Impact of Menopause on Condom Use by HIV-Seropositive and Comparison Seronegative Women

To the Editor: For women with HIV, condom use helps to prevent HIV transmission and sexually transmitted infections. Condoms also provide contraception. Despite this, condom use by HIV-infected women is far from universal1,2 and is less prevalent among women with HIV who do not need its contraceptive effects because they use alternate contraception or have been sterilized.3,4 We set out to determine how condom use changes as HIV-infected women pass through menopause in a substudy of the Women's Interagency HIV Study (WIHS), a multicenter prospective cohort study of the natural history of HIV in HIV-infected women and comparison uninfected women.5 Written informed consent was obtained after local human subjects committee approval. At semiannual visits, women self-reported condom use and menopause, defined as no menses for 12 months. We excluded women with inadequate follow-up; seroconverters; women who reported menopause inconsistently; sexually abstinent women; and women who reported natural or surgical menopause at baseline, the first postenrollment visit, or the first available visit that included a report of vaginal sex with a male partner. Follow-up was censored at hysterectomy or ovarian surgery. Logistic regression analyses were conducted using generalized estimating equations. Factors associated with condom use in a prior WIHS report6 and variables that changed the association between menopause status and condom use by >10% were included. These included HIV status, age, year, ethnicity, number of male sexual partners in the prior 6 months, smoking, alcohol and drug use, depression, or reporting of a sexually transmitted disease. After exclusions, we identified 1177 women with 9846 visits for analysis. Menopause was reported by 142 (15.6%) HIV-seropositive and 31 (11.7%) of HIV-seronegative women (P = 0.11). Women who reported passing through menopause during study reported condom use at 619 (74%) of 834 premenopausal visits and 528 (70%) of 754 postmenopausal visits (odds ratio [OR] = 1.23, 95% confidence interval [CI]: 0.99 to 1.54; P = 0.06). Lack of a significant association between menopause and condom use was confirmed in multivariable logistic regression analysis (OR for condom use at postmenopause visit = 0.98, 95% CI: 0.60 to 1.60; P = 0.93). Menopause also was not correlated with condom use in a multivariable analysis that included only women with HIV (OR = 0.84, 95% CI: 0.58 to 1.21; P = 0.34). We also compared reporting of condoms at the postmenopause visits of women who reported menopause (n = 754) with reporting at visits by nonmenopausal women (n = 8258). The former were less likely to use condoms (OR = 0.84, 95% CI: 0.71 to 0.98; P = 0.03), but this association became nonsignificant in multivariable analysis, including adjustment for HIV serostatus (OR = 1.01, 95% CI: 0.73 to 1.4; P = 0.93). Condom use has been shown to decline with age,6-8 but this study shows that the perception of menopause does not alter condom use among women with HIV, even though menopausal women no longer need condoms to prevent pregnancy. This study is limited by reliance on self-report to determine menopause and condom use. We could not determine the impact of self-selection for study or repeated safe sex messages at study visits on condom use on generalizability of results. Aging women with HIV need to support continued use of condoms to protect themselves and their partners from disease transmission. L. Stewart Massad, MD* Charlesnika T. Evans, PhD† Tracey E. Wilson, PhD‡ Elizabeth T. Golub, PhD§ Lakshmi Goparaju, PhD∥ Andrea Howard, MD¶ Ruth M. Greenblatt, MD# Kathleen Weber, RN** Katherine Schilder, ND** *Southern Illinois University School of Medicine Springfield, IL †University of Illinois Chicago, IL ‡SUNY Downstate Medical Center Brooklyn, NY §Johns Hopkins Bloomberg School of Public Health Baltimore, MD ∥Georgetown University Washington, DC ¶Montefiore Medical Center Bronx, NY #University of California, San Francisco San Francisco, CA **CORE Center of the John H. Stroger Jr Hospital of Cook County Chicago, IL

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