Couples visiting motels in Managua, Nicaragua, for sexual encounters are more likely to use condoms if the condoms are handed directly to them or are available in their rooms than if condoms are available only on request.¹ However, data collected at 19 motels used mainly for sexual encounters indicate that the presence of health education materials in the room decreases condom use among sex workers and their clients and has no effect on use among couples visiting motels for noncommercial sex.

According to the researchers who conducted the study, crowded living conditions in Managua limit opportunities for private sexual encounters. As a result, a substantial number of such encounters--particularly those between sex workers and their clients--occur in motels that rent rooms for short periods of time.

To evaluate whether providing condoms and health education materials in motels that rent rooms for sexual encounters would affect condom use, the researchers identified 36 such motels in Managua and interviewed 29 of the owners regarding characteristics of the motels and their clients. (Seven owners refused to be interviewed.) The interviews covered such topics as whether a motel was used mainly for commercial or noncommercial sex, the charge for the room, the amount of time guests typically spent in a room, and whether the motels' rooms had flush toilets. Nine of the owners who were interviewed refused to participate in the study, and one of the motels closed during the study period, leaving 19 motels in the study. Eleven of these were used mainly for commercial sex and eight mainly for noncommercial sex. One motel used mainly for commercial sex had flush toilets in its rooms, compared with four of the motels used mainly for noncommercial sex.

The researchers tested six combinations of the intervention: providing condoms to couples who request them; making printed health education materials available in motel rooms and providing condoms to couples who request them; making condoms available in motel rooms; making both condoms and printed educational materials available in motel rooms; distributing condoms unsolicited to couples before they enter their rooms; and distributing condoms unsolicited and making printed educational materials available in the rooms. Nicaragua's Ministry of Health requires motels to provide condoms to all guests, but the general practice in most motels is to give condoms only to people who ask for them. Therefore, the researchers used couples who were given condoms on request to provide a baseline for condom use among motel guests in Managua.

The educational materials contained information about the number of people in Nicaragua and Central America who have AIDS and about the use of condoms to prevent the transmission of HIV and other sexually transmitted diseases. The materials also included diagrams with explanations about the correct way to use a condom. The information was provided in the form of leaflets left on the bed and posters hanging in the room.

To assess whether couples had used condoms, fieldworkers dressed as motel cleaning staff collected condoms from the rooms after the couples had left. The research team classified a couple as having used condoms if at least one condom containing semen was retrieved from their room.

From July 31 to October 4, 1997, the researchers visited the motels on the three busiest days of the week--either Thursday through Saturday or Friday through Sunday--for a total of 24 days in each motel. Overall, the fieldworkers collected data on 456 days.

The fieldworkers collected one or more used condoms from the rooms of 3,106 couples (48%), unused condoms from the rooms of 152 couples (2%) and no condoms from the rooms of 3,205 couples (50%). Couples engaging in commercial sex used condoms three times as frequently as couples engaging in noncommercial sex (61% vs. 20%).

At motels used mostly for commercial sex, couples who rented rooms in which health education materials were available used condoms less frequently than did those who rented rooms that did not contain information (59% vs. 62%). This was not the case, however, at motels used mainly for noncommercial sex, where about one in five couples used condoms, regardless of whether health information was available.

Among couples visiting motels used mainly for commercial sex, 64% of those who were given condoms unsolicited used them, compared with 62% of those who rented rooms in which condoms were available and 56% of those at motels where condoms were given on request. At motels used for noncommercial sex, 25% of couples who received condoms in their rooms used them, compared with 21% of those who were given condoms unsolicited before entering their rooms and 15% of couples at motels where condoms were given to couples on request. Multilevel logistic modeling that controlled for characteristics of the motel showed that provision of health information decreased condom use at motels used for commercial sex (odds ratio, 0.89) and had no effect at those used for noncommercial sex.

The largest effect of type of condom distribution on frequency of use was among couples visiting motels for noncommercial sex who received condoms in their rooms. Compared with couples in such motels who received condoms on request, these couples were more likely to use condoms (odds ratio, 1.81). Couples engaging in noncommercial sex who were given condoms unsolicited before entering their rooms also were more likely to use them (odds ratio, 1.52) when compared with couples who received condoms on request.

Compared with couples who rented rooms for commercial sex and were given condoms on request, couples who rented rooms for commercial sex and were provided condoms in their rooms or were handed condoms directly before entering

their rooms were about equally more likely to use condoms (odds ratios, 1.31 and 1.32, respectively).

The presence or absence of health education materials in the room did not alter the effect of the different methods of condom distribution on couples' frequency of use in either type of motel.

The researchers acknowledge that they may have underestimated condom use among couples at motels used mainly for noncommercial sex because such motels were more likely than motels used mainly for commercial sex to have flush toilets in their rooms. However, they note that because their sample was randomized, disposal of used condoms in toilets was not likely to differ among the different intervention groups.

In the motels the researchers studied, use increased by 8% when condoms were available in the rooms. The researchers estimate that approximately 500,000 acts of sexual intercourse per year take place in these 19 motels, and that approximately one million sexual encounters occur in all motels in Managua during an entire year. Thus, according to the researchers, if the intervention they studied were to be implemented in all motels in Managua, approximately 80,000 additional acts of sexual intercourse per year would be protected.

The investigators conclude that providing condoms in rooms increases condom use substantially, possibly because it allows couples to avoid asking for condoms. In addition, they say, their findings confirm that simply providing information, without offering condoms, "is insufficient to change behavior."--B. Brown

REFERENCE

1. Egger M et al., Promotion of condom use in a high-risk setting in Nicaragua: a randomized controlled trial, Lancet, 2000, 355(9221):2101-2105.