Who continues using the diaphragm and who doesn't: implications for the acceptability of female-controlled HIV prevention methods
Introduction
Women need methods to protect themselves against human immunodeficiency virus (HIV) and other sexually transmitted infections (STIs). This need became increasingly apparent with the dramatic increases in acquired immunodeficiency syndrome (AIDS) among U.S. women that occurred in the 1990s and as the proportion of women with AIDS who were infected via heterosexual contact increased (Centers for Disease Control and Prevention [CDC], 1999a). The proportion of women with AIDS who were infected through heterosexual contact first exceeded the proportion who were infected by means of injection drug use in 1994 (CDC, 1999b). Heterosexual contact currently accounts for 41% of cumulative AIDS cases among women (CDC, 2001). Other STIs are also a major health problem for women. Many of these other STIs are considerably more common than HIV (e.g., chlamydia, herpes, human papillomavirus, and trichomoniasis) (Cates, 1999). Women are disproportionately affected by STIs because women are more biologically susceptible to some STIs than men, because STIs are less likely to be detected in women than men, and because STIs have more severe health effects for women than men (Eng & Butler, 1997).
The male (latex) condom, when used consistently and correctly, currently is the most effective method for protecting against HIV and a variety of STIs (Stone, Timyan & Thomas, 1999), and it also prevents pregnancy. However, some men may be unwilling to use condoms and, due to gender-based power imbalances as well as other cultural factors, some women may be unable to negotiate use Amaro, 1995, Amaro and Raj, 2000, Blanc, 2001, Wingood and DiClemente, 2000. Moreover, recent data from the U.S. indicate that individuals having heterosexual sex use condoms consistently only about 19% of the time (Catania et al., 2001). Therefore, multiple methods for preventing HIV and other STIs are needed so that women have choices. Of particular importance are female-controlled methods that women can use without their male partner's knowledge and cooperation. Female-controlled methods are not intended to replace the male condom; rather, they provide women with an alternative method of protection if condoms are not an option or are not used consistently.
Because additional disease prevention methods are needed, a major research initiative is currently under way to develop barrier methods, both chemical and mechanical, that women can use to protect themselves from HIV and other STIs (Schwartz & Gabelnick, 2002). Microbicides are one potential method of HIV and STI prevention that could be female-controlled. Numerous compounds and products are in various stages of development (Van Damme, 2002). It may be years, however, before microbicides and other new methods being developed are approved and available for use in the United States Gollub, 1999, Cohen, 2002; Antwerp, Belgium. Although long-term solutions to HIV and STI prevention are essential, short-term solutions are also necessary (Stein, 1993). Consequently, investigating the acceptability and efficacy for the prevention of HIV and other STIs of existing contraceptive methods is essential Stein, 1993, Stein, 1995, Stein and Susser, 1998.
The diaphragm has recently been touted as a possible candidate for a female-controlled method that could reduce the risk of HIV and STI acquisition Cohen, 2002; Antwerp, Belgium, Ibis Reproductive Health, 2002, Moench et al., 2001. The diaphragm, an internal barrier device that provides physical protection of the cervix, is currently approved by the U.S. Food and Drug Administration (FDA) and available as a method of contraception. Substantial epidemiologic and biologic evidence supports the notion that protecting the cervix can reduce the acquisition of HIV and other STIs (Moench et al., 2001). Although a randomized trial has not been performed, several observational studies Austin et al., 1984, Becker et al., 1994, Kelaghan et al., 1982, Magder et al., 1988, Rosenberg et al., 1992 have shown that the diaphragm used with spermicide is effective in preventing some STIs (i.e., gonorrhea, trichomoniasis) and associated long-term sequelae. In addition, because untreated STIs can increase HIV infectivity and susceptibility Hayes et al., 1995, Rothenberg et al., 2000, St. Louis et al., 1997, primary prevention of STIs could decrease the sexual transmission of HIV Moss et al., 1995, Hoffman et al., 1996, Laga et al., 1997.
The diaphragm is safe, has limited side effects, does not interfere with natural hormones, and has advantages over other female-controlled barrier methods. For example, although the female condom is inserted by the woman, it cannot be used without the sexual partner's knowledge or cooperation. In contrast, the diaphragm can be inserted up to 6 h before intercourse and can be used without the knowledge of the sexual partner (Stone et al., 1999). Moreover, the diaphragm can be reused up to 3 years and, therefore, the cost of diaphragms over time is low. Finally, the diaphragm could serve as a physical barrier device to hold in place microbicides currently under development and, thereby, provide dual protection against pregnancy and HIV/STIs.
Diaphragms are used by only 2% of current contraceptive users (ages 15–44) (Piccinino & Mosher, 1998). As a result, some public health professionals perceive the diaphragm as having low acceptability. Given the immediate need to increase the acceptability of physical barrier methods like the diaphragm, it is important that we understand how to overcome behavioral obstacles to their use. Our project, composed of three studies, fills an important niche in development efforts by providing information about the acceptability of an available female-controlled method among diverse samples of women in the United States. In this article we compare current and former diaphragm users on characteristics that are hypothesized to influence acceptability of contraceptive methods. Our objectives were to 1) assess associations between being a current diaphragm user and characteristics that are hypothesized to influence acceptability of contraceptive methods; and 2) explore reasons for discontinuing use of the diaphragm among former diaphragm users.
Section snippets
Participants and procedures
Potential participants were selected from Kaiser Permanente Northwest (KPNW) members. KPNW, which is a nonprofit health maintenance organization (HMO), provides medical care to over 450,000 members in northwest Oregon and southwest Washington. Using existing administrative databases, we identified women aged 18 to 50 years old who were enrolled as KPNW members for at least 1 month in the previous 2.5 years. We used the KPNW database on pharmacy dispensings to determine which of these women
Comparisons between current and former diaphragm users
Characteristics of current and former diaphragm users are presented in Table 2. Women who currently used the diaphragm were significantly older, more highly educated, and had used the diaphragm for a significantly longer time compared with former diaphragm users. The two groups significantly differed on two of the four importance of contraceptive attributes subscales. Specifically, current diaphragm users placed significantly less importance on attributes of hormonal birth control methods in
Discussion
Whether or not a woman continues to use a contraceptive method, once it has been tried, is an important measure of acceptability. Our study identified several factors that could influence whether women will continue to use the diaphragm. The findings suggest that women who place less importance on the attributes of hormonal methods, who perceive the characteristics of the diaphragm more positively, and who have more confidence in their ability to use the diaphragm may be more likely to continue
Acknowledgements
We thank the following individuals for their contributions to the study: Nancy Padian, PhD, Victor Stevens, PhD, Shannon Sanner, MPH, Alan Bauck, Karen Riedlinger, MPH, Cheryl Johnson, EdM, Cherry Johnson, Andrea Brown, MA, Kennitha Burks, Amanda Petrik, Maile Thiesen, Eleanor Brown, Meredith Roberts Branch, MPH, Anna Wilson and Jillian Henderson, MPH. We acknowledge the Kaiser Permanente Center for Health Research for the development and maintenance of their data systems. This research was
Dr. Harvey’s current research interests include the acceptability of reproductive technologies; the prevention of HIV/STIs and unintended pregnancies among high-risk women, men, and couples; and the influence of relationship factors on sexual risk taking.
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Cited by (0)
Dr. Harvey’s current research interests include the acceptability of reproductive technologies; the prevention of HIV/STIs and unintended pregnancies among high-risk women, men, and couples; and the influence of relationship factors on sexual risk taking.
Dr. Bird’s research interests focus on the prevention of HIV, other STIs, and unintended pregnancy; the influence of discrimination and related factors on reproductive health; and the acceptability of reproductive technologies.
Dr. Maher has an MS in Biostatistics and PhD in Epidemiology, and one of her areas of interest is HIV/STI prevention.
Dr. Beckman conducts research on contraception, abortion, HIV/STI prevention, and other women’s reproductive health issues.