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.
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:
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.
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.
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.
Dual Protection and Consistency of Condom Use
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.
