Contraceptive Choice and Use of Dual Protection Among Women Living with HIV in Canada: Priorities for Integrated Care

CONTEXT

Preventing unintended pregnancy and HIV transmission is important for women with HIV, but little is known about their contraceptive use, particularly under current antiretroviral therapy (ART) recommendations for treatment and prevention.

METHODS

The prevalence of contraceptive use and of dual protection was examined among 453 sexually active women with HIV aged 16–49 and enrolled in the Canadian HIV Women's Sexual and Reproductive Health Cohort Study in 2013–2015; multivariable logistic regression was used to identify correlates of use. Two definitions of dual protection were assessed: the World Health Organization (WHO) definition (consistent condom use alongside another effective method) and an expanded definition (consistent condom use or a suppressed HIV viral load alongside an effective method).

RESULTS

Overall, 73% of women used effective contraceptives, primarily male condoms (45%) or tubal ligation (19%). Eighteen percent practiced WHO‐defined dual protection, and 40% practiced dual protection according to the expanded definition. Characteristics positively associated with contraceptive use were younger age, having been pregnant, being heterosexual, being unaware of ART's HIV prevention benefits and having had partners of unknown HIV status (odds ratios, 1.1–6.7). Younger age and perceived inability to become pregnant were positively associated with both definitions of dual protection (1.04–3.3); additionally, WHO‐defined dual protection was associated with perceiving HIV care to be women‐centered and having had partners of unknown HIV status (2.0–4.1), and dual protection under the expanded definition was related to having been pregnant (2.7).

CONCLUSIONS

Future research should explore how sustained ART and broader contraceptive options can support women's sexual and reproductive health care needs.     

Does the use of a condom involve a risk for contacting sexually transmitted infections,HIV/AIDS?

The aim of this study is to elucidate and review the risk of sexually transmitted infections (STIs) among condom users. Men and women of reproductive age are the subjects of this study. Data were extracted from the literature through the MEDLINE service for the period 2000–2006. Female condoms (0.1%) were reported to be less liable to break than male condoms (3.1%), while slippage occurs more often with female condoms (5.6%) than with male condoms (1.1%). The nonlatex condoms have a higher frequency of breakage or slippage during intercourse or withdrawal (4%) than latex ones (1.3%). Adolescents having multiple sexual partners and/or having sex with someone they met on that same day are about 80% more likely to report condom failure. Condom breakage or slippage is associated with never having received instructions on correct condom use, more than one sexual partner and more frequent condom use. Ineffective condom use is common among young adults. A younger age, primary partner, lack of partner support, multiple recent sexual partners and use of condoms for contraception are positively associated with delayed condom use. However, condoms do offer 30–90% protection against STIs and HIV passed in the semen and 0–30% protection against diseases due to skin-to-skin contact. This inversely implies that there is always a risk of contacting Chlamydia, gonorrhoea and HIV, or genital herpes and warts even when using a condom during sexual intercourse. Only correct – rather than consistent – condom use reduces the risk of STIs and HIV during intercourse. Therefore, condom users need to be cautioned that some risks are involved with the use of this method.     

Preventing syndemic Zika virus,HIV/STIs and unintended pregnancy: dual method use and consistent condom use among Brazilian women in marital and civil unions

Syndemic Zika virus, HIV and unintended pregnancy call for an urgent understanding of dual method (condoms with another modern non-barrier contraceptive) and consistent condom use. Multinomial and logistic regression analysis using data from the Pesquisa Nacional de Demografia e Saúde da Criança e da Mulher (PNDS), a nationally representative household survey of reproductive-aged women in Brazil, identified the socio-demographic, fertility and relationship context correlates of exclusive non-barrier contraception, dual method use and condom use consistency. Among women in marital and civil unions, half reported dual protection (30% condoms, 20% dual methods). In adjusted models, condom use was associated with older age and living in the northern region of Brazil or in urban areas, whereas dual method use (versus condom use) was associated with younger age, living in the southern region of Brazil, living in non-urban areas and relationship age homogamy. Among condom users, consistent condom use was associated with reporting Afro-religion or other religion, not wanting (more) children and using condoms only (versus dual methods). Findings highlight that integrated STI prevention and family planning services should target young married/in union women, couples not wanting (more) children and heterogamous relationships to increase dual method use and consistent condom use.     

Predictors of dual method use for pregnancy and HIV prevention among adolescent South African women

INTRODUCTION: Dual contraceptive method use is advocated for adolescent women to prevent pregnancy, sexually transmitted diseases and HIV. METHODS: We examined data from a nationally representative sample of South African women aged 15-24 years to establish factors associated with dual method use. RESULTS: Only 7% of current contraceptive users reported using dual methods, although this percentage increased to 28.1% when women reporting hormonal contraception and condom use at last sex were included. In multivariate analyses, having talked about condoms with a partner was most strongly associated with dual method use (adjusted odds ratio (AOR), 12.3; 95% confidence interval (CI), 6.1-25.1) and suggests that communication skills might be the most effective way of increasing dual method use. Difficulty in accessing condoms was associated with lower odds of dual method use (AOR, 0.5; 95% CI, 0.2-1.0). CONCLUSION: We conclude with recommendations to increase male involvement and encourage communication between partners for the integration of HIV prevention and other reproductive health care services.     

Safe Sex Versus Safe Love? Relationship Context and Condom Use Among Male Adolescents in the Favelas of Recife, Brazil

This study examined the influence of the relationship context where adolescent sexual activity takes place on contraceptive decisions. The data were collected in a specially designed survey carried out in May 2000 on 1,438 adolescent males aged 13–19 residing in favelas (urban slum areas) of Recife, Brazil. A logistic regression analysis of condom use at last sexual intercourse and a multinomial logit analysis of contraceptive method choice were performed for 678 sexually active adolescents. Educational attainment, degree of knowledge of HIV transmission and prevention, and condom use at first sexual intercourse were found to be significantly associated with current condom use. Regarding the relationship context, the analysis revealed that adolescent males in steady relationships were less likely to use condoms, less likely to regard themselves at risk of HIV infection, and more concerned about pregnancy prevention than adolescents in casual relationships. Differentials in condom use by type of relationship, however, did not result from a higher rejection of contraception by steady partners but from their higher likelihood to rely on other contraceptive methods. Results suggest that prevention campaigns need to take into account the intimate context where adolescents assess potential health risks, and to address the divergent symbolic meanings condoms may have in different types of relationships. If an increase of condom use among stable sexual partners is pursued, public health campaigns might need to romanticize condom use as a sign of love and trust and place more emphasis on the benefits of dual protection.     

Adolescent sexual behavior and associated variables

Proportionally more adolescents are having sexual intercourse and at younger ages. It has been reported that 11.6 million teens in the US between ages 13-19 years have had sexual intercourse. Many, however, do not use contraception, even though the prevalence of condom use has increased over the last ten years. The authors analyzed survey data to identify sexual activity among adolescents by grade, gender, number of partners, and contraceptive use, and to determine the association of intercourse with condom use, alcohol consumption, smoking, and AIDS/HIV education. 56.8% of 568 9th-12th grade respondents reported having had sexual intercourse: 33.5% in 9th grade, 58.9% in 10th grade, 68.5% in 11th grade, and 71.6% in 12th grade. Although more males than females reported having had sexual intercourse, no significant difference was found between males and females in each grade level on the number of lifetime sex partners or sex partners for the previous three months. 25% reported using alcohol during last sexual intercourse, 5% indicated using both alcohol and other drugs, and 22% reported that no contraception was used or that they were not sure if anything was used. Sexually active respondents were significantly more likely to consume alcohol and to smoke. The authors also found no significant difference for use of condoms between those who had AIDS/HIV education and those who had not, except that those who had AIDS/HIV education were less likely to have multiple partners. 42.5% of all sexually active respondents reported using a condom. Only 38.5% of those exposed to AIDS/HIV education in schools reported using a condom during last intercourse compared to 30% of those not exposed to such education.     

Adolescent Males' Combined Use of Condoms with Partners' Use of Female Contraceptive Methods

Objective: Protection from both sexually transmitted diseases and pregnancy is best obtained by the combined use of male condoms and effective female contraceptive methods. This research examines dual contraceptive method use among teenage men. Method: Analyzed data from the 1995 National Survey of Adolescent Males, a nationally representative survey of 15 to 19-year-old males. Used bivariate analyses and logistic regression to examine the correlates of combined use of condoms and female methods. Results: At last intercourse, 17% of sexually active males reported use of a condom and a female method of contraception. Condom use, alone and in combination with a female method, was positively associated with talking with the partner about contraception and condoms, believing that males have a responsibility for contraception, and being in an earlier stage of a relationship. Only high levels of worry about sexually transmitted diseases differentially influenced dual method use, increasing the likelihood of using a condom with a female method, but not using condoms alone. Conclusions: The results suggest that efforts to increase condom use in general should also influence young men's use of condoms when their partner is using a female method. Providing information to young males about the high prevalence and serious consequences of sexually transmitted diseases may increase dual method use among adolescents.     

Social and psychological influences on HIV preventive behaviors of youth in Haiti.

PURPOSE: To examine HIV/AIDS prevention-related sexual behaviors and identify potential predictors of those behaviors among youth living in Haiti. METHODS: Data were gathered from a cross-sectional survey conducted with 845 youth, aged 15-19 years, attending 12 primary and/or secondary schools. A subsample of the 491 students who were sexually active comprised the study sample. Data were collected using a theory-based, self-administered questionnaire. Data were analyzed by multiple logistic regression using SPSS for Windows. RESULTS: Only 18% of sexually active adolescents reported always or sometimes using condoms and 27% reported having used a condom the last time they had sex. Over 40% (43%) had had three or more lifetime sex partners. Findings from the multivariate logistic regression analyses indicate that consistent condom use, condom use at last sexual intercourse, and fewer lifetime sexual partners were significantly associated with high levels of self-efficacy to communicate about HIV/AIDS or use a condom. Significant negative associations were found among consistent condom use, condom use at last sex, and high barriers to condom use. Fewer lifetime sexual partners was significantly associated with high peer preventive norms and low traditional gender norms. CONCLUSION: These findings emphasize the importance of providing HIV prevention programs for young people in the study communities which enhance effective sexual communication and negotiation skills, target prevention-oriented social norms, and address how to overcome barriers to condom use.     

Sexual behavior and condom use among urban women attending a family planning clinic in the United States

In this paper I present data on risky sexual behavior and condom use among a sample of 100 adult women who attended a family planning clinic in an urban area of the United States. Although the women in this study protected themselves from pregnancy by using contraception, they engaged in sexual behaviors that put them at risk for sexually transmitted human immunodeficiency virus (HIV), including unprotected oral, anal, and vaginal intercourse, and sex with risky partners. Alcohol and drug use were also common among the women in this sample. Almost half of the participants reported a history of sexually transmitted infections. Health assessment for women using contraception should include assessment of risk factors for sexually transmitted HIV infection. All women should be counseled regarding methods of reducing their risk for HIV.     

Romantic relationship characteristics and alcohol use: longitudinal associations with dual method contraception use

PurposeDual method contraception use, or the use of one type of contraceptive intended to prevent pregnancy combined with another type intended to reduce the risk of sexually transmitted infection, may be the most effective method to prevent both unintended pregnancy and sexually transmitted infection. This study tested the association between relationship length, relationship type (married, cohabiting, dating but not cohabiting), global alcohol use, and situational alcohol use and the probability of dual method contraception use from 20 to 23 years of age.MethodsHierarchical linear modeling analyses were conducted using longitudinal data from 754 sexually active male and female young adults aged 20–23 years. Dependent variables included both any dual method contraception use and consistent dual method contraception use.ResultsBetween 15% and 20% of respondents reported consistent dual method contraception use at each time point. Longer relationship length and more committed relationship type were associated with a lower probability of both any and consistent dual method contraception use. Situational alcohol use (drinking before sex), but not global alcohol use, also was related to a lower probability of both any and consistent dual method contraception use. Increasing age was associated with a lower probability of any dual method contraception use, but was not related to consistent dual method use.ConclusionsEfforts to promote dual method contraception among young adults should include messages discouraging drinking before sex and supporting dual method use even in the context of committed relationships.     

Use of the “NYC Condom” among People Who Use Drugs

We assessed awareness and use of the “NYC Condom” among persons who use heroin and cocaine in New York City. The NYC Condom distribution program is the largest free condom distribution program in the USA, with over 30 million condoms distributed per year. It includes a condom social marketing program for a specific brand, the NYC Condom with its own packaging and advertising. People who use heroin and cocaine are at relatively high risk for HIV infection and are an important target population for the program. In order to assess awareness of the NYC Condom, structured interviews and blood testing for HIV, HSV-2, and sexually transmitted infections (STI) were conducted among entrants to the Beth Israel Medical Center drug detoxification and methadone treatment programs. Participants were asked about drug use, sexual risk behaviors, and awareness and use of the NYC Condom. Univariate and multivariable regression analyses were conducted to examine the associations between use of NYC Condoms and consistent condom use with primary and casual sexual partners. A total of 970 subjects were recruited between February 2011 and December 2012. Subjects were primarily African–American and Hispanic, with a mean age of 43. Fifty-five percent of subjects reported being sexually active with primary sexual partners, and 25 % reported being sexually active with a casual partner for the 6 months prior to the interview. Sixty-five percent of subjects had heard of the NYC Condom, 48 % of those who had heard of the condom had used it, and 58 % of those who had ever used it were currently using it (in the previous 6 months). In multivariable regression analyses, current use of NYC Condoms was strongly associated with consistent condom use with primary sexual partners (adjusted odds ratio (AOR)?=?3.99, 95 % confidence interval (CI) 1.85–8.58) and consistent condom use with casual sexual partners (AOR?=?4.48, 95 % CI 1.49–13.42). In terms of market share, 38 % of subjects consistently using condoms with primary partners were using the NYC Condom, and 47 % of those consistently using condoms with casual partners were using the NYC Condom. The NYC Condom is an important tool for reducing sexual transmission of HIV and STI among persons who use drugs in the city. Given the strong relationship between using the NYC Condom and consistent condom use, further efforts to promote the NYC Condom brand would be easily justified.     

Sex in Australia: safer sex and condom use among a representative sample of adults

OBJECTIVE: To provide reliable estimates of the frequency of condom use and correlates of condom use among Australian adults. METHODS: Computer-assisted telephone interviews were completed by a representative sample of 10,173 men and 9,134 women aged 16-59 years. The response rate was 73.1% (69.4% men, 77.6% women). RESULTS: Although the majority of respondents had used a condom at some time in their lives, fewer than half of the respondents who were sexually active in the year before being interviewed had used a condom in the past year. Condom use in the past year was associated with youth, greater education, residence in major cities, lower incomes, white-collar occupations, being a former smoker, and having more sexual partners in the past year. In the six months prior to interview, 7.1% of respondents always used condoms with regular cohabiting partners, 22.5% always used condoms with regular non-cohabiting partners, and 41.4% always used condoms with casual partners. Approximately 20% of respondents used a condom the last time they had vaginal intercourse, and one in eight of these condoms were put on after genital contact. Condom use during the most recent sexual encounter was associated with youth, living in a major city, having a lower income, having sex with a casual partner, and not using another form of contraception. CONCLUSION: As in other studies, condom use was strongly associated with partner type and use of other contraception. IMPLICATIONS: People with multiple sexual partners need to be aware that non-barrier methods of contraception (and condoms applied late) do not protect against sexually transmitted infections.     

Assessing the potential of condom use to prevent the spread of HIV: a microsimulation study

In this study, a microsimulation model is used to assess the potential impact of condom use on women's lifetime risk of acquiring HIV in rural southern Malawi. The model draws on survey data for information on sexual activity, marriage and divorce, and on the biomedical literature for input parameters governing the transmission and spread of HIV and other sexually transmitted diseases (STDs). We show that lifetime risk could be as high as 42 percent with no condom use and as low as 8 percent if everyone consistently uses condoms with nonmarital partners. Next, we examine the impact of more realistic, intermediate strategies of condom use, varying men's propensity to use a condom with nonmarital partners, varying the per-coitus probability of condom use, varying probabilities of slippage or breakage, and finally, examining the effect of condom use in the presence of STD symptoms. We demonstrate profound effects of consistent condom use and of condom use prompted by symptomatic STDs.     

Social-cognitive predictors of consistent condom use among young people in Moscow

CONTEXT: Russia is experiencing an explosive HIV epidemic, and young people aged 15-29 have the highest incidence of infection. Understanding factors associated with condom use in this age-group is important in developing effective prevention interventions. METHODS: Telephone interviews were conducted with 1,203 Muscovites aged 15-29 in September 2002 to assess condom use, HIV knowledge and sexual behavior. Multivariate logistic regression was used to determine independent predictors of consistent condom use. RESULTS: Forty-four percent of sexually experienced respondents reported using condoms consistently. In multivariate analysis, the likelihood of consistent use was elevated among single women and men (odds ratios, 1.8 and 2.6, respectively), those who considered condoms reliable protection against unwanted pregnancy (2.4 and 1.6) and those who believed that most of their peers use condoms (2.9 and 4.6). For women, having recently had multiple partners was associated with increased odds of consistent use, and consistent use declined with age. CONCLUSIONS: Strategies to promote condom use should increase awareness about their effectiveness against not only unwanted pregnancies but also HIV and other STDs. Condoms should be recommended for married couples and people with one permanent partner as a contraceptive option as well as for disease prevention.     

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.     

Safe Sext: Adolescents' Use of Technology to Communicate About Sexual Health With Dating Partners

PurposeThis study examined adolescents' technology-based sexual communication with dating partners, and evaluated associations between technology-based communication and condom use.MethodsParticipants were 176 high school students who indicated their use of technology to communicate with partners about condoms, birth control, sexually transmitted infections (STIs), HIV/AIDS, pregnancy, and sexual limits. Sexually active youth also reported their frequency of condom use.ResultsMany adolescents (49%) used technology to discuss sexual health with partners, with rates varying by topic. Girls were more likely than boys to discuss HIV, pregnancy, and sexual limits. Ethnic minorities were more likely than whites to discuss condoms, STIs, HIV, pregnancy, and birth control. Importantly, rates of consistent condom use were three times higher among youth using technology to discuss condoms and birth control.ConclusionsResults provide novel preliminary evidence regarding adolescents' use of technology to discuss sexual health and demonstrate links between technology-based communication and condom use among sexually active youth.     

HIV prevalence, AIDS knowledge, and condom use among female sex workers in Santiago, Chile

This paper describes HIV seroprevalence, knowledge of HIV transmission, and condom use among female sex workers (FSW) attending five specialized sexually transmitted disease (STD) clinics in Santiago, Chile. A short questionnaire with socio-demographic, AIDS knowledge, and condom-use variables was administered to 626 FSW. HIV seroprevalence was estimated with a blood test sent to the Chilean Public Health Institute. ELISA was used to confirm HIV in suspected cases. HIV prevalence was 0%. FSW showed adequate overall knowledge of HIV, even better than reported for the Chilean general population on some items. Condom use with clients was high ("always" = 93.4%), although regular use with steady partners was low ("always" = 9.9%). The zero HIV seroprevalence and consistent condom use with clients confirms the positive impact of intervention strategies for FSW, increasing both correct knowledge of AIDS and condom use with clients and helping decrease these women's HIV/AIDS vulnerability.     

Contraception and sexually transmitted infections

This contribution considers links between different methods of contraception and the risk of acquiring sexually transmitted infections (STIs). This is a major public health issue, because STIs cause a huge disease burden that affects women disproportionately. Worldwide each year, there are 340 million new cases of curable STIs in 15-49-year-olds. In developing countries, STIs, even excluding HIV, are second only to maternal factors as causes of disease, death and life lost. There is particular concern about a putative link between hormonal contraception and STIs. However, the methodological problems facing investigation of a putative link are formidable. They include confounding between sexual behaviour and choice of contraceptive, choice of appropriate control group, and lack of precise measures of level of HIV/STI exposure and other risk factors. The current situation can be summarized as follows. The risk of acquiring HIV/STIs is substatially reduced by barrier methods of contraception. Hormonal contraception is a widely used, safe and highly effective method of preventing unintended pregnancy. Its relationship to HIV/STI transmission remains uncertain. In the absence of better evidence, current approaches to promoting hormonal contraception should continue. The importance and effectiveness of consistent condom use to protect against HIV/STI should be stressed, regardless of whether other contraceptive methods are being used. Future contraceptive research should focus on the dual goal of protection against HIV/STIs and unintended pregnancy.     

The Influence of Sexual Risk Communication Between Parents and Daughters on Sexual Risk Behaviors*

Two hundred thirty‐four 19‐ to 21‐year‐old women completed interviews that assessed parent‐adolescent relations, sexual communication, and selected sexual risk behaviors and outcomes. Overall, Hispanic–Latina respondents reported less parent‐adolescent sexual communication than others. Early parent‐adolescent sexual communication was associated with later age of sexual initiation, consistent condom use and, indirectly, less likelihood of sexually transmitted diseases. Mother‐daughter communication about condoms was associated with consistent condom use. Recommendations for family‐based HIV–STD prevention are presented.     

Who's Responsible? Correlates of Partner Involvement in Contraceptive Decision Making

ObjectivesResearchers have begun looking at joint responsibility for contraceptive decision making as a mechanism to increase effective contraceptive use. This analysis identifies correlates of partner involvement in contraceptive decision making.MethodsParticipants were first-time users of either oral contraceptives or Depo-Provera recruited from 10 family planning clinics in Texas (n = 481). Participants completed a self-administered questionnaire that was available in both English and Spanish. Chi-square statistics were used to compare demographics, relationship characteristics, and condom use before and after initiation of the new hormonal method by who is responsible for birth control use. Characteristics that were significant in bivariate testing were then included in a multivariate logistic regression model.ResultsForty-five percent of women reported sole responsibility for contraceptive use and 55% reported joint responsibility with their partners. In multivariate models, consistent condom use before and after the initiation of hormonal contraception and duration of sexual activity with main partner for less than 2 years were associated with increased likelihood of joint responsibility for contraceptive decision making. Women whose partners were classified as high risk had reduced the odds of joint responsibility for contraceptive decision making.ConclusionWomen at increased risk for sexually transmitted diseases (high-risk partners) and their partners may represent a target population for interventions aimed at increasing joint responsibility for contraception use. Continuous engagement in contraceptive decision making among long-term couples should also be encouraged.