Recommendations for Contraceptive Use
		Barrier Methods

Recommendations	Rationale
a) Against HIV/AIDS? Possibly. Diaphragms and caps, even with spermicides, cannot be currently recommended for human immunodeficiency virus (HIV) prevention. Diaphragm use may indirectly reduce the incidence of HIV, however, by preventing bacterial sexually transmitted disease (STD) co-factors which increase the risk of HIV transmission. For sexually active women who cannot use male or female condoms, a diaphragm, cap with spermicide, or spermicide alone, is unlikely to be riskier than completely unprotected intercourse and may help prevent upper reproductive tract infections (RTI).	a) The effectiveness of the diaphragm and cap against HIV is not known. Much depends on the site of infection; if the portal of virus entry is the cervix, the diaphragm and cap should confer good protection. Until the effectiveness of nonoxynol-9 (N-9) spermicide is established, diaphragm or cap use with N-9 spermicide cannot be recommended for HIV prevention. Stein ZA. More on women and the prevention of HIV infection (editorial). American Journal of Public Health 1995;85(11):1485-8. Centers for Disease Control. Update: barrier protection against HIV infection and other sexually transmitted diseases. Morbidity and Mortality Weekly Report 1993;42:589-91, 597. The highest risk of sexually acquired HIV infection is associated with unprotected intercourse. Women need methods to protect themselves against HIV and other STDs, even if protection is only partial. Feldblum PJ, Weir SS. The protective effect of nonoxynol-9 against HIV infection (letter). American Journal of Public Health 1994;84:1032-4. Rosenberg MJ, Gollub EL. Methods women can use that may prevent sexually transmitted disease, including HIV (commentary). American Journal of Public Health 1992;82:1473-8. Elias CJ, Heise LL. Challenges for the development of female-controlled vaginal microbicides. AIDS 1994;8:1-9.
b) Against other STDs? Probably. Users of diaphragms (and probably cervical caps) with spermicides probably have a modestly lower risk of gonorrhea and chlamydia than non-users.	b) Diaphragm use has been found to reduce the risk of bacterial STD and pelvic inflammatory disease (PID). One study found a 60% reduction in the risk of PID in diaphragm users compared to women using no contraceptive method. The overall reduction of bacterial cervical infections from spermicide use alone is about 25-50%, but that figure is a gross estimate that includes consistent and correct users as well as inconsistent users. Thus, use of spermicides with diaphragms or cap may reduce the risk of cervical infections. In studies of bacterial STDs among diaphragm users and women whose partners used male condoms, diaphragm users had lower STD risk than women depending on their partners' use of a male condom. The effectiveness of any coital-dependent method (i.e., one that must be applied at or around the time of intercourse) depends on the consistency and correctness of use. For these methods, acceptability and compliance are as important, if not more so, as their efficacy in preventing disease. Even if a female method is less efficacious than the male condom, it may have a greater impact on disease rates if it is used more consistently. Since the diaphragm is a method that combines a physical barrier (the latex or silicon device) and a chemical barrier (the spermicide), it may be more effective than spermicide alone, although there are no data to confirm this. Cates W Jr, Stone KM. Family planning, sexually transmitted diseases and contraceptive choice: a literature update-part 1. Family Planning Perspectives 1992;24:75-84. Kelaghan J, Rubin GL, Ory HW, Layde PM. Barrier-method contraceptives and pelvic inflammatory disease. Journal of the American Medical Association 1982;248(2):184-7. Austin H, Louv WC, Alexander WJ. A case-control study of spermicides and gonorrhea. Journal of the American Medical Association 1984;251:2822-4. Feldblum PJ, Morrison CS, Roddy RE, Cates W Jr. The effectiveness of barrier methods of contraception in preventing the spread of HIV. AIDS 1995;9(Suppl A):S85-S93. Cates W Jr, Hinman AR. AIDS and absolutism--the demand for perfection in prevention (sounding board). New England Journal of Medicine 1992;327:492-4.

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