Partner Impairment of Safe Sex Behavior by Women Participating in a Randomized, Controlled STD/HIV Prevention Trial Alan E. C. Holden Ph.D. Sondra T. Perdue Dr.PH. Rochelle N. Shain Ph.D. Jeffrey E. Korte Ph.D. Jeanna M. Piper M.D. Jane D. Champion Ph.D.

Project S.A.F.E. Randomized, controlled trialRandomized, controlled trial - behavioral/cognitive intervention to reduce STD recurrence STD recurrence - high-risk minority women (active STD) - San Antonio, Texas ( ) Significantly reduced STD reinfection at 6 and 12 months and cumulatively by reducing high-risk sexual behaviorSignificantly reduced STD reinfection at 6 and 12 months and cumulatively by reducing high-risk sexual behavior Shain et al. NEJM 1999; 340:93 andShain et al. NEJM 1999; 340:93 and Shain et al. STD 2002; 29:9Shain et al. STD 2002; 29:9

Procedure 477 Women with complete data477 Women with complete data Information about sexual partners (up to 5) at each time point (total 893 partners)Information about sexual partners (up to 5) at each time point (total 893 partners) We identified “Players”: men having sex with more than one participant in our study by matching his initials, age, ethnicity, & other characteristicsWe identified “Players”: men having sex with more than one participant in our study by matching his initials, age, ethnicity, & other characteristics Analysis: chi-square, logistic regressionAnalysis: chi-square, logistic regression “Players” is the term used in the community

Identification Procedure Results Of 893 reported sexual partners:Of 893 reported sexual partners: - 78 (“Players”) partnered with 2-4 women - appear 204 times in data set % of all men Remaining partners: 689 menRemaining partners: 689 men Of 477 women:Of 477 women: - 46 (9.2 %) partnered with Players

Characteristics of Players Compared to Other Partners 1 CharacteristicPlayersOthersP-Value Steady partner 20.5%53.8%<.01 Street drug use %34.8%<.01 Prior STD giver 46.2%20.5%<.01 Has other partners 66.7%17.8%<.01 Age > %38.6% %38.6%<.05 1 worst-case across multiple time points when applicable 2 excludes marijuana

Players vs. Others: Infection Rates During 1-Year Follow-Up OR = 3.23 (CI ) p <.01 Overall Infection Rate = 21.6 %

Unsafe Sex: Never uses condoms in casual sexNever uses condoms in casual sexand/or High number of unprotected actsHigh number of unprotected acts (5+ in last 3 months) coupled with problematic condom use

Problematic Condom Use: Condom use with: Incomplete coverage of the penisIncomplete coverage of the penis Condom slippageCondom slippage Condom breakageCondom breakage Other reported problemsOther reported problems (e.g. stuck inside her)

Unsafe vs. Safe Sex: Infection Rates During 1-Year Follow-Up OR = 3.44 (CI ) p <.01 Shain et al. STD 2002; 29:9

Players vs. Others: Unsafe Sex, No Condom Use, and Problematic Condom Use P <.02 P <.08 P <.01 Overall Unsafe SexNo CondomsProblematic Use n = 46 n = 431 n = 15 n = 208

Reasons Most Frequently Given by Women for No Condom Use Players Players 1.he said he was clean 14.4 % 2.she was drunk/high 9.1 % 3.he refused 7.2 % 4.he forced sex 4.6 % 5.he promised he 3.5 % would “pull out” Others unexpected coitus 18.5 % no condoms 15.2 % mutual trust 11.7 % she loves him 8.3 % erectile problems 2.6 %

Players vs. Others: Vulnerability to Male Control P =.07 P =.08 He has a lot of influence over me Usually have sex when disagree

Players vs. Others: Infection Rates among Women Practicing Unsafe and Safer Sex Unsafe Sex Safer Sex n = 24 n = 148 n = 22 n = 283 Mantel-Haenszel Common OR = 2.89, p <.01

WAS THERE AN INTERVENTION EFFECT?

Study vs. Control Women: Partnering with Players during One-Year Follow-Up OR = 0.61 (CI ) p =.034

Intervention Results: Women Infected with Gonorrhea and/or Chlamydia, 1-Year Follow-Up OR = 1.63 (CI ) p =.03 Shain et al. NEJM 1999; 340:93

Study vs. Control Women: Unsafe Sex when Partnered with Players and Others Study GroupControl Group n = 17 n = 232 n = 29 n = 199 Mantel-Haenszel Common OR = 2.89, p <.01

Study vs. Control Women: Reinfection during Follow-up when Partnered with Players and Others Study GroupControl Group n = 17 n = 232 n = 29 n = 199 Mantel-Haenszel Common OR = 1.52, p <.07

Conclusions: Women partnered with “Players” are:Women partnered with “Players” are: - less likely to practice safe sex: no condom use and/or incorrect condom use - more vulnerable to his influence and control Study women are less likely than Controls to be partnered to “Players” during one-year follow-upStudy women are less likely than Controls to be partnered to “Players” during one-year follow-up