Delayed Application of Condoms Is a Risk Factor for Human Immunodeficiency Virus Infection Among Homosexual and Bisexual Men

The incidence of HIV infection increased among homosexual and bisexual men in Ontario, Canada, during 1998-2001. The authors analyzed a subsample of 183 men (62 cases and 121 controls) enrolled in the Polaris HIV Seroconversion Study as of June 2001. Cases were defined as HIV-antibody-positive men with documented recent infection (within one year of enrollment). Controls must have had evidence of an HIV-antibody-negative test within six months of enrollment. Controls and cases were matched by gender, exposure category, and geographic region.

Focusing on sexual behaviors with HIV-positive partners or partners with unknown HIV status, the authors used multiple logistic regression to identify independent risk factors including receptive anal sex without condoms, condom failure, and delayed application of condoms during receptive anal sex.

There were no significant differences among the men in terms of sexual orientation, age, education, race, region in Ontario, or HIV testing history, the study reports. Cases and controls were equally likely to have regular partners, but cases were less likely than controls to report having HIV-negative partners.

Forty-one percent of cases and 19 percent of controls reported having insertive anal sex without condoms, but an additional 15 percent of cases and 7 percent of controls reported either condom failure, delayed application, or premature removal of condoms during this activity. Fifty-three percent and 14 percent of cases and controls, respectively, reported receptive anal sex without condoms, while 12 percent of cases and 4 percent of controls reported some type of imperfect condom use for this activity.

The investigators were not surprised to find unprotected receptive anal sex to be a risk factor in contracting HIV. "However," they wrote, "we are not aware of any previous studies that examined delayed condom use in the risk of HIV infection. Our analysis found a strong association. The delayed application of condoms may result in exposure to urethral secretions or preejaculatory fluid, both of which have been shown to harbor HIV."

Interviews with 17 of the men in the study elicited that the men delayed condom use because of several factors: having sex "in the heat of the moment," especially under the influence of alcohol or drugs; the perception that preejaculatory fluid poses little risk; and the perception that early penetration poses no risk since rectal trauma is necessary for HIV transmission.

"Now more than ever," the authors concluded, "there is a need to understand why the message of using condoms for anal sex, which had been relatively successful, seems to be becoming less effective. Although the quantification of attributable risk confirmed that the majority of HIV infections among homosexual men are still due to receptive anal sex without the use of a condom, delayed application of condoms and condom failure during receptive anal sex also appear to play important roles. In particular, our study demonstrated that a considerable proportion of homosexual men do not apply the condom prior to penetration and that this practice results in HIV transmission. ... Preventive counseling must continue to focus on ensuring that condoms are always used for anal sex, but it must also emphasize the potential risks of exposure to preejaculatory fluid and reinforce the importance of applying the condom before any penetration."

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