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Many family planning clients need protection not only against pregnancy
but against HIV and other sexually transmitted infections (STIs). They
need dual protection. The safest form of dual protection is mutual
monogamy between noninfected partners using effective contraception.
For other sexually active individuals, dual protection can be achieved
in one of two ways:
- Two contraceptive methods can be used (one highly effective method
for pregnancy prevention and the male or female condom for STI
prevention).
- A condom can be used for both purposes.
Contraceptives offering the best pregnancy prevention during typical
use -- sterilization, injectables, implants and intrauterine devices
(IUDs) -- do not protect against STIs. Thus, simultaneous condom use for
disease prevention is recommended. Condoms used alone can prevent both
STIs and pregnancy, if used correctly and consistently with every high
risk act of intercourse, but are associated with relatively higher
pregnancy rates during typical use because they are often used incorrectly
or inconsistently.
Much remains to be learned about the characteristics of couples who
choose either approach to dual protection. "Identifying such
characteristics brings an awareness of potential barriers to dual
protection, which is important during client counseling," says Dr.
Thulani Magwali, an obstetrician/gynecologist at the University of
Zimbabwe. Under an FHI fellowship, Dr. Magwali is conducting a study of
the prevalence and consistency of use among 900 family planning clients in
Zimbabwe of two contraceptive methods versus use of just male or female
condoms for protection against pregnancy and disease. His study compares
use of the two approaches with a variety of client characteristics, such
as level of education, marital status, age and number of partners.
Which of the two dual protection approaches should providers recommend?
Data comparing the approaches are limited and conflicting. Experts'
opinions vary, although most agree that no one approach is appropriate for
everyone everywhere. Thus, providers "should tailor counseling
messages to the individual client's needs and motivations," says Dr.
Willard Cates, Jr., president of FHI and an STI expert. "Whether the
major goal is to prevent pregnancy, infection or both undoubtedly will
influence selection of an approach.
"A key factor in recommending an approach is the client's
likelihood of being exposed to infection, which may be assessed by the STI
prevalence in the community and by the client's specific risk behaviors.
If exposure is likely, particularly to the more serious infections such as
HIV, condom use should be recommended.
"Also, the consequences of unintended pregnancy versus infection
in an individual's life must be considered," says Dr. Cates.
"For example, a woman who very much wants children but simply wishes
to delay pregnancy probably should be counseled to use condoms alone. She
might be more likely to become pregnant than if she used a condom along
with a highly effective contraceptive method. But sexual partners of women
using highly effective contraception may not use condoms as consistently
as partners of women using less effective contraception. As a result, the
woman may acquire an STI. In this case, any pregnancy resulting from
condom use alone probably would be more desirable than an STI infection
that could leave her infertile."
On the other hand, Dr. Cates says, in cases where unintended pregnancy
is the greater concern, emphasizing the two-method approach as a first
option may be appropriate, especially if emergency contraception or safe
abortion are inaccessible or unaffordable.
"Women using a highly effective contraceptive method could be
counseled on when or with whom concurrent condom use is most important:
with new partners, with partners who have other partners, and with
partners who have not been tested for STIs," he says.
"Particularly encouraging women to use condoms during these high-risk
situations may yield better adherence and fewer infections than advising
use during all coital acts. Otherwise, the notion of using condoms at
every sexual encounter may seem so unrealistic or unacceptable that
couples will not initiate use or will fail to use them when they are most
needed."
Dual method use
Simultaneous use of two methods, or dual method use, may seem to be an
ideal way to prevent both pregnancy and STIs. But there are theoretical
and practical concerns about this approach.
For example, the risk of pregnancy varies during the menstrual cycle,
but the risk of STI infection may be relatively constant, thus justifying
the use of disease-preventing condoms as a primary method. The probability
of an infected person transmitting gonorrhea or syphilis is about 50
percent for each coital act with an uninfected person.1 (The
probability of acquiring chlamydia or viral STIs, especially HIV, during
each coital act may be somewhat lower.2) A woman's risk of
acquiring gonorrhea from an infected partner is about double that of her
becoming pregnant during a single act of unprotected sexual intercourse,
even when she is most fertile.
Dual protection can be achieved in two ways
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Dual method use
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Pregnancy prevention
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STI prevention
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Condom only
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Pregnancy and STI prevention
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Drawings: Salim Khalaf, FHI
Many people will not use two methods simultaneously, given that many
dislike using even one contraceptive method. Consequently, one of the two
methods may be abandoned or, at best, used inconsistently, while the other
is favored.
Several studies have found that the more effective the contraceptive
method, the lower the level of consistent condom use among couples using
condoms and another method.3 Only about a fifth of participants
in various studies examining dual method use reported using condoms, even
when counseled to do so in some cases.4 Only 13 percent of some
900 family planning clients surveyed by FHI in collaboration with the
Family Planning Association of Kenya reported using a condom for disease
protection in conjunction with use of a non-barrier method during the
previous month, even though about 16 percent of the women had been
diagnosed with at least one STI in the previous year and more than
one-third considered themselves at risk of an STI. Common reasons for not
using condoms included use of another method for pregnancy prevention,
partner refusal to use a condom and desire for natural sex. However, women
who reported that they had ever talked with their partner about the risk
of STIs and ways to avoid them were over 13 times more likely to use two
methods for dual protection.5
A similar study in Jamaica found that partner communication about STI
protection was a significant predictor of dual method use.6
And, in a U.S. study among 1,729 men in which 17 percent of sexually
active males reported dual method use, condom use was associated with
talking with the partner about contraception and condoms.7
Other arguments against the dual method approach are that promoting
condoms plus another method undermines the message that condoms can be
good contraceptives, and promoting them only for disease prevention
stigmatizes them as a method associated with promiscuity. This can make it
more difficult for women to negotiate condom use with their partners. In
focus group discussions involving 30 African-American men and women,
participants recognized the need for dual protection but rarely used
condoms. Partners generally distrusted each other, and requests for condom
use would have further aroused suspicions of infidelity.8 Many
women may be unwilling to ask their regular partner to use condoms because
they fear violence or abandonment.
Finally, using two methods may not be financially or logistically
feasible, either for providers or their clients.
Condoms alone
The World Health Organization, Joint United Nations Programme on
HIV/AIDS and United Nations Population Fund recently issued a joint policy
statement emphasizing that the condom, when used correctly and
consistently, can serve a dual role. The statement notes that family
planning counseling "must include the understanding that while most
methods (e.g., hormonal methods of contraception, IUDs and sterilization)
are all highly effective against pregnancy, they offer no protection"
against HIV or other STIs. "Informed choice must also include the
acknowledgement that the condom, when used correctly and consistently, not
only prevents [STIs] but can also be a legitimate and highly effective
contraceptive."9 That condoms can provide effective
contraception is evident in Japan where condoms traditionally have been
the primary contraceptive method and unintended pregnancy rates have been
low.
However, condom use alone for dual protection also has drawbacks.
Because they tend to be used inconsistently, condoms provide less
effective protection against pregnancy than sterilization, hormonal
methods or IUDs. Within the first year of typical use of the male or
female condom, 14 percent of women relying on male condoms and 21 percent
of women using the female condom experience an unintended pregnancy.10
In a study of providers' beliefs and attitudes about dual protection,
the majority of 34 counselors at family planning clinics in New York were
concerned that promoting either male or female condoms instead of hormonal
methods would increase their clients' risk of pregnancy. Half reported
that they would never recommend the female condom as the primary
contraceptive method and 63 percent said they would never recommend the
male condom for this purpose.11
Nevertheless, says Dr. Cates, "Family planning programs must
overcome their hesitancy to counsel clients about the need for more
correct and consistent use of condoms for both pregnancy and STI
protection." Only 3 percent and 5 percent of women experience an
unintended pregnancy within the first year of correct and consistent
(perfect) use of the male condom or female condom, respectively.12
"Moreover, making condoms physically available in the clinic setting
should be an important component of all dual protection programs."
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A public service advertisement in Nepal promotes condom use.
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Correct and consistent use of male latex condoms is the most effective
way of preventing infection among sexually active people who are at risk.
The ability of the female condom to prevent transmission of HIV and other
STIs has not been adequately studied, but experts believe the device is
promising.
Making female condoms more accessible may increase the likelihood that
couples will protect themselves against STIs with either a male or female
condom. In Thailand, some 250 commercial sex workers given both female and
male condoms used some form of condom more often and had a slightly lower
incidence of STIs than did some 250 commercial sex workers given only male
condoms.13 Similarly, in a study of some 900 sexually active
U.S. women given both female and male condoms, the female condom appeared
to allow inconsistent users of the male condoms to achieve high protection
rates by mixing condom types over time.14 High-risk couples in
Zambia given both female and male condoms also tended to have a higher
proportion of protected sexual acts than couples who only used the male
condom.15
The idea that condoms can protect against both disease and pregnancy
might be advantageous for those women whose partners have traditionally
associated condoms with disease prevention and, thus, infidelity. Such
women might be able to negotiate condom use for contraception while
simultaneously achieving the important goal of protecting themselves from
STI infection.
However, advising a client to negotiate condom use strictly for
contraception, as a subterfuge for STI protection, may be unwise if she is
using no other method. A woman who becomes pregnant as a result of condom
failure would no longer have a pretext for negotiating condom use. Also, a
woman would not be able to negotiate condom use during menstruation or
after menopause.
-- Kim Best
References
- Anderson RM. Transmission dynamics of sexually
transmitted infections. In Holmes KK, Mårdh P-A, Sparling PF, et al.,
eds. Sexually Transmitted Diseases, Third Edition. (New York:
McGraw Hill, 1999)25-37.
- Anderson; Brunham RC, Plummer FA. A general model of
sexually transmitted disease epidemiology and its implications for
control. Med Clin North America 1990;74(6):1339-52; Royce RA,
Sena A, Cates W Jr, et al. Sexual transmission of HIV. N Engl J Med
1997;336(15):1072-78.
- Cates W Jr. Contraception, unintended pregnancies,
and sexually transmitted diseases. Why isn't a simple solution
possible? Am J Epidemiol 1996;143(4):311-18.
- Humphries HO, Bauman KE. Condom use by Norplant
users at risk of sexually transmitted diseases. Sex Transm Dis 1994;21(4):217-19;
Rademakers J, Coenders AQ, Dersjant-Roorda M, et al. A survey study of
attitudes to and use of the 'double Dutch' method among university
students in the Netherlands. Br J Fam Plann 1996;22(1):22-24;
Santelli JS, Davis M, Celentano DD, et al. Combined use of condoms
with other contraceptive methods among inner-city Baltimore women. Fam
Plann Perspect 1995;27(2):74-78; Sangi-Haghpeykar H, Poindexter
AN, Bateman L. Consistency of condom use among users of injectable
contraceptives. Fam Plann Perspect 1997;29(2):67-69,75; Spruyt
A, Fox L, Figueroa P, et al. Dual method use among family planning
clients: Kingston, Jamaica. Presentation at the annual meeting of the
American Public Health Association, New York, November 17-21, 1996.
- Kuyoh M, Spruyt A, Johnson L, et al. Dual method use
among family planning clients in Kenya. Final report. Family Health
International and Family Planning Association of Kenya, 1999.
- Spruyt.
- Lindberg LD, Ku L, Sonenstein FL. Adolescent males'
combined use of condoms with partners' use of female contraceptive
methods. Matern Child Health J 1998;2(4):201-9.
- Woodsong C, Koo HP. Two good reasons: women's and
men's perspectives on dual contraceptive use. Soc Sci Med 1999;49(5):567-80.
- Dual Protection against Sexually Transmitted
Infections including HIV, and Unwanted Pregnancy (Joint Policy
Statement), March 5, 2000. Geneva: World Health Organization,
United Nations Programme on HIV/AIDS, United Nations Population Fund,
2000.
- Hatcher RA, Trussell J, Stewart F, et al., eds. Contraceptive
Technology, Seventeenth Revised Edition. (New York: Ardent Media,
Inc., 1998)800.
- Mantell JE, Hoffman S, Exner T, et al. Introducing
dual protection into family planning services in NYC: health care
providers' perspectives. The XIII International AIDS Conference,
Durban, South Africa, July 9-14, 2000.
- Hatcher.
- Fontanet AL, Saba J, Verapol C, 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.
- Macaluso M, Demand M, Artz L, et al. Female condom
use among women at high risk of sexually transmitted disease. Fam
Plann Perspect 2000;32(3):138-44.
- Musaba E, Morrison CS, Sunkutu MR, et al. Long-term
use of the female condom among couples at high risk of human
immunodeficiency virus infection in Zambia. Sex Transm Dis 1998;25(5):260-64.
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