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
Dual method use
Pregnancy prevention
STI prevention
Condom only
Pregnancy and STI prevention
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."
A public service advertisement in Nepal promotes condom use.
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
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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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