HIV prevention heuristics and condom use among African-Americans at risk for HIV.

The goal of this study was to improve understanding of whether incorrect HIV/AIDS heuristics and characteristics-based risk theories are barriers to HIV prevention among young African-Americans at increased risk for HIV. We explored: (1) the beliefs of men and women regarding disease prevention strategies, and (2) the relationship of such beliefs to safer sexual behaviours. In Phase I, semistructured individual interviews were conducted with both members of 22 heterosexual couples at increased risk for HIV/STIs. Subsequently, in Phase II, structured individual interviews were conducted with another 40 women and 40 men (not couples). Participants in Phase I reported use of condoms and monogamy as major strategies for disease prevention. The beliefs that were endorsed by the largest percentage of Phase II participants were related to the 'known partners are safe partners' and 'trusted partners are safe partners' heuristics. Moreover, stronger endorsement of the 'known partners' heuristic was negatively associated with measures of condom use and pregnancy prevention behaviour. Our findings highlight the need for interventions and programmes to encourage intimate partners to consistently use condoms until both members of the dyad are tested and agree to mutual monogamy.

Choice of and satisfaction with methods of medical and surgical abortion among U.S. clinic patients.

CONTEXT: Abortion induced by drugs is now a viable alternative to surgically induced abortion for U. S. women. Women's willingness to use these new methods of medical abortion hinges on the extent to which they prove acceptable, however. METHODS: Among 304 women participating in a clinical trial of medical abortion, 186 received a methotrexate-induced abortion and 118 were offered the option of a medical abortion but chose a surgical procedure instead. Study participants completed self-administered questionnaires before the abortion and again at a follow-up visit. RESULTS: Women in the medical and surgical abortion groups did not differ significantly with regard to demographic and other background characteristics: Their mean age was about 27, more than two-thirds were white, and three-quarters were unmarried and worked either part-time or full-time. However, women's ratings of seven attributes of abortion methods were significant predictors of choosing a medical abortion: Women were more likely to choose medical abortion if they placed greater importance on a method that was nonsurgical, one that resembled a miscarriage or one that could take place at home (odds ratios, 2.0-3.3). Conversely, women were less likely to choose medical abortion if they valued methods that were quick, that did not involve painful cramping or seeing blood or blood clots and that needed a doctor or nurse to be present (odds ratios, 0.3-0.5). Compared with those who had a surgical abortion, women who had a methotrexate-induced abortion expected more bleeding (mean scores, 3.5 vs. 3. 1) and reported more pain (3.4 vs. 2.9), heavier bleeding (3.4 vs. 2.5) and bleeding of longer duration (3.3 vs. 2.6). The overwhelming majority of women in the medical and surgical abortion groups reported that they were either very or somewhat satisfied with their abortion method (81% and 82%, respectively), would recommend it to others (82% and 78%) and would choose the method again (89% and 93%). CONCLUSIONS: Factors affecting the choice of abortion method appear to be numerous and complex. Providers need to be sensitive to differences in women's values and life circumstances when counseling them about an abortion method. In particular, providers should incorporate into their counseling sessions what women need to know about the characteristics of abortion methods and help women to identify what is the best option for them.

Emergency contraception: knowledge and attitudes of health care providers in a health maintenance organization.

One hundred sixty-four health care providers in a health maintenance organization were surveyed in 1996 regarding their knowledge of, attitudes toward, and perception of barriers regarding emergency contraceptive pills (ECPs), as well as their ECP prescribing practices. Providers reported primarily positive attitudes regarding ECPs. Only 42% reported having ever prescribed ECPs; those who had prescribed had more positive attitudes about ECPs. Knowledge of ECP provision was incomplete, with 40% believing treatment had to be initiated in 48 hours or less. Barriers identified by providers included lack of a dedicated product, lack of awareness of ECPs among providers, and liability issues.

Comparing the acceptability of manual vacuum aspiration and electric vacuum aspiration as methods of early abortion.

OBJECTIVE: to compare the acceptability of manual vacuum aspiration (MVA) and electric vacuum aspiration (EVA) as methods of early (< or = 77 days' gestation) abortion. METHODS: We interviewed 42 women who had been randomly assigned to either MVA or EVA and compared their perceptions of the two procedures. RESULTS: The experiences and perceptions of women in the two groups were similar in many ways. The majority of women in both procedure groups were very satisfied with the method used, and most indicated that they would prefer the same method if they were to have another abortion. CONCLUSION: This study found no major differences in the acceptability of MVA and EVA among women undergoing early abortions.

Changes in providers' views and practices about emergency contraception with education.

OBJECTIVE: To assess changes in the prescribing practices, knowledge, attitudes, and perceptions of health care providers after an educational program about emergency contraception. METHODS: Health care providers completed self-administered questionnaires before and 1 year after full implementation of the project. The 102 providers who completed both questionnaires were physicians (64%) and mid-level professionals from 13 San Diego County Kaiser Permanente medical offices working in departments such as obstetrics and gynecology, primary care, and emergency medicine. RESULTS: The frequency of prescription for emergency contraceptive pills increased significantly from baseline to follow-up. There was an increase of almost 20% in the percentage who prescribed emergency contraception at least once a year. Knowledge also improved significantly, and perceptions of barriers to prescribing emergency contraceptive pills within the health maintenance organization decreased significantly. In contrast, attitudes about emergency contraception showed little change. CONCLUSION: This study suggests that providers who participate in in-service training and other aspects of a demonstration project show changes in perceptions, knowledge, and behavior. However, findings also suggest that significant gaps remain in knowledge about medications, side effects, and mode of action. It is likely that many providers in other health care settings also need additional information and training concerning protocols of emergency contraception provision and its modes of action and effects.

A magnetic field exposure facility for evaluation of animal carcinogenicity.

Several animal studies have been carried out at the Institut Armand Frappier (IAF) to determine whether chronic exposure to 60 Hz linearly polarized sinusoidal magnetic fields might increase the risk of cancer development of female Fisher rats. The magnetic field exposure facility was developed to meet the requirements of the study protocol for chronic exposure of large number of animals to field intensities of sham < 0.2 microT, 2 microT, 20 microT, 200 microT, and 2000 microT. At each exposure level, including sham, the animals are distributed in a group of four exposure units. Each exposure unit contains two exposure volumes having uniform distribution of magnetic fields for the animals, while the magnetic field external to the unit falls off rapidly due to the "figure-eight" coil topography used. A program of "shake down" tests, followed by verification and calibration of the exposure facility, was carried out prior to starting the animal experiments. Continuous monitoring of the magnetic field and other environmental parameters was an important part in the overall quality assurance program adopted.

Experiences and satisfaction with providing methotrexate-induced abortions among US providers.

OBJECTIVE: This study examined the acceptability of and experiences with methotrexate as an abortifacient among health care providers in the United States. METHODS: Seventy-six telephone interviews were conducted with providers (28% physicians, 13% midlevel providers, 29% administrators, and 30% counselors/other medical staff) of methotrexate-induced abortions during May and June of 1997. We examined provider satisfaction and several key operational issues relative to medical abortion, including: time spent with patients and staffing, training, and space needs. RESULTS: The majority of providers agreed that overall, more time was spent with methotrexate than with surgical abortion patients. Most agreed that the number of staff needed was the same for both methods, and that methotrexate required less office space. There were differing views on whether methotrexate required more, an equal amount of, or less training than surgical. Overall, providers were satisfied with methotrexate as an abortifacient. CONCLUSION: These data suggest that as knowledge of the method spreads, more providers will add this technique to their services.

Acceptability of suction curettage and mifepristone abortion in the United States: a prospective comparison study.

OBJECTIVE: We sought to compare the acceptability of suction curettage abortion with that of medical abortion with mifepristone and misoprostol in American women. STUDY DESIGN: We performed a prospective, serially enrolled, cohort analysis. The study population consisted of 152 subjects receiving mifepristone and misoprostol and 174 subjects undergoing suction curettage abortion aged > or =18 years with intrauterine pregnancies of up to 63 days' estimated gestation. Questionnaires regarding expectations and experiences were administered before the abortion and at the 2-week follow-up visit. RESULTS: Subjects undergoing medical abortions reported significantly greater satisfaction than those undergoing surgical abortions (mean rank, 121 vs 149; P <.01) but were no more likely to recommend the method they had just experienced to a friend (97% vs 93.3%). If a future abortion was required, however, 41.7% of subjects undergoing surgical abortions indicated they would opt for a medical abortion, whereas only 8.6% of subjects receiving medical abortions would choose a surgical abortion (P <.001). Failure of the abortion decreased satisfaction in the medical group and increased the likelihood of choosing a surgical abortion for a subsequent procedure (P <.001). Surgical subjects who experienced more anxiety than expected during the abortion were more likely to choose a medical procedure for a subsequent abortion (P <.01). CONCLUSION: Women receiving mifepristone and misoprostol were more satisfied with their method and more likely to choose the same method again than were subjects undergoing surgical abortion. Failure of a medical abortion and increased anxiety during surgical abortion were associated with preference for the alternative technique in a future procedure.

Beyond marital status: relationship type and duration and the risk of low birth weight.

CONTEXT: Unmarried women have higher rates of low birth weight than married women. However, assumptions that unmarried women are uniformly at a disadvantage may be unfounded. A woman's relationship characteristics may be more relevant for infant health than her formal marital status. METHODOLOGY: Data from the 1995 National Survey of Family Growth were used to analyze associations between relationship characteristics and low birth weight among U.S. women aged 15-44 with a recent singleton live birth. Unadjusted odds ratios were generated to indicate the crude effects of independent variables, including relationship type and relationship duration at the time of conception. Multiple logistic regressions were performed to assess the impact of relationship variables on the likelihood of low birth weight, taking into account the effects of other covariates. RESULTS: In multivariate models of all women and non-Hispanic black women, relationship type and duration were not associated with low birth weight. However, low birth weight was almost six times as likely among Hispanic women in nonmarital, noncohabiting relationships as among those who were married. Surprisingly, among non-Hispanic white women, low birth weight was less likely among those in nonmarital, noncohabiting relationships than among those who were married. Unexpected associations also were found among low birth weight, race and ethnicity, and relationship duration: Low birth weight was more likely among non-Hispanic white women in relationships of from five to 10 years in length than among those in relationships of longer than 10 years and less likely among Hispanic women in relationships of one year or less than among those in a relationship for more than 10 years. CONCLUSION: Although unmarried women in the United States have higher rates of low birth weight than married women, many unmarried women are at no greater risk of low birth weight than their married counterparts. The findings confirm the need to consider the characteristics of relationships when examining the association of mother's "union status" and birth outcomes.

Nitrogen cycling and community structure of proteobacterial beta-subgroup ammonia-oxidizing bacteria within polluted marine fish farm sediments.

A multidisciplinary approach was used to study the effects of pollution from a marine fish farm on nitrification rates and on the community structure of ammonia-oxidizing bacteria in the underlying sediment. Organic content, ammonium concentrations, nitrification rates, and ammonia oxidizer most-probable-number counts were determined in samples of sediment collected from beneath a fish cage and on a transect at 20 and 40 m from the cage. The data suggest that nitrogen cycling was significantly disrupted directly beneath the fish cage, with inhibition of nitrification and denitrification. Although visual examination indicated some slight changes in sediment appearance at 20 m, all other measurements were similar to those obtained at 40 m, where the sediment was considered pristine. The community structures of proteobacterial beta-subgroup ammonia-oxidizing bacteria at the sampling sites were compared by PCR amplification of 16S ribosomal DNA (rDNA), using primers which target this group. PCR products were analyzed by denaturing gradient gel electrophoresis (DGGE) and with oligonucleotide hybridization probes specific for different ammonia oxidizers. A DGGE doublet observed in PCR products from the highly polluted fish cage sediment sample was present at a lower intensity in the 20-m sample but was absent from the pristine 40-m sample station. Band migration, hybridization, and sequencing demonstrated that the doublet corresponded to a marine Nitrosomonas group which was originally observed in 16S rDNA clone libraries prepared from the same sediment samples but with different PCR primers. Our data suggest that this novel Nitrosomonas subgroup was selected for within polluted fish farm sediments and that the relative abundance of this group was influenced by the extent of pollution.

Women's experience and satisfaction with emergency contraception.

CONTEXT: If any new contraceptive technology is to become a viable option for decreasing unintended pregnancies, women must be willing to use the method and find it acceptable. However, because emergency contraceptive pills have not been widely used, very little is known about this method's acceptability. METHODS: Telephone interviews were conducted with 235 women who had received emergency contraceptive pills through a demonstration project at 13 Kaiser Permanente medical offices in San Diego to assess women's experience and satisfaction with the pills. RESULTS: More than two-thirds of the women (70%) were using a contraceptive method prior to their need for emergency contraception, and 73% of these users were relying on condoms. When asked about the situation that led to unprotected intercourse, 45% reported that their condom broke or slipped, while 23% said they had had unplanned sex. More than three-quarters of the sample (81%) experienced at least one side effect. The overwhelming majority were satisfied with emergency contraceptive pills (91%) and would recommend them to friends and family members (97%). Just one-quarter of the sample (28%) believed that emergency contraceptive pills should be dispensed over the counter, and an even lower proportion agreed that they should be available from vending machines (6%). CONCLUSIONS: Because women were overwhelmingly accepting of emergency contraceptive pills, found them easy to use and did not intend to substitute them for regular contraceptive use, this new method is an important addition to the contraceptive options available to women, providing a way to prevent pregnancy after unprotected intercourse or method failure.

PIP: This study examines the experiences and satisfaction of using emergency contraceptive pills in preventing unintended pregnancy among women in the US. The data used were collected through telephone interviews with 235 women aged 18-48 years receiving emergency contraceptive pills through a demonstration project at 13 Kaiser Permanente medical offices in San Diego. The results of the study revealed that 70% of the women were using contraceptive method prior to their use of emergency contraceptive pills. Moreover, the situation that led them to use emergency contraceptive pills was due to contraceptive failure particularly condom failure. Despite an 81% statistics of women experiencing side effects, 91% were satisfied with emergency contraceptive pills and would recommend them to friends and family members. Only 28% agreed that emergency contraceptive pills should be made available over the counter, and 6% from vending machines. Therefore, this method is an important addition to the contraceptive options among women during unprotected sexual intercourse or method failure.

Emergency contraception: preliminary report of a demonstration and evaluation project.

Kaiser Permanente Southern California and the Pacific Institute for Women's Health began a demonstration and evaluation project on emergency contraceptive pills (ECPs) in the summer of 1996 with the goal of evaluating the feasibility and acceptability of ECPs in a large health maintenance organization and developing institutional templates, provider training and patient education materials that could be used to replicate the project. The ECP program had six components: repackaging of oral contraceptives in an ECP "kit," development of provider education materials, development of patient education materials, in-service training, making ECPs kits available in convenient locations, and development of materials to support replication of the project inside and outside Kaiser Permanente. Although data are still being analyzed, preliminary results are promising. The success of the project within this relatively conservative, but well-established medical care organization provides a model for others. The development of a standard set of educational materials and approaches to implementation should facilitate dispensing ECPs in other settings.

Emergency contraceptive pills: an exploratory study of knowledge and perceptions among Mexican women from both sides of the border.

A focus group study was conducted to explore what Mexican women from both sides of the US-Mexican border do to prevent pregnancy after unprotected intercourse, including their use of emergency contraceptive pills (ECPs); to examine their knowledge and perceptions of ECPs; and to explore what might influence Mexican women's use of ECPs. Eight focus groups (four in Mexico and four in California) were conducted with 55 sexually active Mexican women age 18 to 34. The women discussed a variety of postcoital methods intended to prevent pregnancy including herbs and injections. Although a third of the women had heard of ECPs, their knowledge was very limited. After being informed about the characteristics of ECPs, participants had many positive comments, preferring them to unplanned pregnancies and abortions. A major topic was whether or not ECPs are abortifacients. Having information about ECPs, a woman's personal circumstances, interpersonal factors, and the role of culture and religion were factors they thought would influence a woman's use of ECPs. After the focus group discussions, 95% of the women said they would use ECPs. Mexican women's acceptance and use of ECPs will likely depend on a host of factors within the broader context of their lives.

Risk factors for rifampin mono-resistant tuberculosis.

Use of rifampin is required for short-course treatment regimens for tuberculosis. Tuberculosis caused by isolates of M. tuberculosis with resistance to rifampin and susceptibility to isoniazid is unusual, but it has been recognized through surveillance. Patients with tuberculosis (cases) with rifampin mono-resistance were compared with HIV-matched controls with tuberculosis caused by a drug-susceptible isolate. A total of 77 cases of rifampin mono-resistant tuberculosis were identified in this multicenter study. Three were determined to be laboratory contaminants, and 10 cases had an epidemiologic link to a case with rifampin mono-resistant tuberculosis, suggesting primary acquisition of rifampin-resistant isolates. Of the remaining 64 cases and 126 controls, there was no difference between cases and controls with regard to age, sex, race, foreign birth, homelessness, or history of incarceration. Cases were more likely to have a history of prior tuberculosis than were controls. Of the 38 cases and 74 controls with HIV infection, there was no difference between cases and controls with regard to age, sex, race, foreign birth, homelessness, history of incarceration, or prior tuberculosis. Cases were more likely to have histories of diarrhea, rifabutin use, or antifungal therapy. Laboratory analysis of available isolates showed that there was no evidence of spread of a single clone of M. tuberculosis. Further studies are needed to identify the causes of the development of rifampin resistance in HIV-infected persons with tuberculosis and to develop strategies to prevent its emergence.

Comparisons of cost and accuracy of DNA probe test and culture for the detection of Neisseria gonorrhoeae in patients attending public sexually transmitted disease clinics in Los Angeles County.

BACKGROUND: Strict handling and transport requirements for the successful use of culture in the detection of Neisseria gonorrhoeae warrant investigation of accurate and cost-effective test alternatives such as the Gen-Probe PACE 2 DNA probe assay (Gen-Probe, Inc., San Diego, CA). STUDY DESIGN: The Gen-Probe PACE 2 DNA probe assay for N. gonorrhoeae was compared with conventional culture methods in the principal Los Angeles County (LAC) Department of Health Services (DHS) Public Health Laboratory and three of its branch laboratories. Urethral and endocervical samples were collected from 1,566 patients (921 males; 645 females) attending six LAC DHS sexually transmitted disease clinics. Cost analysis was performed comparing material and labor costs of the two test methods. RESULTS: The overall prevalence based on culture was 11.8% (15.7% for males; 6.4% for females). Nine samples were culture positive, Gen-Probe negative and four samples were culture negative, Gen-Probe positive and remained discordant after discrepant analysis. The sensitivity and specificity were 94.6% and 99.7%, respectively, for the PACE 2 assay compared with culture. The positive and negative predictive values were 97.8% and 99.3%, respectively. No statistically significant difference was found between the two tests. A cost analysis found an average cost of $3.11/test for culture and $3.85/test for PACE 2, given the approximate 12% disease prevalence in this population. CONCLUSIONS: Gen-Probe's PACE 2 assay may provide an acceptable, cost-effective alternative to culture, especially among high-risk males.

Experience and acceptability of medical abortion with mifepristone and misoprostol among U.S. women.

PIP: The acceptability of medical abortion (mifepristone and misoprostol) among US women was investigated in a 1995 survey of 262 women seeking this method of pregnancy termination at 3 clinics in Oregon, Washington, and Vermont. The abortion patients' mean age was 27 years; mean gestational age was 49.5 days. 51.1% of respondents had experienced at least one prior abortion. Women completed a questionnaire at their initial clinic visit and again two weeks after the procedure. Participants chose medical abortion to avoid surgery (62.8%) or because they perceived it to be less invasive (56.3%), more natural (40.5%), and associated with a lesser risk of infection or damage to the uterus (35.1%) than vacuum aspiration, and could be performed earlier in pregnancy (27.2%). 49.8% indicated they preferred to wait for abortion to occur with a partner, friend, or family member, while 30.6% preferred to be alone; only 17.6% wanted to wait with other women undergoing the same procedure. Comparison of pre- and post-abortion questionnaires indicated women expected significantly more discomfort than they actually experienced and underestimated the number of days of bleeding. 72.8% of respondents were very satisfied with their medical abortion and 15.5% were somewhat satisfied. Women in the somewhat satisfied group had experienced significantly more abortion-related discomfort and anxiety than those who were very satisfied. Prior abortion experience and demographic characteristics did not influence satisfaction. 94% stated they would recommend medical abortion to a friend and 87% would select medical abortion if they had to terminate another pregnancy. Medical abortion has the potential to increase access to abortion among underserved groups of US women. Appropriate educational materials should be developed to help women choose between abortion methods.^ieng

Factors affecting the consistent use of barrier methods of contraception.

OBJECTIVES: To discuss the major issues involved in the consistent and effective use of barrier methods of contraception. DATA SOURCES: Major research and review articles on barrier methods published within the last 10 years were considered. One major source of articles was Family Planning Perspectives. METHODS OF STUDY SELECTION: This paper is a focused review and integration of recent literature rather than a comprehensive literature review. Only selected articles published since 1986 that are pertinent to the issues raised are included. TABULATION, INTEGRATION, AND RESULTS: All barrier methods have common characteristics that influence their patterns of use. The correct and consistent use of such methods is determined by the complex interaction of characteristics of the methods themselves, characteristics of users, and the situational context. Method characteristics include the extent of interference with sexual spontaneity and enjoyment, the amount of partner cooperation required, and the ability of the method to protect against human immunodeficiency virus and other sexually transmitted diseases. User characteristics include motivation to avoid unintended pregnancy, ability to plan, comfort with sexuality, and previous contraceptive use. Stage of sexual career, relationship characteristics, and physical and sexual abuse are important situational influences. CONCLUSIONS: Even though most barrier methods can be obtained without a prescription from a provider, clinicians have an extremely important role in promoting effective and consistent method use. Four major ways to improve the use of barrier methods currently available include: 1) improve method characteristics and the distribution systems; 2) change consumers' perceptions of method attributes; 3) train consumers to use methods correctly and overcome-perceived negative characteristics of the methods; and 4) change values about the perceived importance of method characteristics. There also is an urgent need for the development of better barrier methods.

Attitudes about condoms and condom use among college students.

The authors assessed the relationships of ethnicity, gender, previous condom use, and intended condom use to perceived attributes of the condom and the contraceptive pill in a multiethnic sample of 197 college students. Factors that appeared to underlie attitudes toward the condom and the Pill included prevention of health problems, peer acceptance, sexual pleasure and spontaneity, convenience, embarrassment, and effectiveness in preventing HIV and sexually transmitted diseases. African American participants viewed the condom more positively than did students from other ethnic groups and were more likely to use condoms than White participants were. The African Americans appeared to know less about the characteristics of the Pill and were less likely to use it than were the White respondents. Only 60% of the persons in the student sample had used condoms in the last 6 months, and less than one half definitely intended to use condoms in the next month. Those who had used a condom at their most recent intercourse and those who intended to use a condom in the next month viewed the condom more favorably than others did. Intended condom use was associated with a perception of oral contraceptives as a less convenient method of birth control.

PIP: A survey conducted among 196 sexually active students at three diverse US colleges indicated that attitudes about contraceptive use differed according to ethnicity, with Blacks more likely to be condom users than Whites. The study instrument was the Contraceptive Attributes Questionnaire-2 (CAQ-2), which focuses on condom and oral contraceptive (OC) use. The CAQ-2 is based on the assumption that the decision to use or not use a specific contraceptive method is a function of perceived value, importance, and likelihood. Although 90% of students reported ever-use of condoms, only 60% had used this method in the six months preceding the survey; 48% stated they intended to use condoms in the next month. Among the 83 Black students, however, these rates were 76%, 50%, and 61%, respectively. Black students were more concerned with peer acceptance than White students and believed more strongly in the importance of method convenience. Blacks were more likely than Whites to agree that condoms do not interfere with sexual pleasure. On the other hand, Black students--to a greater degree than Whites--viewed OCs as compromising sexual enjoyment. Overall, students who had used condoms at last intercourse more strongly agreed that this method is acceptable to peers, convenient, not embarrassing to use or discuss with a partner, does not interfere with sexual enjoyment, and is not linked to health concerns. The intent to use condoms in the next month was significantly associated with the belief condoms are a convenient method that does not interfere with sexual pleasure.

Perceptions and use of the Male Condom Among African American University Students.

This study examines differences in condom use among female and male African-American young adults; investigates how perceptions of contraceptive characteristics vary by gender; and determines which combination of contraceptive attitudes best discriminates between condom users and nonusers. In a classroom setting, 244 African-American college students completed the Contraceptive Attributes Questionnaire-2. Significantly more men than women reported condom use, both actual and intended. Women and men differed in the importance they place on contraceptive characteristics and in their perceptions of both the condom and the contraceptive pill. Finally, perceived contraceptive attributes significantly differentiated men and women who used condoms from those who did not and predicted those who reported that they definitely intend to use condoms from those who do not. These findings suggest that prevention efforts to promote condom use must be gender specific as well as culture specific if they are to be effective.