AA Guide to AIDS Research andand CounselingCounseling Volume 16 Number 4 March 2001

varying levels of success.2 However, it has Alternatives to Male for proven difficult to transfer experimentally designed interventions to community set- Men Who Have Sex with Men tings where they can be implemented on Alex Carballo-Diéguez, PhD an ongoing basis. As newly “out” become sexually active, and as more expe- rienced gay men endure fatigue in the In the early 1980s, as soon as scientists maintenance of safer sex, there is a and clinicians suspected that the pathogen continuous need to revitalize responsible for AIDS was sexually trans- campaigns. Most men who have sex with mitted, they advised sexually active indi- men use condoms out of necessity, not viduals to use condoms to protect them- pleasure, and maintaining consistent selves and others from infection. At that condom use over time is difficult. The time, condoms were seen as an old- question is whether there are alternative fashioned pregnancy prevention method means of protection for sexually active unpopular among heterosexuals, who men who engage in anal sex with partners favored “the pill,” and almost unheard of of discordant or unknown serostatus. among men who have sex with men. Faced In the general marketplace, products with the appalling spread of AIDS, its that are unpopular among consumers are dramatic physical symptoms, and a bar- replaced by new ones. However, in the rage of AIDS-related deaths, condom use case of condoms, there have been re- increased significantly, especially among peated attempts to modify the consumer men who have sex with men. rather than the product. Although advo- Although this was hailed as one of the cates for women have long pointed out the biggest changes in U.S. health behavior need for alternative methods, especially history, it did not go far enough. Cross- female-controlled techniques or devices sectional studies conducted during the that do not depend on the collaboration of last 15 years have generally shown that the male partner, there has been a disap- about half of sexually active men who pointing lack of creativity and initiative have sex with men do not use condoms devoted to developing alternatives to consistently for anal sex. A recent study of penile condoms. This article discusses 23- to 29-year-old men who have sex with microbicides and “female” condoms as two men in six U.S. cities showed that the potential alternative prevention methods prevalence of unprotected sex during the for men who have sex with men. prior six months was 46 percent, with the prevalence of HIV infection reaching 30 Microbicidal Options for Anal Sex percent among African Americans, 15 per- Most men who have anal sex with men cent among Latinos, 7 percent among use lubricants. They state that lubricants European Americans, 3 percent among facilitate penetration, enhance pleasure, Asians, and 10 percent among “other” and decrease pain and discomfort. Lubri- racial and ethnic groups.1 cant use for anal sex preceded the AIDS epidemic and has continued despite little Condom Fatigue organized effort to promote it. The possi- Social scientists have identified reasons bility of developing a lubricant with an for lack of condom use and developed active, microbicidal component that could programs to promote safe behavior, provide protection against HIV and other including individual, group, and commu- sexually transmitted diseases (STDs) is nity level interventions, that have shown tantalizing for most gay men, since it the life instinct—the survival of Editorial: Condom-Prop the individual organism. But Robert Marks, Editor that’s another issue.) The reality is that it is foolish after all these years of condom It is surprisingly difficult for risk, those whose only consistent education not to see its failures, many of us who work with HIV to HIV response is to be inconsis- as well as its successes: penile truly appreciate the difference tent about condom use. condoms offer only one type of between risk reduction and risk Alex Carballo-Diéguez makes protection to passive partners: a elimination. Our minds know that this point simply and eloquently protection over which they have the goal of HIV prevention is to in this month’s FOCUS, stating: no control, only varying degrees reduce risk, but our hearts whis- “In the general marketplace, of influence. As both Carballo- per to us that what we really, products that are unpopular Diéguez and Nancy Padian dem- really, really want is to annihilate among consumers are replaced onstrate in this issue of FOCUS, it. We seek to be client-centered by new ones. However, in the there are alternatives—rectal and in our approaches, “meeting peo- case of condoms, there have vaginal microbicides, the “female ple where they are,” even if that been repeated attempts to condom,” and variants on the means accepting that someone modify the consumer rather cervical cap—that while not as will use condoms only some of than the product.” effective as penile condoms are the time. But our hearts scream, not ineffective. They offer pas- No! No! you must use condoms all The Triumph of Desire sive partners significantly more the time, or you will get infected. There’s something a little dis- control and protection than any It’s only a matter of time. orienting about all of this, mind other prevention tool, including The penile condom is the per- racing one way, heart the other. especially the appropriately fect prop for the closet risk elim- But, the fact is that desire is far touted “negotiation skills” that inators among us. Used properly stronger than HIV education and nonetheless require insight, emo- and consistently, it approaches often more robust and immediate tional strength, and most impor- 100 percent protection! But, the than the fear of death. Survival as tantly, alternatives, like the abil- only penile condom that would the paramount goal of living is a ity to walk away from a situation. truly eliminate risk would be one myth of some pure Darwinian Researchers like Carballo- that was surgically attached— state of being that may have Diéguez and Padian have been permanent protection, the HIV- existed in the primordial soup, advocating for new approaches blocking equivalent of a vasec- but is notably absent from San for years. The real tragedy here is tomy. The penile condom Francisco’s Castro District or New that the cost of developing and enables us to believe that risk York’s Christopher Street. (Per- distributing these approaches is elimination is possible, when the haps the triumph of desire over far less than the cost of develop- absolutely consistent use it prudence occurs when the mat- ing and distributing HIV antiviral requires is almost impossible— ing instinct—survival of the drugs, demonstrating once more particularly for those at highest species—takes precedence over the immense value of prevention.

could be easily integrated into their usual studies. Others have been tried with ani- sexual behavior. mals, and a few have undergone human Exploratory studies, conducted primar- trials. They have four main mechanisms of ily with women, have established that “the action: killing infectious pathogens, block- ideal microbicide would be effective, safe, ing attachment of target cells, preventing acceptable, affordable, colorless, odorless, infection from taking hold, and enhancing stable, easy to store and use, available in a natural defense mechanisms.3 References variety of preparations, available in con- Examples of microbicides that kill or 1. Valleroy L, Secura traceptive and non-contraceptive formula- inactivate infectious pathogens include G, MacKellar D, et al. tions, and available without a prescrip- detergent-like chemicals that disrupt the High HIV and risk tion.”3 Except for “effective,” most of these lipid membranes of cells and the behavior prevalence desirable characteristics are present in the envelopes (surface) of HIV. Among the among 23- to 29-year- old men who have sex lubricants already used by gay men (for products in this category are the existing with men in 6 US example, Johnson & Johnson’s K-Y jelly spermicides nonoxynol-9, octoxynol-9, cities. Presentation and Mayer’s Aqualube). benzalkonium chloride, menfegol, and from the 8th Confer- Several dozen microbicides are cur- N-docosanol. By blocking attachment to ence of Retroviruses rently under development. Some are in target cells and entry of infectious patho- and Opportunistic Infections, Chicago, early phases, with effectiveness shown in gens, blocking compounds may prevent Ill., February 2001. laboratory studies, but not yet in animal HIV infection. Products in this category

2 FOCUS March 2001 include sulphated and sulphonated poly- thus potentially facilitating the entry of mers such as carrageenan (Carraguard), HIV. This underscores the need to develop Pro 2000, and dextrin 2 sulphate. products that are safe for both vaginal and Examples of microbicides that prevent anal sex. There are many possible microbi- infection from taking hold include cidal agents being tested that, unlike antiretroviral agents like PMPA gel, which nonoxynol-9, are not detergents and do not stops HIV from replicating in cells, and injure the rectal mucosa. “plantibodies,” anti-HIV antibodies geneti- cally engineered from plants that would Acceptability and Protection of Microbicides combat pathogens before infection occurs. Beyond the issue of product develop- Finally, products that enhance natural ment and safety, there is a need to test the defense mechanisms seek, for example, to acceptability of microbicides among differ- amplify the vagina’s naturally acidic envi- ent populations, including gay men. Little ronment and to increase its production of would be gained from developing an effec- hydrogen peroxide, both of which are hos- tive microbicide if people refused to use 2. Ross M, Kelly J. tile to pathogens including HIV. Examples it. Acceptability research needs to explore Interventions to include BufferGel and Acidform, which help how potential users greet different formu- reduce HIV transmis- the vagina to maintain natural levels of lations, mode of use, and applicators. sion in homosexual acidity in the presence of semen, and sup- To date, only a few studies have men. In Peterson J, DiClemente R. eds. positories containing lactobacillus, bacteria explored this issue. One study found that Handbook of HIV that normally live in the healthy vagina and more than three-quarters of 3,093 men Prevention. New York: that produce hydrogen peroxide. who have sex with men and who had anal Plenum Publishers, BufferGel, Pro 2000, and Carraguard are sex used lubricants more than 80 percent 2001. in advanced stages of human trials. How- of the time; about two-thirds said they 3. Population Council ever, these studies have focused almost were definitely or probably willing to par- and International Family Health. The exclusively on vaginal use. This is problem- ticipate in rectal microbicide clinical 6 Case for Microbicides: atic since research has shown that once a trials. In a sample of 307 Latino men who A Global Priority. New substance have sex with men and who York: Population Coun- becomes avail- engage in anal sex, another cil and International able for vaginal study found that 93 percent Family Health. 2000. use, gay men A less effective used lubricants (59 percent 4. Phillips D, Taylor C, are likely to always and 74 percent in at Zacharopoulos V, et al. Nonoxynol-9 causes use it for anal product least 80 percent of sexual rapid exfoliation of sex regardless encounters) regardless of sheets of rectal epithe- of label warn- consistently used condom use.7 Ninety-two lium. Contraception. ings that indi- percent said that they would 2000; 62(3): 149–154. cate the prod- may offer as much use a lubricant with an anti- 5. Hillier S. Microbi- uct has been HIV microbicidal agent, and cide vs. microbicidal spermicides. Presenta- tested only for protection as a 87 percent expressed inter- tion from the Topical vaginal sex. est in participating in an Microbicides Pre-Clini- This was the more effective acceptability trial. cal Workshop III, Balti- case with prod- Finally, in a study of 385 more, Md., January 2001. ucts containing men who have sex with men nonoxynol-9, a recruited in West Hollywood, 6. Gross M, Buch- detergent employed as a spermicide for researchers found that men with negative binder S, Celum C, et al. Rectal microbicides many years and currently sold over the attitudes toward condoms were more likely for U.S. gay men. Are counter. As soon as it was suggested that than men with positive attitudes to say clinical trials needed? nonoxynol-9 was effective against HIV dur- that they would use a rectal microbicide by Are they feasible? ing vaginal intercourse, word quickly itself, provided that it reached the efficacy HIVNET Vaccine Pre- 8 paredness Study Pro- spread among gay men who started using standard that they expected. Furthermore, tocol Team. Sexually lubricants with nonoxynol-9 for anal sex. the authors found that as the percentage of Transmitted Diseases. Unfortunately, the safety and efficacy of unprotected anal intercourse partners in 1998; 25(6): 296–302. nonoxynol-9 for anal sex had not been the prior year increased, participants were 7. Carballo-Diéguez A, demonstrated, and recent studies have increasingly likely to say they would use Stein Z, Sáez H, et al. uncovered worrisome findings. One small an effective microbicide gel by itself. Frequent use of lubri- cants for anal sex study showed rapid exfoliation of sheets of Another important issue is what level of among men who have rectal epithelium in specimens collected 15 protection may be expected from microbi- sex with men: The minutes after nonoxynol-9 application.4 cides. It appears unlikely that microbi- prevention potential The results of this study were recently con- cides will achieve the 95 percent level of of a microbicidal gel. firmed in studies conducted with monkeys.5 protection that correct and consistent con- American Journal of Public Health. 2000; In other words, nonoxynol-9 seems to dam- dom use offers. However, this percentage 90(7): 1117–1127. age, rather than protect, the rectal mucosa, declines dramatically when condom use is

3 FOCUS March 2001 occasional or nonexistent. A less effective sex.9 Out of the 100 men who responded to product that is consistently used may the survey, 86 percent said they would use offer as much protection as a more effec- the condom again, and 54 percent reported tive product that is only seldom used. they would rather use female condoms than The prevailing view is that microbicide penile condoms. Acceptability was higher development is technically feasible. Yet, among men who were HIV-positive, were in progress has been slow. Although there are non-monogamous relationships, or had many scientific challenges to the develop- serodiscordant partners. Negative experi- ment of microbicides, a central problem ences included difficulty inserting (33 per- seems be the scarcity of resources dedi- cent), irritation (17 percent), bunching up cated to this endeavor. Advocacy groups, (12 percent), unpleasant texture (10 per- 8. Marks G, Mansergh including the Alliance for Microbicide cent), and noise (9 percent). Breakage was G, Crepaz N, et al. Future HIV prevention Development, have lobbied Congress to reported three times in 334 episodes of use. options for men who increase the allocation of public funds, There are no available data to compare have sex with men: contacted major pharmaceutical compa- the efficacy of the to the Preferences and inten- nies to stimulate microbicide development, penile condom. Nevertheless, the female tions regarding a potential topical and encouraged private philanthropies to condom almost certainly reduces HIV microbicide for anal provide support. transmission when compared with unpro- intercourse. AIDS and tected anal sex and, therefore, may be an Behavior. 2000; 4(3): The Female Condom alternative for men who have difficulty 279–287. The “female” condom is a strong but consistently using penile condoms. 9. Gibson P, McFarland soft, transparent polyurethane pouch Clearly, the acceptability of the female W, Wohlfeiler D, et al. Experiences of 100 designed to be inserted in the vagina condom among men who have sex with men who have sex before sexual intercourse to provide pro- men requires further study. with men using the tection against both pregnancy and STDs, Reality condom for including HIV. It is stronger than latex, Conclusion anal sex. AIDS Educa- odorless, causes no allergic reactions, and, To bring the HIV epidemic under control, tion and Prevention. 1999; 11(1): 65–71. unlike latex, may be used with both oil- new infections need to be averted. This based and water-based lubricants. It can be task requires many different approaches. Authors inserted prior to intercourse, is not depen- Some individuals may abstain from sex, Alex Carballo-Diéguez, dent on the male erection, and does not others may only have sex with a monoga- PhD, is Associate Pro- require immediate withdrawal after ejacu- mous seroconcordant partner, others may fessor of Psychology lation. It has no known side effects or avoid penetration, and still others may use (in Psychiatry) at Columbia University risks. The pouch has two semi-rigid rings, penile condoms every time they have pen- and a Research Scien- one that remains external to the vagina etrative sex. Yet, for many sexually active tist at the HIV Center and the other that fits against the cervix. people these are not valid options, as evi- for Clinical and As with other disease prevention meth- denced by the levels of new infections doc- Behavioral Studies, New York State Psychi- ods, gay men have experimented to see if umented among young people. Increasing atric Institute. His the female condom could be used for anal the number of available HIV-protection research interests sex. They removed the internal ring and methods may improve primary prevention. include microbicide inserted the condom into the rectum. In one Methods that may be effectively integrated acceptability, partner study, researchers examined the opinions of into people’s habitual sexual behaviors notification, and pri- mary prevention of men who have sex with men about the expe- may be more likely to be used for protec- HIV transmission. rience of using the female condom for anal tion against HIV and other STDs.

Musaba E, Morrison C, Sunkutu M, et al. Clearinghouse: Non-Condom Barriers Long-term use of the female condom among couples at high risk of human immunodeficiency virus infection in References women’s empowerment. American Journal Zambia. Sexually Transmitted Diseases. Blocker ME, Cohen MS. Biologic of Public Health. 2000; 90(9): 1377–1381. 1998; 25(5): 260–264. approaches to the prevention of sexual Hammett TM, Mason TH, Joanis CL, et Seal DW, Ehrhardt AA. Heterosexual transmission of human immunodefi- al. Acceptability of formulations and men’s attitudes toward the female ciency virus. Infectious Disease Clinics application methods for vaginal micro- condom. AIDS Education and of North America. 2000; 14(4): 983–999. bicides among drug-involved women: Prevention. 1999; 11(2): 93–106. Results of product trials in three cities. Choi KH, Roberts KJ, Gomez C, et al. Taylor C. HIV/STD prevention, topical Sexually Transmitted Diseases. 2000; Facilitators and barriers to use of the microbicides, and anal sex. Presentation 27(2): 119–126. female condom: Qualitative interviews from the 12th World AIDS Conference, with women of diverse ethnicity. McNamee K. The female condom. Geneva, Switzerland, June/July 1998. Women and Health. 1999; 30(1): 53–70. Australian Family Physician. 2000; Uckun FM, D’Cruz OJ. Prophylactic 29(6): 555–557. Gollub EL. The female condom: Tool for contraceptives for HIV/AIDS. Human

4 FOCUS March 2001 and pleasure, and are more discreet. Studies Female-Controlled of nonoxynol-9, the principal existing micro- bicide, have demonstrated modest protec- HIV Prevention Methods tion against chlamydia and gonorrhea, but Nancy Padian, PhD mixed results against HIV. In fact, a recent study showed enhanced HIV transmission in the women using nonoxynol-9, possibly due In heterosexual relationships, when a to compromise of the epithelial barrier after man does not offer to use a male condom, intensive use.1 New microbicides are being the best a woman can do is to negotiate developed for vaginal protection. (See “Alter- their use or refuse to have sex. Although natives to Male Condoms for Men Who Have numerous interventions have been devised Sex with Men,” page 1.) to “empower” The female condom is a women by teach- transparent polyurethane ing them negoti- pouch bound by two rings, ation skills, such There are a an inner ring that is squeezed skills depend on together and used for inser- a woman’s ability greater number of tion, and an outer ring that to master them, remains outside the vagina and even so, protected sex and partly covers the labia. References negotiation may Although few studies have 1. Van Damme L. not be possible acts when women evaluated the efficacy of the Advances in topical in all situations. female condom in protecting microbicides. Presen- Widespread vio- are offered a against STDs and HIV, those tation from the XIII International AIDS lence against that have support its value. Conference, Durban, women, the choice of In one study, researchers fol- South Africa, July imbalance of lowed 108 U.S. women with 2000. power in many trichomoniasis for 45 days.2 2. Soper DE, Shoupe sexual partner- No repeat infection was D, Shangold GA, et al. ships, and double standards of sexual detected among the 20 percent who used Prevention of vaginal behavior by which women requesting that female condoms consistently, while there trichomoniasis by compliant use of the their male partners use condoms are was a 14 percent reinfection rate among female condom. accused of cheating—all make prevention inconsistent users and non-users. Sexually Transmitted methods that are controlled by women crit- In one Kenyan study, there was no differ- Diseases. 1993; 20(3): ically important. Among these methods are ence in STD or HIV incidence among women 137–139. microbicides, the “female” condom, the who were counseled to use female condoms 3. Feldblum PJ, Kuyoh diaphragm, and the cervical cap. or male condoms versus women in a control M, Omari M, et al. Baseline STD preva- group who were counseled to use only male lence in a community Microbicides and Female Condoms condoms. This was true even though male intervention trial of Vaginal microbicides are topical chemical condoms were not used as frequently in the the female condom in barriers that protect against a variety of sex- intervention group as they were in the con- Kenya. Sexually ually transmitted disease (STD) pathogens, trol group.3 Comparable rates of infection Transmitted Infec- tions. 2000; 76(6): including HIV. Compared to condoms, micro- in the two groups suggest that female con- 454–456. bicides should interfere less with intimacy doms are as effective as male condoms.

Reproductive Update. 1999; 5(5): Resources Contacts 506–514. Alliance for Microbicide Development, Alex Carballo-Diéguez, PhD, HIV Center Van Damme L. Clinical research with 8701 Georgia Avenue, Suite 804, Silver for Clinical and Behavioral Studies, NYS topical microbicides as a potential HIV Spring, MD 20910, 301-588-8091, Psychiatric Institute and Columbia prevention method. AIDS Reader. 2000; 301-588-8390 (fax), http://www. University, 1051 Riverside Drive, Unit 10(9): 552–554. microbicide.org (web site). Manages 15, New York, NY 10032, 212-543-5261, microbicide research projects and 212-543-6003 (fax), [email protected] Van de Wijgert J, Fullem A, Kelly C, et distributes educational materials (e-mail). al. Phase I trial of the topical microbi- regarding microbicide development. cide BufferGel: Safety results from four Nancy S. Padian, PhD, University of international sites. Journal of Acquired Population Council, One Dag Ham- California San Francisco, 74 New Immune Deficiency Syndromes. 2001; marskjold Plaza, New York, NY 10017, Montgomery Street, Suite 600, San Fran- 26(1): 21–27. 212-339-0500, 212-755-6052 (fax), cisco, CA 94105, 415-597-9348, 415- http://www.popcouncil.org/rhfp/ 597-9300 (fax ), [email protected] microbicides/default.html (web site). (e-mail).

See also references cited in articles in this issue.

5 FOCUS March 2001 Physical Protection of the Cervix intercourse than women who chose other Because both chlamydia and gonorrhea methods and cited safety and freedom (the preferentially infect “columnar epithe- fact that use did not require negotiation lium,” the skin cells characteristic of the with the male sex partner) as factors sig- cervix, there is good reason to suspect that nificantly associated with their choice.7,8 coverage of the cervix would offer protec- It seems obvious that internal barrier tion against these pathogens. In addition, devices would be more acceptable if their the cervix itself may be particularly vul- disease-preventive efficacy were proven nerable to HIV.4 Moreover, since chlamydia through further study. and gonorrhea infections increase suscep- Just as not all women find the same 4. Padian N. A review tibility to HIV infection, protection from product acceptable, not all women use the of the efficacy and these pathogens should further protect same products all the time. In fact, several acceptability of bar- against HIV. Finally, several observational studies have shown that there are a greater rier contraceptives to studies have found that diaphragms, when number of protected sex acts when women prevent STDs. Presen- tation from the Thir- used with a spermicide, decrease suscepti- are offered a choice of protective methods 4 teenth International bility to STDs, suggesting the value of compared to when they are offered only a Society for Sexually protecting the cervix. single method regardless of the frequency Transmitted Disease The diaphragm is only one prototype of intercourse.3,6 In the Kenyan study cited Research, Denver, for recently developed, women-controlled, above, women counseled to use male and Colorado, July 1999. physical barrier methods. Several other female condoms reported more protected 5. Gollub E, Stein Z, barrier methods for the cervix are under acts of intercourse than women in the male el-Sadr W. Short-term acceptability of the fe- development or at various stages of test- condom-only group due to increased use of male condom among ing. These methods include Leah’s shield the female condom. Another study found staff and patients at a (similar to a loose fitting cervical cap similar results when it compared the use of New York City Hospi- made of rubber, with a loop for easy the male condom only to a choice of the tal. Family Planning Perspectives. 1995; removal) the Femcap (also similar to a cer- male condom or a spermicide. Although 27(4): 155–158. vical cap, but a bit softer with a snugger women who had the choice reported lower 6. Farr G, Gabelnick fit, that may be possible to use without rates of male condom use, they also H, Sturgen K, et al. spermicide), and disposable diaphragms, reported a greater number of protected Contraceptive efficacy some of which release spermicide during acts of intercourse.3,6 and acceptability of use. There are no STD or HIV prevention the female condom. Conclusion American Journal of data for these methods. Public Health. 1994; Overall, much attention has been 84(12): 1960–1964. Acceptability of Female-Controlled Methods focused on the development of new meth- 7. Ravindran T. A An HIV prevention method can only be ods that women can use to protect them- Study of User Per- effective if it is used. The acceptability of selves against STDs and HIV. Equally spectives on the female-controlled barrier methods has important should be research focused on Diaphragm in an generally been evaluated in longitudinal evaluation of existing methods, such as Urban Indian Setting. Washington D.C.: Asia studies: female condoms or spermicides the diaphragm or cervical cap. Expanding and Near East Opera- were distributed to women, with or with- method choice may itself prove to be an tions Research and out male condoms, but without the option effective prevention strategy. Although Technical Assistance to choose from among a range of products male condoms may in fact be more effica- Project, 1995. as a woman might in the more natural cious than other prevention methods, 8. Ortayli N, Bulut A, environment of a pharmacy or clinic. finding a method or methods that can be Nalbant H, et al. Is the diaphragm a viable Although many of these studies have indi- used consistently may be more important option for women in cated that the female condom is accept- than prescribing a better method that is Turkey? International able, it is unclear whether these results used occasionally or even frequently. Family Planning Per- would be sustained beyond the study spective. 2000; 26(1): period. In those studies that have been 36–42. able to examine method preference and Authors choice from among a range of prod- 3,5,6 Comments and Nancy Padian, PhD is ucts, women were generally allowed to Submissions Professor in the De- choose from male condoms, spermicides partment of Obstetrics, in various formulations (gel, film, cream), We invite readers to send letters Gynecology and Repro- and the female condom. No method was responding to articles published in ductive Sciences at UCSF. She is also Direc- preferred across all studies, reinforcing FOCUS or dealing with current AIDS tor of International the importance of providing a range of research and counseling issues. We also research for the UCSF method options. encourage readers to submit article pro- AIDS Research Institute Even fewer studies have been conducted posals. Send correspondence to and Co-Director of the UCSF Center for Repro- on the acceptability of the diaphragm. In [email protected] or to Editor, ductive Health these few studies, women who chose the FOCUS, UCSF AIDS Health Project, Box Research and Policy. diaphragm reported a higher frequency of

6 FOCUS March 2001 of risk behaviors and community norms Recent Reports also appeared promising. Intention to Use Microbicides for Anal Sex Effective HIV Interventions for Women Marks G, Mansergh G, Crepaz N, et al. Future HIV Ehrhardt AA, Exner TM. Prevention of sexual risk prevention options for men who have sex with men: behavior for HIV infection with women. AIDS. Intention to use a potential microbicide during anal 2000; 14(Suppl 2): S53-S58. (Columbia University; intercourse. AIDS and Behavior. 2000; 4(3): 279– and the New York State Psychiatric Institute.) 287. (Centers for Disease Control and Prevention.) In a comprehensive review of HIV pre- According to a Los Angeles study, men vention programs for women, the most who have anal sex with other men would be effective interventions were specifically willing to try a rectal microbicide gel as directed toward women, focused on rela- their only means of protection only if it was, tionships and negotiation skills, and on average, at least 84 percent effective in involved multiple, sustained contacts. preventing HIV infection. Fifty-three percent Researchers reviewed 16 studies of HIV of the men said the microbicide would have prevention programs, including pre- and to be at least 95 percent effective. post-intervention data, to help establish Men who engaged in anal intercourse the program’s effectiveness. All interven- with men in the prior 12 months were tions were conducted in the United recruited from the streets of West Holly- States, Canada, or Puerto Rico and de- wood, California, to complete a self- scribed a psychological, behavioral, or administered survey. Participants read a educational component that addressed description of a potential rectal microbi- sexual risk reduction. cide gel and reported their preferences Relational skills-based interventions regarding efficacy level and intention to included topics such as partner negotia- use. Of the 385 participants, 24 percent tion, problem-solving, and communica- were African American, 29 percent were tion. Of eight studies that Hispanic, and 47 percent were White. evaluated relational skills- Twenty-six percent were 18 to 24 years based interventions, four old, 35 percent were 25 to 30, and 39 A study of yielded significant results. percent were older than 30. Each of these specifically Participants did not use condoms with an homeless targeted women and lasted average of 39 percent of their anal sex part- five or more sessions. All ners in the previous year. Men under the adolescents four found that interven- age of 25 reported that 48 percent of their tions effectively increased anal sex experiences were unprotected, found a condom use, and one significantly higher than the other men. study’s follow-up report con- Intent to use the microbicide gel with- preference for firmed the maintenance of out a condom was associated with nega- these behavioral changes tive attitudes toward condoms, high levels male condoms 15 months later. Relational of unprotected anal sex in the last 12 skills-based interventions months, and a higher requirement for over female that did not report signifi- product efficiency. Among participants cant results were targeted at who had consistently used condoms dur- condoms, even both men and women or ing the prior year, 37 percent said they lasted two or fewer sessions. would prefer to use a rectal microbicide after extensive Although brief testing product instead of a condom in the future. and counseling programs However, 85 percent of these men wanted education about generally did not lead to the microbicide gel to be as effective as a significant behavior change, condom before they would use it as their the female two interventions of this only HIV prevention method. type—targeting injection condom. drug users and homeless The Female Condom as STD Prevention people—resulted in de- Macaluso M, Demand M, Artz L, et al. Female creased numbers of sex condom use among women at high risk of sexually partners, according to a transmitted disease. Family Planning Perspec- two-week post-intervention assessment. tives. 2000; 32(3): 138–144. (University of Brief informational interventions without Alabama at Birmingham.) a skills component had limited effective- In a six-month follow-up study investigat- ness in decreasing sexual risk behavior. ing female condom use among women at Community-based interventions that high risk for contracting a sexually transmit- included outreach and encouraged change ted disease (STD), 8 percent of participants

7 FOCUS March 2001 had used female condoms exclusively, 15 vention consisted of small group sessions percent had used male condoms exclusively, discussing various aspects of female con- 73 percent had used both types of condoms, doms, including their construction, their and 3 percent had not used condoms. efficacy, and the proper way to use them. Researchers interviewed 1,159 STD clinic Sixty-three percent of participants used patients in Birmingham and Huntsville, male condoms as their primary contracep- Alabama, and provided study participants tive method: 48 percent said they always AGuidetoAIDS Research and Counseling with a behavioral intervention promoting used male condoms, but 44 percent condoms, including an opportunity to prac- reported having sex without a condom at Executive Editor; Director, AIDS Health Project tice inserting the female condom, a physi- least once in the two weeks prior to the James W. Dilley, MD cal examination, a six-week supply of male study. Ninety-five percent had heard of Editor and female condoms, and instructions on the female condom, but only 15 percent Robert Marks completing a sexual diary. Participants were had ever used one before the study. Assistant Editor between 18 and 35 years of age and had no Twenty-two participants completed the Alex Chase immediate plans for becoming pregnant. extended post-study interview, and all 22 Founding Editor; Advisor Among 895 women who reported having gave reasons why they might use female Michael Helquist engaged in heterosexual vaginal inter- condoms: the female condom provided Medical Advisor Stephen Follansbee, MD course during the study period, half had protection against STDs and pregnancy sex with only one partner, one-quarter had (68 percent), the female condom’s polyure- Design Saul Rosenfield sex with two partners, and one-quarter had thane is stronger than latex (14 percent), Production sex with three or more partners. A total of and the female condom offers women Rosalinda Castaneda 731 women reported using the female con- more control over contraception and STD Carrel Crawford Gabriel Rabu dom at least once during the follow-up protection (9 percent). Seventeen partici- Lisa Roth period, 85 percent of whom reported use pants reported reasons not to use the Cassia Stepak during the first month. Participants who female condom, including difficulty insert- Circulation were employed and those with regular sex ing and using it (47 percent), discomfort or Carrel Crawford Cassia Stepak partners at baseline were significantly irritation (29 percent), and dislike of the more likely to try the female condom. female condom (18 percent). Finally, 73 Interns Carla Stelling Twenty percent of women who tried the percent of the post-study participants female condom used it only once, 13 per- reported that they would still prefer the FOCUS is a monthly publi- cent used it twice, 20 percent used it male condom to the female condom, citing cation of the AIDS Health Project, affiliated with the between five and nine times, and 32 per- availability and discomfort with inserting University of California San cent used it 10 or more times. Of the 309 the device as major obstacles. Francisco. consistent condom users, 75 percent pre- Twelve issues of FOCUS dominantly used both types of condom, 18 are $36 for U.S. residents, $24 for those with limited percent exclusively used the male condom, incomes, $48 for individuals and 7 percent exclusively used the female Next Month in other countries, $90 for condom. Women who used the female con- U.S. institutions, and $110 for institutions in other dom exclusively or who mixed condom Living in the shadow of the epidemic countries. Make checks types were more likely than exclusive users for 20 years magnifies the effects of payable to “UC Regents.” Address subscription re- of the male condom to be Black, to be living with HIV in the moment. In the quests and correspondence employed, and to have a regular partner. April 2001 issue of FOCUS, Steven to: FOCUS, UCSF AIDS Schwartzberg, PhD, Assistant Clinical Health Project, Box 0884, Female Condom Attitudes among Adolescents San Francisco, CA 94143- Professor of Psychology at Harvard Med- 0884. Back issues are $3 Haignere CS, Gold R, Maskovsky J, et al. High-risk ical School, identifies the broad trends each: for a list, write to the adolescents and female condoms: Knowledge, experienced by the gay community, above address or call (415) Journal of Adoles- 502-4930. attitudes, and use patterns. explores their mental health implica- cent Health. 2000; 26(6): 392-398. (Temple Uni- To ensure uninterrupted tions, and proposes four chronologi- delivery, send your new versity, Philadelphia.) cal phases of adaptation: disbelief/ter- address four weeks before you move. A small study of homeless, high-risk ror, action/belonging, burnout/despair, adolescents found that they continued to and early recuperation/fragmentation. Printed on recycled paper. prefer male condoms over female con- Also in the April issue, Lena Nilsson ©2001 UC Regents: All rights reserved. doms, even after extensive education Schönnesson, PhD, Associate Profes- ISSN 1047-0719 about the female condom. sor of Social Work, University of Göte- Researchers gathered a convenience borg, Sweden, and Michael W. Ross, sample of 65 sexually active adolescents PhD, MPH, MHPEd, Professor of Pub- between the ages of 13 and 18 at an emer- lic Health, University of Texas, Hous- gency homeless shelter in a major north- ton, define and examine the concept of eastern city. Participants completed a “chronic risk,” the challenge faced by peer-led intervention and pre- and post- people living in communities with par- study interviews, all of which explored ticularly high HIV seroprevalence. barriers to female condom use. The inter-

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