Lecture | Quiz | Learning Exercise | Answer Key

Developed by JHPIEGO’s Training in Reproductive Health Project with funding from USAID.

Lesson 5: Barrier Methods of Family Planning, Dual Protection, and Emergency Contraception
Instructor: Emmanuel 'Dipo Otolorin, MD

Objectives

By the end of this lesson, participants will be able to:

1. Define common terms relating to barrier methods of contraception (male condom, female condom, diaphragm, cervical cap, spermicide and dual protection)
2. Describe the role of male and female condoms in preventing pregnancy and sexually transmitted infections
3. Discuss the role of spermicides in contraception 
4. Define dual protection
5. Describe the role of emergency contraception in family planning.

Definitions

MALE CONDOMS are thin sheaths of rubber, vinyl or natural products that may be treated with a spermicide for added protection. They are placed on the penis once it is erect. Condoms differ in such qualities as shape, color, lubrication, thickness, texture and addition of spermicide (usually nonoxynol-9). 

1. FEMALE CONDOMS are thin sheaths of polyurethane plastic with polyurethane rings at either end. They are inserted into the vagina before intercourse.
2. DIAPHRAGMS are dome-shaped latex (rubber) cups that are inserted into the vagina before intercourse and cover the cervix.
3. The CERVICAL CAP is a smaller rubber device that fits snugly around the cervix. (Since the cap is not widely available, it will not be discussed extensively in this lesson.) 
4. SPERMICIDES are chemicals (usually nonoxynol-9) that inactivate or kill spermatozoa. The different types include aerosols (foams), vaginal tablets, suppositories or dissolvable film and creams.
5. DUAL PROTECTION is protection from both unintended pregnancy and sexually transmitted diseases (including HIV). 

The goal of contraception for the HIV-positive woman should be high contraceptive efficacy and low risk of HIV transmission. Method selection must also take into consideration potential risks associated with local genital irritation, interference with menstrual bleeding patterns and drug interactions.

Statistics have indicated that men play a critical role in spreading HIV/AIDS and that their attitudes about sexuality and sense of invulnerability put women at risk. Men are also likely to have more sexual partners than women, thus putting them at greater risk of becoming infected and transmitting the virus. Therefore, HIV prevention efforts must target both men and women.

Condoms

Latex condoms are the only contraceptive method proven to reduce the risk of all sexually transmitted infections (STIs), including HIV. Latex condoms act as a physical barrier that prevents spermatozoa from gaining access to the female reproductive tract. Laboratory studies have also shown that viruses (including HIV) do not pass through intact latex condoms even when such condoms are stretched or stressed. However, natural skin condoms are not recommended. Because of the porous nature of these condoms, they do not protect the users from HIV transmission.

Male Condoms

If used consistently and correctly, male condoms can be very effective. Reviews of the literature confirm that condoms can prevent both pregnancy and STIs, including HIV. Male latex condoms are recommended for the prevention of HIV transmission resulting from vaginal sex, anal sex or oral sex with an HIV-infected person. Consistent condom use is very effective at preventing HIV infection, even among serodiscordant couples, where one partner is infected and the other is not. Studies have confirmed that, with consistent condom use, the HIV infection rate among the uninfected partners was less than 1 percent per year. Where one partner is definitely infected, however, inconsistent condom use can be as risky as not using condoms at all. In Thailand, the promotion, by government, of 100% condom use by prostitutes led to a dramatic increase in the use of condoms (from 14% in 1990 to 94% in 1994) and an equally dramatic decline in the nation-wide numbers of bacterial STIs (from 410,406 cases in 1991 to 27,362 cases in 1994) as well as a reduced HIV prevalence in Thai soldiers. 

Apart from preventing pregnancy and STIs/HIV, male condoms promote male involvement in family planning, prolong erection and time to ejaculation and may help prevent cervical cancer. As a contraceptive method, male condoms are effective immediately, do not affect breastfeeding, can be used as a backup to other methods and have no method-related health risks or systemic side effects. Furthermore, they are widely available (in pharmacies and community shops), need no prescription or medical assessment before supply and are inexpensive (in the short-term). The risks of latex allergies are very low, with reported cases less than 0.08% in the USA.

When counseling patients about male condoms, it is important to provide clear instructions for its use. Such instructions may include the following: 

• Use a new condom every time you have vaginal or anal intercourse or oral sex.
• Use a spermicide with condom for maximum effectiveness and protection.
• Avoid using teeth, knife, scissors or other sharp utensils to open the package.
• Unroll the condom onto the erect penis before the penis enters the vagina (because pre-ejaculatory semen contains active sperm).
• If the condom does not have an enlarged end (reservoir tip), about 1 or 2 cm should be left at the tip for the ejaculate.
• Withdraw the penis before losing erection while holding on to the base (ring) of the condom. (This prevents the condom from slipping off and spilling semen.)
• Dispose of used condoms by placing in a waste container, placing in latrine or burying.
• Keep an extra supply of condoms available at all times. Do not store condoms in a warm place where they will deteriorate, resulting in leakages during use.
• Check the date on the condom package to ensure that it is not out of date.
• Do not use a condom if the package is broken or the condom appears damaged or brittle.
• Do not use mineral oil, cooking oils, baby oil or petroleum jelly as lubricants for a condom (as these damage condoms in seconds). If lubrication is required, use saliva or vaginal secretions.

Female Condoms

By and large the benefits of male condoms equally apply to female condoms. Female condoms also have the added advantage of empowering the woman to take control of her own situation. Female condoms are best suited for a woman who finds using a method near or at the time of intercourse acceptable, can learn the insertion technique, and has sufficient privacy for insertion and removal. A review of several female barrier methods has estimated that they reduce transmission of STIs by between 50 and 75 percent. And, unlike latex male condoms, which are weakened by using oil-based lubricants, the female condom may be used with any type of lubricant without compromising its strength. It is prelubricated, but more lubricant may be added. However, female condoms are not designed or recommended for anal sex.

In a recent South African study, prostitutes were allowed to re-use the female condom up to eight times after washing, drying, and re-lubricating with vegetable oil between uses. Results revealed no deterioration in the strength of the condom when evaluated by FDA-approved (United States Federal Drug Administration) seam strength and burst tests. The breakage rate was not significantly different from that found in a single-use study from the U.S. These researchers concluded that, while it is preferable to use a new female condom with each sexual encounter, re-use of a female condom might be an acceptable alternative in situations where a new, unused device is not available.

Diaphragms and Cervical Caps

The diaphragm is a user-dependent, woman-controlled method. It is a latex device that covers the cervix and part of the vaginal wall, and is held in place by a flexible rim. The cervical cap is a smaller rubber device that fits snugly around the cervix. Both the diaphragm and cervical cap are somewhat protective against agents that attack the cervix but may be associated with vaginal anaerobic overgrowth. By being protective against cervical infection, it may also be protective against cervical neoplasia, a malignancy associated with infection with human papilloma virus (HPV).

The limitations for the use of the diaphragm include its moderate effectiveness (6-20 pregnancies per 100 women during the first year of use if used with spermicide), which is a reflection of the user’s willingness to follow instructions, including the fact that it must be left in place for 6 hours after intercourse. It requires continued motivation and use with each act of intercourse. 

Another limitation is the need for a pelvic examination by a trained service provider (who may be non-physician) for initial fitting and postpartum refitting. It is also associated with urinary tract infections in some users. Supplies must be readily available before intercourse occurs, including spermicides that are required with each use.

Female barrier methods are, generally, associated with fairly high failure (pregnancy) rates, with first year rates for typical use reaching 20% for diaphragms, 20% for the cervical cap in women who have not previously had children and 26% for women who have had children and 21% for the female condom user. In contrast, male condoms are associated with a failure rate of up to 14% during the first year of common use (not used correctly every time) and only 3% failure rate during first year of perfect (used correctly every time) use.

Spermicides

Spermicides are chemical products inserted in a woman's vagina before sexual intercourse that inactivate or kill sperm. The main chemicals used in spermicides are nonoxynol-9, octoxynol-9, menfegol, and benzalkonium chloride. Of these, nonoxynol-9 is the most common. Spermicides often are used as a temporary method while waiting for a long-term method or by couples that have intercourse infrequently.

Research on the effectiveness of spermicides, particularly nonoxynol-9 (N-9), in reducing STI transmission has provided conflicting results. Laboratory tests of N-9 consistently show that N-9 kills HIV and other STI pathogens. Early small-scale studies of N-9 use suggest that it may protect against STIs. Results of a two-year study in Cameroon, however, found that where condoms protected a high percentage of sexual acts, use of N-9 (lower-dose film) did not confer additional protection against gonorrhea, chlamydia, or HIV. Data presented at the XIII International AIDS Conference indicated that frequent use and higher doses of N-9 could lead to tissue trauma, thus possibly increasing the risk of infection. These latest data show that N-9 is ineffective against HIV transmission among women who use large amounts of spermicide on a frequent basis. Based on data presented at the conference, the U.S. Centers for Disease Control (CDC) recommends that HIV prevention guidelines be revised to indicate that N-9 should not be recommended as an effective means of HIV prevention. UNAIDS (Joint United Nations Programme on HIV/AIDS) and the CDC are considering official revisions to public health guidelines for the use of N-9 for HIV prevention and for pregnancy prevention in populations at high risk for HIV. 

Emergency Contraception

Emergency contraceptives are methods women can use to prevent pregnancy after unprotected intercourse (such as when a contraceptive fails or when sex occurs without contraception). Only two types of emergency contraception are currently available: emergency contraceptive pills (ECPs) and emergency copper-bearing IUD (intrauterine device) insertion. ECPs can be used up to 72 hours (three days) after unprotected sexual intercourse; emergency IUD insertion can be used up to five days after unprotected sexual intercourse. Both methods are safe and effective if proper service delivery guidelines are followed. The only condition restricting use of ECPs is established pregnancy. Conditions restricting regular use of IUDs also apply to their emergency use. Emergency contraceptives are not protective against HIV infection. They, however, have a role as a backup contraceptive method (to prevent unintended pregnancy) when the condom slips off or bursts.

Dual Protection

Dual protection is protection against pregnancy as well as protection against HIV and other STIs. The safest form of dual protection is mutual monogamy between non-infected partners using effective contraception. There are five internationally recognized approaches to dual protection. They are:

• Condom use alone
• Condom use combined with another contraceptive method
• Mutual monogamy combined with another contraceptive method
• Abstinence/delay
• Avoidance of all penetrative sex

To many clients, dual protection typically involves the combination of a reliable primary method for pregnancy prevention such as combined oral pills, IUD, Norplant implants, AND condoms added for STI prevention. Alternatively, dual protection may involve the correct and consistent use of the condom alone for both pregnancy and STI prevention. However, because of the higher failure rates experienced with incorrect condom use, emergency contraceptive pills may also be used as backup when the condom slips, breaks or was not used in the first place.

Clients who consider themselves or their partners to be at high risk of HIV and other STIs are good candidates for dual method use. Women at risk of STI/HIV who cannot persuade their male partners to use a male condom may choose to use a female condom or the diaphragm with spermicide to protect themselves against both STIs and unintended pregnancy. 

Summary

The condom is the only contraceptive method proven to reduce the risk of all STIs, including HIV. If used consistently and correctly, male condoms can also be very effective in preventing unintended pregnancy. However, because typical use failure rates are fairly high, dual protection which combines condom use with a more reliable contraceptive method such as combined oral pills, implants, IUDs, or voluntary surgical contraception, is advisable for people living with HIV/AIDS.

Regardless of her history, a woman should always be informed if the contraceptive method she is using would not protect her against STIs. She should thereafter be offered the additional protection of barrier methods. 

Next Week's Lesson: Hormonal Methods, IUDS, Fertility Awareness Methods, and Voluntary Surgical Contraception

References and Suggested Additional Reading

1. Lisken, L. et al. Condoms now more than ever. Population Reports H(8) (September 1990).
2. Family Health International (FHI). The Latex Condom -- Recent Advances, Future Directions. Research Triangle Park: FHI. (1998). (Available online at <http://www.fhi.org/en/fp/fpother/conom/index.html>).
3. PATH (Program for Appropriate Technology in Health). Condoms protect against STDs and HIV: correct and consistent use is key. Outlook 12(4) (December 1994).
4. Gardner, R, et al. Closing the condom gap. Population Reports Series H, Number 9 (April 1999). (Available online at <http://www.jhuccp.org/pr/h9edsum.stm>).
5. de Vincenzi I. A longitudinal study of human immunodeficiency virus transmission by heterosexual partners. The New England School of Medicine, 331(6) (August 11, 1994).
6. Beksinska, M.E. et al. Structural integrity of the female condom after multiple uses, washing, drying, and re-lubrication. Contraception 63(1): 33-36 (January 2001).
7. Elias, C.J. et al. Women-controlled HIV prevention methods. In: AIDS in the World II: Global Dimensions, Social Roots, and Responses, The Global AIDS Policy Coalition. Mann, J. and Tarantola, D. (editors), New York: Oxford University Press (1996).
8. Feldblum P. and Joanis C. Modern Barrier Methods: Effective Contraception and Disease Prevention. Family Health International (1994).
9. Family Health International (FHI). Study examines N-9 film effect on STDs; N-9 contraceptive film and the risk of STDs; and Selected research involving N-9 and STDs. Network 17(3):4-8 (Spring 1997).  
10. Kreiss, J. et al. Efficacy of nonoxynol-9 contraceptive sponge use in preventing heterosexual acquisition of HIV in Nairobi prostitutes. Journal of the American Medical Association (JAMA) 268(4) (1992).
11. Niruthisard, S. et al. Use of nonoxynol-9 and reduction in rate of gonococcal and chlamydial cervical infections. The Lancet 339 (1992).
12. Glasier A, Baird D. The effects of self-administering emergency contraception. New England Journal of Medicine 239(1): 1-4 (July 2, 1998).
13. FHI. Emergency contraceptive pills. Network 21(1) (2001). (Available online at <http://www.fhi.org/en/fp/fppubs/network/v21-1/index.html>)