Commentary: Methods Women
Can Use That May Prevent Sexually
Transmitted Disease, Including HIV
---......_->:f Michael J. Rosenberg MD, MPH, and Enca L. Gollub, DrPH
Inrodudion
Sexually transmitted diseases con-
tinue to be a major problem in the United
States. More than 12 million new cases
occur everyyear, including 4 million cases
of chlamydia and 1.4 million cases ofgon-
orrhea. Nearly 500 000 visits were made
to medical facilities for treatment ofpelvic
inflammatory disease, resulting in more
than 180 000 hospitalizations in 1989.1
Sexually transmitted diseases are par-
ticularly serious for women because
women and their offspring bear a dispro-
portionate share of the complications from
them, including pelvic iflammatory dis-
ease, infertlity, tubal pregnancy, and con-
genital syphilis, or human immunodefi-
ciency virus (HIV). Among Black women,
the incidence of syphilis has more than
doubled since 1984. Cervical cancer, a dis-
ease regarded as being sexually transmit-
ted, is diagnosed in 13 000 women each
year.2 And for acquired immunodeficiency
syndrome (AIDS), heterosexual sex is now
the fastest-growing risk behavior for new
infections, especialy among women.3
Despite continuing concern, few
messages aimed at preventing sexually
transmitted disease or HIV infection are
targeted to women. Those that are, and
particularly those for HIV, encourage lim-
itation of the number of partners, selective
choice of partners, and abstinence, all of
which require major life-style changes.
Condom use is also stressed, but urging
women to insist that their partners use
condoms may be unrealistic because tra-
ditional sex roles in most cultures do not
encourage a woman to talk about sex or to
initiate sexual practices or otherwise con-
trol an intimate heterosexual encounter.4-5
Recommendations for preventive
measures to be used by sexually active
women are based primarily on laboratory
studies and clinical trials. Clinical trials,
however, are conducted to define a "gold
standard" for how well a drug or device
works under opimal rcumstances, includ-
ing correct usage at every sexual encounter.
Observational studies, on the other hand,
measure the effectiveness of devices under
crcumstances of everyday life, including in-
termittent or improper use. They also incor-
porate other factors that detenrine how
contraceptives are used, including contra-
ceptive efficacy, perceived risk of sexually
transmitted diseases, price, convenience,
side effects, and cultural values. Thus, use-
effectiveness rates better reflect the efficacy
of a preventive measure in practice. More-
over, unlike results from laboratory and
clinical studies, use-effectiveness rates may
also be improved by public health educa-
tion. Further, they contribute to the under-
standing of barriers that affect women's
choices of prevention measures, and they
allow health messages to be more precisely
targeted. Unfortunately, however, such
data have been largely overlooked in for-
mulating prevention messages.
To help identify methods women will
most readily adopt to protect themselves
against sexually transmitted diseases, we
review currently available prevention mea-
sures and the relevant user-effectiveness
data. We then consider how these findings
might be incorporated into clinical preven-
tion programs oriented toward women.
Sally Tunmited Diwase
Prevention Method
Laboratory and Animal Data
In the laboratory, latex condoms
have been shown to be effective against
nearly all sexually transmissible orga-
nisms tested,6 whereas condoms made of
sheep intestine ("skins") may allow pas-
sage of some sexually transmissible orga-
nisms6 and are therefore not approved for
disease prevention. But while intact latex
male condoms have no holes (not even
microscopic ones), simulation of coitus in
one study produced leakage of particles
Michael J. Rosenberg iswith Health Decisions,
Inc, Chapel Hill, NC. Erica Gollub is with the
HIV Center for Clinical and Behavioral Stud-
ies, New York State Psychiatric Institute, and
the School of Public Health, Columbia Univer-
sity, New York, NY.
Requests for reprints should be sent to
Michael J. Rosenberg, MD, MPH, Health De-
cisions, Inc, PO Box 4151, Chapel Hill, NC
27515.
American Journal of Public Health 1473
Public Health Policy Forum
the same size as HIV in 33% of condoms
tested.7 Polyurethane vaginal pouches
(also known as female condoms) have
proved impermeable to cytomegalovirus
and ETV.8
Spemiicides have been found to be ac-
tive against HIV, cytomegalovirus, herpes
simplexvirus type 2, hepatitis Bvirus,Neirs-
sena gononhoea, Txnema paldum,
Thchornoas vagisn , and Candida albi-
cans.9,10 Several studies, with one excep-
tion, have found that Chiamydia trchoma-
tiS is also inactivated by such products,11'12
although nonoxynol-9, the active ingredient
in most spermicides, was reported to be in-
effective against bovine papillomavirus, a
close relative of human paplllomavirus.'3
Spermicides used to lubricate male con-
dons killed HIV virus that leaked through
intentionally ruptured condoms.'4 Benzal-
konium chloride, chlorhexidine, and
menfegol-compounds in spermicides used
outside the United States-show similar
spermicidal and anti-sexually transmitted
disease/HlV activity in the laboratory.15-18
Vaginal spermicides containing non-
oxynol-9 yield considerable protection
against simian immunodeficiency virus in
macaque monkeys.19 Two of four mon-
keys remained seronegative after vaginal
exposure to this virus in a dose close to
1000 times that found in infected monkey
ejaculate, in contrast to all of six monkeys
infected in the control group.
Human Data
Conoms. Condoms are intended to
provide a physical barnier that prevents con-
tact between vagial or other secretions and
ejaculate or penile lesions. Because con-
doms have not been evaluated in clinical
trials, their method effectiveness against
sexually transitted diseases and HIV is
not known. Although observational studies
reveal them to offer widely divergent de-
grees of protection against sexually trans-
mitted diseases," a meta-analysis indicates
that, for most outcomes, condoms on aver-
age decrease infection rates by approxi-
mately 50%0o.2 The divergence between the
clinical efficacy that might be expected from
laboratory studies and the substantially
lesser protection seen in most observational
studies suggests that nonuse or misuse is
common. The strongest evidence that con-
doms are effective in preventing sexually
trasmitted diseases comes from observa-
tional studies in which compliance was good
and the indication was that protection in-
creased with more consistent use.6,11 Even
used properly, however, condoms may not
protect against organisms trnsmitted by
external genital contact.
1474 American Journal of Public Health
Behavioral studies indicate that con-
dom use is low among heterosexual part-
ners. For example, among more than 3 mil-
lion women at highest risk for sexually
transmitted diseases, only 12% relied on
their partner's use of condoms for birth con-
trol.2' Only 18% of US women in a recent
survey reported that their male partners
used condoms for any reason.22 Ehrhardt et
al. observed that, for heterosexual unions,
consistent condom use has not become in-
tegrated into people's lives as a routine.23
Several types of intravaginal pouch are
currently undergoing clinical testin. These
consist of polyurethane or latex vaginal lin-
ings, including one that is contained within
a panty. A polyurethane pouch is being
evaluated by the Food and Drug Adminis
tration; moreover, as a study of trichomo-
niasis reinfection has suggested that it offers
a level of protection similar to that of the
male condoM,24 thispouch is exected tobe
marketed with an indication for sexually
trasmitted disase prevention. Acceptabil-
ity of the female condom appears reason-
ablygood,25,26but price may ultimately limit
its acceptance.
Spemnicides, inclding the sponge.
Spermicides provide a chemical coating in
the vagina that inactivates sperm and sexu-
ally transmitted disease organisms. The
sponge combines actions of a physical bar-
rier that blocks the cervix, a material that
absorbs ejaculate, and spennicide, of which
an unknown portion (believed to be small)
leaches out during use. Clinical trials (two
involving the contraceptive sponge)27'28 in-
dicated 25 to 40%o reductions in chlanydia
and 10 to 69%o reductions in gonorrhea.27-29
Observational studies indicate that sperni-
cides offer a degree of protection that, as
with male condoms, varies widely. A num-
ber of these studies3-32 indicate substan-
tially better protection than was found in
clinical trials"; meta-analysis of observa-
tional studies estimates a reduction for most
outcomes of approximately 50% which is
also similar to that obtained with con-
doms.20 Spermicide use has also been asso-
ciated with decreased risk of cervical
cancer30-33 and, by inference, with anteced-
ent human papiliomavirus infection. Data
are insufficient, however, to determine
whether spennicides protect against herpes,
syphilis, or chancroid. Because these orga-
nisms can be tansitted gh extemal
genital contact, they may provide a superior
model to predict the anti-HIV effectiveness
of spermicides as well as of other methods.
Little research addresses the specific
question of protection afforded by sper-
micides against HIV.34 Preliminary results
from a study in Cameroon indicate a re-
duced risk of HIV among female sex
workers (prostitutes) using spermicides.35
No control group was used, but the rate of
seroconversion in women who used sper-
micides most frequently was 90%o lower
than that in women who used them least
frequently.
A study of the contraceptive sponge
among Nairobi sex workers found that the
rate of seroconversion was not reduced
among sponge users as compared with us-
ers of a nonspermicidal suppository, and
that more genital ulcers occurred among
sponge users.36 However, interpretation of
this study's findings is problematic. First,
excess ulcers were not found on the vagina
or cervix, where one would expect sponge-
related lesions, but rather on the vulva,
suggesting the influence of other factors
that may not have been adequately mea-
sured. Second, the effects of the sponge
itself, as opposed to the nonoxynol-9, are
unknown because a placebo sponge free of
spermicide was not used. Third, vaginal
irritation may have been induced by the
vaginal concentration of nonoxynol-9 in
the sponge, which was 1000mg; othervag-
inal nonoxynol-9 preparations have be-
tween 60 mg and 350 mg. In other studies,
nonoxynol-9 suppositories and films have
not been associated with an increase in
genital ulcers.35.37 Finally, the study in-
volved sex workers who averaged 42 part-
ners per week. Although an earlier study
involving sex workers and the sponge
found an increased rate of candidiasis,
three subsequent US studieswith nonpros-
titutes found no such increase.20
These results suggest that spermicides
may be an irritant, particularly when used
in high doses orforlongperiods. However,
whether this effect is present in certain
women or is dependent on the dose, sched-
ule, and vehicle remains unclear.'2
Bamners. Diaphragms and cervical
caps, which are assumed to be used in con-
junction with spermicides, are placed on
the interior (cervical) side of the vagina to
provide both mechanical and chemical bar-
riers. However, these methods leave a por-
tion of the vagina unprotected. Hence,
their effects on organisms that infect the
cervix, such as N. gononhoeae and C. tra-
chornatis, and on organisms, including
H1V,m8 that can be transmitted through
other sites may differ. While no clinical tri-
als using these methods have been per-
formed, observational studies indicate a re-
duction in sexually transmitted diseases of
between 50 and 100l%o."
Spermicidal film may be used with
diaphragms and caps for women seeking
an alternative to creams and jellies.39 Cer-
November 1992, Vol. 82, No. 1 1

vical caps provide a high level of contra-
ceptive protection even when spermicide
is not used consistenty40; this suggests
that the cap, with or without spermicides,
offers better protection against cervical
pathogens than the diaphragm. Although
current cervical cap styles are limited,
new ones may be available soon.41
WuthdawaL Withdrawal, by which
exposure to ejacllate is avoided, may re-
duce the risk of certain sexually transmiis-
sible infections just as it reduces the risk of
pregnancy. However, cooperation from
the male partner is required and timing is
crucial. Postcoital application of viricidal/
bacteriocidal agents may be more effective
at preventing infection than they are in pre-
venting pregnancy because sexually trans-
missible pathogens are less motile than
sperm. However, information is wanting
about how quickly tnision of disease
takes place.
Douching. Douching has been asso-
ciated not only with an increased risk of
pelvic inflamatory disease and cervical
Ncyvember 1992, Vol. 82, No. 1 1
cancer but also with a decrease in gonor-
rhea.42w43 No firm causal link has been es-
tablished because risk factors for sexually
transmitted diseases are also associated
with douching.43-45
Honnonal methods, itrautenne de-
vimces, and ste?ilization. Oral contracep-
tives, injections, implants, or other forms
of hormonal contraception offer no pro-
tection against lower reproductive tract in-
fections. Moreover, oral contraceptives
may increase the risk of some sexually
transmitted diseases, notably cervical
cancer"4-46 and possibly HIV and chla-
mydia,47 while affording protection
against upper genital tract infection.48
Intrauterine devices do not protect,
and the insertion process is associated
with an increased risk of pelvic inflamma-
tory disease; thereafter, the devices pose
no additional risk in appropriately selected
women.49,50 Sterilization confers no pro-
tection against sexually transmitted dis-
eases unless the cervix, the site of some
Public Health Policy Forum
sexually transmitted disease infections,
has been surgicaly removed.
Women should be informed that these
methods of birth control offer no protection
against sexually m itted diswas, and
they should be advised to use one or more
additional methods for diwase prevention.
Compalson of Different Methods
Nine of 10 observational studies that
compared the effect of condoms, dia-
phragms, or spermicides on the risk of
sexualy transmitted disease found lower
risk among users of female-controlled de-
vices than among condom users (Table
1).30-33.51-56 In most studies, the differ-
ences were not large, but there is a strong
consistency in findings. In the largest
study, an analysis of 5681 visits to a sex-
ually transmitted disease clinic found the
risks for gonorrhea and trichomoniasis to
be significantly lower with female-con-
trolled methods of contraception.51 Infor-
mation is insufficient to determine
Amencan Journal of Public Health 1475
Public Health Policy Fomm

1476 American Journal of Public Health November 1992, Vol. 82, No. I 1

whether the protection offered by dia-
phragms and spermicides differs.
Simultaneous use of two or more
methods, such as spermicides and con-
doms, improves the theoretical level of
protection against pregnancy57 and pre-
sumably against sexually transmitted dis-
eases as well, but this has not been stud-
ied. One possible problem with pursuing
such an evaluation is that, in practice, cou-
ples may actually have difficulty using two
methods consistently.
Table 2 summarizes the previous dis-
cussion and other factors that influence
the choice of contraceptives. Contracep-
tive efficacy is often a key element in mak-
ing such a choice, but unfortunately, there
is an inverse relationship between the de-
gree of protection afforded against preg-
nancy and that afforded against sexually
transmitted diseases. When used consci-
entiously, however, spermicides, barri-
ers, and condoms can provide strong pro-
tection against both outcomes.
Diwusnion
Although the observational studies
that were reviewed have individual weak-
nesses, several points of consistency
emerge. First, appropriate and regular use
ofcondoms, barriers, and spermicides can
provide a substantial degree of protection
against many but not all sexually transmit-
ted diseases; condoms can help protect
against HIV, but studies of barriers and
spermicides in this regard are scant and
currently inconclusive. Second, in direct
comparisons from observational studies,
female-controlled methods of contracep-
tion have been found to provide more ef-
fective protection against sexually trans-
mitted diseases than methods controlled
by men.
How might the qualifications that ac-
company these findings be reconciledwith
the imperative for action? First, as health
professionals, we must recogiize a com-
pelling and overdue need for methods that
can reduce women's chances of infection
but do not require their partner's cooper-
ation or consent. Couples who agree in
choosing not to use condoms also need
other options.
Second, on an individual level, we
need to encourage the use of female-con-
trolled methods while, of course, not ig-
noring other factors that affect a woman's
contraceptive choice. We must be sensi-
tive to the inhibitions of some women, en-
couraging them to feel confident about
their use of such methods. Although
groups at highest risk-teenagers, minor-
November 1992, Vol. 82, No. 11
ity women, and sex workers-have often
been assumed to be unwilling or unable to
learn the proper use of spermicides and
barrier methods, few programs are de-
signed to confront these problems.
Women need to be made aware that meth-
ods controlled by them, even if not yet
proven to be as effective as condoms, can
also help reduce their chance of sexually
transmitted infection and are considerably
safer than unprotected sex.
Third, we need to recognize that pro-
vision of female-controlled methods of
protection does not preclude the need for
other methods and other steps that protect
against disease. Indeed, prevention mes-
sages need to stress options so that indi-
viduals and couples can find their own
level of comfort. Messages about options
should be arranged in a hierarchy of ef-
fectiveness, rather than exclusively
stressing a single method. Thus, while the
preferred method might be the proper and
consistent use of condoms, other mea-
sures such as barriers, spermicides, and
partner selection should not be neglected.
Finally, prevention messages ori-
ented toward women need to be integrated
into the practices of health and medical
care professionals, particularly family
planners and private gynecologists who
may be the sole health professionals to
have contact with young, sexually active
women. Although uneasiness may exist
with the idea of combining contraception
(health) and sexually transmitted disease/
HIV (disease) prevention messages,58 we
must achieve a better balance between
these two needs of sexually active per-
sons. 0
Acknowledgments
Partial support for this work was provided by
NIMH Behavioral Sciences Training in HIV
Infection grant IT32MH19139 and by HIV Cen-
ter grant 5-P50-MH43520 from NIMH/NIDA.
The authors are grateful for the contnbu-
tions of Zena Stein and Ellen Ruina.
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