Condom male

The contraceptive effectiveness of the condom depends upon how carefully it is used. There is a 2% failure rate for properly used `Kitemark' condoms (this means that in one year, two in 100 women will conceive who have used condoms consistently and properly for all occasions of vaginal intercourse). This failure rate rises to 15% for improperly used condoms (source: Durex).

The condom requires the man to take an active responsibility for contraception. It has no health risks and it substantially reduces the risk of acquiring or transmitting HIV or other infections.

Condoms cannot be used with oil–based lubricants. Some treatments for gynaecological conditions, like thrush, may be oil–based. It is important to check whether any cream or pessary used as a treatment can destroy latex, and to use a different method of contraception if it does (for example, the female condom which is not made of latex).

A word about Nonoxynol 9 –‘N9’ spermicide. Nonoxynol 9 (N-9) is a spermicide which has, in the past, been added to some condoms and lubricants to reduce the risk of pregnancy and also to reduce transmission of HIV and other STIs. N-9 is now known to increase this, particularly when used rectally but also vaginally as it affects the skin lining the vagina and rectum and can cause abrasions and blisters. It is now recommended that N-9 be removed from condoms. Most condoms available via free NHS schemes are now N-9 free, however, there are still some available and individuals should always check their choice of condoms.

The female condom

The contraceptive effectiveness of the female condom depends upon how carefully it is used. There is a 2.4% failure rate when the female condom is used properly, and 12.2% when not used properly and consistently (source: Chartex). For more information on using female condoms see female condoms and spermicides earlier in this chapter.

The diaphragm, or cap

This method of contraception does not protect against HIV transmission for either partner.

If used properly, the cap has a pregnancy failure rate between 2–5%. It has no health risks for women who are not allergic to rubber or spermicide. This is a circle of thick rubber with a rim containing a flexible spring. The cap comes in different sizes and shapes, and has a range of names. Some caps only cover the cervix, while others also cover a large area at the top of the vagina. The cap is put in the vagina before intercourse - several hours before, if wanted - so there is no danger of forgetting it in the heat of the moment. The main contraceptive action comes from the spermicide used with the cap. This has a time limit and has to be topped up just before each time you have sex.

The cap can be re–used, and should be washed thoroughly after removal. It should not be shared.

The sponge

This method of contraception does not protect against HIV transmission for either partner.

Contraceptive sponges have a failure rate of up to 25%. There is no health risk, as long as you are not allergic to the spermicide. A contraceptive sponge is a soft, polyurethane foam circle which contains spermicide. It has a cord for removal. It is placed over the cervix like the cap and should be used only once.

These are often easier to use than the cap and one size fits everyone. They can be difficult to remove, and sometimes they disintegrate. This is not dangerous, but it can be tiresome to remove the bits. Sponges are expensive as they are used only once.

Spermicides

This method of contraception does not protect against HIV transmission for either partner.

Spermicides have a failure rate of up to 70%, especially for young women.

There are several different formulations and brands of spermicide. Spermicides are chemicals which are contained in cream, jelly, pessaries, foams or C-film (a papery square). These are placed in the vagina, and should be inserted as high up as possible since they aim to prevent live sperm from entering the cervix. This is easiest by using them with a cap. Some foams come with applicators to help place them high up in the vagina by the cervix.

There is no health risk, as long as you are not allergic to the spermicide.

For further information on spermicides, see female condoms and spermicides earlier in this chapter.

The combined pill

This method of contraception does not protect against HIV transmission for either partner.

The combined pill is very effective and easy to use with only a 0.5% failure rate.

It contains two hormones which mimic hormonal changes which take place in a pregnant woman and therefore prevents ovulation and conception. For 21 days the woman takes a pill containing hormones, and for the next seven days she either takes a blank pill or no pill. During these seven days she bleeds, although this is not real menstruation as she has not ovulated.

Many women like using the pill because it is a reliable contraceptive which offers confidence, control and regular light periods. However, there are some health concerns relating to the pill, and women should be advised to find out as much information as possible. Potential health problems are widely debated, and here we give those which are most relevant to HIV.

Women with conditions which can be aggravated by oestrogen should not use the pill. These conditions include breast cancer, thrombosis, sickle cell anaemia and recent liver failure. Some (ex-) drug users have poor liver function, and the combined pill is not suitable for them. In theory, the pill might affect the progression of HIV, but research has not been carried out to answer this question.

Some women find that taking the pill sets off vaginal thrush. This may make the pill unsuitable for an HIV–positive woman who has recurrent thrush which is hard to treat. The pill can interact with other drugs. It is not known if AZT interferes with it, but courses of antibiotics and some other drugs can reduce the pills effectiveness as a contraceptive. HIV–positive women who use the pill should be encouraged to check with their doctor whenever they are given medication. Vomiting and diarrhoea can stop the pill from being absorbed, and reduce the contraceptive effectiveness.

The progesterone-only pill or `mini-pill'

This method of contraception does not protect against HIV transmission for either partner.

The mini–pill has a failure rate of 2%, which becomes less in older women.

This pill works by providing extra progesterone, which creates an environment which is hostile to sperm and to a fertilised egg. However, the woman still ovulates.

The mini–pill has to be taken every day at the same time, preferably the early evening. Sticking to a rigid timetable can be difficult for some women. Some of the health problems associated with the combined pill also occur with the mini–pill, but there are fewer side effects. It may be suitable for women who cannot take oestrogen.

Contraceptive injections

This method of contraception does not protect against HIV transmission for either partner.

Contraceptive injections have a failure rate of less than one per cent.

This is a different method of introducing the hormonal changes provided by the pill. Women are given a one-off injection containing a very high dose of progesterone. The effects last on average three months and cannot be reversed during this time.

However, it is convenient, as just one injection gives long–term protection. There is no need to remember to take it.

The treatment is controversial, partly because some women have been given injections without their fully informed consent. There is disagreement about the health implications. Some women have experienced painful and persistent side–effects, including difficulty conceiving after using it. It is not possible to halt the hormone changes (whereas it is possible to stop taking the pill) and this can be a problem for women who experience side–effects.

Contraceptive injections have a failure rate of less than one per cent.

The intrauterine device (IUD) or coil

This method of contraception does not protect against HIV transmission for either partner.

The IUD has a failure rate of about 2%. This varies depending upon the skill with which the IUD is inserted. It is rarely recommended for HIV–positive women, because they are more vulnerable to PID and period problems. Also, the heavy bleeding associated with IUDs may increase anxiety about HIV transmission.

The IUD is a small piece of plastic or copper which is placed inside the uterus (womb) which must be inserted by a Doctor. Removal is usually easy and painless, but inserting an IUD can cause discomfort. It can make periods longer, heavier and more painful. There is a slight risk that the cord from the IUD might damage a condom.

The IUD increases the risk of Pelvic Inflammatory Disease (PID) (see A-Z of sexually transmitted infections above).

Emergency contraception

The 'morning after' pill. This method of contraception does not protect against HIV transmission for either partner.

If a woman fears that she may have conceived, for example because no contraception was used or the condom broke, it is possible to intervene within three days of having sex. The failure rate is about three per cent.

A course of pills is given which contain a high dose of oestrogen to stop ovulation. These methods can result in some sickness. Some doctors will ask the woman to agree to an abortion if the pregnancy continues, as the foetus could have been damaged by the pill medication.

'Natural' methods

This method of contraception does not protect against HIV transmission for either partner.

Women are only fertile for two days in each menstrual cycle (normally 28 days). As sperm can survive in the body for three days, there are some five to seven days in each cycle when a woman can conceive. One method of contraception is to avoid unprotected vaginal intercourse during this fertile week.

The failure rate is about three per cent when this method is followed carefully. However, it does require a great deal of organisation and body awareness to achieve this level of effectiveness.

Women should seek advice about contraception from a Family Planning or Well Woman Clinic or from their Doctor.

Women-controlled contraception

Male and female condoms offer women the best protection against infection with HIV and other STIs, they are also the only form of contraception which can be used by positive women to prevent transmission to their partners. However, often it can be difficult for women to control condom use within a heterosexual relationship. Some men, (and women), dislike condoms and some men complain of discomfort or reduced sensitivity when they are wearing them.

Insisting on condom use can sometimes mean a woman risks being suspected of infidelity, distrusting her partner or may be coerced into revealing her HIV status against her wishes. Disclosing HIV status to a sexual partner can make women vulnerable to rejection or even violence.

The female condom was developed as a method of ‘female controlled’ contraception. However, although this type of condom can be inserted by a woman her male partner can see that it is there and may refuse to have sex while the woman has it in place.

The importance of establishing a method of protection which women can control has led researchers to investigate the potential of ‘Microbicides’. A microbicide is ‘any product which can kill or prevent infection from one or more microbes that can be transmitted during sexual intercourse. (Weeks 2004). A microbicide would be used in the form of a gel, sponge or lubricant and the aim is to develop an agent that will not only prevent transmission of HIV and other STIs but also act as a contraceptive. Further information about microbicides is included in the Prevention section of this chapter.

Reference

Weeks M, Mosack K, Abbott M, Sylla L, Valders B and Prince M. American Sexually Transmitted Diseases Association, Microbicide Acceptability Among High Risk Urban U.S. Women: Experiences and Perceptions of Sexually Transmitted HIV Prevention, 2004.

NAT Campaign Briefing Paper. The need to remove Nonoxynol – 9 (N-9) from condoms and lubricants, 2003.