose partners believe condom use is important had less risk of delayed use. Other researchers have found that couples associated sex without a condom with greater intimacy and commitment in a relationship. Civic and her colleagues observe that delayed condom use may be a way that couples attempt to satisfy both the desire for unprotected sex and the need for protection against unwanted pregnancy and STDs. As noted earlier, though, delayed use actually increases the risk of unwanted outcomes.

On the other hand, relationship characteristics have less impact on condom failure because successful condom use depends to a large extent on technical skill. In other words, skillful use does not imply less intimacy.

Based on their findings, the researchers recommend that interventions promoting condom use for HIV/STD prevention be more specific, particularly in populations that already use condoms at a relatively high rate. Studies of men and such behaviors as putting on a condom properly and timing of withdrawal may be useful areas of additional research. Other factors related to condom failure, such as age and brand, might also be investigated.

Tracey Cohen is a Science Writer based in Cambridge, MA