Contraception and STDs 

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Introduction

In looking at the interaction between contraception and STDs, there are two fundamental issues that need to be addressed:

• Do contraceptive methods and practices affect the acquisition and natural history of STD and HIV infection?
• Does susceptibility to or presence of STDs affect contraceptive efficacy and choice?

A clear understanding of the interaction between STDs and contraception is essential in providing services for family planning and management of STDs. This is particularly important in a situation where both the contraceptive prevalence rate, as well as the prevalence of STDs, is on the rise. The interaction works both ways. It is clear that the use of condoms will provide some reduction in transmission of STDs. On the other hand, it also has been shown that the use of the IUD in the presence of cervical STDs may lead to PID. The presence of STDs or clients’ susceptibility to STDs will influence choice, not only for individuals but also in programs. For example, where there are no diagnostic facilities for gonorrhea and chlamydia, and the prevalence of these organisms is sufficiently high, the provision of IUD services may put clients at increased risk.

The concept of safe sex is particularly relevant both to the control of STDs and the control of fertility. Safe sex should be seen as a means for prevention of unwanted pregnancy as well as the means for protection against STDs and HIV. Providing services for prevention and management of STDs within family planning settings is logical in that both these services serve to make sex safer. Of particular concern to FP workers is that there is gender discrimination in the way STDs affect women. Transmission of STDs from men to women is more efficient because the vagina offers a larger surface area and there is a longer duration of contact with pathogens. In women STDs are frequently asymptomatic, the clinical symptoms are more subtle than in men and the clinical signs are less easily detectable. As a result of this there is delay in seeking care, leading to long-term complications that often are very serious.

Women generally seek care for their STD symptoms later than men. In a study by Moses et al (1994), 30 percent of women had STD symptoms for longer than 2 weeks before seeking health care, as opposed to 15 percent of men (see Table 1).

Table 1. Health Seeking Behavior and STDs

Duration of STD Symptoms More Than 2 Weeks Males 15.5% Females 30.5% Odds Ratio 2.4 (1.4-4.1)

Source: Moses et al 1994.

Another area of concern is the fact that women tend to have sex while symptomatic more often than men. In the same study by Moses et al, 17.8 percent of women with STDs had sex three or more times while symptomatic, as compared to 2.3 percent of men (see Table 2). There are several possible reasons for this difference. It may be that these symptoms are not recognized as serious. Many women will ignore vaginal symptoms, as they have been taught to disregard all but the most serious. Another possible explanation is that women may not have the power to deny sex even when they are not well. Whatever the reason, the combination of delayed treatment and unprotected intercourse is detrimental to the control of STDs. Only a very small proportion of these women reported using the condom, and only 5 percent of coital acts were protected by condoms.

Table 2. Sexual Activity in the Presence of STDs

Sex Once While Symptomatic Sex 3+ Times While Symptomatic Males 12.1% 2.3% Females 38.2% 17.8% Odds Ratio 4.5 9.2 C. I.  2.5-8.2 3.0-23.8

Source: Moses et al 1994.

Efficacy of Condoms in Preventing STDs

Studies show a consistent and significant level of protection against STDs for men who use condoms. A comprehensive review of the literature on the subject is presented by Cates and Stone (1992a, 1992b). This protection has been demonstrated for gonorrhea, herpes, trichomonas, genital ulcers, chlamydia and HIV. These studies also show that women whose partners use condoms also have consistent and significant protection, but the level of protection is lower. It must be recognized, however, that the protection is not absolute. It is estimated that consistent condom use may prevent 60 to 79 percent of gonococcal and chlamydia infections.

There are a number of reasons why condoms sometimes fail to protect against STDs:

• Non use 
  • not available 
  • partner objects 
  • allergy (rarely)
• Incorrect use
• Slippage during coitus
• Breakage (see Table 3) 
  • poor quality manufacture 
  • poor storage
• Leakage

Table 3. Studies of Condoms Breakage in Developed Countries

Author and Year Published Breakage Rate Richters et al 1988  0.5% (anal), 0.8% (vaginal) van Griensven et al 1988  2–4% Consumers Union 1989  1% (anal), 0.6% (vaginal) Golombok, Sketchly and Rust 1989  3–5% (anal) Tindall et al 1989  5–7% (anal) Albert, Hatcher and Graves 1991  1% Trussell, Warner and Hatcher 1992a  1.5–2.0% Trussell, Warner and Hatcher 1992b  1.2–1.3%

Adapted from: Cates and Stone 1992a.

Perhaps the most important reason for the failure of condoms to provide protection from STDs is incorrect use. It is necessary for programs to train couples in the correct use of condoms and not just distribute them in the hope that they will be used properly. Given that condoms and other barrier methods are the only alternative to mutual monogamy in preventing the spread of STDs and HIV, it seems imperative that all FP programs provide consistent and repeated counseling on the proper use of condoms.

The use of condoms, however, is very low. Many men complain of loss of spontaneity, interference with the sex act and loss of sensation. The newer polyurethane condoms have several advantages that may make them more acceptable. They are thinner and therefore more sensitive. They are colorless and odorless. Polyurethane is stronger and less prone to breakage. In contrast to latex condoms, plastic condoms are loose fitting and more comfortable. Another advantage is that plastic condoms are compatible with oil-based lubricants, which will make a wider range of viricidal and spermicidal agents available for use. Finally, the production of these condoms is less dependent on natural products, and consequently costs will be reduced. Initial results indicate good acceptance of this product.

Spermicide

Studies show consistent and significant protection against STDs with the use of spermicides alone. Protection is not complete, however, and is much lower than with condoms alone. Regular use reduces cervical gonorrhea infection by 25 percent and cervical chlamydia by 22 percent. Nonoxynol 9 is the most commonly used spermicide. It acts as a non-ionic surfactant that damages the cell wall of STD pathogens and spermatozoa. Nonoxynol 9 has in vitro activity against:

• Gonorrhea
• Trichomonas
• Herpes simplex virus
• Treponema pallidum
• Ureaplasma
• HIV
• Chlamydia +/-

There is some concern that nonoxynol 9 may cause vaginal ulceration with repeated use. In a randomized controlled study of Nairobi prostitutes by Kreiss et al (1992), users of the contraceptive sponge impregnated with nonoxynol 9 were found to be at greater risk of genital ulceration and vulvitis (see Table 4). This problem has only been noted, however, in clients who have several repeated applications per day, such as prostitutes in whom this risk was first observed. There was no effect on seroconversion for HIV, although the rate of gonorrhea declined in users of the sponge.

Table 4. Risk of Infection among Nairobi Prostitutes Using Contraceptive Sponge with Nonoxynol 9

Relative Risk Increased risk of genital ulcers 3.3 Increased risk of vulvitis 3.3 Reduced risk of cervical gonorrhea 0.4 No effect on HIV seroconversion 1.7 (0.9-3.0)

Source: Kreiss et al 1992.

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