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Good counseling for people infected with a sexually transmitted disease (STD) helps
them comply with treatment, understand their contraceptive choices and encourages them to
notify partners.
Infected individuals who continue to be sexually active, particularly those who are
HIV-positive, need to understand ways to prevent transmission to others and may need
effective contraception to prevent unintended pregnancy.
An STD can seriously endanger a pregnant woman's fetus. Some STDs, such as herpes and
syphilis, can cause spontaneous abortion, premature birth and stillbirth. Some, such as
gonorrhea and chlamydia, can cause eye infections and blindness in babies born to infected
women. Syphilis, HIV and herpes can be transmitted to newborns, potentially causing
chronic disease and death. In addition, herpes can lead to mental retardation in babies.
Latex condoms, when used consistently and correctly, offer the best protection against
transmission of STDs, including HIV, but are not highly effective in preventing pregnancy
in typical use. Modern methods that are very effective contraceptives -- intrauterine
devices (IUDs), pills, injectables, implants and sterilization -- do not prevent STD
transmission.
Male condoms
Considerable laboratory research has found that quality latex condoms prevent the
passage of HIV and other STD-causing organisms. Studies among condom users also indicate
that condoms used consistently and correctly protect against STD infection.
Three large studies show that consistent condom use provides measurable protection
against HIV in heterosexual couples where one partner is HIV-infected and the other is
not. The studies compared how often unin-fected partners became infected in couples using
condoms with varying consistency. With consistent condom use, the HIV infection rate among
the uninfected partners was less than 1 percent per year. Inconsistent condom use,
however, was observed to be as risky as not using condoms at all.1
Making condoms readily accessible can markedly reduce the risk of transmitting STDs. In
Thailand, where sex workers dramatically increased condom use -- achieved through a
government program that made condoms widely available at sex establishments in the country
-- cases of gonorrhea and chancroid in men visiting government hospitals declined by
approximately 85 percent over four years. Syphilis declined by 68 percent.2
Female condoms
Laboratory studies show that polyurethane, the material used in female condoms, blocks
the passage of organisms that cause STDs. Human studies of this device are limited. One
study involving more than 100 women diagnosed and treated for trichomoniasis indicated
that subsequent, consistent use of the female condom protected against recurrences of the
STD. Inconsistent female condom use, however, was observed to be as risky as not using
female condoms at all.3 More research on the female condom's
effectiveness in preventing STD transmission in humans is needed, but experts believe the
device is a promising option for STD prevention.
Some research indicates that overall condom use increases when couples have access to
both male and female condoms, rather than male condoms only. In a randomized study in
Thailand in which 249 female sex workers had access to both types of condoms and 255
female sex workers had access to only the male condom, there was a 17 percent reduction in
unprotected sexual acts in the group that had access to both kinds of condoms, compared
with the male condom-only group.4 This reduction, as well as a
24 percent decrease in STD incidence in the male/female condom group compared with the
male condom-only group, suggest that the female condom can prevent common STDs and is an
attractive alternative to male condoms for some people. Differences in the incidence of
gonorrhea, chlamydia and trichomoniasis among women offered both types of condoms versus
those offered only male condoms are being investigated in a large FHI study of Kenyan
agricultural workers.
Spermicides
In the laboratory, nonoxynol-9 (N-9) inactivates many sexually transmitted pathogens,
including HIV. Some experts have been encouraged by small studies that show a small
protective effect of N-9 against STDs in humans. However, the largest randomized
controlled trial of N-9 to date -- an FHI study in Cameroon of the use of N-9 film in a
group of approximately 1,300 sex workers -- indicated that N-9 did not confer any
additional protection to women against HIV, gonorrhea or chlamydia infection beyond that
provided by condoms.5 The study could not conclusively
determine whether N-9 film alone offered any protection from HIV or other STDs since
participants were encouraged to use condoms every time they had sex. FHI believes more
research is needed to determine whether various N-9 products protect against STDs/HIV and,
if so, to what extent. FHI and others continue to investigate various formulations of N-9,
as well as other potential microbicides.
Hormonal methods
Hormonal methods do not protect people from STDs, including HIV, and there are
theoretical concerns that their use may increase the risk of some infections.
Research in monkeys has demonstrated that progesterone enhances vaginal transmission of
simian immunodeficiency virus,6 prompting concern about
hormonal method use by women. While results from human research have been inconsistent, a
recent study of the effect of hormonal contraception on the risk of heterosexual
transmission of HIV-1 in approximately 800 Kenyan female sex workers found that women
using depot-medroxyprogesterone acetate (DMPA) had an increased incidence of HIV-1
infection. Overall, 27 percent of 111 women who became HIV-1 infected were using DMPA
within 115 days of serocon-version. A trend linking use of high-dose oral contraceptives
(OCs) and HIV-1 acquisition also was observed.7 However, since
only 16 women in the study used high-dose pills, firm conclusions about the association
could not be made. The study authors also noted that these findings were observed in a
population of women with high rates of sexual exposure and other STDs, and may not apply
to other populations.
Meanwhile, a recent study suggested that hormonal contraception could increase the
infectivity of women with HIV. Increased shedding of HIV-1 genetic material from the
cervices of women using combined OCs or DMPA was observed. Viral shedding increased as
dose of OC increased.8
While there is evidence that oral contraceptive use can increase the risk of chlamydial
infection, OC use appears to decrease risks of symptomatic chlamydial pelvic inflammatory
disease (PID).9 However, OCs may not protect against
symptomatic PID, but simply mask it at the tubal or endometrial level. A recent study has
shown that women with unrecognized endometritis (inflammation of the mucous membrane
lining the uterus) were four times more likely than women with recognized endometritis to
use OCs.10 Untreated PID can increase the risk of infertility
and ectopic pregnancy. Also, untreated STDs, such as unrecognized chlamydia, are risk
factors for HIV transmission.
Hepatitis B, caused by hepatitis B virus, is primarily transmitted by heterosexual
intercourse. If a woman has active hepatitis B, the World Health Organization (WHO)
recommends that OCs not be used since their use can adversely affect women whose liver
function is already compromised. Combined injectables (Cyclofem or Mesigyna) should be
withheld until liver function returns to normal or three months after the woman becomes
asymptomatic. Progestin-only contraceptives (progestin-only pills, DMPA, NET-EN or
Norplant) are less desirable than other methods.11
Intrauterine devices
There is serious concern that intrauterine devices (IUDs) increase the risk of PID in
women with STDs, since microorganisms in the vagina can be introduced during IUD insertion
through the cervix into the uterus. Thus, for these women, or women who have had an STD
within the last three months, an IUD should not be inserted.
Due to concerns about pelvic infection and increased blood loss, the use of IUDs in
HIV-infected women is usually undesirable. However, a recent University of Nairobi and FHI
study of IUD use in about 150 HIV-infected and 500 non-infected Kenyan women showed no
greater risk of overall IUD complications or infection-related complications in
HIV-infected women (regardless of degree of immunosuppression) than in non-infected women
at one and four months after IUD insertion. In addition, among HIV-infected women, IUD use
was not associated with increased cervical shedding of HIV. This suggests that the IUD can
be safely used by appropriately selected HIV-infected women with regular access to medical
services.12
Among healthy women who are not at risk of STDs, the levonorgestrel-releasing IUD
(LNg-IUD) may reduce risks of PID. In one study, the incidence of PID at three and five
years of use was lower among LNg-IUD users than among Nova T users.13
However, these progestin-releasing IUDs are not widely available. For women with active
hepatitis B, the LNg-IUD is less desirable than other methods.
Lactational amenorrhea method
Breastfeeding offers effective contraception for up to six months after giving birth,
provided the child is fully or nearly fully breastfeeding and the mother's menstrual cycle
has not returned (called the lactational amenorrhea method or LAM). However, studies
suggest that one in every seven children breastfed by HIV-positive women will become
infected with the virus.
The Joint United Nations Programme on HIV/AIDS, the United Nations Children's Fund and
WHO note that infants of HIV-infected mothers are at greater risk of illness and death if
they are breastfed, rather than given breast milk substitute, provided the substitute can
be safely prepared. However, artificial feeding substantially increases children's risk of
illness and death where infant mortality is high or where sufficient milk substitute
formula cannot be prepared safely (when clean water is not available, for example). In
this case, the risk of death from malnutrition or infection can be greater than the risk
of HIV feeding through breastfeeding.14
Women with unknown HIV status and those who live in areas where infant mortality is
high or where formula cannot be prepared safely should still breastfeed since the practice
substantially benefits the overall health of both women and infants.
A breastfeeding woman at risk for HIV should use condoms. By protecting herself from
HIV infection, she may protect her nursing infant as well.
-- Kim Best
References
- Deschamps MM, Pape JW, Hafner A, et al. Heterosexual transmission of HIV
in Haiti. Ann Intern Med 1996;125(4):324-30; Saracco A, Musicco M, Nicolosi A, et
al. Man-to-woman sexual transmission of HIV: longitudinal study of 343 steady partners of
infected men. J Acq Immun Def Syndr 1993;6(5):497-502; de Vincenzi I. A
longitudinal study of human immunodeficiency virus transmission by heterosexual partners.
European Study Group on Heterosexual Transmission of HIV. N Engl J Med 1994;331(6):341-46.
- Hanenberg RS, Rojanapithayakorn W, Kunasol P, et al. Impact of
Thailand's HIV-control programme as indicated by the decline of sexually transmitted
diseases. Lancet 1994;344(8917):243-45.
- Soper DE, Shoupe D, Shangold GA, et al. Prevention of vaginal
trichomoniasis by compliant use of the female condom. Sex Transm Dis 1993;20(3):137-39.
- Fontanet AL, Saba J, Chandelying V, et al. Protection against sexually
transmitted diseases by granting sex workers in Thailand the choice of using the male or
female condom: results from a randomized controlled trial. AIDS 1998;12(14):1851-59.
- Roddy RE, Zekeng L, Ryan KA, et al. A controlled trial of nonoxynol 9
film to reduce male-to-female transmission of sexually transmitted diseases. N Engl J
Med 1998;339(8):504-10.
- Marx PA, Spira AI, Gettie A, et al. Progesterone implants enhance SIV
vaginal transmission and early virus load. Nat Med 1996;2(10):1084-89.
- Martin HL Jr, Nyange PM, Richardson BA, et al. Hormonal contraception,
sexually transmitted diseases, and risk of heterosexual transmission of human
immunodeficiency virus type 1. J Inf Dis 1998;178(4):1053-59.
- Mostad SB, Overbaugh J, DeVange DM, et al. Hormonal contraception,
vitamin A deficiency, and other risk factors for shedding of HIV-1 infected cells from the
cervix and vagina. Lancet 1997;350(9082):922-27.
- Wolner-Hanssen P, Eschenbach DA, Paavonen J, et al. Decreased risk of
symptomatic chlamydial pelvic inflammatory disease associated with oral contraceptive use.
JAMA 1990; 263(1):54-59.
- Ness RB, Keder LM, Soper DE, et al. Oral contraception and the
recognition of endometritis. Am J Obstet Gynecol 1997;176(3):580-85.
- World Health Organization. Improving Access to Quality Care in
Family Planning. Medical Eligibility Criteria for Contraceptive Use. Geneva: World
Health Organization, 1996.
- Sinei SK, Morrison CS, Sekadde-Kigondu C, et al. Complications of use
of intrauterine devices among HIV-1-infected women. Lancet 1998;351(9111):1238-41.
- Toivonen J, Luukkainen T, Allonen H. Protective effect of intrauterine
release of levonorgestrel on pelvic infection: three years' comparative experience of
levonorgestrel- and copper-releasing intrauterine devices. Obstet Gynecol 1991;77(2):261-64;
Andersson K, Odlind V, Rybo G. Levonorgestrel-releasing and copper-releasing (Nova T) IUDs
during five years of use: a randomized comparative trial. Contraception 1994;49(1):56-72.
- World Health Organization, Joint United Nations Programme on HIV/AIDs,
United Nations Children's Fund. HIV and Infant Feeding, A Policy Statement Developed
Collabor-atively by UNAIDS, UNICEF and WHO. Http://www.unaids.org.
For more information, visit Family Health International's Website at www.fhi.org
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