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RHO archives : Topics : HIV/AIDS

Special Focus: Dual Protection and HIV/AIDS

RHO's HIV/AIDS section provides more information on issues and resources relevant to this topic.

One of the many lessons we have learned from over twenty years of HIV/AIDS is that the virus does not exist in a void; itimpacts many areas of life. Reproductive health is one of the most significant of these areas. In recent years, acknowledgment of this link has led to a focus on the concept of “dual protection.” Dual protection denotes strategies that provide a simultaneous safeguard against both pregnancy and sexually transmitted infections (STIs), with particular emphasis on HIV. These strategies include the following:

  • The use of condoms alone to prevent both pregnancy and STIs.
  • The use of “dual methods”—one to prevent pregnancy (such as the pill, injectables, or implants) and one to prevent STIs (a male or female condom).
  • Non-penetrative sex.
  • Mutual monogamy between partners free of STIs, where at least one partner uses an effective contraceptive method.
  • Abstinence from sex (Wright 2003).

Condoms

Condoms figure prominently in most discussions of dual protection, including dual-method strategies. When used correctly, condoms are the only single contraceptive method that provides protection against both pregnancy and some STIs (including HIV). If condoms are not used correctly, other contraceptive methods may be more effective in helping people avoid unwanted pregnancies, but no other contraceptive method has demonstrated efficiency in preventing STIs. Recent research suggests that dual-method users are less consistent in their condom use than those who use condoms alone for dual protection (Brady 2003; Cates and Steiner 2001; Wright 2003).

For more information on the male condom, see RHO's Contraceptive Methods section.

The Female Condom

The appearance of the female condom in 1997 added a new dimension to efforts to provide dual protection against STIs and pregnancy. Produced by the Female Health Company, the female condom is a strong, soft transparent polyurethane sheath that is inserted in the vagina before sexual intercourse (Warren and Morris 2002). The female condom was notable for its status as an HIV prevention method that women could control; given womens documented difficulty in getting men to use male condoms (or any protection at all) to protect both partners from HIV and other STIs, this represented a significant advance in the fight against HIV/AIDS. When used correctly, the female condom has proved to be a highly effective pregnancy and STI prevention measure, and both men and women have reported enjoying sex while using the new device. However, the comparatively high cost of female condoms has hindered their popularity as a preventive measure. In addition, women are still faced with the prospect of negotiating safer sex with their male partners and overcoming male distrust of their desire to introduce protection into the relationship. Women and men have also objected to the difficulty of inserting the female condoms, the difficulty for men to touch their partners vagina, and mens occasional tendency to insert their penises beside the female condom rather than within it (Francis-Chizororo and Natshalaga 2003). For the female condom to achieve sustained success as a dual-protection measure, it will be important for service providers to become more familiar with the device, how it is used, and how to counsel clients considering the use of female condoms (Mantell et al. 2003).

For more information on the female condom, see RHO's Contraceptive Methods section.

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Family planning

In the context of increasing efforts to integrate reproductive health and STI/HIV-prevention efforts, family planning supplies a natural venue for promoting and explaining dual protection. Yet one challenge to this notion remainsfamily planning provider bias against condoms and in favor of other contraceptive methods considered more effective. In one study of family planning providers views on dual protection, most providers equated dual protection with use of two methods and did not trust condom use alone as a strategy for dual protection. To adequately address the issue of dual protection, many family planning providers may need the following:

  • Training in sexual risk assessment and counseling on barrier methods.
  • Training on client-centered counseling methods.
  • Training on how to help women discuss risk and protective behavior with their partners.
  • Training to assist providers in identifying their own biases about barrier contraceptives.
  • Updates on new developments in microbicides.
  • Training on how to apply different dual-protection counseling approaches for different types of clients and situations (Mantell et al. 2003).

A project conducted in six family planning clinics in Ibadan, Nigeria, demonstrated considerable success in promoting dual protection in family planning clinics. The project team trained family planning providers in promoting dual protection and condom use, introduced a dual-protection counseling protocol (focusing on HIV/STI education, client risk assessment, reproductive health assessment, STI prevention and treatment, condom skills-building, and partner negotiation), and trained providers to offer clients the female condom as part of routine clinical services. During the course of the project, discussions of clients sexual behavior and their partners sexual behavior increased from 19 percent and 16 percent of visits to 34 percent and 36 percent, respectively. Discussions of how to broach the topic of HIV/STI prevention with clients partners increased from 3 percent to 24 percent of visits. The use of counseling adapted to a clients personal situation increased from 28 percent to 67 percent, and discussions of how various family planning methods can protect against HIV/STIs increased from 7 percent of visits to 42 percent of visits. Clients reporting awareness of the concept of dual protection increased from 8 percent prior to project implementation to 50 percent following the project, while 37 percent of clients reported accepted dual-protection or condom brochures from providers at the end of the project, compared to 2 percent before project implementation (Adeokun et al. 2002).

For more information on integrating STI and family planning services, see RHO's Family Planning Program Issues section.

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Partner negotiation

One of the most crucial factors in dual protection against pregnancy and STIs is partner negotiation. Although women become pregnant and are more vulnerable to HIV infection, men often control decision-making about contraception, particularly condom use. In many parts of the world where the risk of HIV infection is high—even when men and women agree on the need to prevent pregnancy and/or STIs and on the effectiveness of condoms in prevention efforts—men may object to condom use on the grounds that it diminishes their sexual pleasure. And even when men and women concur that a woman who fears HIV infection should try to persuade her partner to use condoms, she may not be successful in doing so. When women try to propose condom use or provide condoms to their partners, they are often accused of sexual promiscuity and inspire distrust in their partners, especially if they are already using a contraceptive method and propose condom use as a second method in the context of dual protection. When condom use is accepted, it is often in the context of casual sex; with regular partners or once trust has been established in a relationship, men frequently discontinue the use of condoms, even if their behavior puts their regular female partners at risk.

Successful partner negotiation for dual protection calls for specific strategies, including:

  • Changing the gender norms that put women at a disadvantage in partner negotiation.
  • Innovative methods to involve both men and women in reproductive health.
  • Encouraging men to use condoms, limit their sexual partners, and seek treatment for STIs.
  • Fomenting better communication between men and women about sexual and reproductive health and preferences (Goparaju et al. 2003; Maharaj 2001).

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Dual protection in practice

As dual protection has gained importance as a means of preventing both pregnancy and STIs, researchers have implemented an increasing number of studies on the topic in areas of high HIV prevalence. One study was conducted in 1999-2000 in South Africa among 929 women aged 15 to 49 and attending selected primary health care clinics. Nearly all of the women knew about male condoms; 70 percent reported knowledge that condoms could be used to prevent both pregnancy and STIs. Only 43 percent knew that condoms could be combined with another contraceptive method for dual protection. Twelve percent of respondents reported being protected against both pregnancy and STIs at last intercourse, with only 7.5 percent using dual methods and 4.5 percent using a condom alone. Nearly one third of respondents used no method at all. Those who did use dual methods tended to be better educated, unmarried, and have had multiple sex partners over the previous year. Researchers on the study point to the need for:

  • Greater awareness of different strategies for dual protection.
  • Promotion and counseling for dual methods, including a barrier method.
  • Promotion of the dual use of condoms for contraception and STI prevention (Morroni et al. 2003).

Another South African study, carried out in 1998-1999, interviewed 554 men and women procuring condoms from 12 public health facilities in four regions of the country. Half of the respondents reported having used a condom during their last sexual encounter, while 34 percent reported having used a different contraceptive method. Only 16 percent had used both a condom and another method during their last sexual act. Increased level of schooling and prior instruction on condom use from health care providers were positively associated with use of dual methods. Both men and women concurred that the primary role of condoms was to protect against HIV and other STIs. Male and female respondents felt that either the man or the woman should make decisions about condoms and other contraceptives, but not both. Both sexes agreed that men made the final decision about condom use. Researchers suggest that there is a need for national and local policy to develop guidelines for promoting dual protection as part of primary care services (Myer et al. 2002).

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Triple protection?

One recent article posits the usefulness of focusing on triple protection, a concept that would add the safeguarding of fertility to protection from pregnancy and sexually transmitted infections. The author states that women have a greater vulnerability to STIs than men and suffer more serious repercussions, including conditions leading to infertility. She underscores the vital importance of fertility to many women, an importance that often supersedes the risk of unwanted pregnancy or acquiring STIs, including HIV. In many settings, she adds, "womens identity and status are inextricably bound to childbearing, and women are often blamed for a couples inability to reproduce. A focus on the concept of triple protection would draw out the connection between infertility and STI, and in so doing [] bolster STI prevention and control efforts. A number of measures could help to advance triple protection against unwanted pregnancy, STI transmission, and infertility, including:

  • Recognizing the sexual and reproductive health rights of women, including the right to safe, pleasurable, and consensual sexual relationships and the right to a safe and freely chosen marriage.
  • Educating men and women about sexual behavior and safer sex methods to protect their health.
  • Encouraging family planning programs to help prevent and treat infertility.
  • Conducting research on adolescent understanding and use of both dual and triple protection (Brady 2003).

For more information on protecting fertility through control of STIs, see RHO's Infertility section.

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Future directions

Dual protection remains a relatively new concept, with future research necessary to understand how best to promote and achieve a simultaneous safeguard against unwanted pregnancy and STIs, especially HIV. Sexual and reproductive health service providers and clients are not likely to place equal weight on both areas of protection in all areas of the world; the severity of a countrys HIV epidemic will often determine whether protection against STIs or against unwanted pregnancy receives greater emphasis. Yet with 40 million people worldwide living with HIV/AIDS, an annual occurrence of 340 million curable STIs, and an annual incidence of 133 million unintended pregnancies, dual protection is a vital measure for the health of men and women everywhere. Cates and Steiner argue for the need to instigate large, randomized controlled trials of service delivery; scientific measurement of key variables related to dual protection, including consistency of contraceptive use and prevalence of pregnancy and infection; and the measurement of dual-protection use through biologic outcomes rather than self-reported behavior. These advocates of dual protection also indicate the need to determine whether the following hypotheses are accurate:

  • Promoting condoms to prevent pregnancy will increase condom use and lower infection rates in target populations.
  • When using two methods, providers should counsel the use of condoms when the risk of STI transmission is high rather than necessarily for all sexual acts.
  • Providers should offer clients a choice of contraceptive methods, with the goal of increasing adherence and decreasing rates of pregnancy and sexually transmitted infection (Cates and Steiner, 2001).

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Annotated bibliography

Please note that PDF files require Adobe Acrobat Reader software, which can be downloaded for free at www.adobe.com/products/acrobat/readstep.html.

Adeokun L, et al. Promoting dual protection in family planning clinics in Ibadan, Nigeria. International Family Planning Perspectives. 2002;28(2):8795. Available at: www.agi-usa.org/pubs/journals/2808702.pdf.
The authors of this article report on efforts to introduce dual protection counseling and female-condom provision in six family planning clinics in Ibadan, Nigeria. Project activities included training family planning providers, introducing a dual-protection counseling protocol, providing female condoms as part of routine clinical services, as well as synthesizing management information systems and ongoing supervision. About one year after initiating the project, investigators observed that providers discussions of clients sexual behavior and their partners sexual behavior had increased from 19 percent and 16 percent of visits to 34 percent and 36 percent, respectively. Discussions of how to broach the topic of HIV/STI prevention with clients partners increased from three percent to 24 percent of visits. The use of counseling adapted to a clients personal situation increased from 28 percent to 67 percent, and discussions of how various family planning methods can protect against HIV/STIs increased from 7 percent of visits to 42 percent of visits. Clients reporting awareness of the concept of dual protection increased from 8 percent prior to project implementation to 50 percent following the project, while 37 percent of clients reported accepting dual-protection or condom brochures from providers at the end of the project, compared to 2 percent before project implementation.

Brady M. Preventing sexually transmitted infections and unintended pregnancy, and safeguarding fertility: triple protection needs of young women. Reproductive Health Matters. 2003;11(22):134141.
This article suggests the addition of protecting fertility to the existing concept of dual protection against unwanted pregnancy and sexually transmitted infections. The author maintains that women are more vulnerable to STIs than men, and suffer more serious consequences, including problems leading to infertility. Fertility is also extremely important to womens identity and status in many societies; women most often receive the blame for a couples inability to reproduce. The notion of triple protection would benefit from mens and womens concerns about infertility to help protect them against STIs, including HIV. The challenge remains to respect young womens sexual and reproductive health rights and educate men and women about healthy sexual behavior and safer sex.

Cates W, Steiner M. Dual protection against unintended pregnancy and sexually transmitted infections. Sexually Transmitted Diseases. 2002;168174.
In this article, the authors examine the effectiveness of contraceptive measures against pregnancy and STIs, motivations for dual protection, and approaches to optimize dual protection. Although they point to a lack of rigorous data to make recommendations to promote dual protection, they advise the one-method approach of condom use when the likelihood of exposure to HIV and other STIs is high. When unintended pregnancy is the dominant issue, providers should promote the two-method approach to dual protection. Further (and more systematic) research is needed on promoting condoms for pregnancy prevention, when to counsel clients to use condoms to protect against STIs, and providing a range of contraceptive choices to clients.

Francis-Chizororo M, Natshalaga N. The female condom: acceptability and perception among rural women in Zimbabwe. African Journal of Reproductive Health. 2003;7(3):10116.
This study used individual interviews with women and focus group discussions with both men and women to examine perceptions of female condoms before and after women used them for the first time. Both men and women expressed favorable attitudes toward the female condom. Women expressed positive reactions to the option of inserting the female condom prior to sexual intercourse and to its dual role in preventing pregnancy and STIs. Men, however, felt threatened by womens ability to control their own sexuality and feared that the female condom would encourage promiscuous behavior. Women maintained that introducing the female condom into the home required careful negotiation. The authors conclude that women and their male partners need to be educated on the importance of using the female condom consistently for greater effectiveness in curbing the spread of HIV/AIDS.

Goparaju L, et al. Gender, Power and Multi-Partner Sex: Implications for Dual Method Use in Ghana. Washington, DC: Center for Development and Population Activities; 2003. Available at: www.dec.org/pdf_docs/PNACT915.pdf.
This paper reports on the results of focus group discussions held with adolescents and young men and women on the topic of dual protection in Dodowa, Ghana. Researchers found that men use condoms for their own protection but often refuse to use them with regular partners. Men do not mind using condoms in short-term relationships, but do not like women to provide them. Men often do not use condoms consistently. The introduction of dual methods for dual protection often spawns distrust in relationships. Men and women lie to each other about their sexual partners. The authors conclude that encouraging mutual respect and responsibility between partners should be the foundation of dual-protection programs. Service providers should work toward changing gender norms as well as providing knowledge and access to dual protection.

Maharaj P. Obstacles to negotiating dual protection: perspectives of men and women. African Journal of Reproductive Health. 2001;5(3):15061.
Based on a qualitative study conducted in KwaZulu-Natal, South Africa, in 1998, this article summarizes the perspectives of sexually active men and women on the risks of unwanted pregnancy and HIV/AIDS. Among the study population, awareness of the risks was high. Although both men and women identified HIV/AIDS as a major health problem, men did not identify unwanted pregnancy as a major health problem. Knowledge of condoms among both sexes was almost universal. They also knew about the concept of dual protection, but were unlikely to use condoms along with another contraceptive method. Condom use was more common at the beginning of a relationship, whereas introducing condoms into a stable relationship inspired distrust, especially on the part of men. Men disliked condoms for interrupting sexual activity and pleasure and causing discomfort. Some male participants expressed skepticism about the effectiveness of condoms in preventing HIV transmission. Both male and female participants felt that condoms were unreliable. Women often felt unable to approach the issue of condom use with their partners, and felt there was little they could do to change their husbands behavior if they refused to use condoms. Many women choose to take risks in order to avoid the embarrassment or punishment of having to discuss condoms with their partners. The authors conclude that programs need to find new and innovative strategies of involving both men and women in reproductive health. Moreover, programs should focus on challenging traditional gender stereotypes and promoting new ways of considering gender roles.

Mantell J, et al. Family planning providers' perspectives on dual protection. Perspectives on Sexual and Reproductive Health. 2003;35(2):7178.
In this article, the authors examine the results of a study conducted in 1998 among 22 health care providers from a large New York City family planning agency offering devices to prevent pregnancy and STIs. Providers viewed STI prevention as an integral part of family planning counseling. They understood dual protection as the use of condoms along with another contraceptive rather than the use of condoms alone. They held mainly negative views of the female condom but expressed a willingness to learn more. The authors recommend training to reduce providers negative perceptions of the female condom and to reinforce the importance of individualized counseling tailored to womens specific needs.

Morroni C, et al. Dual protection against sexually transmitted infections and pregnancy in South Africa. African Journal of Reproductive Health. 2003;7(2):1319.
Between November 1999 and August 2000 researchers collected data from female clients of 89 public-sector primary health care facilities in three provinces of South Africa. Nearly all of the women knew about male condoms; 70 percent reported knowledge that condoms could be used to prevent both pregnancy and STIs. Only 43 percent knew that condoms could be combined with another contraceptive method for dual protection. Twelve percent of respondents reported being protected against both pregnancy and STIs at last intercourse, with only 7.5 percent using dual methods and 4.5 percent using a condom alone. Nearly one third of respondents used no method at all. Those who did use dual methods tended to be better educated, unmarried, and have had multiple sex partners over the previous year. Researchers on the study point to the need for greater awareness of different strategies for dual protection; promotion and counseling for dual methods, including a barrier method; and promotion of the dual use of condoms for contraception and STI prevention.

Myer L, et al. Dual method use in South Africa. International Family Planning Perspectives. 2002;28(2):11921. Available at: www.agi-usa.org/pubs/journals/2811902.pdf.
This article reports on a study carried out in South Africa in 1998-1999. Researchers interviewed 554 men and women procuring condoms from 12 public health facilities in four regions of the country. Half of the respondents reported having used a condom during their last sexual encounter; 34 percent reported having used a different contraceptive method. Only 16 percent had used both a condom and another method during their last sexual act. Increased level of schooling and prior instruction on condom use from health care providers were positively associated with use of dual methods. Both men and women concurred that the primary role of condoms was to protect against HIV and other STIs. Male and female respondents felt that either the man or the woman should make decisions about condoms and other contraceptives, but not both. Both sexes agreed that men made the final decision about condom use. Researchers suggest that there is a need for national and local policy to develop guidelines for promoting dual protection as part of primary care services.

Warren M, Morris C. The challenge of introducing the female condom for dual protection. Sexual Health Exchange. 2002;2:910.
This brief article examines obstacles encountered since the Female Health Company launched the female condom in 1997. Challenges have included overcoming long-held biases, balancing gender disparities, addressing existing dynamics between sexual partners and between providers and clients, and responding to the stigma of using any condom. Marie Stopes International is now working with the Female Health Company to introduce the female condom into Bolivia, Honduras, Mexico, and Nicaragua through pilot programs. The programs will focus on female empowerment, gender relations, and the benefits of dual protection.

Wright K. Dual protection. Network. 2003;22(4):1215.
This article defines the various strategies by which to achieve dual protection, as well as discussing dual-protection messages and consistency of condom use. The author interviews experts who recommend providing multiple methods for family planning, especially to clients at low risk of HIV infection. Interviewees also recommend a full understanding of the social context in which people make decisions about dual protection, including gender-power differentials.

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Links to resources

Listed below are some useful resources on dual protection and HIV/AIDS.

Female Condom and Dual Protection: Training for Community-Based Distributors and Peer Educators
www.cedpa.org/publications/dualprotection/dualprotection_all.pdf
This training manual, available as a PDF file from the Centre for Development and Population Studies, takes the form of a two-day curriculum for participants functioning as community health workers. It includes an overview of unintended pregnancies and HIV/STIs, a male and female anatomy review, an introduction to the female condom, a practice session, a discussion of how to stimulate behavior change for dual protection, and a review of the male condom.

IPPF/WHR AIDS Summary No. 9: Dual Protection and HIV/AIDS
www.ippfwhr.org/publications/serial_issue_e.asp?PubID=20&SerialIssuesID=140
Issue no. 9 of the IPPF/WHR AIDS Summary series explores dual protection and HIV/AIDS. The summary includes links to the IPPF statement on dual protection and the WHO declaration on dual protection, as well as descriptions of strategies to promote gender- and youth-sensitive dual protection; IPPF/WHR dual protection programs for youth in Guatemala, Honduras, and Nicaragua; and “Reflections on Dual Protection from the Field.”

IMAP Statement on Dual Protection Against Unwanted Pregnancy and Sexually Transmitted Infections, Including HIV
www.ippf.org/medical/imap/statements/eng/2000_05a.htm
The International Medical Advisory Panel (IMAP) of the International Planned Parenthood Federation issued a statement on dual protection in 1999. IMAP/IPPF maintains that family planning associations have an obligation to promote the concept and practice of dual protection; consistent and correct use of condoms is highly effective for the prevention of both unwanted pregnancy and STIs, including HIV; and clients should be free to use condoms alone for dual protection or to use them with another method. The statement includes a discussion of methods and program implications.

Joint WHO/UNAIDS/UNFPA Policy Statement: Dual Protection Against Unwanted Pregnancy and Sexually Transmitted Infections, Including HIV
www.who.int/reproductive-health/publications/RHR_01_20/annex1.en.html
This link connects viewers to the full text of the WHO/UNAIDS/UNFPA policy statement that expresses support for dual protection as a means to avert unplanned pregnancies and STIs. The statement asserts that it is the responsibility of both government and reproductive health programs to provide accurate information about dual protection and to enable sexually active people to access methods that will provide this protection. The document includes a list of groups for whom dual protection is particularly important and a series of actions that governments and reproductive health programs can take.

Research Summary: Promoting Dual Protection within Family Planning Services in Nigeria
www.popcouncil.org/horizons/ressum/dualprotnig.html
The Population Council website features a summary of research conducted on promoting dual protection as a part of family planning services. The summary covers the work of the Association for Reproductive and Family Health (ARFH) in testing clinic- and community-based strategies to increase the adoption of behaviors that protect against unwanted pregnancy and HIV/STIs among female family planning clients and their partners in Ibadan, Nigeria. Discussion covers intervention components, study methods, and key findings.

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