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Contraception Corner

Condom Use: A Women’s Issue

Miriam Zieman, MD; Anita Nelson, MD

Women who rely only on hormonal contraceptive methods may not be aware of their high risk for sexually transmitted infections and diseases (STIs and STDs). Care should be taken to ensure that such patients are informed about the need for barrier contraception as well.

The 2002 CDC STD Treatment Guidelines state “When used consistently and correctly, male latex condoms are effective in preventing the sexual transmission of human immunodeficiency virus (HIV) infection and can reduce the risk for other STDs (ie, gonorrhea, chlamydia, and trichomonas). However, because condoms do not cover all exposed areas, they are likely to be more effective in preventing infections transmitted by fluids from mucosal surfaces (eg, gonorrhea, chlamydia, trichomoniasis, and HIV) than in preventing those transmitted by skin-to-skin contact (eg, herpes simplex virus [HSV], human papillomavirus [HPV], syphilis, and chancroid).”¹ Female condoms, although not a popular barrier method, also reduce the transmission of these diseases.² Evidence exists, however, that many sexually active women in the United States neglect to use adjunctive barrier methods in addition to hormonal contraceptive methods. For some women, this negligence is born out of an overly relaxed attitude about STIs; for others, the lack of barrier methods represents patients’ ignorance about the ways in which STIs are transmitted. Alerting women to their risk of acquiring STIs, and instructing them about consistent and correct condom use, is an important element of contraception counseling.

CONDOMS AS ADJUNCTIVE PROTECTION

Usage Trends

Women represent the most rapidly growing population of HIV-positive patients in the United States. In 1997, heterosexual contact was identified as the leading category of risk exposure for US women, with 9% more women acquiring HIV infection through heterosexual activity than through intravenous drug use (38% and 29%, respectively).³

Regarding STI acquisition in general and HIV in particular, women inherently have certain disadvantages that make them more vulnerable than men. First, male-to-female transmission of HIV is estimated to be eight times more likely than female-to-male transmission.⁴ There are two main reasons for this increased susceptibility: More men than women are infected with HIV, and, perhaps more significantly, women have a greater exposed surface area in the genital tract than do men.³ In addition, the duration of exposure to virus is longer in women; the ejaculate tends to linger longer in the vagina. The second disadvantage women have in avoiding HIV exposure is that they are typically not the sexual partner responsible for wearing barrier protection. In many cases, women must rely on their own knowledge and negotiation skills to ensure that their partner wears a condom.

The Hormone Conundrum

One study interviewed 3,326 women residing in eight US cities who had one or more risk factors for STIs.⁶ The study subjects qualifying for final analysis reported using one main form of birth control—either condoms or hormonal methods. Of 555 participants who reported having had sex with a “main” sexual partner in the previous 30 days, 56% reported that they had not used condoms the last time they had intercourse. Among the 569 women who had had sex with a “casual” partner in the previous 30 days, 29% reported that they had not used condoms the last time they had intercourse. Moreover, of the women with main partners who used condoms for contraception, 39% said they had not used one the last time they had intercourse; of the participants with casual partners, 22% had forgone condom use during their last sex encounter. Women with main partners who used hormonal contraception or who were surgically sterilized were found to be four times less likely to use a condom than were women who used condoms as their contraceptive method. A separate survey of 174 study participants revealed that 16% believed oral contraceptives offered at least some protection against STDs. Women may be confusing the protection that oral contraceptives afford against some of the STD complications (eg, pelvic inflammatory disease) with protection against the initial infection (eg, chlamydia).

SOLUTIONS

Changes in sexual behavior, such as increased use of barrier contraception, are the most effective means of preventing the transmission of HIV and other STIs in at-risk women. Remember that abstinence and lifetime mutual monogamy are really best at protecting against STDs. A study by Padian and colleagues presents an interesting example of how education and counseling can change behavior and ultimately reduce HIV transmission in a cohort of 144 HIV-positive individuals and their heterosexual HIV-negative partners.⁴ The majority of HIV-positive male partners had acquired HIV through bisexual activity, and the majority of the HIV-positive women were infected through heterosexual intercourse with a previous sexual partner. Couples’ counseling and risk assessments were conducted every 6 months. From study intake, the average duration of the relationships was ^5.6 years. Both condom use and sexual abstinence increased over time with counseling. After 193 couple-years of follow-up, no seroconversion was observed.

Couples’ counseling may not be necessary or possible in many cases; however, identification of risk factors and discussion with appropriate patients by themselves about the importance of barrier contraception is effective. A recent study by the Centers for Disease Control and Prevention serves as a demonstration: Nearly 1,800 sexually active women at inner-city clinic sites across the United States received a session of HIV/STI prevention counseling that included promoting consistent condom use.7 At a follow-up interview 3 months after the session, the proportion of hormonal contraception users who also reported using condoms consistently had tripled.

Goals of Counseling

An important objective in STI prevention counseling is to help women learn how to ask for, even to insist on, the use of either male or female condoms. Strengthening women’s self-esteem and determination to use condoms reinforces training in negotiation. Clinicians and patients working together can plan responses appropriate to women’s personal circumstances and cultures, including a preparation of appropriate responses to men’s objections to condoms.

CONCLUSION

The responsible health care provider is obligated to ensure that contraceptive counseling includes assessment and discussion of patients’ risk for STIs and HIV infection. Heterosexual women are at higher risk for acquiring HIV than ever before; concomitantly, there is an obvious deficiency in women’s knowledge about the need for adjunctive barrier methods with hormonal contraception. Fortunately, counseling about condom use has proven an effective way to reduce women’s acquisition of infections.

REFERENCES

1. Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines 2002. MMWR. 2002;51(RR6):3.
2. Macaluso M, Deman M, Artz L, et al. Female condom use among women at high risk of sexually transmitted diseases. Fam Plann Perspect. 2000;32 (3):138-144.
3. Centers for Disease Control and Prevention. HIV/AIDS surveillance report. 1998;9:10.
4. Padian NS, O’Brien TR, Chang Y, et al. Prevention of heterosexual transmission of human immunodeficiency virus through couple counseling. J Acquir Immune Defic Syndr. 1993;6 (9):1043-1048.
5. Stark M, Tesselaar H, Fleming D, et al. Contraceptive method and condom use among women at high risk for HIV infection and other sexually transmitted diseases: selected US sites, 1993-1994. MMWR. 45(38):820-823.
6. Douglas JM, Hoxworth Y, PhD, Rogers J, et al. Contraceptive practices before and after an intervention promoting condom use to prevent HIV infections and other sexually transmitted diseases among women: selected US sites, 1993-1995. MMWR. 1997;46 (17):371-377.

About ARHP
ARHP is a nonprofit, national medical organization that has been educating front line providers and their patients since 1963. The organization and members are dedicated to educating physicians and health care providers, and the public about important reproductive health issues including contraception, sexually transmitted diseases, menopause, abortion, sexuality, and infertility. ARHP contact information: 2401 Pennsylvania Ave, N.W., Suite 350, Washington DC 20037-1718; ph: (202) 466-3825; fax: (202) 466-3826; e-mail: arhp@arhp.org; Web: www.arhp.org.

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