1
|
Jackson A, Angel A, Bagourmé ARM, Boubacar M, Maazou A, Issoufa H, Bouanchaud P. A New Contraceptive Diaphragm in Niamey, Niger: A Mixed Methods Study on Acceptability, Use, and Programmatic Considerations. GLOBAL HEALTH: SCIENCE AND PRACTICE 2022; 10:GHSP-D-21-00532. [PMID: 35294389 PMCID: PMC8885346 DOI: 10.9745/ghsp-d-21-00532] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 12/22/2021] [Indexed: 11/15/2022]
Abstract
Through a pilot introduction in Niamey, Niger, we found that expanding method options to include the Caya diaphragm, a new self-care contraceptive product without side effects for most users, may address some of the challenges that contribute to very low contraceptive use. Introduction: Methods: Results: Discussion:
Collapse
Affiliation(s)
| | | | | | | | | | - Harou Issoufa
- Ministry of Public Health, Population, and Social Affairs of Niger, Niamey, Niger
| | | |
Collapse
|
2
|
Cottingham J. Historical note: How bringing women's health advocacy groups to WHO helped change the research agenda. REPRODUCTIVE HEALTH MATTERS 2015; 23:12-20. [PMID: 26278829 DOI: 10.1016/j.rhm.2015.06.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Revised: 06/08/2015] [Accepted: 06/09/2015] [Indexed: 11/18/2022] Open
Abstract
The politics of population control and its sometimes coercive methods in developing countries documented during the 1960s, 70s and 80s, gave rise to strong opposition by women's groups, and put into question the safety of contraceptive methods that were being developed and introduced into countries. In 1991, the Special Programme on Human Reproduction at the World Health Organization, a research programme focused on development of new methods and safety assessments of existing fertility regulation methods, started a process of "dialogue" meetings between scientists and women's health advocacy groups which lasted for nearly a decade. This paper describes the process of these meetings and what they achieved in terms of bringing new or different research topics into the agenda, and some of the actions taken as a result.
Collapse
|
3
|
Gollub EL, Cyrus E, Dévieux JG, Jean-Gilles M, Neptune S, Pelletier V, Michel H, Sévère M, Pierre L. 'Men don't need to know everything': a field trial of a discreet, female-initiated, contraceptive barrier method (FemCap™) among Haitian-American women. CULTURE, HEALTH & SEXUALITY 2015; 17:842-58. [PMID: 25703101 DOI: 10.1080/13691058.2015.1005672] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
Worldwide, women report the need for safe, non-hormonal, woman-initiated methods of family planning. Cervical barriers provide such technology but are under-researched and under-promoted. In the USA, there are few studies of cervical barriers among women at high unmet need for contraception. A feasibility study of the FemCap™ was conducted among US women of Haitian origin. Participants were heterosexual and seeking to avoid pregnancy. At first visit, participants completed baseline assessments, underwent group counselling and were fitted with FemCap™. Women were asked to insert or use the cap at home. The second visit (2-3 weeks) included an interviewer-administered questionnaire and a focus-group discussion. Participants (n = 20) were Haitian-born (70%), married (55%) and parous (85%). Their mean age was 32.6 years. Seventy percent reported recent unprotected sex. All women inserted the device at home and 9 women used it during intercourse, including 5 without prior partner negotiation. Of 20 women, 11 liked FemCap™ very much or somewhat; 7 considered it 'OK'; 2 disliked it. Best-liked attributes were comfort, discreet wear and reusability. Difficulties with removal abated over time. Qualitative data revealed a high value placed on lack of systemic side effects. Use of FemCap™ was feasible and acceptable, supporting expansion of research, particularly among relevant populations with unmet need.
Collapse
Affiliation(s)
- Erica L Gollub
- a Department of Epidemiology , Stempel College of Public Health and Social Work, Florida International University , Miami , USA
| | | | | | | | | | | | | | | | | |
Collapse
|
4
|
Brady M, Manning J. Lessons from reproductive health to inform multipurpose prevention technologies: Don’t reinvent the wheel. Antiviral Res 2013; 100 Suppl:S25-31. [DOI: 10.1016/j.antiviral.2013.09.019] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2013] [Accepted: 09/23/2013] [Indexed: 11/25/2022]
|
5
|
Hyttel M, Rasanathan JJ, Tellier M, Taremwa W. Use of injectable hormonal contraceptives: diverging perspectives of women and men, service providers and policymakers in Uganda. REPRODUCTIVE HEALTH MATTERS 2012; 20:148-57. [DOI: 10.1016/s0968-8080(12)40654-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
|
6
|
Living with uncertainty: acting in the best interests of women. AIDS Res Treat 2012; 2012:524936. [PMID: 23193463 PMCID: PMC3501797 DOI: 10.1155/2012/524936] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2012] [Revised: 09/20/2012] [Accepted: 09/25/2012] [Indexed: 11/18/2022] Open
Abstract
A recent multi-country study on hormonal contraceptives (HC) and HIV acquisition and transmission among African HIV-serodiscordant couples reported a statistically significant doubling of risk for HIV acquisition among women as well as transmission from women to men for injectable contraceptives. Together with a prior cohort study on African women seeking health services, these data are the strongest yet to appear on the HC-HIV risk. This paper will briefly review the Heffron study strengths and relevant biological and epidemiologic evidence; address the futility of further trials; and propose instead an alternative framework for next steps. The weight of the evidence calls for a discontinuation of progestin-dominant methods. We propose here five types of productive activities: (1) scaling injectable hormones down and out of the contraceptive mix; (2) strengthening and introducing public health strategies with proven potential to reduce HIV spread; (3) providing maximal choice to reduce unplanned pregnancy, starting with quality sexuality education through to safe abortion access; (4) expanding provider training, end-user counseling and access to male and female barriers, with a special renewed focus on female condom; (5) initiating a serious research agenda to determine anti-STI/HIV potential of the contraceptive cervical cap. Trusting women to make informed choices is critical to achieve real progress in dual protection.
Collapse
|
7
|
Alexander KA, Coleman CL, Deatrick JA, Jemmott LS. Moving beyond safe sex to women-controlled safe sex: a concept analysis. J Adv Nurs 2011; 68:1858-69. [PMID: 22111843 DOI: 10.1111/j.1365-2648.2011.05881.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIM This paper is a report of a conceptual analysis of women-controlled safe sex. BACKGROUND Women bear disproportionate burdens from sexually related health compromising outcomes. Imbalanced societal gender and power positions contribute to high morbidities. The expression, women-controlled safe sex, aims to empower women to gain control of their sexual lives. Few researchers focus on contextualized socio-cultural definitions of sexual safety among women. DATA SOURCES The sample included scientific literature from Scopus, CINAHL, PubMed, PsychINFO and Sociological Abstracts. Papers were published 2000-2010. REVIEW METHODS Critical analyses of literature about women-controlled safe sex were performed in May 2011 using Rodgers' evolutionary concept analysis methods. The search focused on social and cultural influences on sexual practices aimed at increasing women's control over their sexual safety. RESULTS The analysis uncovered five attributes of women-controlled safe sex: technology; access to choices; women at-risk; 'condom migration' panic; and communication. Three antecedents included: male partner influence; body awareness; and self-efficacy. Consequences were categorized as positive or negative. Nine surrogate terms included: empowerment; gender power; female-controlled sexual barrier method; microbicides; diaphragm; sexual negotiation and communication; female condom; women-initiated disease transmission prevention; and spermicides. Finally, a consensus definition was identified: a socio-culturally influenced multi-level process for initiating sexual safety by women deemed at-risk for sexually related dangers, usually sexually transmitted infections and/or HIV/AIDS. CONCLUSION This concept analysis described current significance, uses, and applications of women-controlled safe sex in the scientific literature. The authors clarified its limited nature and conclude that additional conceptual refinement in nursing is necessary to influence women's health.
Collapse
Affiliation(s)
- Kamila A Alexander
- Center for Health Equity Research University of Pennsylvania School of Nursing, Pennsylvania, USA.
| | | | | | | |
Collapse
|
8
|
Kulczycki A, Qu H, Bosarge PM, Shewchuk RM. Examining the diverse perspectives of nurse practitioners regarding obstacles to diaphragm prescription: a latent class analysis. J Womens Health (Larchmt) 2011; 19:1355-61. [PMID: 20575680 DOI: 10.1089/jwh.2009.1730] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND The diaphragm is receiving renewed attention not only for its dual method potential but also because of improved design. To facilitate method re-introduction, we examined what providers think about this female-controlled barrier contraceptive. METHODS A questionnaire administered to 450 women's health nurse practitioners (NPs) asked about their practice experience and issues concerning diaphragm use. Latent class analysis (LCA) was used to identify different groups of providers, based on patterns of perceptions regarding various potential obstacles to diaphragm use. Provider profiles were further described in terms of individual and practice characteristics. RESULTS The survey achieved a 47% response rate (n = 214). Respondents saw, on average, 31 family planning patients/week; 87% had fitted a diaphragm, although only 40% had done so in the previous year. Three groups holding significantly different perceptions of obstacles to diaphragm prescription were identified. Group 1 (13% of respondents), with more practice experience in delivering women's healthcare and fitting diaphragms, considered all obstacles relatively inconsequential. Group 2 (40%) had comparatively minor concerns, whereas Group 3 (47%) perceived all issues as major obstacles. All groups stressed the diaphragm's limited promotion, and for 87% of the respondents, concerns about effectiveness and nonfamiliarity with the method also assumed more salience. CONCLUSIONS Emerging statistical modeling approaches that go beyond standard aggregate analyses helped identify three groups of women's health nurse practitioners. By considering their diverse perceptions of potential obstacles to diaphragm use, strategies aimed at changing provider behaviors may be developed to reverse declining prescribing rates and retain the diaphragm as a viable reproductive healthcare option for women.
Collapse
Affiliation(s)
- Andrzej Kulczycki
- Maternal and Child Health Concentration, Department of Health Care Organization and Policy, University of Alabama at Birmingham, Birmingham, Alabama 35294-0022, USA.
| | | | | | | |
Collapse
|
9
|
The importance of male partner involvement for women's acceptability and adherence to female-initiated HIV prevention methods in Zimbabwe. AIDS Behav 2011; 15:959-69. [PMID: 20844946 PMCID: PMC3111667 DOI: 10.1007/s10461-010-9806-9] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Enlisting male partner involvement is perceived as an important component of women’s successful uptake of female-initiated HIV prevention methods. We conducted a longitudinal study among a cohort of 955 Zimbabwean women participating in a clinical trial of the effectiveness of a female-initiated HIV prevention method (the diaphragm and lubricant gel) to: (a) describe the extent to which women involved their male partners in the decision to use the study products, and (b) measure the effect perceived male partner support had on their acceptability and consistent use of these methods. Reported levels of male partner involvement in discussions and decisions regarding: joining the study, study activities, the outcome of HIV/STI test results, and product use were very high. In multivariate analyses, regular disclosure of study product use and partner approval for the diaphragm and gel were significantly associated with women’s acceptability and consistent use of the products; an essential component for determining efficacy of investigational prevention methods. These results support the need for more sophisticated measurement of how couples interact to make decisions that impact study participation and investigational product use as well as more rigorous adaptations and evaluations of existing strategies to involve male partners in female-initiated HIV prevention trials.
Collapse
|
10
|
van der Straten A, Cheng H, Minnis AM. Change in condom and other barrier method use during and after an HIV prevention trial in Zimbabwe. J Int AIDS Soc 2010; 13:39. [PMID: 20955629 PMCID: PMC2984577 DOI: 10.1186/1758-2652-13-39] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2010] [Accepted: 10/19/2010] [Indexed: 11/16/2022] Open
Abstract
Background We examined the use of male condoms and the diaphragm following completion of a clinical trial of the diaphragm's HIV prevention effectiveness. In the trial, called Methods for Improving Reproductive Health in Africa (MIRA), women were randomized to a diaphragm group (diaphragm, gel and condoms) or a condom-only control group. At trial exit, all women were offered the diaphragm and condoms. Methods Our sample consisted of 801 Zimbabwean MIRA participants who completed one post-trial visit (median lapse: nine months; range two to 20 months). We assessed condom, diaphragm and any barrier method use at last sex act at enrolment, final MIRA and post-trial visits. We used multivariable random effects logistic regression to examine changes in method use between these three time points. Results and discussion In the condom group, condom use decreased from 86% at the final trial visit to 67% post trial (AOR = 0.20; 95% CI: 0.12 to 0.33). In the diaphragm group, condom use was 61% at the final trial visit, and did not decrease significantly post trial (AOR = 0.77; 95% CI: 0.55 to 1.09), while diaphragm use decreased from 79% to 50% post trial (AOR = 0.18; 95% CI: 0.12 to 0.28). Condom use significantly decreased between the enrolment and post-trial visits in both groups. Use of any barrier method was similar in both groups: it significantly decreased between the final trial and the post-trial visits, but did not change between enrolment and the post-trial visits. Conclusions High condom use levels achieved during the trial were not sustained post trial in the condom group. Post-trial diaphragm use remained relatively high in the diaphragm group (given its unknown effectiveness), but was very low in the condom group. Introducing "new" methods for HIV prevention may require time and user skills before they get adopted. Our findings underscore the potential benefit of providing a mix of methods to women as it may encourage more protected acts.
Collapse
Affiliation(s)
- Ariane van der Straten
- Women's Global Health Imperative, RTI international, San Francisco Project Office, San Francisco, CA, USA.
| | | | | |
Collapse
|
11
|
Montgomery ET, Cheng H, van der Straten A, Chidanyika AC, Lince N, Blanchard K, Ramjee G, Nkala B, Padian NS. Acceptability and use of the diaphragm and Replens lubricant gel for HIV prevention in Southern Africa. AIDS Behav 2010; 14:629-38. [PMID: 19757018 PMCID: PMC2865647 DOI: 10.1007/s10461-009-9609-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2009] [Accepted: 08/25/2009] [Indexed: 11/16/2022]
Abstract
The acceptability and use of the diaphragm and lubricant gel were assessed as part of a large randomized controlled trial to determine the effectiveness of the methods in women’s HIV acquisition. 2,452 intervention-arm women were enrolled at five Southern African clinics and followed quarterly for 12–24 months. Acceptability and use data were collected by face-to-face interviews at Month 3 and Exit. Participants were “very comfortable” with the physical mechanics of diaphragm use throughout the trial, and approval of the gel consistency, quantity and the applicator was high. At Exit, consistent disclosure of use (AOR 1.97, 95% CI: 1.10–3.55); an overall high diaphragm rating (AOR 1.84, 95% CI: 1.45–2.34) and perception of partner approval (AOR 1.75, 95% CI: 1.35–2.26) were the most significant acceptability factors independently associated with consistent use. Despite being female-initiated, disclosure of use to male partners and his perceived approval of the products were factors significantly associated with their consistent use.
Collapse
|
12
|
|
13
|
Coffey PS, Kilbourne-Brook M. Wear and care of the SILCS diaphragm: experience from three countries. Sex Health 2010; 7:159-64. [DOI: 10.1071/sh09049] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2009] [Accepted: 02/08/2010] [Indexed: 11/23/2022]
Abstract
Background: Women have been regularly underestimated in their ability to care for and wear cervical barrier devices such as diaphragms appropriately. Methods: Data from two non-randomised, non-blinded, non-significant risk acceptability studies of a novel cervical barrier device, the SILCS diaphragm, conducted in the Dominican Republic (n = 20), South Africa (n = 21) and Thailand (n = 20), are used to provide insights into the fundamental question of how women actually use an intravaginal device within the constraints of low-resource settings. In all sites, couples not at risk of pregnancy and at low risk of sexually transmissible infections used the SILCS diaphragm four times and provided feedback on acceptability, care and use of the device via product use questionnaires and gender-specific debriefing interviews. Results: Data from user acceptability studies in these three countries provide an intimate view of how women care for and store the SILCS diaphragm, and both female and male perceptions about handling and re-using it. Results support the view that women are able to wear and care for diaphragms successfully in a variety of settings. In general, male partners were also supportive of care and reuse of the diaphragm. Conclusions: While the results from these studies indicate that women are able to find ways to cope successfully with the logistics of wearing and caring for an intravaginal device, further supportive evidence from a woman-centred perspective is crucial for reproductive health policymakers and program managers. The authors contend that it is time to reassess perceived constraints to barrier protection.
Collapse
|
14
|
Luchters S, Chersich MF, Jao I, Schroth A, Chidagaya S, Mandaliya K, Temmerman M. Acceptability of the diaphragm in Mombasa Kenya: A 6-month prospective study. EUR J CONTRACEP REPR 2009; 12:345-53. [PMID: 17853168 DOI: 10.1080/13625180701516989] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVES If proven acceptable, safe and effective, the diaphragm could be used as a female-controlled method of preventing both sexually-transmitted infections (STIs) and pregnancy. This study's aim was to assess the acceptability and safety of the diaphragm among sexually-active women in Mombasa, Kenya. METHODS We conducted a 6-month prospective study among female sex workers (FSWs), and women attending sexual and reproductive health services. Diaphragm acceptability was assessed using continuation rates and factors associated with acceptability. Safety evaluations included colposcopy findings and incidence of urinary tract infections (UTIs) and STIs. RESULTS Half the 185 participants were FSWs who had less schooling and were less likely to be married than other women. After 6 months, 55% (56/102) of sexually-active women reported having used the diaphragm each sex act during the preceding month. Women liked using the diaphragm (95%, 104/109), and 96% (125/130) reported willingness to continue using it. Colposcopy did not reveal significantly more vaginal or cervical lesions. Use of the diaphragm was not associated with an increase in bacterial vaginosis or UTIs. A pregnancy rate of 12 per 100 women/years was observed. CONCLUSION After 6 months of diaphragm use in this setting, continuation rates were sustained, user satisfaction was high and adverse effects were few.
Collapse
Affiliation(s)
- Stanley Luchters
- International Centre for Reproductive Health (ICRH), Tudor Four Estate, Tom Mboya Avenue, PO Box 91109, Mombasa, Kenya.
| | | | | | | | | | | | | |
Collapse
|
15
|
Patterns and Predictors of Adherence to Diaphragm Use in a Phase III Trial in Sub-Saharan Africa: A Trajectory Analysis. J Acquir Immune Defic Syndr 2009; 50:419-26. [DOI: 10.1097/qai.0b013e3181958511] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
16
|
Coffey PS, Kilbourne-Brook M, Brache V, Cochón L. Comparative acceptability of the SILCS and Ortho ALL-FLEX® diaphragms among couples in the Dominican Republic. Contraception 2008; 78:418-23. [DOI: 10.1016/j.contraception.2008.07.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2008] [Revised: 07/01/2008] [Accepted: 07/01/2008] [Indexed: 11/16/2022]
|
17
|
Evidence-based planning of a randomized controlled trial on diaphragm use for prevention of sexually transmitted infections. Sex Transm Dis 2008; 35:238-42. [PMID: 18166850 DOI: 10.1097/olq.0b013e31815abaa2] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES We conducted formative research to evaluate the acceptability and feasibility of continuous diaphragm use among low-income women highly exposed to sexually transmitted infections (STIs) in Madagascar. GOAL To identify potential obstacles to researching the effectiveness of diaphragm use for STI prevention in a randomized controlled trial. STUDY DESIGN Mixed methods to collect complex information. In a quantitative pilot study, women were asked to use diaphragms continuously (removing once daily for cleaning) for 8 weeks and promote consistent male condom use; they were interviewed and examined clinically during follow-up. Focus group discussions (FGDs) were conducted pre-/postpilot study. Audiotaped FGDs were transcribed, translated, coded, and analyzed. RESULTS Ninety-three women participated in prepilot FGDs, 91 in the pilot study, and 82 in postpilot FGDs. Diaphragm use was acceptable and feasible, but participants reported lower condom use in FGDs than during interviews. Most participants reported in interviews that they used their diaphragms continuously, but FGDs revealed that extensive intravaginal hygiene practices may impede effective continuous diaphragm use. Despite counseling by study staff, FGDs revealed that participants believed the diaphragm provided effective protection against STIs and pregnancy. CONCLUSIONS Mixed methods formative research generated information that the prospective pilot study alone could not provide and revealed contradictory findings. Results have methodological and ethical implications that affect trial design including provision of free hormonal contraceptives, and additional instructions for vaginal hygiene to avoid displacing the diaphragm. Mixed methods formative research should be encouraged to promote evidence-based study design and implementation.
Collapse
|
18
|
van der Straten A, Moore J, Napierala S, Clouse K, Mauck C, Hammond N, Padian N. Consistent use of a combination product versus a single product in a safety trial of the diaphragm and microbicide in Harare, Zimbabwe. Contraception 2008; 77:435-43. [DOI: 10.1016/j.contraception.2008.02.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2007] [Revised: 02/08/2008] [Accepted: 02/12/2008] [Indexed: 10/22/2022]
|
19
|
Gollub EL. A neglected population: drug-using women and women's methods of HIV/STI prevention. AIDS EDUCATION AND PREVENTION : OFFICIAL PUBLICATION OF THE INTERNATIONAL SOCIETY FOR AIDS EDUCATION 2008; 20:107-120. [PMID: 18433317 DOI: 10.1521/aeap.2008.20.2.107] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Women drug users are at extremely high risk of HIV and sexually transmitted infections (STIs) from sexual transmission, but remain seriously neglected in intervention research promoting women-initiated methods of HIV/STI prevention. Sparse available data indicate a high interest and enthusiasm for women-initiated methods among these women. Moreover, drug-using women may be in a position to capitalize most on the myriad advantages of women-initiated methods and be the least hindered by their disadvantages, as compared with other populations of at-risk women. These advantages include, for example, the potential for prior placement and use of a female condom without being noticed by a drunk or "high" partner, long-term and/or clandestine use of cervical barriers, and the "contraceptive justification" to partners or clients initially unwilling to accede to use of a female barrier. Targeted, community-based outreach and educational efforts to this extremely hard-to-reach group as well as expanded public funding for women's methods are urgent priorities.
Collapse
Affiliation(s)
- Erica L Gollub
- Visiting Professor of Epidemiology, Institut de Santé Publique, d'Epidémiologie et de Développement (ISPED), Université de Bordeaux II/INSERM U897, Bordeaux, France.
| |
Collapse
|
20
|
Harvey SM, Branch MR, Thorburn S, Warren J, Casillas A. Exploring diaphragm use as a potential HIV prevention strategy among women in the United States at risk. AIDS EDUCATION AND PREVENTION : OFFICIAL PUBLICATION OF THE INTERNATIONAL SOCIETY FOR AIDS EDUCATION 2008; 20:135-147. [PMID: 18433319 DOI: 10.1521/aeap.2008.20.2.135] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Given the immediate need for physical cervical barrier methods like the diaphragm to protect against HIV/STIs, understanding what factors influence the acceptability of these products and how to overcome obstacles to their use is important. We explored perceptions of the diaphragm and factors that might enhance its acceptability in 25 focus groups with racially/ethnically diverse young women in the U.S. at risk for HIV/STIs (N = 140). Women believed the diaphragm has positive attributes, and most indicated they would be more likely to use the diaphragm if they were confident they could use it correctly and it protected against HIV. They also considered it messy to use and difficult to insert or remove. Findings suggest that the diaphragm could be a desirable option for pregnancy and disease prevention for some women at risk for HIV/STIs. Although disadvantages to diaphragm use were identified, many could be eliminated through changes in product design and provider intervention.
Collapse
Affiliation(s)
- S Marie Harvey
- Department of Public Health, Oregon State University, Corvallis, OR 97331-6406, USA.
| | | | | | | | | |
Collapse
|
21
|
Barriers to the use of modern contraceptives and implications for woman-controlled prevention of sexually transmitted infections in Madagascar. J Biosoc Sci 2008; 40:879-93. [PMID: 18198005 DOI: 10.1017/s0021932007002672] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Globally, unplanned pregnancies and sexually transmitted infections (STIs) persist as significant threats to women's reproductive health. Barriers to the use of modern contraceptives by women might inhibit uptake of novel woman-controlled methods for preventing STIs/HIV. Use of modern contraceptives and perceptions and attitudes towards contraceptive use were investigated among women in Antananarivo, Madagascar, using qualitative research. The hypothetical acceptability of the diaphragm--a woman-controlled barrier contraceptive device that also holds promise of protecting against STIs/HIV--was assessed. Women consecutively seeking care for vaginal discharge at a public health clinic were recruited for participation in a semi-structured interview (SSI) or focus group discussion (FGD). Audiotaped SSIs and FGDs were transcribed, translated and coded for predetermined and emerging themes. Of 46 participating women, 70% reported occasional use of male condoms, mostly for preventing pregnancy during their fertile days. Although women could name effective contraceptive methods, only 14% reported using hormonal contraception. Three barriers to use of modern contraceptives emerged: gaps in knowledge about the range of available contraceptive methods; misinformation and negative perceptions about some methods; and concern about social opposition to contraceptive use, mainly from male partners. These results demonstrate the need for programmes in both family planning and STI prevention to improve women's knowledge of modern contraceptives and methods to prevent STI and to dispel misinformation and negative perceptions of methods. In addition, involvement of men will probably be a critical component of increased uptake of woman-controlled pregnancy and STI/HIV prevention methods and improved health.
Collapse
|
22
|
Padian NS, van der Straten A, Ramjee G, Chipato T, de Bruyn G, Blanchard K, Shiboski S, Montgomery ET, Fancher H, Cheng H, Rosenblum M, van der Laan M, Jewell N, McIntyre J. Diaphragm and lubricant gel for prevention of HIV acquisition in southern African women: a randomised controlled trial. Lancet 2007; 370:251-261. [PMID: 17631387 PMCID: PMC2442038 DOI: 10.1016/s0140-6736(07)60950-7] [Citation(s) in RCA: 265] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Female-controlled methods of HIV prevention are urgently needed. We assessed the effect of provision of latex diaphragm, lubricant gel, and condoms (intervention), compared with condoms alone (control) on HIV seroincidence in women in South Africa and Zimbabwe. METHODS We did an open-label, randomised controlled trial in HIV-negative, sexually active women recruited from clinics and community-based organisations, who were followed up quarterly for 12-24 months (median 21 months). All participants received an HIV prevention package consisting of pre-test and post-test counselling about HIV and sexually transmitted infections, testing, treatment of curable sexually transmitted infections, and intensive risk-reduction counselling. The primary outcome was incident HIV infection. This study is registered with ClinicalTrials.gov, number NCT00121459. FINDINGS Overall HIV incidence was 4.0% per 100 woman-years: 4.1% in the intervention group (n=2472) and 3.9% in the control group (n=2476), corresponding to a relative hazard of 1.05 (95% CI 0.84-1.32, intention-to-treat analysis). The proportion of women using condoms was significantly lower in the intervention than in the control group (54%vs 85% of visits, p<0.0001). The proportions of participants who reported adverse events (60% [1523] vs 61% [1529]) and serious adverse events (5% [130] vs 4% [101]) were similar between the two groups. INTERPRETATION We observed no added protective benefit against HIV infection when the diaphragm and lubricant gel were provided in addition to condoms and a comprehensive HIV prevention package. Our observation that lower condom use in women provided with diaphragms did not result in increased infection merits further research. Although the intervention seemed safe, our findings do not support addition of the diaphragm to current HIV prevention strategies.
Collapse
Affiliation(s)
| | | | - Gita Ramjee
- HIV Prevention Research Unit, Medical Research Council, Durban, South Africa
| | | | - Guy de Bruyn
- Perinatal HIV Research Unit, University of the Witswatersrand, Johannesburg, South Africa
| | | | | | | | | | - Helen Cheng
- University of California, San Francisco, CA, USA
| | | | | | | | - James McIntyre
- Perinatal HIV Research Unit, University of the Witswatersrand, Johannesburg, South Africa
| |
Collapse
|
23
|
Kang MS, Buck J, Padian N, Posner SF, Khumalo-Sakutukwa G, van der Straten A. The importance of discreet use of the diaphragm to Zimbabwean women and their partners. AIDS Behav 2007; 11:443-51. [PMID: 17160486 DOI: 10.1007/s10461-006-9190-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2006] [Accepted: 11/07/2006] [Indexed: 11/26/2022]
Abstract
We conducted a 6-month acceptability study of diaphragms as a potential HIV/STI prevention method among Zimbabwean women. We examined partner involvement in diaphragm use, and importance of discreet use (use without partner awareness). Of the 181 women who completed the study, 45% said discreet use was "very or extremely important" and in multivariate logistic regression, women were more likely to value discretion if their partners: had other partners; drank alcohol; or were believed to prefer condoms to diaphragms. Qualitative data confirmed these findings. Both women and their partners reported that diaphragms can be used discreetly and saw this as advantageous, for both sexual pleasure and female control. However, many were concerned that use without partner approval could lead to marital problems. Discreet use should be considered in development of barrier methods and in diaphragm promotion, if proven effective against HIV/STI.
Collapse
Affiliation(s)
- Mi-Suk Kang
- UZ-UCSF Collaborative Research Programme in Women's Health, Harare, Zimbabwe.
| | | | | | | | | | | |
Collapse
|
24
|
Beckman LJ, Harvey SM, Thorburn S, Maher JE, Burns KL. Women's acceptance of the diaphragm: the role of relationship factors. JOURNAL OF SEX RESEARCH 2006; 43:297-306. [PMID: 17599251 DOI: 10.1080/00224490609552329] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
The vaginal diaphragm is a candidate for a female-controlled method of reducing risk of HIV/STI acquisition. We examined the association between relationship and partner factors and three measures of diaphragm acceptability: current use, consistency of use, and satisfaction with use. We conducted a telephone survey with 448 female members of a managed care organization, aged 18-49, who currently used contraception (including 140 diaphragm users, 187 pill users, and 121 male condom users). Use of a specific contraceptive was significantly associated with relationship length, condom-use negotiation self-efficacy, importance of covert use, perceived motivation of partner to prevent HIV/STIs, and perceived satisfaction of partner with current method. In addition, among diaphragm users, communication about HIV/STIs and perceived partner motivation to use a diaphragm were related to consistent use. These results suggest that acceptability of contraceptive methods among women is influenced by their perceptions of their male partner and relationship factors.
Collapse
|
25
|
Mantell JE, Dworkin SL, Exner TM, Hoffman S, Smit JA, Susser I. The promises and limitations of female-initiated methods of HIV/STI protection. Soc Sci Med 2006; 63:1998-2009. [PMID: 16814912 PMCID: PMC4115800 DOI: 10.1016/j.socscimed.2006.05.008] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2005] [Indexed: 11/21/2022]
Abstract
New methods are now available, and others are being developed, that could enable women to take the initiative in preventing sexually transmitted infections. However, attempts to capitalize on "female-controlled" preventive methods thus far have met with limited success. Female-initiated methods were introduced to intervene in the state of gender relations and assist women who are disempowered vis-à-vis their male partners. Paradoxically, however, we underscore that it is the very structure of regional and local gender relations that shapes the acceptability (or lack of acceptability) of these methods. This paper specifically addresses how the structure of gender relations-for better and for worse-shapes the promises and limitations of widespread use and acceptance of female-initiated methods. We draw on examples from around the world to underscore how the regional specificities of gender (in)equality shape the acceptance, negotiation, and use of these methods. Simultaneously, we demonstrate how the introduction and sustained use of methods are shaped by gender relations and offer possibilities for reinforcing or challenging their current state. Based on our analyses, we offer key policy and programmatic recommendations to increase promotion and effective use of women-initiated HIV/STI protection methods for both women and men.
Collapse
Affiliation(s)
- Joanne E. Mantell
- HIV Center for Clinical and Behavioral Studies, NYS Psychiatric Institute and Department of Psychiatry, Columbia University NY, NY, USA
| | - Shari L. Dworkin
- HIV Center for Clinical and Behavioral Studies, NYS Psychiatric Institute and Department of Psychiatry, Columbia University NY, NY, USA
| | - Theresa M. Exner
- HIV Center for Clinical and Behavioral Studies, NYS Psychiatric Institute and Department of Psychiatry, Columbia University NY, NY, USA
| | - Susie Hoffman
- HIV Center for Clinical and Behavioral Studies, NYS Psychiatric Institute and Department of Psychiatry, Columbia University NY, NY, USA
- Mailman School of Public Health, Columbia University NY, NY, USA
| | - Jenni A. Smit
- Reproductive Health and HIV Research Unit, University of the Witwatersrand, South Africa
| | | |
Collapse
|
26
|
Sharma A, Bukusi E, Posner S, Feldman D, Ngugi E, Cohen CR. Sex preparation and diaphragm acceptability in sex work in Nairobi, Kenya. Sex Health 2006; 3:261-8. [PMID: 17112438 DOI: 10.1071/sh06021] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2006] [Accepted: 08/06/2006] [Indexed: 11/23/2022]
Abstract
Background: Women in sex work stand to benefit if the contraceptive diaphragm alone or combined with a microbicide proves to be an effective barrier method against HIV and sexually transmissible infection (STI). Currently, contraceptive diaphragm users are advised to leave the diaphragm in situ without concomitant use of other intravaginal substances for at least 6 h after intercourse. Methods: We conducted in-depth interviews on sexual behaviour including post-coital intravaginal practices with 36 women in sex work and 26 of their clients and held two focus-group discussions, each with 10 women. Results: The women described adapting several potentially harmful substances, such as cloth and soapy water, for post-coital vaginal use to ensure personal hygiene, disease prevention and client pleasure. Some wanted to clean themselves and remove the diaphragm early, fearing exposure to HIV infection for themselves and their subsequent clients. Clients indicated their desire for ‘dry sex’, vaginal cleanliness and reduced risk of infection through vaginal cleaning. Conclusions: The diaphragm as a female-controlled barrier method for HIV/STI prevention may have limited acceptability among women in sex work if its effectiveness depends on a 6-h post-coital wait before removal, along with avoidance of concomitant use of intravaginal substances. In keeping with the beliefs of the the female sex workers and their needs and practices, alternative intravaginal substances and modes of insertion that will not disrupt vaginal flora, injure vaginal epithelium, damage the diaphragm or counteract potentially beneficial effects of microbicides are needed. The possibility of removing the diaphragm sooner than the recommended 6 h for contraception should be further studied.
Collapse
Affiliation(s)
- Anjali Sharma
- Centre for Microbiology Research, Kenya Medical Research Institute, Kenyatta National Hospital, PO Box 19464-00202, Nairobi, Kenya.
| | | | | | | | | | | |
Collapse
|
27
|
Buck J, Kang MS, van der Straten A, Khumalo-Sakutukwa G, Posner S, Padian N. Barrier method preferences and perceptions among Zimbabwean women and their partners. AIDS Behav 2005; 9:415-22. [PMID: 16254738 DOI: 10.1007/s10461-005-9013-2] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
In Zimbabwe, adult HIV prevalence is over 25% and acceptable prevention methods are urgently needed. Sixty-eight Zimbabwean women who had completed a barrier-methods study and 34 of their male partners participated in focus group discussions and in-depth interviews to qualitatively explore acceptability of male condoms, female condoms and diaphragms. Most men and about half of women preferred diaphragms because they are female-controlled and do not detract from sexual pleasure or carry stigma. Unknown efficacy and reuse were concerns and some women reported feeling unclean when leaving the diaphragm in for six hours following sex. Nearly half of women and some men preferred male condoms because they are effective and limit women's exposure to semen, although they reportedly detract from sexual pleasure and carry social stigma. Female condoms were least preferred because of obviousness and partial coverage of outer-genitalia that interfered with sexual pleasure.
Collapse
Affiliation(s)
- Jessica Buck
- Pritzker School of Medicine, University of Chicago, 30 East Huron #4601, Chicago, Illinois, USA.
| | | | | | | | | | | |
Collapse
|
28
|
Posner SF, van der Straten A, Kang MS, Padian N, Chipato T. Introducing diaphragms into the mix: what happens to male condom use patterns? AIDS Behav 2005; 9:443-9. [PMID: 16235134 DOI: 10.1007/s10461-005-9016-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The objective of this analysis was to assess the effect of introducing the diaphragm on condom use patterns. Participants included one hundred eighty-nine women attending family planning clinics in Harare, Zimbabwe who reported less than 100% condom use. The proportion of acts where at least one method was used significantly increased over using follow-up; male condom use remained stable. A diaphragm was used with 50% to 54% of acts; male condoms were also used about 50% of the time. The proportion of acts where a female condom was used decreased. Women who used both male and female condoms were more likely to use diaphragms than those who reported not using female condoms. Introducing the diaphragm increased the overall proportion of protected acts. The proportion of acts where a male condom was used did not change. Female condoms use declined because concurrent use with the diaphragm is not possible.
Collapse
Affiliation(s)
- Samuel F Posner
- Centers for Disease Control and Prevention, National Center for Chronic Disease, Prevention and Health Promotion, Division of Reproductive Health, 4770 Buford Highway MS K-20, Atlanta, GA 30341, USA.
| | | | | | | | | |
Collapse
|
29
|
van der Straten A, Kang MS, Posner SF, Kamba M, Chipato T, Padian NS. Predictors of diaphragm use as a potential sexually transmitted disease/HIV prevention method in Zimbabwe. Sex Transm Dis 2005; 32:64-71. [PMID: 15614123 DOI: 10.1097/01.olq.0000148301.90343.3a] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Women who are the most vulnerable to sexually transmitted diseases/HIV are often unable to consistently use condoms. One potential alternative method currently under investigation is the diaphragm. GOALS The goals of this study were to assess diaphragm uptake and use over time in Zimbabwe and to identify factors associated with self-reported consistent diaphragm use. STUDY Women attending family planning clinics who were inconsistent condom users received a diaphragm intervention and were followed for 6 months. RESULTS Of the 186 participants, 99% ever reported using the diaphragm, and, at study exit, 96% had used it in the previous 2 months. Consistent diaphragm use since the previous visit was reported by 13% to 16% of the women, and in multivariate regression analysis, it was significantly associated with never using condoms (adjusted odds ratio, 24.08; 95% confidence interval, 6.71-86.34). Other factors included discreet use, preferring diaphragms to condoms, timing of insertion, domestic violence, and contraception. CONCLUSION Diaphragms were well accepted among women at risk for sexually transmitted diseases/HIV.
Collapse
Affiliation(s)
- Ariane van der Straten
- Center for Reproductive Health Research & Policy, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, 74 New Montgomery Street, Suite 400, San Francisco, CA 94105, USA.
| | | | | | | | | | | |
Collapse
|
30
|
Mantell JE, Hoffman S, Exner TM, Stein ZA, Atkins K. Family planning providers' perspectives on dual protection. PERSPECTIVES ON SEXUAL AND REPRODUCTIVE HEALTH 2003; 35:71-78. [PMID: 12729136 DOI: 10.1363/3507103] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
CONTEXT Family planning providers can play an important role in helping women to identify their risk of HIV and other sexually transmitted diseases (STDs) and to adopt preventive measures. In-depth investigation of providers' attitudes about approaches to STD risk assessment, contraceptive counseling and dual protection--concurrent protection from STDs and unintended pregnancy--has been limited. METHODS In semistructured interviews conducted in 1998, 22 health care providers from a large New York City agency offering contraceptive and STD services described how they balanced STD and pregnancy concerns, viewed risk assessment and assessed various contraceptive methods. RESULTS STD prevention was seen as an integral part of family planning counseling, and most providers believed that risk assessment should be conducted universally. Providers viewed dual protection as use of condoms along with an effective contraceptive; few advocated use of the male or female condom alone. The female condom was believed to be a disease prevention method of last resort and was considered appropriate only for specific groups of women. Although providers lacked understanding about the effectiveness of the female condom and how to counsel clients concerning its use, they expressed interest in learning more. CONCLUSIONS Training is needed to reduce providers' negative perceptions of the female condom and to reinforce the importance of individualized counseling tailored to women's specific circumstances. Studies are needed on how to encourage family planning providers to promote male and female condoms as effective contraceptive methods.
Collapse
Affiliation(s)
- Joanne E Mantell
- HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute, Columbia University, New York, USA.
| | | | | | | | | |
Collapse
|
31
|
Abstract
In response to an increasing prevalence of sexually transmitted diseases, especially AIDS, efforts to prevent further infections have been heightened. One of those approaches has been the development of topical microbicidal agents or microbicides. These are compounds designed to protect the body's mucosal surfaces from infection by sexually transmitted disease-causing pathogens. Numerous candidates are currently in preclinical stages; however, only a handful have been tested for safety, and even fewer are ready for clinical efficacy trials. In this update, we describe some of the specific features of microbicide research and development, including preclinical screening algorithms, candidate's ideal properties, examples of compounds presently in the pipeline, and future prospects.
Collapse
Affiliation(s)
- Christine Mauck
- CONRAD Program, 1611 North Kent Street, Arlington, VA 22209, USA.
| | | |
Collapse
|