Journal of Urban Health: Bulletin of the New York Academy of Medicine, Vol. 84, No. 4
* 2007 The New York Academy of Medicine
Beliefs that Condoms Reduce Sexual
Pleasure—Gender Differences in Correlates
Among Heterosexual HIV-Positive Injection Drug
Yuko Mizuno, David W. Purcell, Mary H. Latka, Lisa R. Metsch,
Cynthia A. Gomez, and Carl A. Latkin
ABSTRACT Studies consistently find that negative condom beliefs or attitudes are
significantly associated with less condom use in various populations, including HIV-
positive injection drug users (IDUs). As part of efforts to reduce sexual risk among
HIV-positive IDUs, one of the goals of HIV interventions should be the promotion of
positive condom beliefs. In this paper we sought to identify the correlates of negative
condom beliefs and examined whether such correlates varied by gender, using a
subsample (those with an opposite-sex main partner; n=348) of baseline data collected
as part of a randomized controlled study of HIV-positive IDUs. In multivariate
analyses, we found more significant correlates for women than for men. With men,
perception that their sex partner is not supportive of condom use (negative partner
norm) was the only significant correlate (Beta=j0.30; pG0.01; R2=0.18). Among
women, negative partner norm (Beta=j0.18; pG0.05); having less knowledge about
HIV, STD, and hepatitis (Beta=j0.16; pG0.05); lower self-efficacy for using a condom
(Beta=j0.40; pG0.01); and more episodes of partner violence (Beta=0.15; pG0.05)
were significantly associated with negative condom beliefs (R2=0.36). These findings
suggest important gender-specific factors to consider in interventions that seek to
promote positive condom beliefs among HIV-positive IDUs.
KEYWORDS Condom beliefs, Correlates, Gender differences, Partner norm.
Injection drug users (IDUs) represent about one-third of persons living with AIDS in the
USA.1Recent CDC initiatives have emphasized the need to work with HIV-infected
populations in an effort to prevent the spread of HIV.2–4HIV-positive IDUs are one of
the groups that particularly need such attention. Early in the epidemic, injection risk
behaviors were the primary source of HIV infection among IDUs; more recent studies
among IDUs.5,6Studies also have found that some HIV-positive IDUs continue to
Mizuno and Purcell are with the Prevention Research Branch, Division of HIV/AIDS Prevention National
Center for HIV/STD/TB Prevention, Centers for Disease Control and Prevention, Altanta, GA, USA; at
time of the study, Latka was with the Center for Urban Epidemiologic Studies, New York Academy of
Medicine, New York, NY, USA; Metsch is with the University of Miami, Miami FL, USA; at time of the
study, Gomez was with the University of California - San Francisco, San Francisco, CA, USA; Latkin is
with the Johns Hopkins University, Baltimore, MD, USA.
Correspondence: Yuko Mizuno, PhD, Prevention Research Branch, Division of HIV/AIDS Prevention,
National Center for HIV/STD/TB Prevention, Centers for Disease Control and Prevention, 1600 Clifton
Road, NE Mail Stop E37, Atlanta, GA 30333, USA. (E-mail: firstname.lastname@example.org)
engage in risky sexual behaviors that could transmit HIV to uninfected persons.7–11It
is imperative that prevention efforts with HIV-positive IDUs focus not only on reducing
their injection risk behaviors but also on reducing their sexual risk behaviors.
Studies have consistently found that negative beliefs or attitudes about condoms are
significantly associated with less frequent condom use in various populations.12–22This
pattern has been confirmed in analyses of HIV-positive IDU men11and women.10
Reducing negative condom beliefs or attitudes among people at risk of acquiring or
transmittingHIV maybe animportant steptoward reducing sexual risk, andidentifying
to better promote condom use among those who need to use them. However, factors
associated with negative condom beliefs or attitudes particularly among HIV-positive
populations, including HIV-positive IDUs, have not been investigated greatly.
In this exploratory study, we sought to identify correlates of negative condom
beliefs, specifically, beliefs that condoms would reduce sexual pleasure among a
subsample of HIV-positive IDUs. We examined three categories of potential
correlates, namely, individual characteristics, partner characteristics, and social
characteristics. Individual characteristics included sociodemographic factors (age,
race, education, and income); depression; knowledge about HIV, STD, and
hepatitis; self-efficacy (one_s perceived ability) for using a condom; self-efficacy
for disclosing HIV status to a sex partner; and HIV status disclosure. Partner
characteristics included partner norm supporting condom use, physical violence
inflicted by partner, and partner_s HIV serostatus. For social characteristics, we
examined social norms supporting condom use.
major theories of behavioral change (e.g., the information-motivation-behavior skills
model;23the theory of reasoned action24) that have been shown to predict HIV risk
reduction. Other variables (HIV status disclosure and partner_s serostatus) were
considered because of their relevance to sex lives of HIV-positive IDUs.25,26Depression
might also be a relevant correlate, as depressed persons could be expected to perceive
things (including condoms) in a negative manner. Drawing on the studies that point to
the significant role of intimate partner violence in shaping HIVrisk among women,27–29
we also examined intimate partner violence as a potentially gender-relevant correlate.
Because condoms are worn by men, and thus, because men may be the ones to
actually experience physical discomfort such as erection problems and loss of
sensation,30–33men may have more negative condom beliefs than women and
differential correlates of negative condom beliefs could be found between men and
women. To explore gender differences, the majority of analyses were conducted
separately by gender.
We report baseline data from a convenience sample of HIV-positive IDUs who
participated in the Intervention for Seropositive Injectors—Research and Evalua-
tion (INSPIRE), a randomized controlled trial of an HIV prevention intervention
designed for HIV-positive IDUs. The study was conducted in four cities in the
United States (Baltimore, Miami, New York, and San Francisco) from 2001
through 2005. Participants were recruited using active (e.g., street outreach) and
passive strategies (e.g., posters and leaflets, word of mouth) in a variety of HIV care
MIZUNO ET AL.524
and community venues including AIDS service organizations, medical clinics, and
methadone clinics, as well as street-based settings. Individuals were screened for
eligibility and were eligible for the study if they were at least 18 years old,
confirmed to be HIV-positive by testing of oral specimen, reported injection drug
use in the past 12 months, and reported having sex with an opposite-sex partner in
the past 3 months.
At baseline, participants were administered an audio computer-assisted self
interview to answer questions regarding sexual and drug using behaviors,
utilization of health care, and adherence to HIV medications. Participants also
provided an oral fluid sample for confirmatory HIV-antibody testing (OraSure,
OraSure Technologies, Bethlehem, PA, USA) and a blood specimen for CD4 count
and viral load. HIV confirmation testing was performed at local laboratories, and
immunoassays at the CDC laboratories. Participants were reimbursed $30 for
their time and effort for the baseline appointment. More detailed description of
INSPIRE and its methodology has been reported elsewhere.34Study protocols
were approved by institutional review boards of CDC and collaborating study sites.
For the present paper, we used a subsample of 348 participants (179 men and 169
women). Of the total sample of 1,161 participants enrolled into the study, 7% (80/
1,161) said they had not had sex in the past 3 months at the time of baseline
(although they had had sex sometime in the 3 months prior to screening), 45%
(517/1,161) reported having one sex partner, and 48% (552/1,161) reported having
more than one sex partner in the past 3 months. We restricted our study sample to
participants who reported having one sex partner so that partner-specific correlates
(see BMeasures^ section below) did not have to be averaged or summed across
different sex partners, and thus, more precise measurements of the correlates could
be used. Some of the measures of correlates were assessed only from participants
who reported having heterosexual relationships or those with main sex partners.
Because of these restrictions, we used a subsample of participants who reported
having one opposite-sex main or Bsteady^ partner in the past 3 months. This
subsample included more participants from the Baltimore site (36%) and fewer
participants from the Miami site (16%) than the total sample (27% from Baltimore
and 26% from Miami); however, other demographic characteristics and the average
condom beliefs scores remained similar to the total sample. Preliminary analyses
with this subsample found a significant association between negative condom
beliefs and unprotected sex in both gender groups (pG0.001).
Measures used in this study, when appropriate, were tested for their psychometric
properties by factor and reliability analyses.
Negative Condom Beliefs Beliefs that condoms would reduce sexual pleasure were
assessed by a four-item scale adapted from the Bhedonistic outcome expectancy^
scale developed for a study on HIV-positive men who have sex with men.35The
items included Bcondoms ruin the mood,^ Bsex doesn_t feel as good when you use a
condom,^ Bsex with condoms doesn_t feel natural,^ and Busing condoms breaks up
the rhythm of sex.^ Reponses were scored from Bstrongly disagree^ (=1) to
CORRELATES OF CONDOM BELIEFS 525
Bstrongly agree^ (=5) and the mean score was computed. A higher score indicated
more negative beliefs. (Cronbach_s alpha=0.85 for males and 0.94 for females).
Potential Correlates—Individual Characteristics
Sociodemographic Characteristics Sociodemographic variables examined include
age (in years), biological sex, race/ethnicity (non-Hispanic white, non-Hispanic
black, Hispanic, or other), city of residence (Baltimore, Miami, New York, or San
Francisco), education (high school or more vs. less than high school), and income
($10,000 or more per year vs. less than 10,000 per year).
Knowledge About HIV, STD, and Hepatitis Participants_ knowledge about HIV,
STD, and hepatitis were tested using 18 true–false questions. Participants scored 1
for correctly answering each question, and percentage of correct answers was
computed for each participant. Thus, a higher percentage indicated greater correct
knowledge. Examples of questions included BUsing latex condom is highly effective
in reducing the risk of transmitting HIV^ and BYou can still transmit HIV even
when your viral load is undetectable.^
Self-efficacy for Using a Condom for Vaginal Sex This construct was measured in
reference to the specific main sex partner that a participant identified. The construct
was assessed using a nine-item scale that asked about participants_ self-perceived
ability to use condoms with the main partner during various situations. Examples
of situations included BWhen you want to have vaginal sex with [Name of Partner],
you can use a condom even if [Name of Partner] does not want to^ and Beven if you
both really want to feel close.^ Responses were scored from 1 (absolutely sure I
cannot) to 5 (absolutely sure I can), and the mean score was computed. A higher
score indicated higher self-efficacy (alpha=0.93 for males, 0.95 for females).
Self-efficacy for Disclosing HIV Status to a Sex Partner This construct was assessed
using a six-item scale that asked about participants_ confidence to disclose their
HIV status to a sex partner in various situations. Unlike the self-efficacy for using a
condom scale mentioned above, this scale did not have any particular sex partner as
a reference. Examples of items included BI can tell a new sex partner my HIV status
before having sex even if I am really attracted to them^ and BI can tell...even if they
might know some of my friends.^ Responses were scored from 1 (absolutely sure I
cannot) to 5 (absolutely sure I can), and the mean score was computed. A higher
score indicated higher self-efficacy (alpha=0.94 for males and females).
Disclosure of HIV Sero-status to the Partner Participants were asked whether they
had disclosed their HIV status to the specific main partner that they identified.
Response options were Byes,^ Bno,^ and Bunsure.^ We further created a dichotomous
variable indicating Byes^ (=1) and Bno or unsure^ (=0).
Depressive Symptoms Depressive symptoms were measured by the seven-item
depressionsubscaleoftheBriefSymptomInventory.36Examples of questions included
BIn the past week, how much have you been bothered by thoughts of ending your
life,^ or Bfeeling lonely.^ Reponses were scored from 1 (not at all) to 5 (extremely),
and the mean score was computed. A higher scale score indicated more depressive
symptoms. (alpha=0.88 for males and females).
MIZUNO ET AL. 526
Potential Correlates—Partner Characteristics
Partner Norm Supporting Condom Use for Vaginal Sex Like self-efficacy for using
a condom for vaginal sex, the partner norm construct was measured in reference to
the specific main partner that a participant identified. The construct was assessed
using two questions: (1) whether participant perceived that the main partner
thought that a condom should be used for vaginal sex (normative belief) and (2)
whether the participant felt it was important to comply with that expectation
(motivation to comply).24This construct could also be referred to as Bperceived
normative pressure.^37Responses to the Bnormative belief^ item ranged from j2
(strongly disagree) to +2 (strongly agree). Reponses to the Bmotivation to comply^
item ranged from 1 (strongly disagree) to 5 (strongly agree). The normative belief
score was multiplied by the motivation score to create the final score ranging from
j10to+10,withahigher score indicating strongerpartnernormsupporting condom
Physical Violence from the Partner Again, this construct was measured in reference
to a specific main partner and was assessed using an adapted version of the Conflict
Tactics Scale.39The scale included eight items. Questions asked whether, in the
prior 12 months, the main partner had Bthreatened to hit you or throw something
at you;^ Bslapped you;^ Bkicked, bit, or hit you with a fist;^ Bchoked or strangled
you;^ Bphysically forced you to have sex;^ Bbeaten you up;^ Bthreatened you with a
knife or gun;^ and Bused a knife or gun on you^ with response options Byes^ (=1)
and Bno^ (=0). The number of Byes^ responses was summed across items for a total
score (alpha=0.75 for males and 0.77 for females).
Partner_s HIV Serostatus Participants were asked whether the main partner that
they identified was perceived by them to be HIV positive, HIV negative, or of
unknown serostatus. We created a dichotomous variable indicating BHIV-positive^
(=1) and BHIV-negative or of unknown serostatus^ (=0).
Potential Correlates—Social Characteristics
Social Norms Supporting Condom Use for Vaginal Sex This construct was mea-
sured in a similar manner as the partner norm variable. Instead of using sex partner
as a reference person, this construct used Bmost people who are important to me^
as the reference group. Again, a higher score indicates stronger social norm sup-
porting condom use.
All of these analyses were conducted separately by gender. First, we compared the
descriptive statistics for major variables. Then, bivariate analyses (Pearson correla-
tion and analysis of variance) were conducted to examine the associations between
the outcome measure and each of the potential correlates. Lastly, all the bivariate
correlates that were associated with the outcome (pG0.1) were included in
multivariate models (linear regression) predicting negative condom beliefs. Prelim-
inary analysis indicated that distribution of residuals was approximately normal.
This, together with examination of plots of the residuals against the predicted
values and the independent variables, suggested that linear regression would be an
appropriate statistical method for the multivariate analyses.40
CORRELATES OF CONDOM BELIEFS527
TABLE 1Sample characteristics of HIV-positive IDUs who reported having one main partner
All (n=348) Male (n=179) Female (n=169)
n (%)n (%)n (%)
Less than high school
High school or more
Less than $10,000/year
$10,000/year or more
Disclosed HIV status
to this partner
Negative condom beliefs*2.87 (1.10)
Knowledge about HIV,
STD, and hepatitis
on 18-item index)
Self-efficacy for using a
Self-efficacy for disclosing
HIV status to a sex
Partner norm supporting
MIZUNO ET AL. 528
Sample Characteristics—Differences Between Men and Women
Characteristics ofthe348participantsinthestudysample aresummarizedinTable1.
There were a few significant differences (pG0.05) between the gender groups
(Table 1). A higher percentage of women than men reported having less than high
school education. Women were also younger, reported greater depressive
symptoms, and reported weaker partner norm supporting condom use and social
norm supporting condom use than men.
With respect to condom beliefs, there was a marginally significant gender
difference (pG0.1), where male participants reported more negative beliefs about
condoms than female participants. When closely looking at the frequency
distributions of condom belief scores, 47% of male participants and 35% of
female participants scored higher than 3, showing negative condom beliefs. We
further compared scores of male and female participants for each of the items in the
condom beliefs scale (results not shown in the table) and found that males rated
condoms more unfavorably with respect to the items Bsex doesn_t feel as good when
you use a condom^ (3.18 for men vs. 2.82 for women, pG0.01) and Bsex with
condom doesn_t feel natural^ (3.26 for men vs. 2.90 for women, pG0.01). No
significant gender differences were observed with respect to the items Bcondom
ruins the mood^ and Busing condoms breaks up the rhythm of sex.^
Bivariate Associations with Negative Condom Beliefs
Male Analysis Bivariate analysis with the male sample found the following
correlates of negative condom beliefs (pG0.1). Among individual characteristics,
negative condom beliefs were associated with lower self-efficacy for using a condom
with this partner (r=j0.33; pG0.01), lower self-efficacy for disclosing HIV status to
a sex partner (r=j0.16; pG0.05), and greater depressive symptoms (r=0.13; pG0.1).
Among partner characteristics, partner norm not supporting condom use (r=j0.39;
pG0.01) and the partner_s serostatus being HIV-positive as opposed to HIV-negative
or of unknown status (3.13 vs. 2.78; pG0.05) were associated with negative condom
beliefs. Social norm not supporting condom use was also associated with negative
condom beliefs (r=j0.21; pG0.01).
Female Analysis In the female sample, bivariate correlates of negative condom beliefs
include individual characteristics, such as less knowledge about HIV, STD, and
hepatitis (r=j0.14; pG0.1); lower self-efficacy for using a condom with this partner
TABLE 1 Continued
All (n=348)Male (n=179)Female (n=169)
n (%)n (%)n (%)
Physical violence inflicted
by this main partner*
Social norm supporting
*pG0.1; **pG0.05; ***pG0.01
CORRELATES OF CONDOM BELIEFS 529
(r=j0.53; pG0.01); greater depressive symptoms (r=0.13; pG0.1); partner character-
istics, such as partner norm not supporting condom use (r=j0.42; pG0.01); and
greater physical violence from this partner (r=0.23; pG0.01). Social norm not
supporting condom use was also associated with negative condom beliefs (r=j0.25;
Tables 2 and 3 show the results of multivariate analyses for men and women,
respectively. Table 2 indicates that, among correlates found to be associated with
condom beliefs in bivariate analysis, only perceived partner norm remained as a
significant multivariate correlate among men. The model for men explained 18% of
the variance in the outcome. Table 3 indicates that, among women, significant
multivariate correlates were individual characteristics, such as self-efficacy for using
a condom with this partner and knowledge about HIV, STD, and hepatitis, and
partner characteristics, such as partner norm and physical violence from the
partner. The model for women explained 36% of the variance in the outcome.
positive IDU women with one main partner (n=166)
Final multiple regression model predicting negative condom beliefs among HIV-
B SE B Betap value
Knowledge about HIV, STD, and hepatitis
Self-efficacy for using a condom
Partner norm supporting condom use
Physical violence from this partner
Social norm supporting condom use
positive IDU men with one main partner (n=172)
Final multiple regression model predicting negative condom beliefs among HIV-
B SE BBetap value
Self-efficacy for using a condom
Self-efficacy for disclosing HIV status to a sex partner
Partner norm supporting condom use
Partner is HIV-positive
Social norm supporting condom use
0.0040.021 0.018 NS
MIZUNO ET AL.530
We sought to identify the correlates of condom beliefs and examined whether such
correlates varied by gender among a subsample of HIV-positive IDUs who reported
having an opposite-sex main partner. This paper is unique for its focus on HIV-
positive IDUs and gender differences in correlates of condom beliefs and is a rare
analysis for including HIV-positive heterosexual men; past studies of HIV-positive
men were primarily focused on men who have sex with men.13It is crucial to
examine beliefs and behaviors of HIV-positive heterosexual men, as HIV is more
readily transmitted from men to women.41We found partner norm, i.e., what the
sex partner thought about condom use and how the participant valued such views,
to be a significant correlate of condom beliefs for both men and women. In other
words, regardless of gender, the stronger the normative pressure to use a condom
perceived from a sex partner, the more positive a person_s beliefs about condoms. It
is noteworthy that social norm (i.e., normative pressure from most people who are
important to participants) was not a significant multivariate correlate in both male
and female models. Additional analyses suggest that this finding was probably due
to overlap between partner and Bmost people who are important^ as significance of
the latter variable disappeared after partner norm was entered into the models
(results not shown).
In multivariate analysis, we found more significant correlates of condom beliefs
among women than among men. Women_s beliefs about condoms were also
associated with individual characteristics such as HIV (STD and hepatitis)
knowledge and self-efficacy to use a condom, as well as partner characteristics
such as partner violence. That is, the more knowledge and self-efficacy a woman
had and the less that violence was inflicted by her sex partner, the more positive her
condom beliefs were. Knowledge and self-efficacy are some of the major constructs
drawn from theories of behavioral change used in HIV risk reduction interventions.
In fact, many behavioral interventions do address these factors by providing
information about HIV/STD transmission and prevention and/or providing skills-
building exercises to enhance communication skills (how to effectively convince
their partners to use condoms in various situations) or to teach participants how to
put on a condom using an anatomical model.42,43Thus, these interventions are
already likely to positively affect condom beliefs among women.
On the other hand, addressing partner-related characteristics such as
violence within the relationship can be a challenge for HIV prevention
interventions. Our finding does indicate that partner violence is clearly an
important problem to tackle among our sample of HIV-positive IDU women.
In fact, given that HIV preventions based on cognitive behavioral models of
behavior change largely assume participants have free agency to enact changes,
new approaches may be needed to more adequately address the larger context
in which risk behaviors occur, particularly among marginalized, drug-using
women.25For example, Pronyk and his colleagues44found in a study conducted in
South Africa that a structural intervention that combined a poverty-focused
microfinance initiative with a curriculum of gender and HIV education reduced
the levels of intimate-partner violence reported among the women receiving the
intervention. Such a model is worth exploring in the US context as well. Our
finding that partner norm was a significant correlate of condom beliefs in both
men and women suggests that HIV prevention approaches need to be expanded to
address relationship dynamics.
CORRELATES OF CONDOM BELIEFS531
It is noteworthy that men tended to have more negative condom beliefs.
Specifically, men rated condoms significantly more negatively for items such as Bsex
doesn_t feel as good when you use a condom^ and Bsex with a condom doesn_t feel
natural.^ Also, only 18% of the variance in the male model was explained by
psychosocial factors. For men, it may be that experience of physical discomfort
with condoms is the salient problem largely shaping their belief about condoms. To
further investigate this issue, we need to consider additional factors such as
participants_ previous unfavorable experiences (e.g., loss of erection or sensation)
with condoms. These results suggest that more research is needed to fully
understand what shapes the condom beliefs of men.
However, we found one significant correlate, namely, partner norm in the
men_s model, and this result suggests that it may be possible to address men_s
negative condom beliefs by working together with them and their partners. The
question then is to come up with a strategy so that men would perceive strong
normative pressure to use a condom from their partners. One potential strategy
would be couples-based interventions where men and women each practice to
develop norms supporting condom use. Another strategy would be to provide
women with skills to clearly communicate their positive beliefs about condoms and
also to apply appropriate pressure on their partners to use condoms. Partner
violence may need to be factored into the discussion, particularly for women, as
that might affect how they would comfortably apply such pressure.
This study has the following limitations: First, the data are cross-sectional, thus
we are unable to establish causal relationships from this analysis. For example, we
found a significant association between self-efficacy and condom beliefs among
women, which suggests a possibility that skill-building interventions might promote
better condom beliefs. However, it is plausible that having positive condom beliefs
promote the sense of self-efficacy (e.g., I don_t believe condoms will interfere with
sexual pleasure and thus I can negotiate with my partner about condom use even if
he is not willing to), rather than self-efficacy promoting better condom beliefs.
Experimental data are needed to determine the causal sequence and, thus, to better
inform interventions about important components.
The second limitation is that we only examined data from participants who
reported having an opposite-sex main partner. This sample restriction was due to
the design of the data collection instrument in which some of the key measures were
partner-specific and collected in reference to only certain types of partners (e.g.,
opposite-sex, main partners). While the sample restriction allowed us to use precise
measures that were collected for specific sex partners, it raises the possibility that
our findings may not be replicated in a broader sample of HIV-positive IDUs. To
further address this question, we conducted additional analyses by expanding the
study sample to also include participants with multiple opposite-sex partners
(n=527). Analyses with this expanded sample produced similar results in that (1)
partner norm was a significant multivariate correlate for both men and women; (2)
for women, self-efficacy and knowledge were also significant correlates; and (3) the
male model had only one significant correlate (partner norm) and the model did not
explain much of the variance in the outcome (results not shown). However,
reproducibility of the results in samples including men who have sex with men or
those without any main partners is still unknown. Future studies should design a
data collection instrument that can fully address the associations between condom
beliefs and potential correlates in a variety of partnership situations. In addition, it
MIZUNO ET AL.532
should be noted that because we used a convenience sample, the results are not
generalizable to the general population of HIV-positive IDUs.
Finally, the data were collected as part of a randomized trial of a behavioral
intervention; thus, our survey instrument did not ask all the questions needed for
this paper, including participants_ previous experience with condoms, either
favorable or unfavorable, or even beliefs or attitudes about condoms worn by
women (female condoms). This limitation may have been particularly germane to
the analysis among men, as the correlates available for analysis had very little
predictive power among men.
With these caveats, we have generated a list of correlates of beliefs that
condoms reduce sexual pleasure. Addressing negative condom beliefs may be an
important step toward HIV sexual risk reduction in many populations including
HIV-positive IDUs, the target population of this study. Our findings suggest a
number of important gender-specific factors to be considered in interventions for
HIV-positive IDUs, particularly those with opposite-sex main partners. These
findings may be used to inform the development of interventions that might better
promote positive condom beliefs among HIV-positive IDUs.
The authors wish to acknowledge the study participants in all four communities
who made this research possible and the study staff for their outstanding
commitment to the success of this project. The authors also wish to thank the
members of the community advisory boards and HIV program review panels at
each site for providing constructive feedback on the intervention and trial designs.
The INSPIRE Study Group includes the following people: Carl Latkin, Amy
Knowlton, Karin Tobin (Baltimore), Lisa Metsch, Eduardo Valverde, James
Wilkinson, Martina DeVarona (Miami), Mary Latka, Dave Vlahov, Phillip Coffin,
Marc Gourevitch, Julia Arnsten, Robert Gern (New York), Cynthia Gomez, Kelly
Knight, Carol Dawson Rose, Starley Shade, Sonja Mackenzie (San Francisco),
David Purcell, Yuko Mizuno, Scott Santibanez, Richard Garfein, Ann O_Leary
(CDC), Lois Eldred, and Kathleen Handley (Health Resources and Services
We would also like to acknowledge the following people for their contributions
to this research: Susan Sherman, Roeina Marvin, Joanne Jenkins, Donny Gann,
Tonya Johnson (Baltimore), Clyde McCoy, Rob Malow, Wei Zhao, Lauren
Gooden, Sam Comerford, Virginia Locascio, Curtis Delford, Laurel Hall, Henry
Boza, Cheryl Riles (Miami), George Fesser, Victoria Frye, Carol Gerran, Laxmi
Modali, Diane Thornton (New York), Caryn Pelegrino, Barbara Garcia, Jeff
Moore, Erin Rowley, Debra Allen, Dinah Iglesia-Usog, Gilda Mendez, Paula Lum,
Greg Austin (San Francisco), Craig Borkowf, Ying Chen, Gladys Ibanez, Hae-Young
Kim, Toni McWhorter, Jan Moore, Lynn Paxton, John Williamson (CDC), Lee Lam,
Jeanne Urban, Stephen Soroka, Zilma Rey, Astrid Ortiz, Sheila Bashirian, Marjorie
Hubbard, Karen Tao, Bharat Parekh, and Thomas Spira (CDC Laboratory).
This study was supported by the Centers for Disease Control and Prevention
and the Health Resources and Services Administration. The findings and
conclusions in this report are those of the authors and do not necessarily represent
the views of the Centers for Disease Control and Prevention.
CORRELATES OF CONDOM BELIEFS533
1. Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report, 2004, vol. 16.
Department of Health and Human Services, Centers for Disease Control and Prevention;
2. Centers for Disease Control and Prevention. Advancing HIV prevention: New strategies
for a changing epidemic—United States, 2003. MMWR Morb Mortal Wkly Rep.
3. Centers for Disease Control and Prevention. Incorporating HIV prevention into the
medical care of persons living with HIV. Recommendations of CDC, the Health
Resources and Services Administration, the National Institutes of Health, and the HIV
Medicine Association of the Infectious Diseases Society of America. MMWR Recomm
4. Janssen RS, Valdiserri RO. HIV prevention in the United States: increasing emphasis on
working with those living with HIV. J Acquir Immune Defic Syndr. 2004;37(Suppl 2):
5. Kral AH, Bluthenthal RN, Lorvick J, Gee L, Bacchetti P, Edlin BR. Sexual transmission
of HIV-1 among injection drug users in San Francisco, USA: risk-factor analysis. Lancet.
6. Strathdee SA, Sherman SG. The role of sexual transmission of HIV infection among
injection and non-injection drug users. J Urban Health. 2003;80:iii7–iii14.
7. Avants SK, Warburton LA, Hawkins KA, Margolin A. Continuation of high-risk behavior
by HIV-positive drug users: Treatment implications. J Subst Abuse Treat. 2000;19:15–22.
8. Kwiatkowski CF, Booth R. HIV-seropositive drug users and unprotected sex. AIDS
9. Metsch LR, McCoy CB, Lai S, Miles C. Continuing risk behaviors among HIV-
seropositive chronic drug users in Miami, Florida. AIDS Behav. 1998;2:161–169.
10. Lakta MH, Metsch LR, Mizuno Y, et al. Unprotected sex among HIV-positive injection
drug using women and their serodiscordant male partners: Role of personal and partner
influences. J Acquir Immune Defic Syndr. 2006;42:222–228.
11. Purcell DW, Mizuno Y, Metsch LR, et al. Unprotected sexual behavior among
heterosexual HIV-positive injection drug using men: associations by partner type and
partner serostatus. J Urban Health. 2006;83:656–668.
12. Boone TL, Lefkowitz ES. Safer sex and the health belief model; considering the
contributions of peer norms and socialization factors. J Psychol Hum Sex. 2004;16:51–68.
13. CrepazN,MarksG.Towardsanunderstanding ofsexualriskbehaviorinpeopleliving with
HIV: a review of social, psychological, and medical findings. AIDS. 2000;16:135–149.
14. DiClemente RJ. Psychological determinants of condom use among adolescents.
In: DiClemente RJ, ed. Adolescents and AIDS: A Generation in Jeopardy. Newbury Park,
CA: Sage; 1992:34–51.
15. Fernandez-Esquer ME, Krepcho MA, Freeman AC, Magee E, McAlister AL, Ross MW.
Predictors of condom use among African American males at high risk for HIV. J Appl
Soc Psychol. 1997;27:58–74.
16. Ford K, Wirawan DN, Muliawan P. Social influence, AIDS/STD knowledge, and condom
use among male clients of female sex workers in Bali. AIDS Educ Prev. 2002;14:496–
17. Hinkle YA, Johnson EH, Gilbert D, Jackson L, Lollis CM. African-American women
who always use condoms: attitudes, knowledge about AIDS, and sexual behavior. J Am
Med Womens Assoc. 1992;47:230–237.
18. O_Leary A, Maibach E, Ambrose TK, Jemmott JB, Celentano DD. Social cognitive predictors
of sexual risk behavior change among STD clinic patients. AIDS Behav. 2000;4:309–316.
19. Reitman D, St. Lawrence JS, Jefferson KW, Alleyne E, Brasfield TL, Shirley A. Predictors
of African American adolescents_ condom use and HIV risk behavior. AIDS Educ Prev.
MIZUNO ET AL.534
20. Sacco WP, Levine B, Reed DJ, Thompson K. Attitudes about condom use as an AIDS-
relevant behavior: their factor structure and relation to condom use. Psychol Assess.
21. Sonenstein FL, Ku L, Pleck JH. Why young men don_t use condoms: factors related to the
consistency of utilization. In: Besharov DJ, Steward FH, Gardiner KN, Parker M, eds.
Why Some Men Don_t Use Condoms: Male Attitudes About Condoms and Other
Contraceptives. Menlo Park, CA: Henry J. Kaiser Family Foundation; 1997:1–26.
22. St. Lawrence JS, Reitman D, Jefferson KW, Alleyne E, Brasfield TL, Shirley A. Factor
structure and validation of an adolescent version of the Condom Attitudes Scale:
an instrument for measuring adolescents_ attitudes toward condoms. Psychol Assess.
23. Fisher JD, Fisher WA. Changing AIDS-risk behavior. Psychol Bull. 1992;111:455–474.
24. Ajzen I, Fishbein M. Understanding Attitudes and Predicting Social Behavior. Engle-
wood Cliffs, NJ: Prentice Hall; 1980.
25. Knight KR, Purcell D, Dawson-Rose C, Halkitis PN, Gomez CA, & the Seropositive
Urban Injectors Study Team. Sexual risk taking among HIV-positive injection drug users:
contexts, characteristics, and implications for prevention. AIDS Educ Prev.
26. Parsons JT, Missildine MA, Van Ora J, Purcell DW, Gomez CA, and the Seropositive
Urban Injectors Study Team. HIV status disclosure to sexual partners among HIV-
positive injection drug users. AIDS Patient Care STDS. 2004;18:457–469.
27. Gielen AC, McDonnell KA, O_Campo PJ. Intimate partner violence, HIV status, and
sexual risk reduction. AIDS Behav. 2002;6:107–116.
28. Wu E, El-Bassel N, Witte SS, Gilbert L, Chang M. Intimate partner violence and HIV
risk among urban minority women in primary health care settings. AIDS Behav.
29. Saul J, Moore J, Murphy ST, Miller LC. Relationship violence and women_s reactions to
male- and female-controlled HIV prevention methods. AIDS Behav. 2004;8:207–214.
30. Basuki E, Wolffers I, Deville W, et al. Reasons for not using condoms among female sex
workers in Indonesia. AIDS Educ Prev. 2002;14:102–116.
31. Crossby RA, Graham CA, Yarber WL, Sanders SA. If the condom fits, wear it: a
qualitative study of young African-American men. Sex Transm Infect. 2004;80:306–309.
32. Crosby RA, Sanders SA, Yarber WL, Graham CA. Condom-use errors and problems: a
neglected aspect of studies assessing condom effectiveness. Am J Prev Med.
33. Thomsen S, Stalker M, Toroitich-Ruto C. Fifty ways to leave your rubber: how men in
Mombasa rationalize unsafe sex. Sex Transm Infect. 2004;80:430–434.
34. Purcell DW, Metsch LR, Latka M, et al. Interventions for seropositive injectors-research
and evaluation: an integrated behavioral intervention with HIV-positive injection drug
users to address medical care, adherence, and risk reduction. J Acquir Immune Defic
Syndr. 2004;37(Suppl 2):S110–S118.
35. O_Leary A, Hoff CC, Purcell DW, et al. What happened in the SUMIT trial? Mediation
and behavior change. AIDS. 2005;19(Suppl 1):S111–S121.
36. Derogatis LR, Spencer PM. The Brief Symptom Inventory (BSI): Administration,
scoring, and procedure manual—1. Baltimore, MD: Wiley; 1982.
37. Mizuno Y,KennedyM,SealsB,MyllyluomaJ.Predictors ofteens_ attitudestoward condoms:
gender difference in the effects of norms. J Appl Soc Psychol. 2000;30:1381–1395.
38. Corby NH, Jamner MS, Wolitski RJ. Using the theory of planned behavior to predict
intention to use condoms among male and female injection drug users. J Appl Soc
39. Straus MA. Measuring intrafamily conflict and violence: the conflict tactics scales.
J Marriage Fam. 1979;41:75–88.
40. Neter J, Wasserman W, Kutner M. Applied Linear Regression Models, 2nd edn. Burr
Ridge, IL: Irwin; 1989.
CORRELATES OF CONDOM BELIEFS 535
41. Padian NS, Shiboski SC, Glass SO, Vittinghoff E. Heterosexual transmission of human Download full-text
immunodeficiency virus (HIV) in northern California: results from a ten-year study.
Am J Epidemiol. 1997;146:350–357.
42. Kalichman SC, Carey MP, Johnson BT. Prevention of sexually transmitted HIV infection:
a meta-analytic review of the behavioral outcome literature. Ann Behav Med.
43. Semaan S, Kay L, Strouse D, et al. A profile of U.S.-based trials of behavioral and social
interventions for HIV risk reduction. J Acquir Immune Defic Syndr. 2002;30:S30–S50.
44. Pronyk PP, Hargreaves JR, Kim JC, et al. Effect of a structural intervention for the
prevention of intimate-partner violence and HIV in rural South Africa: a cluster
randomized trial. Lancet. 2006;368:1973–1983.
MIZUNO ET AL. 536