Targeting Populations at Increased Infection Risk

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FHI's Quarterly Health Bulletin Network

Targeting Populations at Increased Infection Risk

Condom promotion remains an important HIV prevention measure.

Network: 2003, Vol. 22, No. 4

Copyright Family Health International, 2003.
Network is reprinted with permission from Family Health International.

Traditionally, efforts to prevent HIV infection by promoting condom use — as part of a comprehensive array of risk-reduction approaches — have targeted individuals at increased risk of infection. One such targeted population is sex workers based in brothel establishments, as well as those based in non-brothel establishments (where condom use often is low). The second is men, since they often make the final decisions on condom use in sexual relations.

Sex work in non-brothel establishments such as restaurants, bars, and massage parlors is so common in many settings that a variety of interventions are attempting to reach these populations with condom use messages. (Notably, while it is recognized that many social, cultural, and economic conditions foster commercial sex work, FHI and similar organizations are unable to eliminate these conditions. Rather, FHI intervenes to help such women protect themselves from acquiring or transmitting HIV/STIs and prevent unplanned pregnancy.)

A Dominican Republic condom promotion intervention highlighted in this issue (see Public Health Initiative Nearly Halves STI Rates) involves sex workers employed in both brothel and non-brothel establishments. Meanwhile, FHI is conducting an intervention targeting female employees of two Asian-based breweries who supplement their income with sex work.

"Female beer promoters, who serve beer to customers in restaurants, are paid little and are under constant pressure to either meet sales targets or lose income," says Michael Merrigan, senior program officer in FHI's Cambodia office. "They are in close contact with customers, and many supplement their meager income by having sex with customers after hours." To help these women protect themselves against HIV/STIs, FHI offers a comprehensive prevention approach that includes peer education, building relationships with establishment owners to facilitate women's access to HIV/STI education and services, STI services delivered at beer promoters' homes, as well as condom promotion.

FHI's work with female beer promoters is part of a larger program that regularly targets both brothel-based and non-brothel-based sex workers in Cambodia for HIV/STI outreach education. FHI's HIV/STI prevention and care activities with non-brothel-based sex workers also focus on women working in such establishments associated with commercial sex as karaoke beer gardens, massage parlors, and guest houses/hotels. FHI-supported interventions include outreach and peer education to provide information and behavior change messages about HIV/STI prevention, provision of and referral to STI treatment services, and condom promotion. And, as more sex workers have learned their HIV status, FHI has begun to address care, treatment, and support issues for this group.

Greater emphasis on men

Use of a wide array of HIV/STI prevention strategies holds the most promise for reducing the spread of these infections. FHI both promotes and implements what it calls an "ABC to Z" model: abstinence, be faithful to one partner, or — if "A" or "B" cannot be achieved — use condoms. These three strategies can be further complemented by a number of other effective HIV prevention approaches; that is, the "to Z" component of the "ABC to Z" model. (See The "ABC to Z" Approach.) Although condom use is an important element of this comprehensive approach, men often express a dislike for condoms and are particularly likely to abandon condom use with regular partners, whom they assume are not infected with HIV/STIs. In Thailand, young men are decreasing their patronage of brothel-based sex establishments,¹ but they are increasingly engaging in unprotected sexual relationships with female peers.² A 2001 study found that two-thirds of 5,646 young men inducted into the Royal Thai Army in May 1999 had sex with a girlfriend within the past year, but just 13 percent used a condom.³ Research also indicates that some young men continue to buy sex in informal venues while concurrently having unprotected sex with female peers.⁴ This puts their presumably low-risk, regular partners at high risk of infection.

The vulnerability to HIV infection of presumably low-risk individuals is also illustrated in a modeling exercise, conducted in Cambodia with assistance from FHI. In 2002, the Cambodia Working Group on HIV/AIDS Projection estimated that almost half of new infections in the country that year were transmitted between husbands and wives.⁵

Given that men often make the final decision on condom use in sexual relations, attempting to increase their condom use is a challenge that reproductive health workers continue to address.

In Harare, Zimbabwe, FHI re-searchers and in-country collaborators began to explore in 2002 whether partners of 344 women (who had been through a two-month condom promotion intervention) felt more comfortable learning about condom use in all-male group sessions or in couple sessions with their regular partners. Preliminary results from this randomized trial show that a similar and unexpectedly high proportion of men (about 40 percent) attended condom promotion sessions when invited, regardless of type of session.

"That level of male involvement is much higher than expected and is encouraging in terms of getting males involved in condom promotion activities via their regular partners," says Dr. Markus Steiner, an FHI senior epidemiologist who helped design the study. "We think our results show that, in a country like Zimbabwe where there is a very good existing family planning infrastructure, it is possible to get men more involved in a family planning setting."

Meanwhile, a review of operations research in 13 countries found that having men promote condoms through community-based distribution (CBD) programs can increase not only the total number of condoms that programs distribute, but also the number dispensed to male clients.⁶ The report highlighted research in Peru that found that male CBD workers with the Promoción de Labores Educativas y Asistenciales en Favor de la Salud (PROFAMILIA) CBD program in Lima sold twice as many condoms per month as did female CBD workers: a median of 49 condoms and 24 condoms per month, respectively. The Peruvian study found similar performance patterns among workers in the Centro NorPeruano de Capacitación y Promoción Familiar (CENPROF) CBD program in Trujillo,⁷ as did a 1995 study among CBD volunteers in the Kilifi district of Coast Province, Kenya. Fifteen male CBD volunteers in the Kilifi district each distributed approximately 9,550 condoms during the 18-month study period, while 15 female CBD volunteers in the same district each distributed approximately 3,523 condoms.⁸ Both studies adjusted for other factors that could influence worker performance, including education, occupation, marital status, training, length of time in the program, and CBD post location.

Having men promote condoms through CBD programs may require adjustments in attitudes, recruitment methods, and training schedules. The Peruvian study found that female program managers never fully accepted men in the CBD program and that, in spite of male CBD workers' high productivity, female managers continued to have doubts about the men's work. "Men have less free time to do the work," one manager observed. Another com-mented, "Men produce less." Such attitudes may have contributed to the fact that female CBD workers replaced male counterparts who left the program.⁹ Research in Tanzania found that men in some communities initially had reservations about male CBD workers distributing condoms and other contraceptives to their wives, although they changed their views after becoming more familiar with the program.¹⁰

While recruiting men into CBD programs can be difficult, research has found that CBD training curricula do not need to be markedly altered to accommodate male workers.¹¹ Only the timing of sessions may need to be changed. In Peru, both the PROFAMILIA and CENPROF CBD programs scheduled training on weekends to accommodate men's work schedules.¹²

Offering a choice

In the effort to encourage condom use among men, researchers are studying whether offering them a choice of male condoms increases rates of use and decreases STI rates. FHI researchers are conducting randomized controlled trials in Jamaica, Ghana, Kenya, and South Africa to explore this idea.¹³

In Kingston, Jamaica, FHI is studying condom preferences of 1,000 men attending the capital's largest STI clinic for treatment of urethral discharge. Half of the men will be offered only the standard condoms distributed at the clinic. The other group will be offered Rough Rider condoms, designed with ribbed "pleasure bumps"; Inspiral condoms, which have a loose-fitting shape to enhance sensation; standard condoms issued by the U.S. Agency for International Development (USAID); and standard clinic condoms. At study enrollment, the men are being screened and treated for gonorrhea, trichomoniasis, and chlamydial infection. Screening for these STIs will continue at regular intervals during this six-month study. Structured individual interviews are being conducted at each study visit to learn about condom use and selection. Data collection is expected to be complete in July 2004.

"If we find that providing a choice of condoms has no impact on self-reported use and STI incidence, then programs should just provide the least expensive condom available and not spend resources providing slightly more expensive condoms with fancy packaging or features to enhance pleasure, such as ribs or a looser fit," says FHI's Dr. Steiner, the study's principal investigator. "However, if we find that choice increases condom use and decreases STI rates, then providing a choice is an intervention that could be easily replicated elsewhere."

FHI's condom choice trials in Ghana, Kenya, and South Africa are similar to the trial in Jamaica, except that only self-reported condom use data are being collected. In all three sites, men assigned to a "choice" group are being given their selection of four condoms: Rough Rider, Inspiral, USAID-issued, or each country's socially marketed condom. Men in a "no-choice" group are being offered only the USAID condom.

The studies in Ghana and South Africa are yielding interesting early findings. FHI researchers have noted that study participants are selecting the Rough Rider as their first choice and the Inspiral and the socially marketed condoms as their second choices. "The interesting thing is that in both countries, the socially marketed condoms are essentially the same as the USAID condoms — they are just packaged differently," says Carol Joanis, an FHI associate director and the principal investigator of the studies in Ghana, Kenya, and South Africa. Joanis plans to conduct focus groups with study participants to find out reasons for their condom selections.

"We need to know why participants like particular condoms," Joanis says. "Do they prefer condom attributes, like the bumps and ridges? Are they attracted to a condom based on the way it was promoted? Or, do they simply like the color of the packaging?"

— Emily J. Smith

References

Nelson KE, Eiumtrakol S, Celentano DD, et al. HIV infection in young men in northern Thailand, 1991-1998: increasing role of injection drug use. J Acquir Immune Defic Syndr 2002;29(1):62-68; Nelson KE, Celentano DD, Eiumtrakol S, et al. Changes in sexual behavior and a decline in HIV infection among young men in Thailand. N Engl J Med 1996;335(5):297-303.
VanLandingham M, Trujillo L. Recent changes in heterosexual attitudes, norms and behaviors among unmarried Thai men: a qualitative analysis. Int Fam Plann Perspect 2002;28(1):6-15; Saengdidtha B, Ungchusak K. Sexual behaviours and sexually transmitted diseases among young Thai men in 1999. Venereology 2001;14(4):157-59.
Saengdidtha.
VanLandingham.
The Cambodia Working Group on HIV/AIDS Projection. Projections for HIV/AIDS in Cambodia: 2000-2010. Phnom Penh, Cambodia: National Center for HIV/AIDS, Dermatology and STDs, 2002.
Population Council. Program Brief No. 2. Using Men as Community-Based Distributors of Condoms. Washington, DC: Frontiers in Reproductive Health, Population Council, 2002.
Foreit JR, Garate MR, Brazzoduro A, et al. A comparison of the performance of male and female CBD distributors in Peru. Stud Fam Plann 1992;23(1):58-62; Population Council.
Family Planning Association of Kenya and Population Council/Africa OR/TA Project. Increasing Male Involvement in the Family Planning Association of Kenya (FPAK) Family Planning Program. Nairobi, Kenya: Population Council, 1995.
Foreit.
Chege J, Rutenberg N, Janowitz B, et al. Factors Affecting the Outputs and Costs of Community-Based Distribution of Family Planning Services in Tanzania. Nairobi, Kenya: Population Council, 1998; Population Council.
Family Planning Association of Kenya and Population Council/Africa OR/TA Project; Foreit.
Foreit.
Steiner M. Update — condom choice initiative. Annual meeting of the FHI Technical Advisory Committee, Contraceptive Technology and Family Planning Research, Chapel Hill, NC, May 2, 2002.

Campaigns with Uniformed Services Change Behaviors

In Thailand, HIV prevalence has declined markedly over the past decade. This has been attributed to various condom promotion campaigns, including a 100 percent condom use program implemented in 1991 that mandated consistent condom use in all brothels. The decline in HIV prevalence has been especially notable among Thai military inductees.¹ A 2002 study of some 7,000 men inducted into the Royal Thai Army found that HIV prevalence fell from 11 percent among those inducted in 1991 to 2 percent among those inducted in 1998.²

Although not uniform throughout the country, Thailand's 100 percent condom program generally enforces condom use by requiring that sex workers be examined monthly for sexually transmitted infections (STIs) and by gathering information about specific brothel use from men attending governmental clinics for STI treatment. Some brothels regularly associated with STIs have been closed.

In Cambodia, similar condom promotion campaigns — including a 100 percent condom use policy initiated in 1998 and expanded to all provinces in 2001 — also have been highly effective. A recent report issued by the Cambodia Working Group on HIV/AIDS Projection found that some 35,000 new HIV infections a year were due to sex work in the mid-1990s. In contrast, by 2002, fewer than 2,000 infections a year were attributable to sex work.³

HIV prevalence for Cambodian police — a traditionally high-risk population — has also decreased, dropping from 6 percent in 1998 to 3 percent in 2000, according to HIV Sentinel Surveillance (HSS) reports.⁴ And policemen's reported consistent condom use with sex workers rose from 65 percent to 85 percent between 1997 and 2001, according to Behavioral Surveillance Survey (BSS) data. Although HIV sentinel data for the Cambodian military — another traditionally high-risk population — has not been collected since 1997, BSS condom-use data showed that military personnel's reported consistent condom use with sex workers doubled from a traditional low of 43 percent in 1997 to 87 percent in 2001. During that same period, the percentage of military men reporting sex with female sex workers over the month before the survey decreased from 51 percent to 20 percent.⁵

"What Cambodia has done is remarkable," says Anthony Bennett, deputy director of the care and treatment division of FHI's Institute for HIV/AIDS and, between 1995 and 1998, senior technical officer in FHI's Asia regional office.

One factor that may be contributing to the rising rates of condom use within these populations is the implementation in 1998 of a uniformed services peer education program developed by FHI's Implementing AIDS Prevention and Care (IMPACT) project and conducted in collaboration with the Cambodian Ministry of National Defense, the Cambodian Ministry of the Interior, and the Cambodian Red Cross. The program is one of several that FHI is conducting with military and police in selected countries in Asia and Africa to help them integrate HIV/AIDS prevention activities into their systems. As part of a comprehensive approach to HIV/STI prevention, the program provides STI services and counseling and addresses various high-risk behaviors such as substance abuse. (Recognizing that use of various, mutually reinforcing techniques holds the most promise for reducing the spread of HIV/STIs, FHI both promotes and implements what it calls an "ABC to Z" model: abstinence, be faithful to one partner, or — if "A" or "B" cannot be achieved — use condoms. These three strategies can be further complemented by a number of other effective HIV prevention approaches; that is, the "to Z" component of the "ABC to Z" model. [See The "ABC to Z" Approach.])

"An estimated 78 percent or more of Cambodia's military and 23 percent of the country's police will have been reached with condom promotion and other HIV prevention messages by the end of 2003," says Michael Merrigan, senior program officer in FHI's Cambodia office. "Peer education networks are now operating in four out of five Cambodian military regions."

Condoms are promoted in a number of ways:

Remote military bases have FHI-supplied condom boxes that men can access confidentially.

Peer educators demonstrate correct condom use with penis models.

Peer educators counsel that condom use is one of many HIV risk-reduction strategies. Other counseling messages are that peers should reduce their number of sexual partners and avoid heavy alcohol consumption or social situations that could lead to use of commercial sex establishments.

Peer educators emphasize that using condoms can help one protect oneself and one's family from HIV infection.

Peer education drama teams promote condoms during theatrical productions.

"During conversations with servicemen, peer educators also try to address and correct the many common misconceptions about condoms and HIV infection that exist," Merrigan says.

— Emily J. Smith
References

Nelson KE, Celentano DD, Eiumtrakol S, et al. Changes in sexual behavior and a decline in HIV infection among young men in Thailand. N Engl J Med 1996;335(5):297-303; Celentano DD, Nelson KE, Lyles CM, et al. Decreasing incidence of HIV and sexually transmitted diseases in young Thai men: evidence for success of the HIV/AIDS control and prevention program. AIDS 1998;12(5):F29-F36.
Nelson KE, Eiumtrakol S, Celentano DD, et al. HIV infection in young men in northern Thailand, 1991-1998: increasing role of injection drug use. J Acquir Immune Defic Syndr 2002;29(1):62-68.
The Cambodia Working Group on HIV/AIDS Projection. Projections for HIV/AIDS in Cambodia: 2000-2010. Phnom Penh, Cambodia: National Center for HIV/AIDS, Dermatology and STDs, 2002.
Ministry of Health. National Center for HIV/AIDS, Dermatology and STDs. Report on HIV Sentinel Surveillance in Cambodia. Phnom Penh, Cambodia: Ministry of Health. National Center for HIV/AIDS, Dermatology and STDs, 2000.
Sopheab H, Gorbach P, Bunleng H. Cambodia's Behavioral Surveillance Survey, 1997-1999 (BSS I-III). Phnom Penh, Cambodia: National Center for HIV/AIDS, Dermatology and STDs; Ministry of Health, Cambodia; San Diego State University/Family Health International, 2001; National Center for HIV/AIDS, Dermatology and STDs. Behavioral Surveillance Survey 2001, Cambodia. Phnom Penh, Cambodia: National Center for HIV/AIDS, Dermatology and STDs, in press.

Public Health Initiative Nearly Halves STI Rates

A 40 percent decline in rates of sexually transmitted infections (STIs) occurred among a sample of 400 female sex workers who participated in a recent initiative to promote 100 percent condom use in 68 commercial sex establishments in two Dominican Republic cities.

Conducted over a year, the initiative — supported by the Horizons Program of the Population Council, the Johns Hopkins School of Public Health, and the AcciónSIDA project of the Academy for Educational Development (AED) — involved two condom promotion approaches. The first, carried out at 34 sex establishments in Santo Domingo, encouraged solidarity among female sex workers, sex establishment owners and managers, and other employees (such as disc jockeys, bartenders, and doormen) to commit to consistent condom use in the establishments. The second approach, carried out at 34 sex establishments in Puerto Plata, was similar but also applied a regional governmental 100 percent condom use policy and a graduated sanction system directed at sex establishment owners. Both approaches were conducted not only in brothels, but also in other establishments (such as bars and discos) where sex work may occur.

STI data collected among 200 sex workers at each site before and immediately after the interventions showed at both sites comparable declines in the prevalence of one or more of three STIs (chlamydial infection, gonorrhea, and trichomoniasis). In Santo Domingo, rates declined from 25 percent to 16 percent, while those in Puerto Plata declined slightly more, from 29 percent to 16 percent.

The initiative measured condom use with new clients and with regular paying and regular nonpaying partners at both sites. Self-reported consistent condom use increased significantly in both cities. Notably, consistent condom use with new clients increased from 75 percent to 94 percent in Santo Domingo, while in Puerto Plata it more than doubled (from 13 percent to 29 percent) with regular paying and regular nonpaying partners. Additionally, observed rates of sex workers' verbal rejection of unsafe sex with clients increased significantly (from 50 percent to 80 percent) in Puerto Plata only.

"The combined community-based solidarity/governmental policy and sanction model implemented in Puerto Plata produced much higher rates of compliance with key intervention components than the solidarity-only model implemented in Santo Domingo," says Dr. Deanna Kerrigan, assistant research professor with Johns Hopkins University's Department of International Health in Baltimore, MD, USA, and a principal investigator in the study. "However, given that relatively few sanctions were levied during the intervention in Puerto Plata, the governmental policy and perhaps the threat of sanctions — rather than sanctions themselves — appear to have made this critical difference."

Creating a norm and a governmental policy endorsing consistent condom use, Dr. Kerrigan says, involved fostering relationships among members of three key groups:

Community members, including sex workers, owners, managers, and other employees of female commercial sex establishments;

Governmental employees, such as health inspectors, STI clinic physicians, and policy-makers affiliated with the country's national HIV/AIDS/STI control program and regional health departments; and

Nongovernmental organizations such as the Centro de Promoción y Solidaridad Humana (CEPROSH) in Puerto Plata and Centro de Orientación e Investigación Integral (COIN) in Santo Domingo, both of which have conducted peer education and HIV prevention activities with sex workers in the country for more than 15 years. The national organization of sex workers, Movimiento de Mujeres Unidas-MODEMU, also participated.

The forging of such alliances generated innovative collaborations that allowed for a more comprehensive approach to HIV/STI prevention. In the case of sex workers, a comprehensive approach and messages centered around condom use, STI services, and creating an environment that encouraged safe sex practices. As part of the Dominican Republic initiative, sex worker peer educators provided counseling before and after STI testing at governmental STI clinics. Governmental health inspectors and employees of the nongovernmental organizations visited sex establishments to reinforce the importance of complying with monthly STI exams. Non-governmental employees collaborated with sex worker peer educators to train governmental health inspectors and STI clinic physicians to provide guidance on improving sex workers' health care service quality.

Educational materials geared toward female sex workers, sex establishment owners and managers, employees, and clients were also developed. Solidarity among these groups was nurtured during workshops that stressed that condom use is a team effort. These activities resulted in such changes as disc jockeys routinely promoting condoms over public announcement systems at participating sex establishments in both sites.

Participatory workshops gave sex workers an opportunity to role-play how to negotiate condom use with different types of sexual partners. They focused on sex workers' condom use with both regular paying and regular nonpaying partners, with whom condom use in the Dominican Republic has been observed to be much lower than with new clients.¹ Such efforts seek to develop a norm of safer sex among a critically important group at risk for HIV/STIs.

— Emily J. Smith

Reference

Kerrigan D, Moreno L, Rosario S, et al. Adapting the Thai 100% condom programme: developing a culturally appropriate model for the Dominican Republic. Cult Health Sex 2001;3(2):221-40; Kerrigan D, Moreno L, Rosario S, et al. The impact of two 100% condom use models in reducing HIV-related risk among female sex workers in the Dominican Republic. Unpublished paper. Horizons Program, 2002. Available online; Kerrigan D, Ellen JM, Moreno L, et al. Environmental-structural factors significantly associated with consistent condom use among female sex workers in the Dominican Republic. AIDS 2003;17(3):415-23.

Measuring Condom Use Better

Among sexually active individuals at risk for HIV infection, consistent and correct condom use remains the best protection against HIV. Because some people who report that they use condoms consistently still become infected with HIV,¹ doubts have been raised about condom effectiveness. But growing awareness that self-reports of consistent condom use may be inaccurate has led researchers to seek ways to measure more accurately the consistency of condom use.

"Research documenting transmission of HIV/STIs among individuals self-reporting consistent condom use has cast doubt on the inherent effectiveness of condoms among some people," says Dr. Markus Steiner, an FHI senior epidemiologist and coauthor of a recent editorial on the subject of measuring condom efficacy.² "Instead, it should prompt recognition of the difficulty of determining true consistency of condom use." Furthermore, Dr. Steiner and his coauthors emphasize, the misdirected debate over condom effectiveness can undermine overall condom use because potential users may lose confidence in the method.

Scientists have increasingly questioned the validity of self-reported consistent condom use.³ Individuals queried about condom use may fail to fully understand interviewers' questions. They may be unable to recall whether they always used condoms. Most importantly, wishing to please interviewers, they may change their answers to ones they perceive as being more acceptable.

"There is a lot of bias in self-reports of condom use, but researchers can also do a lot to reduce that bias," notes Dr. Cynthia Waszak Geary, an FHI senior scientist who has researched ways of increasing the validity of data on self-reported condom use.

Asking more focused questions can reduce some reporting bias, Dr. Waszak says, as can "creating a bias toward telling the truth. This can be done by explaining to study participants that it is more important that the researchers know the truth about condom use than it is for researchers to know that participants have used condoms all the time. Respectful interviewers may also be more likely to gather unbiased information."

The question of whether self-reports of condom use are valid has implications for providers: Clients who say they use condoms consistently may, for a variety of reasons, exaggerate their condom use. Also, providers wishing to promote honest dialogue with clients about condom use should remain nonjudgmental.

Other condom use measures

Seeking more reliable ways to measure the consistency of condom use, FHI researchers have begun to study the use of biological markers of semen exposure in the vagina.

Cervical and vaginal swab samples are being collected from approximately 400 sex workers in Madagascar who are participating in an FHI study comparing two condom promotion initiatives. The samples will be examined in U.S. laboratories for prostate-specific antigen (an antibody found in semen) and Y chromosomes (normally found only in men, but present in women exposed to semen). Lab results will be compared with self-reports of condom use. Detection of prostate-specific antigen (possible from 24 to 48 hours after exposure to semen, depending upon semen quantity) or Y chromosome fragments (possible up to 14 days after exposure) would indicate either condom failure (breakage or slippage) or condom non-use. While exposure to semen sometimes occurs because condoms break, slip, or are used incorrectly, most exposure is due to condom non-use.⁴

"Biological markers of semen exposure may provide an alternative for measuring condom use and supply evidence for assessing the validity of traditional condom use measurements," says María Gallo, an FHI research associate who is coordinating this biological marker investigation, which should yield results in 2004.⁵ Similar FHI research initiatives using biological markers will begin this year in Tanzania and Kenya.

– Emily J. Smith

References

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 Hum Retrovirol 1993;6(5):497-502.
Steiner M, Feldblum P, Padian N. Invited commentary: condom effectiveness – will prostate-specific antigen shed new light on this perplexing problem? Am J Epidemiol 2003;157(4):298-300.
Weir S, Roddy R, Zekeng L, et al. Association between condom use and HIV infection: a randomized study of self reported condom use measures. J Epidemiol Community Health 1999;53(7):417-22.
Steiner MJ, Cates W Jr, Warner L. The real problem with male condoms is nonuse. Sex Transm Dis 1999;26(8):459-62.
Macaluso M, Lawson L, Akers R, et al. Prostate-specific antigen in vaginal fluid as a biologic marker of condom failure. Contraception 1999;59(3):195-201; Lawson L, Macaluso M, Bloom A, et al. Objective markers of condom failure. Sex Transm Dis 1998;25(8):427-32.

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