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Among barrier contraceptives, the male latex condom offers the best
protection against sexually transmitted infections (STIs), including
HIV/AIDS. When used consistently, male condoms also provide highly
effective contraception.
In theory, the female condom should also protect against STIs,
including HIV/AIDS, but more research is needed to confirm the
effectiveness of the female condom in preventing disease. Vaginal barrier
methods such as the diaphragm, cervical cap, sponge and spermicides are
less effective, even when a barrier device such as a diaphragm is used
with a spermicide.
The major public health challenge in reducing HIV/AIDS and other STIs
is to encourage greater use of condoms among people at risk. Women and men
report not using male condoms for many reasons, including fear of
partners' reactions, partner opposition, lack of confidence in the
product, lack of access to condoms or decreased pleasure if used.1
In addition, family planning providers often encourage clients to consider
the more effective contraceptives, such as injectables, and discourage
reliance on the condom as a means of preventing pregnancy.
Despite the fact that the condom is very effective against STIs, many
people at risk do not use them. Some bacterial STIs, such as gonorrhea and
chlamydial infection, are easily transmitted, making consistent condom use
especially important. Promoting condoms among men and youth, and
encouraging better attitudes about condom provision among family planning
providers and other health professions may help reduce the number of new
infections.
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Do Contraceptives Protect against
Sexually Transmitted Infections?
|
| |
Condom
|
Diaphragm
|
Spermicide
|
Hormonal
|
IUD
|
|
Viral
- HIV/AIDS
- Herpes Simplex (HSV)
- Human Papilloma (HPV)
|
Protective against HIV; protection
unproven against skin-to-skin infections (HSV, HPV) |
Little known about protection |
Not protective |
Not protective |
Not protective |
|
Bacterial
- Chancroid
- Chlamydia
- Gonorrhea
- Syphilis
|
Protective against gonorrhea;
presumed protective for others |
Some protection against cervical
gonorrhea and chlamydia; associated with vaginal anaerobic
overgrowth |
Possibly protective against cervical
gonorrhea and chlamydia |
Associated with increased cervical
chlamydia; protective against symptomatic PID, but higher risks of
unrecognized endometritis |
Associated with PID in first month
after insertion |
Source: Cates W Jr. Contraceptive choices
and sexually transmitted infections among women. In Ness RB, Kuller LH,
eds. Health and Disease among Women: Biological and Environmental
Influences. (New York: Oxford University Press, 1999)401-19.
Reaching men
"A focus on men is a crucial aspect of any strategy to promote
safer sex and consistent and correct condom use," says a joint policy
statement by the World Health Organization and other United Nations
agencies. "The activities of family planning programmes need to be
expanded to reach men and young people at risk as well as their
traditional clients -- married women."2
Some family planning programs, including the Jamaica Family Planning
Association and other affiliates of the International Planned Parenthood
Federation, have promoted condoms among men through outreach workers and
special clinic hours.3 But most condom promotion programs
targeting men are AIDS prevention efforts with truck drivers, military
personnel, those at commercial sex establishments and others in high-risk
groups. Such efforts to increase condom use have reduced infection rates
in a few notable cases, especially in the "100 percent" condom
campaign among sex workers in Thailand.4
A study among men with casual sex partners in Uganda found that only
about half ever used condoms and, among those who did, only about six of
10 always used a condom with casual partners.5 In a year-long
intervention at 12 Kenyan tea plantations, condom use increased markedly
and STI rates decreased by 25 percent. However, multiple factors could
have caused the STI reduction. "The most important reason the rates
went down is probably that we found and treated more infections than had
been done before we conducted the study," says Dr. Paul Feldblum, an
FHI epidemiologist who coordinated the study. "Condom use was most
likely secondary to treatment in reducing the rate of infections."
Participants in the study were tested and treated for three curable
diseases -- gonorrhea, chlamydial infection and trichomoniasis.
Researchers debate whether measures of condom use and other behaviors
accurately explain shifts in STI rates, especially when the measurements
rely on self-reported behaviors. A recent analysis of a behavioral
intervention suggests that people tend to avoid condom use if they believe
their partner is "safe." "Using behavior as a surrogate for
STI risk may be particularly problematic when studying persons who might
vary their use of condoms with partners of varying risk," it
concludes.6
Addressing gender issues may be as important as focusing on increased
condom use. Consistent, sustained use of condoms requires behavioral
change. Men's sexual behaviors are linked to their sense of masculinity.
In many cultures, assumptions about masculinity may encourage excessive
alcohol use or violent behavior toward women, which can increase risky
sexual behaviors. "We need to help men to begin to question the value
placed on risk-taking behavior as a defining characteristic of
masculinity," says Dr. Benno de Keijzer of Salud y Genero, a
nongovernmental agency in Mexico that works with men on gender roles.
"Addressing the underlying gender issues must be acknowledged if the
HIV/AIDS epidemic is going to be curbed."
Young adults
Encouraging young people to use condoms and to develop skills to refuse
unwanted sex is also crucial. HIV infections are rising fastest among
those under age 25, especially women. Youth are often inexperienced with
condoms, feel invulnerable to risk, have spontaneous sex and are
embarrassed to interrupt sex to put on a condom. Some young women need
skills to refuse risky sex from older men. All of these factors present
challenges to programs that target adolescents and to condom social
marketing campaigns.
Some marketing campaigns are designed specifically for adolescents. A
seven-country campaign in Central America recently directed television and
radio ads to adolescents, with an emphasis on how condoms prevent disease
transmission. "Our field research told us that boys and especially
girls think about pregnancy prevention, not sexually transmitted infection
prevention," says Françoise Armand, senior marketing manager for
Population Services International (PSI), which is coordinating the
campaign. "So we had to adjust the campaign to focus on the dual
protection qualities of condoms."
One current television message aired in the seven countries, for
example, presents a game show format with young couples answering
questions about pregnancy and STIs, designed to remove the stigma of
condom use. "We are trying to change social norms so that unprotected
sex becomes uncool," says Armand.
Greater awareness among young adults of STI risks may be difficult to
achieve. In Cameroon, PSI conducted a year-long condom marketing campaign
among youth that included media promotions, peer education and the
involvement of youth clubs. In addition to condom use, the campaign
addressed abstinence, other contraceptive methods and early detection of
STIs. Despite the fact that youth reported increased use of condoms and
other contraceptives for pregnancy prevention, there appeared to be no
significant increase in condom use for STI prevention.7
Similarly, PSI youth campaigns in South Africa and Guinea did not increase
youth's perception of STI risks.8
Family planning programs in some countries are often unwilling to
distribute condoms to unmarried youth. Accessibility to condoms may also
be difficult for youth due to cost, stigma, embarrassment and other
barriers. A study among adolescents in Botswana found that females in
particular feared they would be stigmatized if they obtained condoms.9
Youth are more likely to use condoms that are more readily available at
shops, grocery stores and in vending machines.
Provider attitudes
A study in 11 African countries found that many family planning
providers did not mention condoms to new clients, despite the high rates
of STIs in these countries. In Zimbabwe, for example, providers told only
one of every five new clients about condoms, and in Senegal, one of four.10
A recent FHI service delivery analysis in Kenya drew similar conclusions.
"The vast majority of interviewed providers correctly demonstrated
most of the essential steps in condom use," says Dr. Theresa Hatzell
of FHI, who coordinated the study. "But unfortunately, they do not
share that knowledge with their clients. Providers showed a condom sample
in only 7 percent of the observed family planning visits."
Many providers do not emphasize condoms as a good choice to family
planning clients because of contraceptive effectiveness rates. In typical
use, the annual pregnancy rate is 14 percent. If used consistently and
correctly (perfect use), the pregnancy rate is 3 percent. In contrast,
pregnancy rates for the pill are 5 percent and less than 1 percent for
typical and perfect use respectively.11
Even if providers counsel clients about the need for condom use,
condoms must be readily available. A study in four African countries found
that 41 percent of providers in Kenya require spousal consent for condom
use, with between 14 percent and 19 percent of providers facing this
restriction in Botswana, Burkina Faso and Senegal. "These findings
may suggest an unwillingness to recognize the frequency of HIV
transmission within married couples or a fear that the woman would use the
condoms in extramarital relationships," the researchers concluded.12
Reliable information and assistance from pharmacists who sell condoms
is important. In Ghana, men posing as clients with urethral discharge
visited 96 pharmacies to gather information for a study. Half of the
pharmacists had been trained in condom promotion. However, only six of the
96 pharmacists advised the study clients that they should use condoms
until the discharge stopped.13
Some providers may not feel comfortable addressing sexual practices and
risks of STIs with their clients. However, if providers do not ask clients
about sexual practices and the ability to control the timing and
circumstances of sex, providers may not realize when condoms are
appropriate. A couple's sexual history is important in evaluating the
level of risk involved, and clients should understand this aspect.
Better designs
Better condom designs that men and women will find more acceptable,
especially regarding how they affect pleasure, may encourage condom use.
Unlike latex condoms, polyurethane male condoms facilitate body heat
transfer, which may increase pleasure. Some products are designed to be
easier to put on than traditional latex condoms. Synthetic non-latex
condoms can also be used with a broader range of lubricants and will not
cause an allergic reaction to latex.
While scientists have assumed the non-latex products would be more
acceptable than latex, initial research has been mixed. In a study of more
than 800 monogamous couples randomly assigned to use either a polyurethane
or latex device for six months, 15 percent of those using polyurethane
said they would not recommend it to others, compared to 7 percent of the
latex users not willing to recommend latex. More than twice as many
couples using polyurethane dropped out of the study citing a
condom-related reason. However, males rated the polyurethane condom more
highly than the latex in several subjective categories, including
sensitivity and odor, and they were less likely to complain of discomfort
from constriction than were men using latex devices.14
A study involving 54 couples compared acceptability of latex,
polyurethane and a new material called styrene ethylene butylene styrene
or SEBS. Each couple tested three condoms of each material. About
two-thirds of both men and women preferred one of the two synthetic
materials over latex, "suggesting that consumers will appreciate the
availability of these products," the authors concluded.15
New shapes and designs may address other concerns about traditional
condom products, such as the tight fit. Based on early research, however,
whether availability of these new designs will actually increase
acceptability is not clear. A study involving 443 couples compared results
of using three new designs of a synthetic elastomer condom, called
Tactylon, and a latex device. On use, fit, appearance, comfort and
sensitivity, one type of Tactylon condom design was rated highest among
the four condom types in the study. A baggy Tactylon style, however, was
rated less satisfactory than a latex condom.16
Reversible condoms that can be unrolled in either direction may address
some concerns that condoms are troublesome to use and make sex less
spontaneous -- factors that could lead to less consistent or incorrect
use. If a man begins putting on a latex condom in the wrong direction, he
should discard the condom and open a new one because he may transfer
pathogens from his body to the outside of the condom by simply turning it
over. Reversible condoms would help prevent this mistake. A loose-fitting
polyurethane condom that can be put on in either direction and has broad
lubricant capability is currently manufactured by a private company and
sold in Europe and Canada.
-- William R. Finger
References
- Spruyt AB, Finger WR. Acceptability of condoms --
user behaviors and product attributes. In McNeill ET, Gilmore CE,
Finger WR, et al. The Latex Condom. (Research Triangle Park,
NC: Family Health International, 1998)12-23; Mehryar A. Condoms:
awareness, attitudes and use. In Cleland J, Ferris B, eds. Sexual
Behavior and AIDS in the Developing World. (London: Taylor and
Francis, 1995)124-56.
- 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.
- Becker J, Leitman E. Introducing sexuality within
family planning: the experience of three HIV/STD prevention projects
from Latin America and the Caribbean. Quality/Calidad/Qualité 1997;8.
- Rojanapithayakorn W, Hanenberg R. The 100 percent
condom program in Thailand. AIDS 1996;10:1-7.
- Kamya M, McFarland W, Hudes ES, et al. Condom use
with casual partners by men in Kampala, Uganda. AIDS
1997;11(suppl 1):S61-66.
- Peterman, TA, Lin LS, Newman DR, et al. Does
measured behavior reflect STD risk? An analysis of data from a
randomized controlled behavior intervention study. Sex Trans Dis 2000;27(8):446-51;
Fishbein M, Jarvis B. Failure to find a behavioral surrogate for STD
incidence -- what does it really mean? Sex Trans Dis 2000;27(8):452-54.
- Van Rossem R, Meekers D. An evaluation of the
effectiveness of targeted social marketing to promote adolescent and
young adult reproductive health in Cameroon. AIDS Educ Prev
2000;12(5):383-404.
- Meekers D. The effect of targeted social marketing
to promote adolescent reproductive health: the case of Soweto, South
Africa. J HIV/AIDS Prev Educ Adolesc Child 2000;3(4):73-92; Van
Rossem R, Meekers D. An Evaluation of the Effectiveness of Targeted
Social Marketing to Promote Adolescent Reproductive Health in Guinea,
Working Paper No. 23. Washington: Population Services
International, 1999.
- Meekers D, Ahmed G. Contemporary patterns of
adolescent sexuality in urban Botswana. J Biosoc Sci
2000;32(4):467-85.
- Miller K, Miller R, Askew I, et al. Clinic-based
Family Planning and Reproductive Health Services in Africa: Findings
from Situation Analysis Studies. (New York: The Population
Council, 1998)79.
- Stewart F. Vaginal barriers. In Hatcher RA, Trussell
J, Stewart F, et al., eds. Contraceptive Technology, Seventeenth
Revised Edition. (New York: Ardent Media, Inc., 1998)216.
- Miller, 166-70.
- Adu-Sarkodie Y, Steiner MJ, Attafuah J, et al.
Syndromic management of urethral discharge in Ghanaian pharmacies. STI
2000;76(6). In press.
- Frezieres RG, Walsh TL, Nelson AL, et al. Evaluation
of the efficacy of a polyurethane condom: results from a randomized,
controlled clinical trial. Fam Plann Perspect 1999;31(2):81-87.
- Frezieres RG, Walsh TL. Acceptability evaluation of
a natural rubber latex, a polyurethane, and a new non-latex condom. Contraception
2000;61(6):369-77.
- Callahan M, Mauck C, Taylor D, et al. Comparative
evaluation of three Tactylon condoms and a latex condom during vaginal
intercourse: breakage and slippage. Contraception
2000;61(3):205-15.
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