Family planning, sexually transmitted diseases and contraceptive choice: a literature update--Part I.

Couples who use contraceptives not only protect themselves against unwanted pregnancies, but also may reduce their risk of becoming infected with a sexually transmitted disease (STD). No currently available method, however, is highly effective in protecting simultaneously against pregnancy and infection. Thus, couples who place high priority on minimizing both risks may have to use two methods. The need for contraceptive methods that provide effective protection against both pregnancy and STDs has been intensified by the HIV epidemic, but progress has been slowed by the lack of integration between the STD and family planning fields. The first part of this two-part article discusses the similarities and differences between the two fields, examines the impact of STDs on contraceptive use and services, and reviews the scientific literature dealing with the effects of condoms, spermicides and barrier-and-spermicide methods on the risk of STD transmission. Part II (which will appear in the next issue) examines what is known about the effects of oral contraceptives, the IUD, tubal sterilization and abortion on reproductive tract infections. The second part also includes a discussion of the trade-offs involved in choosing a contraceptive and presents estimates of the first-year rates of unplanned pregnancy and gonorrhea infection (given an infected partner) that would occur among women using various contraceptive methods.     

Sexual partnership patterns as a behavioral risk factor for sexually transmitted diseases

CONTEXT: Women's and men's number of sexual partners and protective practices such as condom use can have a direct effect on their risk of contracting sexually transmitted diseases (STDs), including HIV. METHODS: The 1988 and 1995 cycles of the National Survey of Family Growth and five rounds of the General Social Survey conducted from 1988 to 1996 are used to examine women's and men's numbers of recent sexual partners. Levels of direct risk for STDs (two or more partners in the past year) and the social and demographic correlates of multiple partnership are analyzed among women and men. In addition, women's indirect risk for STDs (their partners' involvement with other partners in the past year) is used to estimate their overall risk of STDs through multiple partnerships. RESULTS: At least three-quarters of sexually active U.S. women and men in the late 1980s and mid-1990s had had only one sexual partner in the preceding 12 months. Moreover, there is no indication that the proportion with more than one partner in the past year changed substantially over that period. Nevertheless, combining women's and men's partnership reports suggests that about 17 million women aged 15-44--34% of those sexually active in the past year--were at risk for STDs because of direct exposure to multiple partners (5.4 million), indirect exposure (6.3 million) or both direct and indirect exposure (5.5 million). In all, 21% of women were at direct risk and 23% were at indirect risk. In comparison, among men aged 18-44, 24% were at direct risk for STDs and an unknown proportion were at indirect risk. Multivariate analyses indicated that unmarried individuals, women younger than 40 and men aged 20-29, blacks and women in the South were all at elevated risk for STDs because of multiple partnership. Overall, in 1995, 19% of sexually active women aged 15-44 had used condoms to protect against STDs over the preceding year, and 19% of those sexually active in the three months before the survey were current condom users. Condom use specifically for STD prevention was more common among women reporting both direct and indirect risk for STDs (58%) and among those at direct risk (46%) than among other women; women whose partners put them at indirect risk only were less likely to be current or recent condom users than women who were not at risk or were only at direct risk. CONCLUSIONS: There is a continuing need to educate people regarding their risk for STDs, to increase the use of existing barrier methods and to develop new methods that protect against STD infection. In addition, if we are to develop a better understanding of the extent of STD risk through multiple partnership, the collection of information on number of partners and relationships between partners must be expanded and improved.     

Contraception and STDs

Since behavioral research indicates that assumption of less risky sexual practices is unlikely, prevention of sexually transmitted diseases (STDs) by alteration in contraceptive practice is more realistic. Condoms, known from laboratory tests to be impermeable to semen, body fluids, and all STD organisms except hepatitis B fragments, only reduce transmission of most STD infections by 50% in actual use. Those who use condoms more consistently achieve better protection, while condom failure due to breakage is concentrated among some users. Spermicides, including nonoxynol-0, benzalkonium chloride, menfegol, and octoxynol, act as lipid solvent, killing sperm and all STD agents. Most studies suggest about a 50% reduction in transmission, with perhaps a 33 less transmission of chlamydia. There is one report of possible enhancement of transmission of HIV by use of spermicides, among prostitutes in Africa. Neither condoms nor spermicides protect against extragenital transmission, especially for organisms transmitted by skin contact, i.e., syphilis, herpes, or chancroid. Oral contraceptives provide clear protection, about 50%, against pelvic inflammatory disease (PID), while they may facilitate cervical ectopy, and associated cervical chlamydia and gonorrhea. IUDs, once believed to heighten the risk of PID, now are considered increase this risk only a few days or months after insertion. Such insertion-related infection can be controlled with a single dose of a broad-spectrum antibiotic. Unfortunately those methods which are most effective in preventing pregnancy, pill and IUDs, are not particularly useful in preventing STDs, as are the less effective barriers and spermicides.     

Risk assessment and other screening options for gonorrhoea and chlamydial infections in women attending rural Tanzanian antenatal clinics.

Sexually transmitted diseases (STDs) are a major cause of morbidity and mortality in developing countries and may play a key role in enhancing the heterosexual transmission of human immunodeficiency virus (HIV). Treatment of STDs is one of the most cost-effective of all health interventions in developing countries; however, STDs among women in rural populations have received little attention. In this study, we report that prevalences of STDs among 964 women attending antenatal clinics in a rural area of the United Republic of Tanzania. A total of 378 (39%) of these women were infected with at least one STD pathogen, 97 (10%) had syphilis, and 81 (8%) has Neisseria gonorrhoeae (NG) and/or Chlamydia trachomatis (CT) infection. The recommended syndromic approach to screening for NG/CT infection, based on reported genital symptoms, had a low sensitivity (43%) and failed to discriminate between infected and uninfected women. A risk score approach that we developed, based on sociodemographic and other factors associated with NG/CT infection, had a higher sensitivity and lower cost per true case treated than other approaches, although its positive predictive value was only about 20%.     

丽江市古城区娱乐场所性工作者HIV、梅毒监测报告

[目的]为了解古城区娱乐场所女性性工作者中性病／艾滋病的分布及其发生频率、现状和流行趋势，为古城区防治性病／艾滋病策略提供依据。[方法]按照全国AIDS／STD检测工作规范要求，对女性性服务人群进行检测。[结果]对483名娱乐场所女性性工作者进行监测，查出艾滋病病毒感染者4例，梅毒4例。[结论]在女性性工作者中检出率较高，应加大对女性高危人群的干预力度，增强其自我保护意识，推广使用安全套，规范性病诊治，加大对古城区预防控制艾滋病／性病传播的有力措施。     

Original Research: Sexual Risk in Lesbians and Bisexual Women

Objective: To describe the frequency of human immunodeficiency virus (HIV)/sexually transmitted diseases (STDs) sexual risk behaviors in lesbian and bisexual women. Design: Cross-sectional anonymous self-administered questionnaire. Setting: Women's cultural events; HIV/STD service organizations; women's health collectives. Participants: 504 self-identified lesbian and bisexual women. The sample was composed of predominantly white, well-educated women with a mean age of 35 years. Results: Both lesbian and bisexual women engaged in behaviors that potentially lead to transmission of HIV and other STDs. Lesbians were more likely to have a single sexual partner than were bisexual women. Bisexual women were more likely to report a history of STD. Of those sexually active with male partners, one-third reported multiple male partners in the previous year. Significantly more bisexual women reported condom use. Women with multiple partners were more likely to consider themselves at risk for HIV/STD. Having unprotected sex or male partners was not associated with an increased risk perception. Conclusions: Lesbian and bisexual women are engaging in sexual behaviors that may increase their risk for HIV or STD infection. Culturally sensitive prevention programs are needed.     

Sexual knowledge, attitudes, and risk behaviors of students in Turkey

This survey produced baseline information about student knowledge of sexually transmitted diseases (STDs), their sexual attitudes, and their behavior to help establish control and education programs. The study was conducted at Ege University, Izmir, Turkey, during the 1999-2000 academic year. A total of 2,217 first- and fourth-year students determined by stratified sampling constituted the study group. All students who volunteered to participate completed a questionnaire assessing sociodemographic and knowledge factors, sexual attitudes, behavior, and history of STDs. The rate of students having had sexual experience was 36.6%. Males were more sexually active than females. Most students (71.4%) began sexual activity at ages 15-19 without any difference by gender. Males reported significantly more sexual partners than females. Similarly, the rate of male students never using condoms was significantly higher than females. Condom was the most frequent contraception method, followed by oral contraceptives and withdrawal. Mean score on the knowledge questions was 16.29 (highest score 30). The most widely known STD was HIV infection and AIDS. Students' knowledge of transmission routes, signs and symptoms, and risk groups of STDs was insufficient. Main sources of knowledge were visual and print media, and friends. Most students (84.7%) viewed prevention from STDs as a person's own responsibility. Young people in Turkey are sexually active and tend to engage in high-risk behavior. However, their knowledge on sexual health and sexually transmitted diseases is insufficient. Study results suggest a need for implementation of STD control programs and provision of school sexuality education for adolescents and young adults.     

Prospective study of hormonal contraception and women's risk of HIV infection in South Africa

BACKGROUND: Many women using hormonal contraceptives are also at risk of sexually transmitted HIV infection, but data are mixed on whether hormonal contraception increases women's risk of HIV. We investigated associations between HIV incidence and use of combined oral contraceptives (COC), norethindrone enanthate (NET-EN) or depot medroxyprogesterone acetate (DMPA) in a cohort of South African women. METHODS: Participants were 4200 HIV-negative women aged 35-49 years enrolled into a cervical cancer screening trial. At enrollment, women were tested for sexually transmitted infections and reported on their sexual behaviour and contraceptive use. During the 24 months of follow-up, women reported on their sexual behaviours and contraceptive use and underwent repeat HIV testing. RESULTS: During the 5010 person-years of follow-up, 111 incident HIV infections were observed (HIV incidence, 2.2 infections/100 person-years). At enrollment, 21% of women reported using hormonal contraception, primarily DMPA (14% of all women) or NET-EN (5%). After adjusting for sexual risk behaviours and sexually transmitted infections, the incidence of HIV was similar among women using COC, NET-EN or DMPA compared with women not using any hormonal method [incidence rate ratios and 95% confidence intervals, 0.65, 0.16-2.66; 0.79, 0.31-2.02 and 0.96, 0.58-1.59, respectively]. There was also no association between increased duration of DMPA use and HIV incidence (P-value for trend, 0.51). CONCLUSIONS: These findings contribute to the evidence from general population cohorts of women that hormonal contraceptive use is not associated with increased risk of HIV acquisition. Nonetheless, family planning services are an important venue for HIV prevention activities.     

The fight against sexually transmitted diseases in Ivory Coast: what strategies can we use in the face of HIV/AIDS?

In the AIDS era, sexually transmitted diseases (STDs) have become a major health problem in developing countries, particularly in Africa. Delays in the diagnosis and treatment of such infections may result in complications, many of which primarily affect women. Epidemiological studies in Abidjan have shown that more than 10% of the pregnant women attending antenatal clinics present STDs potentially serious for their own health or that of their infants (gonorrhea, chlamydia infection, genital ulcers or active syphilis). There is evidence that STDs increase the transmission of HIV and that improving the syndromic management of STDs reduces the incidence of HIV infection. This provides a strong argument in favor of controlling STDs in areas of high HIV prevalence. In Ivory Coast, as in other African countries, a STD control program has been integrated into the AIDS control program since 1992, as recommended by the World Health Organization. During the first six years of the STD program, considerable progress was made in some areas, but not without difficulty. Simple syndrome-based decision trees have been adopted for the management of STDs in primary health care. Clinical studies have shown these therapeutic algorithms to be effective. At the same time, effective and affordable drugs for treating STDs were added to the list of essential drugs in Ivory Coast, after an international invitation to tender. The entire staff of the public health sector in Abidjan has been trained in syndromic STD management. Training is now being extended to other parts of Ivory Coast, including the private health sector and, in particular, private nurses. The surveillance of syndromic STDs, mainly genital ulcers in both sexes and urethral discharge in men, facilitates monitoring and evaluation of the STD program, following health care activities and adapting orders for drugs for treating STDs to real needs. In the near future, some parts of the STD program will be strengthened, particularly the management of sexual partners of STD patients and reduction of the cost of STD treatment for pregnant women.     

Update to CDC's U.S. Medical Eligibility Criteria for Contraceptive Use, 2010: revised recommendations for the use of hormonal contraception among women at high risk for HIV infection or infected with HIV

Prevention of unintended pregnancy among women at risk for human immunodeficiency virus (HIV) infection or infected with HIV is critically important. One strategy for preventing unintended pregnancies in this population is improving access to a broad range of effective contraceptive methods. In 2010, CDC published U.S. Medical Eligibility Criteria for Contraceptive Use, 2010 (US MEC), providing evidence-based guidance for the safe use of contraceptive methods among women with certain characteristics or medical conditions, including women who are at high risk for HIV infection or are HIV infected. Recently, CDC assessed the evidence regarding hormonal contraceptive use and the risk for HIV acquisition, transmission, and disease progression. This report summarizes that assessment and the resulting updated guidance. These updated recommendations affirm the previous guidance, which stated that 1) the use of hormonal contraceptives, including combined hormonal contraceptives, progestin-only pills, depot medroxyprogesterone acetate (DMPA), and implants, is safe for women at high risk for HIV infection or infected with HIV (US MEC category 1), and 2) all women who use contraceptive methods other than condoms should be counseled regarding the use of condoms and the risk for sexually transmitted infections. However, a clarification is added to the recommendation for women at high risk for HIV infection who use progestin-only injectables to acknowledge the inconclusive nature of the body of evidence regarding the association between progestin-only injectable use and HIV acquisition. The clarification also notes the importance of condom use and other HIV preventive measures, expansion of the variety of contraceptive methods available (i.e., contraceptive method mix), and the need for further research on these issues.     

Pregnant women as a reservoir of undetected sexually transmitted diseases in rural South Africa: implications for disease control.

OBJECTIVES: This study was undertaken to determine the prevalence of sexually transmitted diseases (STDs) in pregnant women in rural South Africa and to determine the value of using abnormal urogenital symptoms to identify infected women. METHODS: This was a cross-sectional study of 327 patients attending prenatal clinics. RESULTS: Of the 271 women with complete data, 141 (52%) had at least 1 STD and 49 (18%) had more than 1. Abnormal symptoms were common (n = 225; 83%), but associations were weak, and the positive predictive value of different symptoms for infection ranged from 2% to 54%. CONCLUSIONS: Most STDs in rural South African women remain undetected and untreated. As the scope for laboratory diagnosis in resource-poor settings is limited, presumptive treatment of pregnant women and their partners may be a cost-effective option to reduce transmission of STDs and HIV infection.     

Traditional women's associations as channels for HIV / AIDS / STD prevention

Women of the Laobe ethnic group and the Dimba, a traditional women's association, provide advice about sexuality and reproductive health in southern Senegal. Research was initiated in October 1992 by the Cheikh Anta Diop University to determine whether these women could also help in HIV/AIDS and STD prevention activities. The study investigated men's and women's knowledge, attitudes, beliefs, and practices (KABP) related to sexuality and HIV/AIDS/STDs in the community of Kolda; practices potentially increasing women's risk of HIV/STD infection; and possibilities for integrating HIV/STD prevention messages into the interactions which take place between the Laobe and Dimba groups and the Kolda community. The KABP study was a questionnaire administered to 250 men and 250 women of reproductive age representing five ethnic groups residing in Kolda. 11 men and 14 women older than age 40 participated in in-depth sexual life history interviews. The survey and interviews indicate that people in Kolda do not generally see a link between sexual relations and STD transmission. Instead, STDs are attributed to behaviors such as urinating, walking barefoot on the urine of an already-infected person, encountering a "bad wind", and being cursed. Women may be at increased risk of HIV infection through practices designed to enhance sexual pleasure, including the insertion of organic and mineral product into the vagina, and the cutting of bumps and warts in and around the vagina. Sexual practices, knowledge, prevention through the Laobe and Dimba, and outcome and follow-up are discussed.     

IPPF statement on sexually transmitted diseases and reproductive health

At least 32 pathogens are known to be spread through sexual transmission. Sexually transmitted diseases (STDs) cause serious health problems that greatly affect the fetus and newborn and often result in both infant and adult death. The spread of STDs can be hindered by examining sexual behavior and attitudes, and by advocating monogamy in relationships as one of the best methods of protections against an STD. As the number of partners increases, so does the risk of transmission. Availability of centers for treatment and detection is another factor able to hinder the spread of disease. Condoms and spermicides offer some protection against STDs, whereas other methods of contraception such as diaphragms and hormonal methods have not been shown to prevent disease transmission. Family planning staff should be aware of the impact of STDs and should be able to make the public aware as well. Factors such as sexual background and behavior should be considered when recommending a form of contraception. Education, training and counselling are all crucial components of a successful family planning clinic and further promote safe sex practices.     

Knowledge of partner risk and secondary transmission of HIV

BACKGROUND: The number and proportion of people living longer with HIV and the proportion of people infected heterosexually have increased. We measured the frequency with which people with heterosexually acquired AIDS knew their partners' risk behaviors, the extent of secondary heterosexual transmission of HIV, and characterized people at risk for secondary heterosexual transmission. METHODS: For each of five sites (Alabama, California, Florida, New Jersey, and Texas) and for New York City, a sample of adults with AIDS was interviewed. Primary heterosexual transmission was contact with a partner who had a known risk factor for HIV infection. Secondary transmission was contact with an HIV-positive partner not known to have a risk for HIV. RESULTS: Among men, 35% knew that a sexual partner was HIV infected, 56% of women knew that a sexual partner was HIV infected. Among women, 12% knew that a partner was bisexual. Overall, 79% (460 of 581) reported a partner with a primary risk for HIV; among men, 236 of 293 (81%), and among women, 224 of 288 (78%) reported a partner with a primary risk. People categorized with secondary transmission were significantly more likely to be black and never married. People categorized with secondary transmission were more frequently women (53%), had less than a high school education (48%), and a history of drug use (52%). Men categorized with secondary transmission of HIV had a mean of 22 heterosexual partners; women had a mean of 16 partners. CONCLUSIONS: We found that many heterosexuals with AIDS did not know their sexual partners' risk for HIV, and that secondary heterosexual transmission probably results in a small proportion of all AIDS cases in the U.S.     

HIV infection, genital ulcer disease, and crack cocaine use among patients attending a clinic for sexually transmitted diseases.

BACKGROUND. Recently there has been a rise in genital ulcer disease (GUD) in urban minority heterosexuals in the United States. The impact of these increased GUD rates on HIV transmission patterns in this population is unknown. METHODS. Sexually transmitted disease (STD) diagnoses were correlated with HIV antibody status and risk factor history in 194 patients who consented to HIV testing at an STD clinic in central Brooklyn. RESULTS. Of 36 HIV-positive patients, 23 (64%) denied HIV risk factors other than heterosexual contact with persons of unknown HIV status. HIV antibody was associated with GUD (odds radio [OR] = 2.72, 95% confidence interval [CI] = 1.20-6.24), multiple concurrent STDs (OR = 2.51, 95% CI = 1.08-5.81), and a history of crack cocaine use (OR = 2.98, 95% CI = inexact-9.61). Crack use was also associated with GUD (OR = 15.15, 95% CI = 3.27-inexact) and multiple simultaneous STDs (OR = 13.87, 95% CI = 4.62-inexact). In a log-linear model analysis, HIV infection was independently associated with GUD and crack use. HIV infection, genital ulcer disease, and crack cocaine use were more common in women than men. CONCLUSIONS. The association between HIV infection and GUD seen here may be secondary to high-risk sexual behavior, which in turn may be partially attributable to crack cocaine use and drug-related prostitution. The high rate of coinfection with HIV and GUD raises a concern about the increased efficiency of sexual transmission of HIV in this population.     

Extrarelational sex among Mexican men and their partners' risk of HIV and other sexually transmitted diseases

OBJECTIVES: This study explored the risk of HIV and other sexually transmitted diseases (STDs) among married and cohabiting women in Mexico City, Mexico, derived from their partners' sexual behaviors. METHODS: Results were derived from the first population-based household survey in Mexico that investigated male sexual behavior. Analyses were restricted to sexually active married or cohabiting men (n = 3990). RESULTS: Fifteen percent of the men reported extrarelational sex during the past year, 9% reported condom use during last intercourse, and 80% perceived no HIV risk. Most secondary partners were coworkers, mistresses, or friends. CONCLUSIONS: Targeted HIV and STD prevention efforts appear necessary because a substantial number of women may be at risk.     

STDs and HIV / AIDS: a KAP study among drug operators

This study presents the findings of a Knowledge, Attitude, and Practice Survey about sexually transmitted diseases (STDs) and HIV/AIDS in Rajasthan, India. Data were obtained from 153 truck drivers covering "Dhabas" at different highways. Truck operators (TOs), commercial sex workers (CSWs), and iv drug users are the primary at risk populations for HIV/AIDS. In 1997, 73.3% of the 3188 HIV-infected persons were infected through heterosexual intercourse. Findings from TOs indicate a high level of knowledge about STDs, which are prevalent among TOs. Many TOs rely on cleanliness (68.9%) as a safety measure, followed by use of condoms with multiple partners (56.8%). About 50% go for regular check-ups at clinics to avoid the problem of STDs. About 75% of 132 TOs had had at least one problem with STDs during the prior year. About 46.2% consulted a doctor for treatment, 26.5% ignored the problem, and 18.2% received no treatment. 72.7% of 132 TOs had accurate knowledge about AIDS, 62.1% were aware of transmission routes, and 50% knew about prevention. About 85% visited CSWs. Only 14.3% of 112 TOs who visited CSWs used condoms during sexual relations. 10.7% used condoms most of the time, 47.3% used condoms irregularly, and 27.7% never used condoms. Condom availability was an issue. Most TOs learned about HIV/AIDS from mass media, especially posters and banners, followed by the radio. Only 28% of all TOs had complete knowledge of STDs; 13.6% had misconceptions. 37.1% had complete knowledge of HIV/AIDS; 10.6% had misconceptions.     

娱乐场所暗娼艾滋病知识态度及行为特征的调查分析

目的了解某市娱乐场所暗娼人群艾滋病病毒(H IV)感染情况及艾滋病知识态度、行为特征,为制定预防策略和措施提供理论依据。方法对目标区域的娱乐场所按档次进行分层抽样,对抽得的娱乐场所内暗娼进行问卷调查和H IV、梅毒抗体检测。结果调查对象H IV抗体检测均为阴性;检出梅毒抗体阳性2例,年龄最小为16岁,初中文化占53.5%;首次性行为和首次从事暗娼活动的平均年龄分别为17.6岁和19.6岁。调查对象虽然对艾滋病知识有一定的了解,但对艾滋病深层认识仍很缺乏;其中一部分调查对象从不使用安全套。高档与低档娱乐场所暗娼人群在艾滋病知识、态度、性行为特征和安全套使用方面无统计学差异。结论考虑到暗娼艾滋病相关危险行为发生率高。应加强健康教育和安全套推广工作,以减少H IV经性行为传播。     

Heterosexual women of color and HIV risk: sexual risk factors for HIV among Latina and African American women

This paper examines sexual risk for HIV among 2,318 Latina (60%) and African American (40%) women with a steady male partner who were attending an urban outpatient clinic. We compared ethnic groups on demographic characteristics (including being born in the U.S.) and sexual HIV risk factors (number of partners, history of sexually transmitted infection, condom use, and reported knowledge and perception of partner risk) while controlling for other demographic characteristics. African American women were about 1.5 times more likely than Latinas to report five or more sexual partners in their lifetime, to report two or more partners in the past year, and to perceive their partners as being risky. African American women were about 2.5 times more likely than Latinas to have had a history of sexually transmitted infections (STIs). They were also nearly twice as likely as Latinas to report having used condoms with their main partner in the past 90 days. Intervention strategies for HIV prevention must address ethnic/racial differences in sexual risk factors for HIV among Latina and African American women.