A preliminary profile of HIV risk in a clinic-based sample of MSM in Puerto Rico: implications for sexual health promotion interventions.
Despite the importance of MSM in the emerging HIV epidemic in PR most of the available epidemiological research has focused on injection risk and there is a remarkable absence of detailed epidemiological information about the MSM population. With a few notable exceptions (3, 7, 8, 9, 10, 11), there is little information available about sexual practices and partnering of MSM in PR, or contact and engagement in prevention services in this group. Similarly there is no information about STI screening and treatment among MSM, nor about HIV testing, enrollment in antiretroviral therapy, and treatment compliance. Similar limitations in both epidemiology and targeted prevention exist for MSM populations throughout the Caribbean region.
In an effort to begin to redress these gaps in the available epidemiological information about MSM in PR, the objective of this paper is to use data derived from an ongoing clinic-based study as the basis for developing a preliminary epidemiological description of behavioral risk and to identify priorities for sexual health promotion. Since half of the currently sexually active MSM in the sample are living with HIV, and with the goal of informing both primary and secondary prevention needs, the paper is structured as a comparison between these two subgroups.
In 2007, researchers from the School of Public Health at the University of PR initiated a strategic research collaboration with the clinical staff of Centro Latinoamericano de Enfermedades de Transmision Sexual (CLETS), one of the largest publicly funded centers for STI/HIV screening and treatment in the San Juan metropolitan area. The study design and data collection procedures have been detailed elsewhere (12). Briefly, the design involves random selection of subjects from the patient waiting room, a brief screening to assess eligibility, written informed consent, and participation in a face-to-face computer-assisted behavioral risk survey interview.
The interview is divided into four sections: The first section, sociodemographic characteristics, includes questions on date of birth, education, sources of income, sexual self-concept and identification, history of incarceration, military services, and history of suicide. Section 2 includes a detailed assessment of drug use, including lifetime exposure to a broad range of substances, the year that the individual first used the substance, age at first injection, use of drugs in the 90 days prior to the interview, and injection in the past 90 days. Section 3 involves an assessment of sexual risk included onset of oral, vaginal, and anal sex, sexual practices and partners in the last 90 days, experience in buying or selling sex, participation on group sex in the last year, and details of the individual last sexual contact (13). The fourth and final section includes questions about health history and utilization of health services, including the subjects' purpose for visiting the clinic, self-reported history of STI, Hepatitis B Vaccination, and circumcision status. Additionally, selected clinical data are recovered from the patient's medical files, including current STI and HIV status, HIV treatment status, and indicators of HIV disease (including CD4 and viral load tests).
Frequency distributions and summary measures are used to describe the study sample. Univariate relationships between sexual practices and participants' HIV status were assessed using chi-square tests and t tests. Median values for lifetime measures and mode values for measures of current practices (last 90 days) were used as cut-offs to compare numbers of partners and number of events and to support comparisons between HIV-negative and HIV-positive MSM. All statistical analyses were performed using SPSS version 20.
Study participation was voluntary and included written informed consent. Participants received a small interview fee ($5.00) in compensation for their time in participating in the interview. Study procedures were approved by the Human Research Subjects Protection Office of the University of Puerto Rico--Medical Sciences Campus.
As of June 2011, a total of 626 male clinic patients have participated in the study. Almost a third (29.2%, n=183) have had sexual contact with another male in their lifetime and within this group, roughly two-thirds (65.6%, n = 120) have had sexual contact with a male partner within the last 90 days. Since the primary objective of this paper is to profile current sexual risk among HIV+ and HIV- MSM, the following analysis is limited to men who reported current sexual activity with a male partner within the last 90 days (n=120).
As included in Table 1, mean age of the sample is 34.2 years (SD=11.3, Range =17-63) with most (52.5%) being older than 30 years. Overall, the majority (87.5%) of MSM report having been born in PR and most (85.8%) are residing in the San Juan metropolitan area. Nearly a third (28.3%) are students. Three-quarters (79.3%) have attended college and 35.0% have at least a Bachelor's degree. About two thirds (65.0%) have at least part time employment. Nearly half (40.8%) are living alone, a third (33.3%) with their family, 13.3% with a sex partner, and 11.7% with a non-family, non-sex partner roommate.
Almost all (95.0%) described their gender as male, with four participants identifying as female and three as transgender. More than half (63.3%) describe themselves as exclusively attracted to men, 21.7% are primarily attracted to men but sometimes to women, 10.0% are equally attracted to men and women, and 5.0% are primarily or exclusively attracted to women. 75.6% describe themselves as homosexual or "Gay," and 21.8% as bisexual.
HIV-positive MSM are significantly older (mean age = 39.9 years) than HIV-negative MSM (mean age = 27.9 years; p-value = <0.001).
Lifetime and current use of tobacco, alcohol, and other drugs
As shown in Table 2, almost two-thirds (63.3%) have used tobacco in their lifetime. Among those who have ever used tobacco, two-thirds (71.9%) are current tobacco users (defined as within the last 90 days). Similarly, most (92.5%) have used alcohol in their lifetime and most of these (82.0%) are current alcohol users. Lifetime exposure to a wide range of illicit or illegal drugs is relatively high (55.0%), including cannabis (48.3%), nitrate inhalants (40.8%), cocaine (28.3%), heroin (7.6%), methamphetamine (5.8%), and one or more types of club drugs including Hydroxybutyric acid (GHB), Ketamine, and 3,4-methylenedioxy-N-methylamphetamine (MDMA) (9.2%). 15.2% have a prior history of injection drug use.
Levels of current drug use are considerably lower, including marijuana (39.7%), nitrate inhalants (38.8%), and cocaine (14.7%). However, among those MSM who have ever used an illicit drug, 40.9% have used at least one illicit drug during the last 90 days.
HIV-positive MSM have higher prevalence of lifetime illicit drug use (excluding marijuana) than HIV-negative MSM (68.3% vs. 40.4%, p=0.002), but did not significantly differed in relation to current drug use.
Selected mental health and clinical indicators
Overall, nearly a quarter (22.2%) of the MSM had one or more suicide attempts in their lifetime, and nearly half of these (45%) had multiple attempts (see Table 3). Two-thirds (61.7%) self-report diagnosis with one or more STI (excluding HIV), including Syphilis (33.3%), Gonorrhea (19.2%), Herpes (17.5%), Genital Warts (16.8%), Chlamydia (7.6%), Hepatitis B (6.7%), and Hepatitis C (5.9%). A large proportion (43.3%) has had two or more STI diagnoses. Only a third of these men (38.5%) are circumcised. Only half (52.5%) could confirm being vaccinated against Hepatitis B.
HIV-positive MSM are significantly more likely than HIV-negative MSM to have had multiple STI diagnoses (p <0.001) and a previous diagnosis of Herpes (p=0.017). Consistent with the fact that the clinic where the sample was drawn is also a primary center for HIV care, nearly half of the MSM (52.5%) are living with HIV infection. Most of these are enrolled in antiretroviral therapy treatment (77.8%). However, consistent with patterns observed in other high risk groups in the study, (14) MSM initiate care at a relatively late stage in the course of HIV disease. In a preliminary analysis of data recovered from chart review, mean CD4 among newly diagnosed HIV+ MSM was 425 cells/[mm.sup.3] (SD=209; Range: 193-806) and mean viral load was 6,947 copies/ml (SD=11,047; Range: 294-28,805), both indicative of substantial immune impairment at time of treatment enrollment.
Onset of sex
Mean age of first oral sex with a male partner was 17.4 years (SD=4.8, Range 10-41). Half the sample (49.5%) had more than 10 male oral sex partners in their lifetime (see Table 4). Mean age of first anal intercourse with a male partner was 18.9 years (SD=5.3, Range 10-41). More than a third (36.7%) had more than 10 anal sex partners in their lifetime. Almost half (47.5%) had sex with a female partner in their lifetime, with a mean age of 18.2 years (SD=5.1, Range 11-40) at first penetrative sex with a female partner. However, only 5.0% had sex with a female partner within the last 90 days (see Table 5).
HIV-positive MSM have had more male sexual partners in anal intercourse (p=0.005) and more likely had a female partner in their lifetime (p=0.063). HIV-negative MSM had an earlier onset (Mean age=15.2 years) of penetrative sex with a female partner (p=<0.001).
Current sexual practices (Last 90 days)
Overall, MSM evidence relatively large numbers of multiple, concurrent sex partners, substantial age-discordance, and limited condom use. As included in Table 5, within the last 90 days, 29.1% performed oral sex on a male partner on 9 or more occasions and 35.0% received oral sex from a male partner on 9 or more occasions during the same interval. Nearly a quarter (22.8%) engaged in more than 6 receptive anal intercourse (RAI) events within the last 90 days and a third (32.9%) engaged in more than 6 insertive anal intercourse (IAI) events in this interval. In the overall 90 days measures, no significant differences were found by HIV status.
Last sexual intercourse
At last RAI, nearly half of the exchanges (47.4%) involved a primary partner, 35.5% were with a casual (repeat) partner, and 17.1% with a new partner (See Table 6). Over half (54.0%) of the last RAI exchanges involved an age-discordant partner ([+ or -] 5 years). More than one quarter of the exchanges involved receptive penetration (27.8%) without a condom, including receipt of ejaculation without a condom (45.5%) or withdraw of the penis before ejaculation (54.4%). At last RAI, HIV-negative MSM were less likely than HIV-positive MSM to use a condom (41.7% vs. 16.3%, p=0.012) and HIV-positive MSM were more likely than HIV-negative MSM to have engaged in receptive penetration with a condom (81.4% vs. 58.3%, p = 0.025).
At last exchange involving IAI, half (50.0%) involved a primary partner, 29.4% involved a causal (repeat) partner, and roughly one fifth were with a new partner (20.6%). Half (51.5%) involved exchanges with an age discordant partners ([+ or -] 5 years). At last IAI, 40.2% of the exchanges involved insertive penetration without a condom, including insertive ejaculation without a condom (51.5%) and withdraw of the penis before ejaculation (53.7%). At last IAI, HIV-negative MSM were more likely to have engaged in insertive penetration without a condom (58.1% vs. 20.5%, p = 0.001), and HIV-positive MSM were more likely to have engaged in insertive penetration with a condom (79.5% vs. 48.8%, p = 0.004).
The data are limited to MSM recruited from a clinic environment, notably one that may be expected to select for high risk individuals. Consequently, the findings may not be generalizable to the overall MSM population in PR. Moreover, the measures of sexual risk that were employed were intended for use in a general clinic sample and may not adequately capture the complexity of sexual practices of MSM. Similarly, the modest sample size limits the types of analysis that can be advanced at this time. For example, some differences between HIV-positive and HIV-negative MSM may be an artifact of the significant differences in age between these two groups but we are unable to assess this question in the current sample. Similarly, we note that 21.8% of the sample self-identified as bisexual. However, the current sample does not include a sufficient number of subjects to support independent analysis of this subgroup. There is a growing body of literature which shows that gender identity, sexual identity, and sexual self-concept can have important implications for sexual roles and partnering and additional research on these issues is needed. Lastly, our data is cross-sectional and consequently we cannot assess the way in which sexual risk practices of MSM in PR have changed over time, including for example, whether or not behavioral risks among MSM are increasing or decreasing.
These limitations notwithstanding, the data support the following preliminary observations about sexual risk among MSM in PR: First, even allowing for the fact that the sample was recruited in an STI clinic, MSM in this sample have an extraordinarily high rate of lifetime diagnosis with STI. Second, sexual profiles of MSM include high rates of multiple, concurrent partners (including both new and repeat partners) as well as substantial age cohort mixing. Third, MSM have relatively high rates of current sex with female partners, suggesting potential for epidemiological bridging between MSM and female partner sexual networks. Fourth, substantial levels of sexual transmission risk remain among both HIV-positive and HIV-negative MSM. For example, at last anal intercourse with a male partner, MSM had relatively high rates of unprotected anal penetration, limited condom use, and high rates of semen exchange. HIV-negative MSM have higher rates of unprotected semen exchange in both RAI and IAI compared to HIV-positive MSM. These behavioral patterns contribute to new infections and suggest the potential for a self-sustaining HIV epidemic among MSM in PR.
The data highlight the critical need for both primary and secondary prevention programming for MSM populations in PR. The following recommendations may be considered: MSM evidenced relatively high rates of oral sex as well as relatively high rates of multiple concurrent partners, a pattern that facilitates diffusion of some types of STI (consistent with the high rates of self-reported STI history evidenced in this sample). Noteworthy is the fact that two of the key STI, HPV and HBV, are preventable by vaccination. Yet MSM evidence low rates of vaccination. Targeted interventions are needed to engage and retain MSM in vaccination programs.
Interventions are needed to engage and retain MSM in preventative health services, including routinization of HIV screening. It may be expected that effective engagement in health services would contribute to earlier detection, more timely engagement in HIV treatment, and reduced risk of secondary transmission. In this context, it should be emphasized that substantial thought must be given as to how to effectively engage younger MSM cohorts, many of whom are sexually active with both men and women, and who may not accessible using identity-based service delivery models. Targeted interventions are also needed for MSM living with HIV in order to improve engagement and retention in HIV care and to reduce secondary infection in their sexual networks.
MSM have high rates of suicide, including substantial rates of multiple attempts, a fact that may reflect high levels of untreated mental health distress. High rates of anxiety, depression, and suicidality may contribute to sexual risk and may also contribute to poor health outcomes among HIV+ MSM (e.g., poor ART treatment compliance, etc.). Increased attention to mental health programming for MSM is needed.
Beyond these specific issues, there is a more fundamental need to reconsider existing approaches to HIV prevention for MSM in PR, most of which are limited to relatively generic testing and counseling programing. MSM in PR are not unique in evidencing substantial rates of behavioral risk. Similar behavioral patterns have been observed in other MSM populations in the US (15, 16), particularly among ethnic and racial minority MSM (17). In reflecting upon the persistence of behavioral risk among MSM populations, a number of recent review articles (18) have suggested that part of the problem may lie in the fact that most behavioral interventions for MSM have been conceptualized within a disease-containment model and largely absent the kind of holistic sexual health promotion programming that is increasingly recognized to be required in order to foster and sustain sexual health. For example, while increasing HIV testing is a necessary and important component to any health promotion program, in and of itself it does not advance sexual health. Yet conventional HIV testing and counseling remains the primary HIV interventions available to MSM in PR. Both behavioral and ecological interventions are needed to promote comprehensive sexual health among MSM in PR and thereby reduce underlying determinants of poor health outcomes in this group. Noteworthy in this socio-cultural context is the fact that MSM face substantial risk for stigma and discrimination, particularly in health care settings. Health services interventions are needed that will change the nature of the health services environment in order to enhance open communication between MSM and health care providers and to foster improved engagement in care. Such models may be expected to contribute to more timely screening and treatment of STIs and earlier engagement in HIV care among HIV-positive MSM. This latter goal is particularly important for reducing secondary HIV infection, a noteworthy outcome given escalating HIV incidence rates.
We wish to thank the men who agreed to participate in the study. Additionally, we thank the UPR undergraduate and graduate students who assisted in data collection. Finally, we wish to extend our gratitude to the clinical staff at Centro Latinoamericano de Enfermedades de Transmision Sexual (CLETS) for their assistance in facilitating the data collection.
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(11.) Finlinson HA, Colon HM, Robles RR, et al. An exploratory study of Puerto Rican MSM drug users: The childhood and early teen years of gay males and transsexual female. Youth Soc 2008;39:362-384.
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Michael C. Clatts, PhD *; Carlos E. Rodriguez-Diaz, PhD, MPHE *; Hermes Garcia, MD, MPH ([dagger]); Ricardo L. Vargas-Molina, MA *; Gerardo G. Jovet-Toledo, BS *; Lloyd Goldsamt, PhD ([double dagger])
* Graduate School of Public Health, University of Puerto Rico Medical Sciences Campus, San Juan, Puerto Rico; ([dagger]) Centro Latinoamericano de Enfermedades de Transmision Sexual (CLETS), Puerto Rico Department of Health, San Juan, Puerto Rico; ([double dagger]) National Development and Research Institutes, Inc. New York, New York, United States of America
The authors have no conflict of interest to disclose.
Address correspondence to: Michael C. Clatts, PhD, PO Box 365067, San Juan, PR 00936-5067. Email: firstname.lastname@example.org
Table 1. Sociodemographic characteristics of a sample of men Who Have Sex with Men (MSM) in Puerto Rico by HIV serostatus (n=120) Characteristics All MSM HIV+ MSM HIV- MSM n (%) n (%) n (%) p-value Age (mean, SD) 34.2 (11.3) 39.9 (9.6) 27.9 (9.6) <0.001 * Education <High School 26 (21.7) 12 (19.0) 14 (24.6) 0.464 >High School 94 (78.3) 51 (81.0) 43 (75.4) Employment At least 78 (65.0) 42 (66.7) 36 (63.2) 0.687 part-time Unemployed (Excluding 20 (16.7) 14 (22.2) 6 (10.5) 0.086 ** students) Annual Incomme 0.064 ** None 20 (16.8) 9 (14.3) 11 (19.6) < $20,000 68 (57.1) 32 (50.8) 36 (64.3) [greater than 31 (26.1) 22 (34.9) 9 (16.1) or equal to] $20,000 Area of residence San Juan Metropolitan Area 103 (85.8) 50 (79.4) 53 (93.0) 0.033 * Non-San Juan Metropolitan Area 17 (14.2) 13 (20.6) 4 (7.0) Sexual identity Homosexual or gay 90 (75.6) 48 (77.4) 42 (73.7) 0.635 * Significant at p<0.05; ** Significant at p<0.10 Table 2. Lifetime and current (Last 90 days) tobacco, alcohol, and illicit drug use among a sample of MSM in Puerto Rico by HIV serostatus (n=120) Practices All MSM HIV+ MSM HIV- MSM p-value n (%) n (%) n (%) Drug use Lifetime use of tobacco, alcohol and other illicit/ illegal drugs Tobacco 57 (63.3) 33 (63.5) 24 (63.2) 0.976 Alcohol 111 (92.5) 58 (92.1) 53 (93.0) 0.849 At least one Illicit/Illegal drug (excluding marijuana) 66 (55.0) 43 (68.3) 23 (40.4) 0.002 * Injecting drug use 10 (15.2) 6 (14.0) 4 (17.4) 0.711 Current use of tobacco, alcohol and other illicit/illegal drugs (<90 days) Tobacco 41 (71.9) 24 (72.7) 17 (70.8) 0.875 Alcohol 91 (82.0) 45 (77.6) 46 (86.8) 0.207 Used one or more least one Illicit/Illegal drug (excluding marijuana) 27 (40.9) 16 (37.2) 11 (47.8) 0.403 Injected illicit drug 2 (20.0) 2 (33.3) 0 (-) -- * Significant at p<0.05 Table 3. Self-reported mental health and clinical indicators among a sample of MSM in Puerto Rico by HIV serostatus (n=120) Indicators All MSM HIV+ MSM HIV- MSM p-value n (%) n (%) n (%) History of suicide attempts At least one suicide attempt 20 (22.2) 13 (25.0) 7 (18.4) 0.458 Age at first suicide attempt (mean, SD) 28.8 (12.4) 30.3 (12.6) 25.9 (12.6) 0.461 Multiple suicide attempts 9 (45.0) 7 (53.8) 2 (28.6) 0.287 History of STI Syphilis 40 (33.3) 24 (38.1) 16 (28.1) 0.245 Gonorrhea 23 (19.2) 12 (19.0) 11 (19.3) 0.972 Herpes 21 (17.5) 16 (25.4) 5 (8.8) 0.017 * Warts 20 (16.8) 12 (19.0) 8 (14.3) 0.488 Chlamydia 9 (7.6) 4 (6.3) 5 (8.9) 0.597 HBV 8 (6.7) 6 (9.5) 2 (3.6) 0.213 HCV 7 (5.9) 5 (7.9) 2 (3.6) 0.325 At least one STI (not HIV) 74 (61.7) 42 (66.7) 32 (56.1) 0.236 Two or more STI 52 (43.3) 42 (66.7) 10 (17.5) <0.001 * Circumcised 45 (38.5) 28 (46.7) 17 (29.8) 0.061 ** HBV vaccination 63 (52.5) 28 (44.4) 35 (61.4) 0.063 ** HIV treatment 63 (52.5) 49 (77.8) -- -- * Significant at p<0.05 ** Significant at p<0.10 Table 4. Onset and cumulative sexual risk among a sample of MSM in Puerto Rico by HIV serostatus (n=120) All MSM HIV+ MSM n (%) n (%) Lifetime Sex with Men Age at first oral sex Mean = 17.4, 17.8 (4.9) SD = 4.8, Range = [10,41] Number of oral sex More than 35 (60.3) partners 10 Partners: 55 (49.5) Age at first anal sex Mean = 18.9, 19.1 (5.2) SD = 5.3, Range = [10,41] Number of anal sex More than 28 (49.1) partners 10 Partners: Lifetime Sex with 40 (36.7) Women Oral, vaginal or 57 (47.5) 35 (55.6) anal sex Age at first Mean=18.2, 19.9 (5.4) penetrative sex SD=5.0, Range = [11,40] HIV- MSM p-value n (%) Lifetime Sex with Men Age at first oral sex 17.0 (4.8) 0.428 Number of oral sex 20 (37.7) 0.017 * partners Age at first anal sex 18.7 (5.5) 0.671 Number of anal sex 12 (23.1) 0.005 * partners Lifetime Sex with Women Oral, vaginal or 22 (38.6) 0.063 ** anal sex Age at first 15.2 (2.0) <0.001 * penetrative sex * Significant at p<0.05; "Significant at p<0.10 Table 5. Current (Last 90 days) sexual practices and partners among a sample of MSM in Puerto Rico by HIV serostatus (n=120) All MSM HIV+ MSM HIV- MSM p-value n (%) n (%) n (%) Oral Sex Frequency of More than 9 performing oral Events: 32 sex (29.1) 19 (33.3) 13 (24.5) 0.310 Frequency of More than 9 receiving oral Events: 36 sex (35.0) 17 (31.5) 19 (38.8) 0.438 Anal Intercourse Frequency of anal More than 8 intercourse Events: 26 (24.8) 14 (27.5) 12 (22.2) 0.535 Frequency of RAI More than 6 Events: 18 (22.8) 10 (23.3) 8 (22.2) 0.913 Numbers of partners More than 2 in RAI Events: 17 (22.4) 11 (25.6) 6 (18.2) 0.443 Frequency of IAI More than 6 Events: 27 (32.9) 14 (35.9) 13 (30.2) 0.586 Numbers of partners More than 2 in IAI Events: 15 (18.5) 8 (21.1) 7 (16.3) 0.581 Oral, vaginal or anal sex with female partner 6(5.0) 2 (3.2) 4 (7.0) 0.347 * Significant at p<0.05; ** Significant at p<0.10 Table 6. Sexual practices at last sexual encounter among a sample of MSM in Puerto Rico by HIV serostatus (n=120) All MSM HIV+ MSM HIV- MSM p-value n (%) n (%) n (%) Last RAI 79 (65.8) 43 (68.3) 36 (63.2) 0.557 Repeat primary sex partner 36 (47.4) 16 (38.1) 20 (58.8) 0.114 Repeat casual partner 27 (35.5) 16 (38.1) 11 (32.4) 0.114 New partner 13 (17.1) 10 (23.8) 3 (8.8) 0.114 Age discordance ([+ or -] 5 years) 41 (54.0) 25 (59.5) 16 (47.1) 0.278 Receptive penetration without condom 22 (27.8) 7 (16.3) 15 (41.7) 0.012 Receipt of ejaculation without condom 10 (45.5) 2 (28.6) 8 (53.3) 0.286 Receptive penetration with condom 56 (70.9) 35 (81.4) 21 (58.3) 0.025 * Receipt of ejaculation with condom 30 (53.6) 15 (42.9) 15 (71.4) 0.038 * Partner withdrew before ejaculation 43 (54.4) 25 (58.1) 18 (50.0) 0.469 Last IAI 82 (68.3) 39 (61.9) 43 (75.4) 0.111 Repeat primary sex partner 34 (50.0) 14 (43.8) 20 (55.6) 0.598 Repeat casual partner 20 (29.4) 11 (34.4) 9 (25.0) 0.598 New partner 14 (20.6) 7 (21.8) 7 (19.4) 0.598 Age discordance ([+ or -] 5 years) 35 (51.5) 20 (62.5) 15 (41.7) 0.086 ** Insertive penetration without a condom 33 (40.2) 8 (20.5) 25 (58.1) 0.001 * Insertive ejaculation without a condom 17 (51.5) 3 (37.5) 14 (56.0) 0.367 Insertive penetration with a condom 52 (63.4) 31 (79.5) 21 (48.8) 0.004 * Insertive ejaculation with a condom 25 (48.1) 15 (48.4) 10 (47.6) 0.957 Withdraw before ejaculation 44 (53.7) 21 (53.8) 23 (53.5) 0.974 * Significant at p<0.05; ** Significant at p<0.10
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|Title Annotation:||FULL-LENGTH ARTICLE|
|Author:||Clatts, Michael C.; Rodriguez-Diaz, Carlos E.; Garcia, Hermes; Vargas-Molina, Ricardo L.; Jovet-Tole|
|Publication:||Puerto Rico Health Sciences Journal|
|Date:||Sep 1, 2012|
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