Male-condom and female-condom use among women after counseling in a risk-reduction hierarchy for STD prevention

Background: A concern with hierarchy messages, which promote male condoms and female-controlled barrier methods along a prevention continuum, is that they may discourage condom use. Goal: To measure male-condom and female-condom use among women who received hierarchy counseling and compare this with women counseled about condoms only, Study Design: Three observational cohorts that correspond to prevention message received were assembled, and consisted of female sexually transmitted disease clinic patients who were counseled about male condoms, female condoms, or a hierarchy message. The hierarchy message promoted male and female condoms, the diaphragm and cervical cap, spermicides, and withdrawal, in descending order of effectiveness against sexually transmitted diseases. After counseling, women were interviewed and returned for follow-up visits at 2 weeks, 4 months, and 6 months. The outcome was the mean proportion of male condom- or female condom-protected coital acts at each follow-up visit in the hierarchy cohort. The outcome was dichotomized as high (greater than or equal to 70% of coital acts protected) or low (< 70%), and generalized estimating equations were used to compare observed follow-up condom use with baseline within the hierarchy cohort and observed follow-up condom use between cohorts. It was assumed that condom use in persons not present at 6 months was equal to baseline levels, and condom use estimates were calculated for each full cohort that was initially enrolled. Results: The mean proportion of condom-protected coital acts in the hierarchy cohort was significantly increased from baseline at each follow-up visit. There were no differences in observed condom use during follow up between the hierarchy cohort and either the male-condom or the female-condom cohort. However, when the full cohort initially enrolled was considered, 6-month condom use was significantly higher in the hierarchy cohort than in the male-condom cohort. Conclusion: Hierarchy counseling was associated with a significant increase in condom use. Our findings suggest that offering a choice of male and female condoms results in increased protection over counseling in male condoms alone.