Dual protection: best approach to recommend may vary.

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, page 14) and that appropriate dual protection messages may differ according to individual situations.

"Whether a condom-only or dual method approach 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 approaches. 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."

DUAL PROTECTION STRATEGIES

ADVANTAGES                           DISADVANTAGES

USE OF CONDOMS ONLY

* Destigmatizes condoms, which--in   * Not the most effective means of
  this case--are promoted for a        preventing pregnancy
  dual purpose                       * Rates of incorrect and
* Low-tech and relatively              inconsistent use are high
  affordable                         * May be difficult for some to
                                       negotiate use within
                                       relationships

DUAL METHOD USE

* Best protection against            * May be unrealistic for people to
  pregnancy                            be motirated to use two methods
* Most effective dual protection     * May decrease consistent use of
  if both methods are used             one of the methods
  consistently                       * Could stigmatize condoms,
                                       which--in this case--are
                                       promoted for STI prevention only
                                     * May be financially or
                                       logistically difficult

REFERENCES

(1.) 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.

(2.) Cates, Steiner.

(3.) 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.

(4.) Cates W Jr, Spieler J. Contraception, unintended pregnancies, and sexually transmitted infections. Still no simple solutions. Sex Transm Dis 2001;28(9):552-54.

(5.) 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.

(6.) 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.