For barrier methods to be most effective against both pregnancy and disease, they should be used during every act of intercourse and be used correctly.
Barrier methods are the only contraceptive methods that have been shown to protect against sexually transmitted diseases (STDs). The best scientific data available suggest that the level of STD protection from condoms or spermicides is closely linked with consistent use.
Two recent studies found that condoms must be used with every act of intercourse to achieve dependable protection against HIV from an infected partner. The studies tracked monogamous couples in which one partner was infected with HIV and the other was not.
One study followed couples an average of 20 months. Among 124 couples who used condoms during every act of intercourse, covering some 15,000 episodes of intercourse, no new HIV cases occurred. Among the 121 couples who used condoms inconsistently, there were 12 new HIV cases, a yearly rate of 4.8 per 100 person-years. Moreover, the study found that the couples who used condoms more than half the time had about the same number of new HIV cases as did those couples who used condoms less than half the time.1
A study of 343 steady partners of infected men found similar results, with a new HIV incidence rate of 7.2 per 100 person-years among those who did not always use condoms, compared to a rate of 1.1 per 100 person-years among those who always used condoms.2
"In these studies, because one partner was infected, every act of intercourse involved the possibility of HIV transmission," explains Dr. Paul Feldblum of FHI, an epidemiologist who studies barrier methods. "That's why even using condoms half of the time did not make a significant difference over time. Similarly, during a woman's fertile period, the condom must be used every time for pregnancy prevention. In these situations, inconsistent condom use does not provide protection."
However, people who have multiple sexual partners, a minority of whom are HIV infected, will achieve some protection even with inconsistent condom use. For these people, "50 percent condom use will reduce the probability of contact with an infected partner by half," Dr. Feldblum and his colleagues wrote in a review of the effectiveness of barrier methods in preventing HIV.3
Incidence rates of gonorrhea and chlamydial infection, two STDs that can enhance the possibility of HIV transmission, have been found to decrease as spermicides are used more consistently.4 Hence, there could be less chance of HIV transmission. Using hypothetical scenarios involving multiple factors, an FHI computer analysis also predicts that HIV infections in a high-risk group would be reduced if the overall proportion of coital acts protected by condom or spermicide use increased.5
"The key is the proportion of unprotected coital acts," explains Dr. Feldblum. "We must reduce that proportion. A method of limited efficacy, such as spermicides or the diaphragm, may offer some protection against HIV for women in situations where men do not use condoms consistently."
Counseling
Counseling can help people assess their own risk of STD infection or unintended pregnancy, as well as gain the necessary skills to assure consistent and correct use of barrier methods. Just saying "use it every time" does not help a client to understand the problem or help alter his or her behavior.
The risk of STD transmission varies depending on the number of partners involved (including partners of partners), prevalence rates of STDs in the region, demographic issues and other factors. To avoid unintended pregnancy while using barrier methods, a woman needs to understand her fertile period.
While most family planning associations offer barrier methods, many providers feel that they are not as effective as other methods and they should promote injectables or IUDs or some other highly effective contraceptive method. "At the same time, there has been more emphasis on counseling in the clinic for all methods," says Marc Okunnu, African regional director for the International Planned Parenthood Federation. "Counseling is seen as very important, and the trend to emphasize counseling will increase."
In most cases, using a barrier method consistently requires a change in sexual behavior. As with other personal matters, such as changing a diet, this involves moving through several stages: a person considers making the change, may use the new behavior on a sporadic basis, and finally may continue the change over time.
To sustain behavior change, counseling needs to help people assess the stage they are in and move toward the maintenance stage. "The main point of counseling is to bring into cognitive awareness the specific behaviors needed to begin and maintain their contraceptive intentions; not to say, 'use a condom every time,'" explains Dr. Deborah Oakley of the University of Michigan, who has studied the effectiveness of counseling on barrier method use.
"The user, not the counselor, has responsibility for the behavior change," she says. "Counseling should go beyond the traditional notion of simply providing information. The main messages need to be: What is important in your life? How do you solve a problem? What behaviors do you want to use for your life? For people at risk, the most important counseling message is to bring them into awareness of how they even know that they have a problem."
In a study of consistent condom use for contraceptive purposes, Dr. Oakley and her colleagues identified groups of women who needed intensive counseling to achieve consistent use.6 "People who use condoms as a backup method -- for example, when a pill was missed -- are highly motivated," says Dr. Oakley. "However, those who choose condoms as their contraceptive method may have underestimated how hard it is to use them every time."
Counseling appears to increase condom use when being done with both partners in a monogamous situation and when focusing on skill building. In a project that counseled heterosexual HIV discordant couples every six months over six years, there were no HIV seroconversions. Over time, condom use and abstinence increased.7 Another study compared women who received four, 90-minute group sessions and a one-month follow-up session in skill training with women who received only general health prevention messages. Three months later, the group receiving the training had increased condom use from 26 percent to 56 percent while the control group only increased marginally, from 26 percent to 32 percent.8
A less intensive approach did not prove successful. In 1991, a study in Kenya informed all HIV-infected women of their HIV test results and counseled them about the potential risks of transmission to future children, giving special emphasis to using condoms. A year later, the same group was surveyed and compared to an HIV-negative control group. "Counseling women did not seem to influence their decisions on condom use and family planning," the researchers found. "More effective ways of informing and counseling women are urgently needed."9
To assess risk for STD infection, a counselor must ask confidential questions about sexual behaviors. Risk assessment checklists can help guide a counselor. Another approach is self assessment, in which the client is given materials to help evaluate his or her own risk.
Family planning agencies might consider using strategies that AIDS prevention campaigns have found successful. For example, rather than relying on professionals for counseling, a clinic could use peer counseling, where members of a group work with their peers.
Successful AIDS prevention projects have used peer education widely, especially among adolescents, commercial sex workers, truck drivers and other targeted groups. In Abidjan, capital of Côte d'Ivoire in West Africa, Population Services International (PSI) sponsors about 20 kiosks where young men and women sell condoms, hand out information and demonstrate correct condom use. Kiosks are located at high traffic areas such as taxi stands and market areas, and can be moved for use at community events.
Community factors
Consistent use of barrier methods is influenced by a variety of cultural or community factors. "Two of the most important predictors of condom use in the developing world are availability and affordability," says Michael Sweat, who works with FHI's AIDS Control and Prevention (AIDSCAP) project. "If people can't afford condoms they will not use them no matter what interventions you design."
From the beginning of the AIDS epidemic, promoting condoms and their use has been a primary strategy. Social marketing projects, which use mass media, entertainment and other commercial marketing approaches, have led to large-scale changes in condom use, particularly in Africa. Just a few years ago, there were less than a million condoms used annually in all of Africa. Today, there are nearly 20 million condoms sold a year in Ethiopia alone, with similar levels in several other African countries. "This pattern in condom sales across sub-Saharan Africa indicates a major behavioral change among African men," says Dr. Godfrey Sikipa, African regional director for AIDSCAP.
For counseling condom use among women to be effective, men have to be willing to use condoms. "Because women in many countries are not in a position to insist on condom use for cultural and economic reasons, men should be specifically targeted in AIDS prevention programs," concluded a study on condom promotion in Africa.10
"You've got to get to the men," says William Schellstede, FHI executive vice-president, who has worked with condom distribution for more than 20 years. "Counseling is a good, worthwhile thing. But the mass media approach is much more cost effective in reaching people who need to be using condoms but are not. You've got to do what the toothpaste industry did. 'Brush your teeth twice a day.' That jingle is what sells toothpaste, not individual counseling."
When possible, social marketing projects promote condoms for both disease and pregnancy prevention. "This double message allows women to bring up pregnancy prevention as a reason for using condoms, hence avoiding the issue of disease prevention or unfaithfulness," says Judith Timyan of PSI, the world's largest social marketing condom distributor. Entertainers, rock groups and others get people talking about condoms, helping to remove the stigma, she says.
PSI and other AIDS prevention efforts have used many tools to take the mass media message to a personal level. Illustrated brochures on correct condom use are usually distributed with condoms. Some programs have wooden penis models and demonstrate proper condom use. Ideally, various barrier methods would be available for people to see and handle, at a clinic or from a community-based provider. Drawings, flipcharts, and wallcharts can be used to show correct placement of female methods. Also, women should have the opportunity to practice putting the diaphragm or cervical cap in place while at the clinic. Informational pamphlets or booklets to take home can be helpful.
Political decisions can affect condom use. In Thailand, political leaders approved a nationwide "100 percent condom" program, which has led to a sharp decrease in STD rates as condom use increased. "We concentrated the program on a limited goal, the use of condoms in commercial sex," explains Dr. Wiwat Rojanapithayakorn of the Thailand Ministry of Health. If a man came to an STD clinic with an infection, the clinic asked him which sex establishment he has used and enforced the rule at that establishment, closing it if necessary. Condom use has increased from about 14 percent when the program began in 1989 to 90 percent in 1994, and STDs in the country have decreased by 85 percent.11
-- William R. Finger
Footnotes
de Vincenzi I. A longitudinal study of human immunodeficiency virus transmission by heterosexual partners. N Eng J Med 1994; 331(6):341-46.
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 Immune Defic Syndr 1993; 6(5):497-502.
Feldblum PJ, Morrison CS, Roddy R, et al. The effectiveness of barrier methods of contraception in preventing the spread of HIV. AIDS 1995; 9(suppl A):S85-S93.
Louv WC, Austin H, Alexander WJ, et al. A clinical trial of nonoxynol-9 for preventing gonococcal and chlamydial infections. J Infect Dis 1988; 158:518-23; Niruthisard S, Roddy RE, Chutivongse S. Use of nonoxynol-9 and reduction in rate of gonococcal and chlamydial infections. Lancet 1992; 339:1371-75.
King TDN, Sokal DC, Crane S, et al. Modeling the efficacy of vaginal virucides. IX International Conference on AIDS/IV STD World Congress. Berlin, June 1993, abstract PO-C33-3300.
Oakley D, Bogue E-L. Quality of condom use as reported by female clients of a family planning clinic. Am J Public Health 1995; 85(11):1526-30.
Padian NS, O'Brien TR, Chang Y, et al. Prevention of heterosexual transmission of human immunodeficiency virus through couple counseling. J Acq Immune Defic Syndr 1993; 6(9):1043-48.
Kelly JA, Murphy DA, Washington CD, et al. The effects of HIV/AIDS intervention groups for high-risk women in urban clinics. Am J Public Health 1994; 84(12):1918-22.
Annual report: World Health Organization collaborating centre for research and training in sexually transmitted diseases. Unpublished report. Department of Medical Microbiology, University of Nairobi, Kenya, 1991.
Allen S, Serufilira A, Bogaerts J, et al. Confidential HIV testing and condom promotion in Africa. JAMA 1992; 268(23): 3338-43.
Rojanapithayakorn W, Hanenberg R. The 100 percent condom program in Thailand. AIDS 1996;10: 1-7.
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