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Continuing research and discussion on the two major strategies for
dual protection against both unplanned pregnancy and sexually
transmitted infections (STIs) indicate that each strategy has distinct
advantages and disadvantages (see table)
and that appropriate dual protection messages may differ according to
individual situations.
Whether a condom-only or dual method ap-proach to dual protection is
appropriate and feasible depends on the individuals involved and the
settings in which an approach is offered, says Dr. Jason Smith, a senior
scientist in FHI's behavioral and social science research group.
Various strategies offer dual protection. For example, abstinence
provides dual protection. So, too, does being in a monogamous
relationship in which both partners are free of STIs (and at least one
partner is using effective contraception). Furthermore, avoiding all
forms of penetrative sex affords dual protection. But for many sexually
active men and women, one major way to achieve dual protection is to use
simply condoms to protect against both pregnancy and STIs. Another major
option is dual method use: using one method to protect against unplanned
pregnancy (often a hormonal method or other highly effective noncoitally
dependent contraceptive) and a second method to protect against STIs (a
male or female condom).
No large randomized trials have been conducted to compare these two
ap-proaches. And, results of observational research on dual method use
are limited and inconsistent.1 But experts recognize that
determining appropriate dual protection messages depends on assessing
individuals' separate risks of unplanned pregnancy and HIV/STIs and then
determining how effectively various contraceptive methods reduce those
risks.
Assessing risks
Hormonal implants and injectables, intrauterine devices (IUDs), or
sterilization provide the greatest protection against pregnancy, but
condoms (male and female) are the only method known to provide
protection against HIV, other STIs, and pregnancy. Thus, the primary
goal of dual protection — whether to prevent pregnancy, infection, or
both — will influence what dual protection strategy is adopted, say
Dr. Markus Steiner, an FHI senior epidemiologist, and Dr. Willard Cates
Jr., president of FHI's Institute for Family Health, in a recent
commentary.2 They also emphasize that "to achieve dual
protection under typical circumstances, trade-offs must be made."
Promoting only condoms (which are often used inconsistently) among
family planning clients at low risk of HIV, says Dr. Steiner, could
increase a client's pregnancy risk. In those cases, providers might want
to offer a hormonal method or an IUD to ensure effective pregnancy
prevention but also suggest condoms to be used in situations in which
there is increased risk of infection (such as with new partners,
partners who are not monogamous, or partners who have not been tested
for STIs).
"If, on the other hand, one works in a clinic where 40 percent
of clients are HIV positive, the equation is very different," says
Dr. Steiner. Since HIV prevention is likely the primary goal in this
setting, condoms alone may be a more appropriate option. This is because
some clients who use effective noncoitally dependent contraceptives are
less likely to use a second method, such as condoms, to prevent STIs.3
If emergency contraceptive pills are available, they might be offered as
backup to condoms to provide occasional extra protection against
pregnancy if a condom is not used or fails (breaks or slips).
Social contexts
Understanding the full social context in which individuals are making
decisions about dual protection also helps to clarify which strategy to
implement, says Dr. Smith, who has conducted qualitative research on
dual method use in the United States.
Social context involves both individual and community factors.
Individual factors include partner attitudes about different methods,
how often a person has sexual intercourse, and a person's own
perceptions of risk and the consequences of pregnancy or STIs. Community
factors include the social acceptability of contraception, access to and
availability of different methods, attitudes toward sexual intercourse,
and gender-related power differentials.4
Gender-related power differentials may be especially influential. For
example, the fact that men often control the use of condoms in
relationships can leave women powerless to make decisions or afraid to
ask their partners to use condoms. "The condom itself may be a risk
to these women," says Dr. Smith. "It could represent risk of a
beating, loss of status, or perhaps worse: loss of trust in a
relationship that gives meaning to their lives or that they depend on
for survival."
To explore such barriers to dual protection, particularly dual method
use, 11 focus group discussions were recently conducted among 47
in-school adolescents, 14 out-of-school adolescents, and 19 teachers and
former teachers in Ghana.5 Results confirmed earlier findings
that issues of mistrust make condom negotiation within long-term
relationships difficult.6 Most men said they would react with
anger or suspicion if their partners suggested using condoms in addition
to another contraceptive method. "I will think that she does not
trust me," said one male student. "If she mistrusts me, I have
to end the relationship." Similarly, said a female teacher,
"If you tell him you are using a birth control method but you still
want him to use a condom, he will be furious because he will feel like
you don't trust him." (Negotiating condom use for pregnancy
prevention — rather than for HIV/STI prevention — can destigmatize
condoms and facilitate their acceptance.)
In the study in Ghana, both men and women admitted to having multiple
partners. Yet, couples rarely discussed risks of pregnancy and STIs, and
men were unwilling to acknowledge that women might have more than one
partner, further demonstrating the complexity of relationships and of
negotiating dual protection within them.
Given all these factors, dual protection messages may differ for men
versus women, just as they may differ for sex workers versus low-risk
married women, educated versus uneducated individuals, and youth versus
adults. "Their lives are different, their situations are different,
their risks are different," says Dr. Smith. "So we need to
better define these differences and then try to tailor sensible messages
to individuals' particular needs."
— Kerry L. Wright
References
- Cates W Jr, Steiner MJ. Dual protection against unintended
pregnancy and sexually transmitted infections. What is the best
contraceptive approach? Sex Transm Dis 2002;29(3):168-74.
- Cates.
- 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.
- Cates W Jr, Spieler J. Contraception, unintended pregnancies, and
sexually transmitted infections. Still no simple solutions. Sex
Transm Dis 2001;28(9):552-54.
- Goparaju L, Afenyadu D, Benton A, et al. Gender, Power and
Multi-Partner Sex: Implications for Dual Method Use in Ghana.
Washington, DC: Centre for Development and Population Activities (CEDPA),
2002.
- 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.
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Dual protection messages are being integrated into family
planning counseling services, and providers are embracing the
new messages, research from Nigeria shows.
Between 1999 and 2001, the nongovernmental Association for
Reproductive and Family Health (ARFH) in Ibadan, Nigeria, and
U.S. collaborators completed the first phase of a project to
integrate HIV and sexually transmitted infection (STI)
prevention into family planning services by promoting dual
protection counseling among new clients in six family planning
clinics.1 ARFH conducted participatory training
with 15 family planning providers on topics such as helping
clients recognize their risk of HIV and other STIs,
emphasizing the role of condoms in dual protection, and
tailoring counseling messages to meet clients' individual
needs. Providers were also encouraged to use a dual protection
flip chart during counseling sessions, offer clients both
female and male condoms, and distribute brochures on dual
protection and male and female condom use.
Structured observations of provider-client interactions,
conducted among 325 female clients before provider training
and 289 female clients after training, showed that the
percentage of new clients counseled on various components of
dual protection increased significantly after training. Some
of the most notable increases occurred in discussions on how
dual protection can be achieved using either one or two
methods (from 5 percent to 75 percent), how effectively
various family planning methods prevent HIV and other STIs
(from 7 percent to 42 percent), and how clients might convince
their partners to use condoms (from 0 percent to 18 percent).
According to client exit interviews, the percentage of
clients aware of the concept of dual protection also
increased, from 8 percent before provider training to 50
percent after training. And while only 2 percent of family
planning clients who visited the clinics in 1999 left with
condoms as their only method of contraception, 6 percent who
visited in 2000 left with condoms as their only method.
Other ongoing interventions to provide training that
emphasizes dual protection messages include the following:
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New York-based EngenderHealth and FHI are collaborating
to implement and evaluate comprehensive dual protection
training in Ethiopia. EngenderHealth has developed and
field-tested a training protocol — covering sexuality
and gender, HIV and STI prevention, dual protection, and
integrated counseling skills — and is using it to train
staff at primary health care facilities in three regions
of Ethiopia. FHI will soon assess the training's impact on
providers' and clients' knowledge and attitudes,
providers' counseling practices, and clients' use of dual
protection strategies.
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With technical assistance from FHI, the Reproductive
Health Research Unit (RHRU) in South Africa is
implementing the National Dual Protection Strategies
Program, which includes a South Africa Department of
Health program to introduce the female condom into the
country.2 Training materials on dual
protection, barrier methods, and how to integrate these
topics into family planning counseling have been developed
and used to train service delivery providers in nine
provinces. The RHRU and FHI will continue to revise the
training materials, supervise training, and monitor
provider performance related to the new curriculum.
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In Kenya, FHI and other organizations are collaborating
to train youth counselors to promote male condoms among
their peers, using either a standard STI protection
message or a dual protection message. Over 60 counselors
have been trained in western Kenya. Using pre- and
post-training surveys, FHI is assessing counselors'
knowledge and attitudes about condom use, STIs, and
consequences of unplanned pregnancy and STIs; whether the
standard STI protection message is distinct from the dual
protection message; and how well counselors are
remembering the messages. (Of note, FHI views such condom
promotion efforts as just one component of a more
comprehensive approach to HIV/STI prevention. FHI promotes
and implements what it calls an "ABC to Z"
model: abstinence, be faithful to one
partner, or — if "A" or "B" cannot
be achieved — use condoms. These three strategies
can be further complemented by a number of other effective
HIV prevention approaches; that is, the "to Z"
component of the "ABC to Z" model. [See The"ABC
to Z" Approach.])
— Kerry L. Wright
References
- Adeokun L, Mantell JE, Weiss E, et al. Promoting dual
protection in family planning clinics in Ibadan, Nigeria. Int
Fam Plann Perspect 2002;28(2):87-95.
- Family Health International. Expanding Barrier Method
Strategies Program. Process Data Report. Research
Triangle Park, NC: Family Health International, 2002.
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Dual Protection
and Consistency of Condom Use
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Results from a recent, cross-sectional observational study
from Zimbabwe suggest that dual method users do not use
condoms as consistently as those who use only condoms for dual
protection against pregnancy and sexually transmitted
infections.1 But this does not necessarily mean
that providers should recommend a condom-only, rather than a
dual method, approach to dual protection, says Dr. Markus
Steiner, an FHI senior epidemiologist and coauthor of the
study.
"Almost certainly, those people using condoms alone
are different from the people using them in conjunction with
other methods," he says. This suggests that consistency
of condom use may depend at least as much on individual
characteristics (such as background, lifestyle, and
motivations for behavior) as on whether a condom-only or a
dual method approach to dual protection is used.
Research from Ethiopia illustrates this point. Results of a
cross-sectional survey of some 370 sex workers in Addis Ababa
showed that sex workers who used condoms consistently (with at
least 95 percent of their clients) had several unique
characteristics: generally, they were at least 30 years old,
had been counseled by peer educators, had very few clients
each day, refused sex unless their clients used condoms, and
had used condoms for contraception in the previous five years.
Of note, 65 percent of 145 sex workers who had used condoms
for contraception used them consistently in the study,
compared with only 24 percent of 224 sex workers who had not
previously used them for contraception. (Women in the former
group also were less likely to be HIV-infected.) Furthermore,
those sex workers motivated to use condoms for contraception
were more likely to refuse sex with clients who would not use
a condom (54 percent versus 10 percent).2
In the study conducted in Zimbabwe, researchers sought to
determine the prevalence and consistency of condom use, alone
or in conjunction with another contraceptive method, among
nearly 900 family planning clients. Preliminary results of
structured questionnaires showed that about one-third of the
women were using two methods and 5 percent were using condoms
alone. But those using only condoms used them more
consistently than did those using condoms plus another method.
"The most striking finding was the low level of condom
use in a place of such high HIV prevalence," notes former
FHI fellow Dr. Thulani Magwali, a lecturer at the University
of Zimbabwe and lead author of the study. This may have been
at least partly due to difficulties women have negotiating
condom use within their relationships, he speculates.
— Kerry L. Wright
References
- Magwali TL, Steiner MJ, Brown JM, et al. Dual method and
dual purpose use among family planning clients at three
family planning clinics in Zimbabwe. Unpublished paper.
Family Health International, 2002.
- Aklilu M, Messele T, Tsegaye A, et al. Factors
associated with HIV-1 infection among sex workers of Addis
Ababa, Ethiopia. AIDS 2001;15(1):87-96.
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