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American Journal of Epidemiology Advance Access originally published online on November 5, 2007
American Journal of Epidemiology 2008 167(3):341-349; doi:10.1093/aje/kwm300
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American Journal of Epidemiology Published by the Johns Hopkins Bloomberg School of Public Health 2007.

ORIGINAL CONTRIBUTIONS

Problems with Condom Use among Patients Attending Sexually Transmitted Disease Clinics: Prevalence, Predictors, and Relation to Incident Gonorrhea and Chlamydia

Lee Warner1, Daniel R. Newman1,2, Mary L. Kamb2, Martin Fishbein3, John M. Douglas, Jr2, Jonathan Zenilman4,5, Laura D'Anna6, Gail Bolan7, Judy Rogers8, Thomas Peterman2 and for the Project RESPECT Study Group

1 National Center for Chronic Disease Prevention and Health Promotion, Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, GA
2 National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, GA
3 Annenberg Public Policy Center, Annenberg School for Communication, University of Pennsylvania, Philadelphia, PA
4 Baltimore City Health Department, Baltimore, MD
5 Infectious Diseases Division, Johns Hopkins University School of Medicine, Baltimore, MD
6 California State University Long Beach, Long Beach, CA
7 San Francisco Department of Health, San Francisco, CA
8 Newark Department of Public Health, Newark, NJ

Correspondence to Dr. Lee Warner, Division of Reproductive Health, Centers for Disease Control and Prevention, 4770 Buford Highway, NE, Mailstop K-34, Atlanta, GA 30341 (e-mail: dlw7{at}cdc.gov).

Received for publication March 8, 2007. Accepted for publication September 19, 2007.


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 References
 
Condom use remains important for sexually transmitted disease (STD) prevention. This analysis examined the prevalence of problems with condoms among 1,152 participants who completed a supplemental questionnaire as part of Project RESPECT, a counseling intervention trial conducted at five publicly funded STD clinics between 1993 and 1997. Altogether, 336 participants (41%, 95% confidence interval: 38, 45) reporting condom use indicated that condoms broke, slipped off, leaked, or were not used throughout intercourse in the previous 3 months. Correspondingly, 8.9% (95% confidence interval: 7.0, 9.5) of uses resulted in STD exposure if partners were infected because of delayed application of condoms (4.3% of uses), breakage (2.0%), early removal (1.4%), slippage (1.3%), or leakage (0.4%). Use problems were significantly associated with reporting inconsistent condom use, multiple partners, and other condom problems. One-hundred thirty participants completing the questionnaire were tested for gonorrhea and chlamydia at this time and also 3 months earlier. Twenty-one (16.2%) were infected with incident gonorrhea and chlamydia, with no infections among consistent users reporting no use problems. Exact logistic regression revealed a significant dose-response relation between increased protection from condom use and reduced gonorrhea and chlamydia risk (ptrend = 0.032). Both consistency of use and use problems must be considered in studies of highly infectious STD to avoid underestimating condom effectiveness.

chlamydia; contraceptive devices, male; gonorrhea; HIV infections; sexual behavior; sexually transmitted diseases

Abbreviations: aPOR, adjusted prevalence odds ratio; STD, sexually transmitted disease


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 References
 
How effectively condoms reduce risk for sexually transmitted diseases (STDs) remains uncertain. Although laboratory studies indicate that condoms provide a virtually impermeable barrier (1–4) and that infections transmitted via the male urethra should be preventable through condom use (5), clinical studies suggest inconsistent protection from usage against most STDs (except human immunodeficiency virus) (6, 7). The protection that condoms provide against other infections transmitted via the urethra (e.g., gonorrhea and chlamydia) has varied widely (8–11).

Previous studies have been limited by design and measurement problems that may influence observed effectiveness, including lack of information on exposure to infected sex partners (11–16), unclear temporal relations between initiation of condom use and acquisition of infection (9, 11, 17), and inaccurate measurement of STD outcomes (18) and condom use. Specifically, incomplete assessment as to whether condoms were used consistently and correctly may help to explain lower-than-expected estimates of effectiveness against many STDs transmitted via the urethra, particularly those which are highly infectious (11, 13, 17, 19–22).

Problems with condom use that may compromise their effectiveness (including breakage, slippage, and failure to use them throughout intercourse) occur commonly, according to several studies (19–21, 23–31). While breakage and slippage typically occur during 2 percent of uses (32, 33), in some studies these problems are reported by large percentages of participants (25–27, 30). Failure to use condoms for the duration of intercourse, although less well researched, may be more common (21, 23, 26, 28, 31).

Far fewer studies have assessed the impact of problems with condom use on estimating effectiveness. Recent reviews of studies of condom use and risk of gonorrhea, chlamydia (11), and human immunodeficiency virus (6, 7) have found that almost none provided any information on problems with use. Newly published studies have documented associations between use problems and increased prevalence (19, 23, 24, 34, 35) and, less commonly, incidence (15) of a variety of STDs transmitted via the urethra.

This article reports on a secondary analysis of data from Project RESPECT (36), a trial of counseling interventions among STD clinic patients. An earlier report (20) briefly described the large proportion of participants who reported problems with condom use. Here, we extend on that report by analyzing specific use problems that directly place users at risk for exposure to STD. Specifically, we 1) examine the prevalence of use problems, 2) identify characteristics of participants who reported problems with use, and 3) assess the dose-response relation between consistent use and use problems and risk of incident gonorrhea or chlamydia.


   MATERIALS AND METHODS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 References
 
Study design
Project RESPECT was a multisite trial conducted among male and female patients attending publicly funded STD clinics in five cities (Baltimore, Maryland; Newark, New Jersey; Denver, Colorado; San Francisco, California; and Long Beach, California) between 1993 and 1997. The protocol was reviewed and approved by the institutional review board at each site. The study design has been described elsewhere (36). Briefly, at baseline and at follow-up visits at 3, 6, 9, and 12 months, participants completed a structured interview detailing their sexual behaviors and condom use. At baseline and at 6- and 12-month visits, participants also received testing for STDs, including polymerase chain reaction testing of urethral (males) or cervical (females) swabs for gonorrhea or chlamydia. Additional examinations at 3- and 9-month visits were provided to participants who reported symptoms, who had a partner with symptoms or STD diagnosis, or who requested STD testing. Altogether, 4,328 patients were assigned to intervention conditions requiring follow-up every 3 months.

Structured interviews administered at the baseline and 3-, 6-, and 9-month visits included substantial information on consistency of use but did not include information on problems with use, including incorrect use. Beginning in July 1995, a supplemental questionnaire on use problems was added to the 12-month visit interview and systematically administered to all patients enrolled after this date, i.e., approximately one third of participants. The module of questions, adapted from an earlier study (21), focused on problems that could compromise effective use. We focused on five problems that place users at increased risk if a partner was infected: 1) breakage during intercourse or withdrawal ("breakage"); 2) slippage off the penis during intercourse or withdrawal ("slippage"); 3) initial application after onset of genital contact ("delayed application"); 4) removal before completing intercourse ("early removal"); and 5) leakage of semen onto the partner's genital area after withdrawal ("leakage"). Other condom-related problems (e.g., failure to check the expiration date or leave space at the tip) do not directly result in exposure to genital secretions and increased STD risk, even when partners are infected, and were therefore not included.

Predictors of problems with use
Participants reported the number of times in the past 3 months that they had vaginal or anal intercourse, used condoms, and experienced the five problems described above. The prevalence of each problem was calculated by dividing the total number of episodes of that problem by the number of condom uses. We also calculated the maximum proportion of uses affected by one or more problems by dividing the total number of problems reported by the total number of uses reported; for any given participant, however, the total number of problems could not exceed the total number of uses. Because multiple problems could occur during a single use (e.g., delayed application followed by breakage) and we could not link problems with specific coital acts, we additionally calculated the minimum proportion of uses affected by one or more problems to avoid double-counting the number of uses in which problems occurred. This minimum proportion was computed by dividing the number of occurrences for the most common problem for each participant by the total number of condom uses reported.

General estimating equations methodology was used to account for the correlation of use problems within participants in computations of standard errors and 95 percent confidence intervals for the proportion of individual condom problems as well as the proportion of condom uses affected by one or more problems (37, 38).

Use problems were distinguished by the degree to which they were modifiable by the user. Delayed application and early removal of condoms were classified as intentional (i.e., fully user related), while breakage, slippage, and leakage were classified as unintentional problems (i.e., partially product related). For participants reporting any condom use, separate multivariable logistic regression models were created to evaluate predictors of these two categories of problems. For each model, the outcome was dichotomized to indicate whether the problem was reported. All models contained the following predictors: sex, education, age group, race/ethnicity, diagnosis of gonorrhea or chlamydia at entry, and, during the 3-month interval before the 12-month visit, consistency of condom use (100 percent vs. <100 percent use), number of partners (>1 vs. 1), number of condom uses (≥10 vs. <10), number of coital acts, report of symptoms, and whether other use problems were reported. Each model was also adjusted for study site and assigned intervention arm in Project RESPECT. Given the exploratory nature of this analysis, no adjustments were made for multiple comparisons.

Condom use and incident gonorrhea or chlamydia
To evaluate the association between condom use and risk of incident infection, we further restricted analyses to participants who completed the supplemental questionnaire at their 12-month visit and also received STD examinations at their 12-month and earlier at their 9-month visit. For this subset, we could distinguish incident from prevalent infection at the 12-month visit and establish the temporal relation between condom use and acquisition of infection. STD outcomes were limited to gonorrhea and chlamydia, as these infections have strong biologic plausibility for condom effectiveness (5, 9, 11), are highly transmissible (39, 40), are prevalent in STD clinic populations, and occur among both males and females.

Following the convention specified in our previous work (15), we categorized condom use as 1) consistent use (100 percent) with no reported problems, 2) consistent use with one or more reported problems, 3) inconsistent use (less than 100 percent), or 4) nonuse. The percentage of condom use was calculated by dividing the number of acts of vaginal and anal intercourse in which condoms were used by the number of total acts of intercourse. We used multivariable logistic regression to assess the association between condom use and risk of gonorrhea and chlamydia (combined outcome), adjusted for sex, race/ethnicity, age, diagnosis of gonorrhea/chlamydia at entry, presence of symptoms, and number of coital acts. All analyses but one were conducted by use of SAS, version 8.2, software (SAS Institute, Inc., Cary, North Carolina). The exception was that, for the analysis examining the relation between condom use and risk of infection, we used LogXact, version 4.1, software (Cytel Software Corporation, Cambridge, Massachusetts) to conduct conditional exact inference for logistic regression for calculation of risk odds ratios and 95 percent confidence intervals, as the data did not meet the assumption of large strata required for unconditional likelihood-based inference. All statistical tests were two tailed, and results were considered significant when p < 0.05.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
DISCUSSION
 References
 
Study population
Of 4,328 participants who entered active follow-up, 2,863 (66 percent) completed the 12-month questionnaire, of whom 1,396 were eligible (based on enrollment date) to receive the supplemental questionnaire. Eligible participants who completed the supplemental questionnaire did not differ from those who were not eligible (i.e., whose 12-month visit occurred before July 1995). Among those eligible, 1,353 (97 percent) completed the supplemental questionnaire. Overall, 1,152 participants reported vaginal or anal intercourse during the previous 3 months (median = 10 acts, range = 1–440); of these, 811 (70 percent) reported using condoms consistently or inconsistently (median = five uses, range = 1–130).

Overall, 336 participants (41 percent) who reported condom usage experienced at least one problem during use, and 189 (23 percent) experienced problems on multiple occasions (table 1). Of those experiencing problems, 129 (38 percent) reported intentional-use problems only (i.e., delayed application, early removal); 135 (40 percent), unintentional-use problems only (i.e., breakage, slippage, leakage); and 72 (21 percent), both intentional- and unintentional-use problems. The most common problem was delayed application of condoms (4.3 percent of uses), followed by breakage (2.0 percent), early removal (1.4 percent), slippage (1.3 percent), and leakage (0.4 percent); these percentages were similar for males and females (data not shown). Overall, 7.2–8.9 percent of uses were affected by one or more problems that could have exposed users to STD risk if a partner was infected.


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  		TABLE 1. Prevalence of selected problems with condom use reported by study participants* during the past 3 months, Project RESPECT, 1993–1997

 
Multivariable analyses revealed several characteristics significantly associated with reporting of use problems (table 2). Compared with consistent users, inconsistent users were more likely to report any use problem (52 percent vs. 30 percent: adjusted prevalence odds ratio (aPOR) = 2.4, p < 0.01), as well as two specific use problems—delayed application (30 percent vs. 10 percent: aPOR = 3.8, p < 0.01) and early removal of condoms (17 percent vs. 2 percent: aPOR = 10.2, p < 0.01). Use problems were also more likely to be reported by participants aged <25 years (early removal: aPOR = 2.1, p < 0.01; breakage: aPOR = 1.6, p = 0.03) and who had multiple partners (breakage: aPOR = 2.0, p < 0.01; slippage: aPOR = 2.2, p < 0.01). For each of the five problems (delayed application, early removal, and so on), participants who reported experiencing that problem were more likely to report having other problems with condom use (range of aPOR estimates: 2.3–6.4, all p < 0.01).


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  		TABLE 2. Percentage of participants* reporting selected condom use problems in the past 3 months, according to problem type and selected characteristics, Project RESPECT, 1993–1997

 
Association with incident gonorrhea and chlamydia
Of the 130 participants who completed the supplemental questionnaire and received STD testing at both the 9- and 12-month visits, 21 (16.2 percent) were diagnosed with incident gonorrhea or chlamydia at the 12-month visit. The risk of incident infection varied by whether condoms were used consistently and whether use problems were reported (table 3). Of the 18 participants who used condoms consistently and reported no problems, none acquired gonorrhea or chlamydia. Two (13.3 percent) participants who reported using condoms consistently but experienced problems acquired infection. In contrast, infection was acquired by 17.7 percent of inconsistent users and 22.9 percent of nonusers. The dose-response relation between increased protection from condom use and decreased risk of infection was significant in analyses adjusted for other factors (p = 0.032). Among the other variables assessed, only having a diagnosis of gonorrhea or chlamydia at entry (30 percent vs. 11 percent: p = 0.040) and symptoms of possible STD (26 percent vs. 8 percent: p = 0.005) were associated with infection (not shown).


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  		TABLE 3. Association between condom use in the past 3 months and incident gonorrhea/chlamydia among sexually transmitted disease clinic patients, Project RESPECT, 1993–1997*

 

   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
References
 
This study of STD clinic patients enrolled in Project RESPECT found that many experienced problems with condom use that increased their risk for STD. As in previous studies (28, 29, 41, 42), problems in using condoms were more common among groups historically at increased risk for infection. Additionally, our finding that inconsistent users were more likely than consistent users to report problems with condoms indicates that STD risk is not limited to episodes of nonuse for these persons. Whether experiencing problems with condoms also facilitates less consistent use, or even nonuse, is an area that merits further research.

In this high-risk population, we found no incident gonorrhea or chlamydia infections among participants who used condoms during every act of intercourse and reported no problems with use. Conversely, approximately one fourth of nonusers acquired these infections. Our findings add to the growing number of studies (15, 19, 23, 24, 26, 35, 43–45) documenting both that people commonly experience problems during use and that failure to account for these problems may attenuate estimates of condom effectiveness for STD prevention. For example, our analysis of STD outcomes would have overestimated the incidence of infection among consistent users had condom problems not been measured.

Assessment of condom use could be improved, in part, by asking participants more detailed questions about use problems. Our analysis revealed a high frequency of use problems, as condoms reportedly broke, slipped off, leaked, or were applied late or removed early during one of every 11 uses. Moreover, more than 40 percent of participants (including one third of consistent users) reported problems over a brief (3-month) period. These findings indicate that in this population infections observed among consistent users are not necessarily attributable to inaccurately reported condom use or to device failure. Rather, these infections could have resulted from use problems not fully assessed by investigators, as we speculated in our earlier analysis of Project RESPECT data (14, 46). In that analysis, we demonstrated that confounding from differential exposure to infected partners underestimates condom effectiveness, but we also documented that 30 percent of consistent users were infected with gonorrhea or chlamydia. Despite identifying patients with known exposure to infected partners, our previous analysis (limited to enrollment visit data) lacked information on the extent to which consistent users experienced problems with use. Given the complexities of using condoms and the frequency of problems identified in this study, measurement of such problems needs to be more precise.

Consistent with an earlier study (21), approximately two thirds of use problems were intentional and fully modifiable, where participants failed to use condoms for the duration of intercourse. Both applying condoms after genital contact begins and removing condoms before completion of intercourse represent incorrect use, rather than product failure, and signify a type of unprotected intercourse. These behaviors reflect disadvantages of condom use, including loss of spontaneity, loss of sensation, and inability to maintain an erection or ejaculate (32). Participants may have placed condoms on after genital contact (but before ejaculation) to help prevent unwanted pregnancy (29, 47, 48) and may have removed condoms early because of decreased sensation or inability to ejaculate (49).

Breakage, slippage, and leakage, largely unintentional phenomena, accounted for one third of use problems. These problems, however, have been associated with lack of user experience (41, 42, 50, 51) and user behavior (52–54). Breakage has been associated with inappropriate use of lubricants (55) and incorrect application of condoms (53). Slippage has been associated with failure to hold the condom's rim during withdrawal (21). As these problems may also be inherent in the product, further research is needed to determine the proportion of these problems preventable with skills-based counseling. One study of male STD clinic patients in Jamaica suggested that condom-skills counseling may reduce breakage by approximately 50 percent (56).

Our findings are subject to several limitations. First, although we identified a clear trend between increasing condom use and decreasing risk of infection, we had aggregate data and were unable to link transmission to specific acts of intercourse or partners.

Second, our analyses could not address misclassification of condom use status, which may result from poor recall or intentional misreporting of condom use or use problems (57, 58). Some nonusers, for example, may have falsely reported experiencing problems during use (e.g., breakage) because of their unwillingness to admit having unprotected intercourse. This type of misclassification, however, would generally bias results toward the null, suggesting that the protection observed from condom use may have been greater. Objective biologic markers that detect the presence of semen or other male genital fluids in the vagina (e.g., prostate-specific antigen or Y chromosome) (43, 59, 60) could help to minimize misreports of condom failure and warrant further exploration.

Third, although we demonstrated a clear dose-response relation between consistent and correct condom use and reduced STD risk, this analysis was based on a small sample and should be interpreted with caution. This sample was limited for two reasons: 1) as an artifact of the design of Project RESPECT, since participants were not required to have an STD examination at 9 months; and 2) the supplemental questionnaire on use problems was not administered until more than half of participants' scheduled 12-month follow-up visits were completed. Because we wanted to examine incident infection over a 3-month period (i.e., the same time frame ascertained for condom use), we were able to include only the participants tested for STD at both their 9-month and 12-month visits. To validate that this limited sample represented the patient population of Project RESPECT, we compared the 130 participants who received testing during the 9-month visit and also completed the supplemental questionnaire first with participants who received testing at their 9-month visit (but were not offered the questionnaire) and then with participants who completed the questionnaire (but were not tested at their 9-month visit). Our first comparison revealed no statistical or meaningful differences in characteristics. The second comparison indicated that our sample was higher risk (i.e., younger and of minority race/ethnicity) and thus reflective of Project RESPECT participants who would have received STD testing at 9 months, but otherwise no different (data not shown). The results of these two comparisons further reinforce the validity of our finding that condom use is associated with reduced STD risk.

This analysis lacked information on whether participants were exposed to infected partners, information which has proven beneficial for addressing differential condom use by partner type and obtaining more accurate estimates of condom effectiveness (11). Although partner infection status has been difficult to measure in observational studies of curable STDs, recent advances in epidemiologic study design (14–16) have allowed investigators to distinguish participants who had known exposure to infected partners from those without known exposure. Three recent studies of STD clinic populations that used these designs (including our earlier work from Project RESPECT (14)) indicate that failure to account for differential exposure to infected partners between users and nonusers underestimates the protective effect of consistent use against gonorrhea and chlamydia (12, 14, 15). One major limitation is that none of those studies fully assessed problems during use that may have affected observed effectiveness. Given that participants had known exposure to infected partners and that the estimated per-act infectivity for these infections is high (from 20 percent to 80 percent) (39, 40), investigators should assess problems with condom use, including incorrect use. Our current analysis of Project RESPECT suggests that these studies of patients exposed to infected partners might have demonstrated stronger protection for consistent use (vs. nonuse) had problems such as breakage, slippage, and failure to use condoms throughout intercourse been evaluated.

These limitations are offset by several strengths. First, although most earlier studies of use problems were conducted in small, low-risk populations (21, 27, 28) or single clinic sites (24–26, 44), Project RESPECT included patients from five STD clinics. A second strength was our general approach to evaluating the association between condom use and risk of infection. We ascertained condom use and use problems before results of STD testing were known to participants or research staff. By restricting analyses to participants who were tested for STD at both their 9- and 12-month visits, we matched the recall period between assessment of condom use (past 3 months) and the period of likely STD exposure, as emphasized by others (11, 17, 61). Finally, we were able to evaluate the association between condom use and risk of incident (rather than prevalent) infection. To our knowledge, this evaluation is among the first cohort studies to document that consistent use, in the absence of key problems with use, confers a strong protective effect against gonorrhea and chlamydia. An earlier follow-up study of STD clinic patients comparing case-crossover and cohort analyses (15) assessed breakage and slippage among consistent users but did not assess late application or early removal of condoms, thus likely missing the majority of problems during use. The ideal cohort study, which would assess the association between consistent use (in the absence of use problems) and risk of infection during the same time period as when STD exposure occurred, has yet to be conducted.

In summary, we found substantially reduced risk of gonorrhea and chlamydia among STD clinic patients who reported using condoms consistently, particularly those who did not experience problems using condoms. We also documented high levels of use problems, primarily from incorrect usage. Condom use for STD prevention may be more complex than has been portrayed in public health prevention messages that simply encourage the use of condoms. Although few intervention studies have specifically targeted problems with use, promoting condoms without paying adequate attention to the need for both consistent and correct use is likely to substantially undermine the public health benefit of this prevention strategy. We encourage other investigators to continue monitoring the occurrence of specific problems with condom use, not only to improve estimation of effectiveness but also to identify interventions to increase effective use by persons at risk for STD.


   ACKNOWLEDGMENTS
 
This project was funded by the Centers for Disease Control and Prevention, Atlanta, Georgia.

The authors thank Katherine Stone, Maria Gallo, Adrienne Hegarty, Kevin Malotte, Maurizio Macaluso, Peter Taylor, and Sam Posner for helpful suggestions provided on the text. They are grateful to the counselors and research and clinical staff in Baltimore, Denver, Long Beach, Newark, and San Francisco.

The following persons are members of the Project RESPECT Study Group: Baltimore, Maryland: Carolyn Erwin-Johnson, Andrew L. Lentz, Dr. Mary A. Staat, Dr. Dawn Sweet, and Dr. Jonathan M. Zenilman (Principal Investigator); Denver, Colorado: Dr. John M. Douglas (Principal Investigator), Dr. Tamara Hoxworth, Ken Miller, and Dr. William McGill; Long Beach, California: Dr. Ruth Bundy (co-Principal Investigator), Laura D'Anna, Dr. C. Kevin Malotte, and Dr. Fen Rhodes (Principal Investigator); Newark, New Jersey: Michael Iatesta, Eileen Napolitano (co-Principal Investigator), Judy Rogers, and Dr. Ken Spitalny (Principal Investigator); San Francisco, California: Dr. Gail A. Bolan (Principal Investigator), Coleen LeDrew, Kimberly A. J. Coleman, Luna Hananel, and Charlotte K. Kent; NOVA, Inc., Bethesda, Maryland: Dr. Robert Francis (Principal Investigator), Christopher Gordon, Nancy Rosenshine (Principal Investigator), and Carmita Signes; and Centers for Disease Control and Prevention, Atlanta, Georgia: Dr. Sevgi Aral, Dr. Robert H. Byers, Beth Dillon, Dr. Martin Fishbein, Dr. Sandra Graziano, Dr. Mary L. Kamb, Daniel Newman, Dr. Thomas A. Peterman, and Karen L. Willis.

The findings and conclusions in this article are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.

Conflict of interest: none declared.


   References
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 References
 

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T A Peterman, L H Tian, L Warner, C L Satterwhite, C A Metcalf, K C Malotte, S M Paul, J M Douglas Jr, and the RESPECT-2 Study Group
Condom use in the year following a sexually transmitted disease clinic visit
Int J STD AIDS, January 1, 2009; 20(1): 9 - 13.
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