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Promoting Dual Protection in Family Planning Clinics in Ibadan, Nigeria



Context: Integration of efforts to prevent HIV and sexually transmitted infections (STIs) and of condom promotion into family planning services is urgently needed because of the escalating HIV epidemic in Sub-Saharan Africa. Methods: Counseling on dual protection-concurrent protection from unintended pregnancy and HIV and other STIs-and provision of the female condom were introduced in six family planning clinics in Ibadan, Nigeria. Structured observations of interactions between clients and service providers, clinic service statistics, provider interviews, and other qualitative and quantitative methods were used to assess family planning providers' promotion of dual protection. Results: Following intensive training, providers delivered dual-protection counseling to a majority of clients and demonstrated the female condom to 80% of the new clients observed. Discussion of the sexual behavior of clients and their partners, of the relative ability of various contraceptives to protect against HIV infection and of how to negotiate condom use increased significantly, as did STI assessment. Providers' internalization of the importance of HIV/AIDS prevention was crucial to promoting and sustaining the dual-protection initiative. Condom purchases increased from a baseline of 2% of all family planning visits in 1999 to 9% in January-June 2001. This increase came mainly from acceptance of the female condom, used either alone or in conjunction with another contraceptive. Conclusions: Integrating dual-protection counseling and female condom provision into family planning services appears feasible, as is service providers' acceptance of dual-protection objectives. While providers and clients are key to transforming family planning to dual-protection services, the attitudes and behaviors of clients' male partners must be considered in gauging the success of the dual-protection intervention.
87Volume 28, Number 2, June 2002
With the rapid spread of HIV throughout Sub-Saharan Africa,
new approaches to HIV prevention are urgently needed, es-
pecially among young women. Family planning services have
traditionally focused on promoting methods that are high-
ly effective at preventing pregnancy but provide no protec-
tion against HIV. Further, thousands of women receiving
family planning services every day are not informed of what
they can do to protect themselves from HIV infection.
Since the mid-1990s, various strategies have been im-
plemented, primarily in Africa and in Latin America and the
Caribbean, to integrate family planning with HIV and sex-
ually transmitted infection (STI) services.1These efforts have
consisted primarily of teaching family planning providers
about HIV and STIs and of providing STI treatment; how-
ever, they have not been shown to be effective in increasing
condom use.2They have also generally failed to promote
the condom’s role in dual protection—a strategy for providing
concurrent protection from unwanted pregnancy and dis-
ease prevention, mainly through the use of condoms (ei-
ther alone or in conjunction with another method).3
Structured observations of family planning services in
Botswana, Ghana, Kenya, Zambia and Zimbabwe showed
that only one-quarter of family planning clients had received
information on HIV and other STIs and that fewer than one-
third had heard about the dual-protection benefits of con-
doms.4The compartmentalization of family planning ser-
vices from HIV and STI prevention in health care delivery
systems has generated the need for a paradigm shift in fam-
ily planning services—one that places family planning and
HIV and STI prevention under a single umbrella.5
Integrating dual protection into family planning services
will require changes in service-delivery practices and poli-
cies, including making newer HIV and STI prevention op-
tions (such as the female condom and, when they become
available, microbicides) available, documenting dual-pro-
tection practice within management information systems
and changing how family planning service providers per-
ceive their role and carry out client counseling. As gate-
keepers in the family planning service delivery system,
providers are in a position to determine how dual protec-
tion is incorporated into family planning services.6How-
ever, they have not been well trained in many key aspects
of HIV prevention, such as in conducting sexual risk as-
sessments, promoting condoms and teaching clients how
to negotiate condom use with their sexual partners. Fur-
ther, simply educating family planning providers about HIV
and its prevention is not enough to bring about significant
changes in counseling practices.7
In this article, we focus on the first phase of an ongoing
project of the Association for Reproductive and Family
Promoting Dual Protection in Family Planning Clinics
In Ibadan, Nigeria
CONTEXT: Integration of efforts to prevent HIV and sexually transmitted infections (STIs) and of condom promotion
into family planning services is urgently needed because of the escalating HIV epidemic in Sub-Saharan Africa.
METHODS: Counseling on dual protection—concurrent protection from unintended pregnancy and HIV and other
STIs—and provision of the female condom were introduced in six family planning clinics in Ibadan, Nigeria. Struc-
tured observations of interactions between clients and service providers, clinic service statistics, provider interviews,
and other qualitative and quantitative methods were used to assess family planning providers’ promotion of dual pro-
RESULTS: Following intensive training, providers delivered dual-protection counseling to a majority of clients and
demonstrated the female condom to 80% of the new clients observed. Discussion of the sexual behavior of clients and
their partners, of the relative ability of various contraceptives to protect against HIV infection and of how to negotiate
condom use increased significantly, as did STI assessment. Providers’ internalization of the importance of HIV/AIDS
prevention was crucial to promoting and sustaining the dual-protection initiative. Condom purchases increased from
a baseline of 2% of all family planning visits in 1999 to 9% in January–June 2001. This increase came mainly from ac-
ceptance of the female condom, used either alone or in conjunction with another contraceptive.
CONCLUSIONS: Integrating dual-protection counseling and female condom provision into family planning services
appears feasible, as is service providers’ acceptance of dual-protection objectives. While providers and clients are key
to transforming family planning to dual-protection services, the attitudes and behaviors of clients’ male partners
must be considered in gauging the success of the dual-protection intervention.
International Family Planning Perspectives, 2002, 28(2):87–95
By Lawrence
Adeokun, Joanne E.
Mantell, Eugene
Weiss, Grace Ebun
Delano, Temple
Jagha, Jumoke
Olatoregun, Dora
Udo, Stella Akinso
and Ellen Weiss
Lawrence Adeokun is
director of research
and evaluation, Stella
Akinso is director of
training, Grace Ebun
Delano is vice presi-
dent and executive
director, Temple Jagha
is senior research offi-
cer, Jumoke Olatore-
gun is research officer,
Dora Udo is former
director of training
and Eugene Weiss is
trustee and consul-
tant, all with the Asso-
ciation for Reproduc-
tive and Family
Health, Ibadan, Nige-
ria. Joanne E. Mantell
is research scientist at
the HIV Center for
Clinical & Behavioral
Studies, New York
State Psychiatric
Institute, Columbia
University, New York,
and senior research
associate at the New
York Academy of Med-
icine, New York. Ellen
Weiss is research
utilization director for
the Horizons Program
and a staff member of
the International
Center for Research on
Women, Washington,
88 International Family Planning Perspectives
Health (ARFH), a nongovernmental reproductive health
organization located in Ibadan, Nigeria. It is intended to
incorporate HIV and STI prevention into family planning
service delivery in six clinic settings through the promo-
tion of dual-protection counseling (known as Onise Meji,
or two purposes, in the local language, Yoruba), by bring-
ing about changes in service providers’ attitudes and core
values and in their counseling of clients. We also examine
the obstacles encountered in bringing about changes in
service-delivery practices.
Our analysis concentrates on efforts among new clients,
because dual-protection counseling was designed to be in-
tegrated into overall family planning counseling, which is
provided in its entirety only to new clients. The counsel-
ing offered to continuing clients is usually more limited,
and therefore is likely to provide fewer details about dual
protection and to have less of an effect. The overall impact
of the program on the level and consistency of condom use
will not be addressed in this article.
The consequences of the spread of HIV are of urgent con-
cern for family planning services in Nigeria. In populations
at antenatal clinic sentinel sites, HIV prevalence rose from
1.2% in 1992 to 5.8% in 2000.8Thus, according to World
Bank criteria, HIV infection has begun to move beyond high-
risk populations to the general population.9Perceptions
of invulnerability to HIV, coupled with low rates of con-
dom use for family planning* and the pattern of extramarital
sexual relationships among married men,10 create an en-
vironment of significant HIV risk for Nigerian women seek-
ing family planning services. With more than one million
inhabitants, Ibadan provides an ideal setting for integrat-
ing dual-protection services in family planning clinics that
serve a primarily homogenous (Yoruba) population.
Research Setting
In 1998, we selected six family planning clinics (three gov-
ernment clinics and three clinics sponsored by non-
governmental organizations) with a total of 15,000 client
visits yearly to participate in the project. In four of the six
clinics, the IUD and the injectable accounted for more than
90% of all contraceptive methods dispensed; a large ma-
jority of visits were made by continuing clients. Only one
of the six facilities had an STI clinic on the premises. Al-
though the male condom was available, most clinics’ records
of condom distribution were inadequate. Most did not
record purchasers’ personal identifiers, believing that the
anonymous provision of condoms was a positive service
attribute. Providers were well trained in family planning,
but few had received training about HIV and other STIs or
in counseling. Infection-control procedures were inadequate,
with latex gloves being reused and instruments inadequately
The Dual-Protection Intervention
Dual protection, or concurrent protection from unintend-
ed pregnancy and HIV and other STIs, can be achieved in
three ways: use of a male or female condom alone; use of
two methods (a condom along with some nonbarrier con-
traceptive); or use of an effective contraceptive in the con-
text of long-term mutual monogamy. (Although the latter
was recommended, it was not recorded as a dual-protec-
tion practice.)
•Training of family planning providers. Project investigators
and ARFH’s training team adapted a training program that
had been developed earlier in South Africa and New York.11
A “Training of Trainers” workshop was first conducted with
managers of the participating clinics and with senior ARFH
staff to modify existing materials for the Nigerian context
and to determine training strategies for helping family plan-
ning providers put the workshop content into practice. This
workshop produced a manual and curriculum for provider
training, which took place between March and May 1999,
and promoted senior clinic management’s commitment to
and ownership of the intervention. Most trainees were reg-
istered nurse-midwives who had training and experience
in family planning service delivery.
A participatory training approach was used to discuss
behavioral strategies for increasing the practice of dual pro-
tection, for mitigating judgmental responses to the sexual
practices of clients or their partners, and for promoting pos-
itive attitudes about dual protection and condom use. Sex-
ual desensitization exercises were conducted to help
providers become more comfortable in talking about sex-
ual issues. Role plays that addressed how to communicate
about sex and how a woman could convince her husband
to use condoms were featured throughout the workshop.
Additionally, providers were given male and female con-
doms and were asked to use them (if possible) and to re-
port their personal experiences. The training also strength-
ened providers’ skills in assessing sexual risk behavior, in
counseling about HIV and STIs, and in teaching about con-
dom use. A clinical field practicum that used a standard-
ized dual-protection counseling protocol provided feed-
back on providers’ progress.
•Introduction of a dual-protection counseling protocol. The
dual-protection protocol was based on the Female-Initiated
Protection Paradigm (FIPP).12 Dual-protection counseling
based on this framework integrates HIV and STI education
and client risk assessment, reproductive health assessment,
STI prevention and treatment (or referral), and condom skills-
building, partner negotiation and other behavior-change
strategies into traditional family planning counseling.
A central feature of the counseling consists of increas-
ing clients’ recognition of their HIV/STI risks and of the
role of condoms in dual protection. Providers were trained
in how to tailor the counseling to clients’ individual needs
and situations. They were then given a locally developed
dual-protection flip chart,which helped to standardize the
counseling across the six clinics. In addition to seeing
posters at the clinics, clients received pamphlets (in both
Promoting Dual Protection in Family Planning Clinics
*Current condom use levels are 2% among married women and 9% among
married men, and 7% among unmarried women and 15% among unmar-
ried men.
†Copies of the flip chart in English can be obtained from ARFH.
89Volume 28, Number 2, June 2002
in client counseling between the two sets of observations.
Client exit interviews were conducted with more than
half of the clients observed at baseline (n=175) and with
all clients observed at Time 2 (n=289). Except for a few con-
tinuing clients, the clients interviewed at Time 2 were not
the same as those interviewed at baseline.
Service providers conducted interviews with 47 purposively
selected dual-protection acceptors at their follow-up clinic
visits in 2000. In addition, 24 focus groups were conducted,
four with family planning service providers, four with clients
and 16 with groups of men of different ages and socioeco-
nomic status who were representative of the community.
Monthly service statistics and documentation on clients’
use of dual protection were collected from each clinic. Fi-
nally, in-depth interviews with 10 providers were conducted
in August 2001 to assess their personal experiences and
reactions to the dual-protection program.
Characteristics of Family Planning Clients
Baseline data (Table 1) indicated that the great majority of
clients were married (95%), were in monogamous sexual
partnerships (71%) and were aged 25–44 (84%). About
half had had at least some secondary education. Nearly all
Yor uba and English) on dual protection and on male and
female condom use. The dual-protection intervention be-
came the standard of care in these clinics, and all family
planning providers were expected to implement it.
•Provision of the female condom. Clients were offered the
female condom as part of routine clinical services. (The fe-
male condoms were donated by UNAIDS.) Initially, in mid-
December 1999, up to three female condoms were given
out free (on a trial basis). Later, distribution policies and
supply practices were altered: Female condoms were sold
for $0.10 each, and the funds were used to purchase sup-
plies for improving infection-control practices at the clinics.
•Management information system. Prior to the study, each
clinic used a different management information system,
and requests for male condoms often were not recorded.
Management information system tools were developed to
document providers’ dual-protection counseling and clients’
dual-protection decision-making, as well as to improve
recording of clients’ acceptance of male and female con-
doms, including their concurrent use of these methods wit h
other contraceptives (dual method use).
•Supervision. Continuing supervision was provided by
ARFH, including on-site assessment of clinic conditions
and client counseling and monthly meetings with providers
for program feedback.
Data Collection
We used a number of quantitative and qualitative data col-
lection strategies in this research. For example, we carried
out structured observations of interactions between fami-
ly planning providers and all new and continuing clients
over a 3–4 week period. These observations occurred at
two different times in the five largest clinics, which had more
than 98% of all clients, and were followed by exit interviews
with clients. The objective was to rapidly accrue a large num-
ber of observations of family planning clients’ experiences.
Observers assessed the counseling offered by family plan-
ning providers, including whether they discussed HIV/AIDS
and sex, initiated an HIV and STI risk assessment, used the
dual-protection flip chart, discussed the female condom
and demonstrated use of male and female condoms.
The observations were based on a methodology used by
the Population Council for a series of situation analysis stud-
ies of family planning clinics in Africa.13 The baseline ob-
servations involved 15 service providers (plus nurse
trainees) and 325 clients; these were conducted in March
and April 1999, prior to the training of providers and the
introduction of the female condom. The second set of ob-
servations involved 15 service providers (plus nurse
trainees) and 289 clients. Referred to as the Time 2 obser-
vations, these took place in June and July 2000.
Ten of the providers observed at baseline were also ob-
served at Time 2. No client refused to be observed during
her counseling visit. The research team, which consisted of
two men and five women, was trained in conducting struc-
tured observations of provider-client interactions and in using
a detailed checklist. We used chi-square tests to assess changes
TABLE1. Percentage distribution of new and continuing
family planning clients interviewed at baseline or at Time 2,
by selected characteristics
Characteristic Baseline Time 2
(N=175) (N=289)
Marital status
Monogamous 70.9 76.8
Polygamous 24.0 19.7
Unmarried 5.1 3.5
15–24 5.7 7.6
25–34 50.3 52.9
35–44 33.7 32.6
45 10.3 6.9
None 11.4 10.4
Primary only 37.2 28.7
Secondary 30.8 38.4
Postsecondary 20.6 22.5
Heard about AIDS
Yes 93.7 88.6
No 6.3 11.4
Had multiple sexual partners in past year*
Yes 7.4 4.8
No 92.6 95.2
Suspected partner had other partners in past year
Yes 41.1 32.2
No 58.9 67.8
Was ever told she had an STI*
Yes 17.3 4.5
No 82.7 95.5
Total 100.0 100.0
*Difference between samples is statistically significant at p<.05 by chi-square
90 International Family Planning Perspectives
(94%) said that they had heard about AIDS. Forty-one per-
cent reported knowing or suspecting that their partner had
had other partners in the past year, whereas 7% said that
they themselves had had multiple sexual partners. Seven-
teen percent reported ever having been told by a medical
provider that they had an STI.
Few statistically significant demographic differences were
found between the two exit-interview samples. However,
compared with clients interviewed at Time 2, clients in the
baseline sample were less educated, were more likely to re-
port that they had had an STI and engaged in greater sex-
ual risk behavior.
Contraceptive Distribution and Condom Acceptance
Table 2 presents the distribution of family planning visits
by the type of client (new vs. continuing) and by the con-
traceptive method provided during the baseline period in
1999 (before the intervention fully began), in 2000 and dur-
ing the first six months of 2001. The large majority of vis-
its were by continuing clients, although this proportion de-
creased from 82% in 1999 to 74% in 2001.
Additionally, visits in which condoms were the only fam-
ily planning method distributed increased from 2% to 6%
in 2000, but decreased to 5% in the first six months of 2001.
Changes in the acceptance of other methods seemed to be
related to long-term trends rather than to this increase, as
use of injectables increased and reliance on the pill and the
IUD decreased. It appears that the overall client load did
not increase as a result of the intervention, although many
other client and management factors may have limited the
clinics’ client load.
These data, however, greatly underrepresent the impact
of the program. When we examined the proportion of all
clients who accepted male and female condoms in 2000
and the first six months of 2001, we found that 14% of all
family planning visits in 2000 included condom distribu-
tion (Table 3). This proportion differs from that shown in
Table 2, in that more than half of condom visits in 2000
(54%) involved a client taking condoms along with another
contraceptive—i.e., using dual methods. About four-fifths
of condom acceptors took the female condom. New fami-
ly planning clients were more likely to accept a condom
(25%) than were continuing clients (10%).
In the initial phases of the project, as we noted earlier,
up to three female condoms were provided free for all clients
who accepted them, and clients who wanted more were
charged $0.10 each. However, after mid-October 2000, all
female condoms were sold for $0.10 each, a meaningful cost
in the Nigerian context and about five times the cost of the
male condom. Thus, in the first six months of 2001, the
proportion of all clients accepting a condom decreased to
9%, as free female condoms were no longer available. Most
condom acceptance continued to be by new clients who
purchased female condoms. Recorded male condom dis-
tribution decreased during this period as well. Information
on levels of continuing condom use among dual-protec-
tion acceptors is not available.
Changes in Provider Practices
A number of changes took place in service providers’ coun-
seling of clients as they incorporated dual-protection issues
into their family planning counseling practices. Our focus
here is on the experience of new clients, because they are
expected to have received comprehensive family planning
and dual-protection counseling. (Continuing clients often
come to the clinic only to receive additional supplies and
may receive minimal counseling, although they were ex-
pected to be told about dual-protection issues if they had
not been counseled previously.)
Observational data on the counseling of new clients in-
dicate that HIV and STI risk assessment and dual-protec-
tion counseling increased significantly from baseline to Time
2. Although a large majority of new clients were given a
demonstration of the female condom (80%) and were told
about dual protection (75%), only between one-fifth and
one-half received each of the detailed aspects of the FIPP-
based counseling (Table 4).
However, the differences from the baseline measures were
dramatic. Discussions of the client’s and her partner’s sex-
Promoting Dual Protection in Family Planning Clinics
TABLE2. Number and p ercentage distribution of family
planning visits, by client type and method, 1999–2001
Client and 1999 2000 2001*
No. % No. % No. %
Client type
New 2,655 17.7 3,792 25.2 1,906 26.4
Continuing 12,347 82.3 11,231 74.8 5,304 73.6
IUD 9,490 63.3 8,134 54.2 3,949 54.8
Injectables 4,211 28.1 5,199 34.6 2,597 36.0
Pill 966 6.4 726 4.8 310 4.3
Condoms† 335 2.2 964 6.4 354 4.9
Total 15,002 100.0 15,023 100.0 7,210 100.0
*January–June. †Includes male and female condoms (single method only);
female condoms were available in the clinics as of mid-December 1999.
TABLE3. Number and p ercentage of visits in which male
and female condoms were provided, by selected measures
Measure 2000 2001*
N% of N% of
visits visits
Typ e of condom
All 2,116 14.1† 651 9.0†
Female 1,672 11.1† 576 8.0†
Male 444 3.0† 75 1.0†
Typ e of use
Single method 964 45.6‡ 354 54.4‡
Double method 1,152 54.4‡ 297 45.6‡
Type of client
New 948 25.0§ 453 23.8§
Continuing 1,168 10.4** 198 3.7**
*January–June. †Of all family planning visits. ‡Of all condom visits. §Of all
new-client visits. **Of all continuing-client visits. Note: From January through
October 12, 2000, up to three female condoms were given free to any client
who requested them. Beginning October 13, 2001, every client paid 10 naira
(US $0.10) per condom.
91Volume 28, Number 2, June 2002
tributed dual-protection brochures in 28% of visits.
Exit interviews with clients reinforced the findings of
the observations (not shown). The proportion of new clients
who indicated that they were aware of the concept of dual
protection increased from 8% to 50%, and the proportion
who responded to an open-ended question that they were
aware that condoms can protect them from HIV and other
STIs increased from 27% to 51%. Thirty-seven percent of
new clients at Time 2 said that they had taken a dual-pro-
tection or condom brochure from the provider, compared
with just 2% who said at baseline that they had received
any educational materials.
In general, new clients received more extensive dual-pro-
tection counseling than did continuing clients, although
the latter were generally informed of the female condom.
For example, only 56% of continuing clients were told of
the need for dual protection, compared with 74% of new
clients; moreover, 62% of continuing clients were informed
about the female condom, compared with 90% of new
clients. Only half as many continuing clients as new clients
were told about male condoms.
The project described here moved the field beyond earlier
HIV and STI integration efforts and their analysis in at least
four ways. First, it was focused on a systems approach that
recognized the interdependence of the family planning ser-
vice delivery system, providers and clients. Second, we ex-
amined the acceptability of dual protection in a society with
relatively low levels of family planning use and within a con-
text of routine family planning services in a limited-resource
setting. Third, the intervention incorporated the female con-
dom into the contraceptive method mix. Finally, it described
the personal involvement of service providers in develop-
ing dual-protection services.
Implementation of Dual-Protection Counseling
Evidence from a number of sources suggests that service
providers’ counseling practices improve as a result of dual-
protection training and ongoing monitoring and supervi-
sion.14 In this study, providers informed clients of the con-
cept of dual protection and the extent to which their
preferred family planning method provided protection
against HIV and other STIs. They also paid more attention
to STIs, conducted sexual risk assessments, discussed HIV
risk-reduction strategies, demonstrated male and female
condom use, and helped clients develop condom-negoti-
ation strategies.
New clients received more extensive dual-protection
counseling than did continuing clients. When interviewed,
providers said that most continuing clients had already been
exposed to dual-protection counseling—which may have
been true after the first year of the intervention. Providers
also reported that they had limited time for counseling, as
continuing clients usually expected that their family plan-
ning visit would be brief. Consequently, when faced with
large numbers of waiting clients, some providers gave lower
ual behavior increased from 19% and 16% of visits to 34%
and 36%, respectively. Coverage of how to bring up HIV
and STI prevention with the client’s partner increased from
3% to 24% of the visits observed, while the number of vis-
its in which staff talked with clients about how they might
convince their partner to use a condom increased from 0%
at baseline to 18% at Time 2.
Counseling tailored to the client’s personal situation in-
creased from 28% to 67%. In addition, discussions about
the ability of different family planning methods to protect
against HIV and STIs increased from 7% of visits prior to
the dual-protection intervention to 42% of visits at Time
2. In nearly half (49%) of the Time 2 visits that were ob-
served, providers discussed whether the method that clients
had selected (among those who had had an initial method
preference) protected against HIV and other STIs. In con-
trast, such a discussion took place in only 2% of baseline
visits. The providers’ awareness of the importance of STI
assessment was also indicated by the number of clients who
were told that they might have an STI, which increased from
4% at baseline to 22% at Time 2.
Although providers demonstrated the female condom at
most new client visits at Time 2 (80%), counseling regard-
ing the male condom occurred less frequently. Neverthe-
less, actual demonstrations of how to use a male condom
increased from 11% of visits at baseline to 34% at Time 2.
Moreover, an indication of the effectiveness of the counsel-
ing is that 42% of new clients were observed to have taken
at least one female condom at Time 2 (not shown), although
they still were being given out at no charge at that time. Fol-
lowing implementation of dual-protection services, providers
used the flip chart in 47% of the new client visits and dis-
TABLE4. Percentage of new client visits in which providers
addressed specific components of dual-protection counseling
Indicator Baseline Time 2
(N=88) (N=76)
HIV/STI risk assessment and risk reduction
Discussed client’s sexual behavior 19.4 34.2*
Discussed partner’s sexual behavior 16.4 35.5*
Discussed HIV/AIDS 12.1 42.1*
Discussed client’s STI concerns 9.1 21.1*
Indicated to client that she might have an STI 3.6 22.4*
Discussed how to bring up HIV/STI
prevention with partner 3.0 23.7*
Dual protection family planning counseling
Tailored counseling and education to
client’s personal situation 28.0 67.1*
Compared HIV/STI protective effects of
different family planning methods 7.0 42.1*
Showed client how to use the male condom 10.5 34.2*
Showed client how to use the female condom 80.3
Discussed how dual protection could be achieved
by either one or two family planning methods 4.7 75.0*
Discussed if client’s initially preferred method
provided protection against HIV/STIs 2.3 49.2*
Discussed with client how she might convince
her partner to use a condom 0.0 18.4*
Used dual-protection flip chart 47.4
Distributed brochures 3.8 27.6*
*Difference is statistically significant at p<.05 by chi-square test. †Female
condom and dual-protection flip chart were unavailable at baseline.
92 International Family Planning Perspectives
priority to discussing dual protection with continuing
clients. Ultimately, the model of dual-protection counsel-
ing for continuing clients may need to be different from that
for new clients.
Changes in Providers’ Values
Meetings and interviews with service providers indicated
that providers were committed to promoting dual protec-
tion and viewed this new responsibility as their role. They
were energized by their awareness that the AIDS epidem-
ic is in its nascent stage and that they were pioneers in pro-
moting dual protection as a viable response. Providers ex-
pressed personal concern with preserving the lives of
Nigerians. The interviews also revealed that participating
in the dual-protection project gave providers newfound con-
fidence and skills in talking about sex, not only with clients
but in their personal lives as well. For most, the project made
them more aware of their personal vulnerability to HIV and
was a catalyst for them to talk about sex and protection with
their husbands and other family members. One provider
reported that she kept condoms in strategic places in her
household and continually replenished the supply.
One unanticipated effect of the project was providers’
increased awareness of the need for infection prevention
measures for both themselves and their clients. The con-
stant reminders of HIV risk created a sense of vulnerabili-
ty at work, made providers more aware of the need for in-
fection prevention measures and provoked a sense of
self-preservation that contributed to their ability to reori-
ent family planning to dual-protection services. When in-
terviewed, most providers noted that they now understood
the importance of universal precautions and of the use of
latex gloves and sterilization solutions for their equipment.
The income generated from female condom sales has been
used to purchase latex gloves and disinfectant.
Identification of Implementation Problems
A number of problems developed as we attempted to im-
plement dual-protection services. Providers appeared not
to promote the male condom aggressively. Clients’ low and
unchanged rates of male condom use suggest a possible con-
tinuation of both provider and client bias against the male
condom. Other studies have reported that family planning
providers are often biased against both male and female con-
doms and promote them inadequately.15 However, providers
of dual protection reported in individual interviews and
monthly meetings that they had not given up promoting
the male condom. They believed that because the female
condom was new and a female-initiated method, it was more
acceptable, especially for women who were unable to con-
vince their husbands to use the male condom. The use of
the female condom along with another family planning
method—typical of more than 50% of condom acceptors—
also likely increased its acceptance. Some acceptors of the
female condom, however, reported that they disliked its slip-
periness and that their husbands objected to using it.
Providers’ perceptions that the female condom is more
acceptable than the male condom to their largely married
clientele and the association of male condom use with non-
marital partners may have contributed to the limited pro-
motion and acceptance of the male condom. Focus groups
with men elaborated the problems that women who brought
home male condoms would face, including assumptions
that the wife had been unfaithful, that the decision to use
a male condom should be made by the man and that the
condom might threaten the marital relationship. Other fac-
tors identified with a decline in male condom use in 2001
included a lack of supply from the state Ministry of Health
and the unrecorded sale of male condoms.
Problems continued throughout the study period with
accurately documenting clients’ dual-protection status, es-
pecially dual method use. Providers found this difficult to
accommodate within their clinic reporting routines. Most
family planning management information systems afford
no room for reporting dual method use. The integration of
the dual-protection service registry with the standard clin-
ic reporting forms, implemented on a trial basis in one of
the clinics, should help make documentation more com-
plete and make evaluation of the intervention easier.
The relatively high level of dual method use to achieve
dual protection (mainly a female condom used along with
an IUD or hormonal contraceptive) was unanticipated. It
indicates that despite the obvious disadvantages of using
two methods, many clients wish to maximize both their
protection from pregnancy and their protection from HIV
and other STIs. Similar findings have been reported recently
from family planning clinics in South Africa where the fe-
male condom was introduced.16
Substantial numbers of clients, however, were not ex-
posed to dual-protection messages. A primary expectation
of the project was that all clients would receive dual-pro-
tection counseling, with the flip chart serving as an inte-
gral part of routine family planning services. One problem
was that some of the trained staff were transferred and were
replaced with staff who received inadequate on-the-job train-
ing in dual-protection counseling. At Time 2, for example,
a substantial number of providers were family planning
nurse trainees on short-term assignment. Another prob-
lem was that some providers simply forgot to use the flip
chart with every client. Underutilization of the flip chart
was subsequently addressed through in-service training.
Although we had expected greater use of the dual-pro-
tection flip chart, it nevertheless was regarded as a major
innovation and a key to making the integration of dual-pro-
tection concepts into traditional family planning counsel-
ing more concrete. In the monthly meetings and interviews,
providers described how using the flip chart structured their
counseling: It provided a memory aid and prevented them
from skipping core information, and it helped clarify con-
cepts for clients and presented important prevention con-
cepts using culturally appropriate illustrations.
Given that all stakeholders in the project—investigators,
providers and clients—concluded that family planning clients’
male partners are the major impediment to dual protection
Promoting Dual Protection in Family Planning Clinics
93Volume 28, Number 2, June 2002
method use. Family planning providers have made cogni-
tive and attitudinal changes that are crucial to promoting
and sustaining the dual-protection initiative, assisted by
both an intensive two-week initial training and continuing
supervision. The involvement of clinic managers and ser-
vice providers in the design of the dual-protection inter-
vention facilitated their commitment to change. In addi-
tion, a system for integrating dual-protection counseling
into traditional family planning education, in the form of
a detailed flip chart using locally drawn illustrations, proved
an important aid in the dual-protection counseling of clients.
Although providers’ attitudes about condoms are an im-
portant factor in dual-protection promotion, the attitudes
and behaviors of clients and their partners must also be
considered in gauging the success of the intervention. Men’s
objections to both male and female condom use have been
important in this setting.17 With a substantial proportion
of clients reporting that they suspect their partner has had
other partners, the HIV and STI risk of family planning
clients is a reality. Our experience points to the potential
value of the female condom, used either alone or in con-
junction with other contraceptives, as a facilitator of dual-
protection practices.
The need to expand the scope of the intervention beyond
clinic-based dual-protection services for women is essen-
tial. Data from Phase 2 of the intervention, which will in-
clude clinic-based and community-based activities target-
ing men, the follow-up of dual-protection acceptors and a
management assessment of clinic practices, will further our
understanding of ways to foster dual-protection practices
within family planning services in Nigeria.
1. Kisubi W, Farmer F and Sturgis R, An African Response to the Chal-
lenge of Integrating STD/HIV-AIDS Services into Family Planning Programs,
Nairobi, Kenya: Pathfinder International, 1997; Baakile B et al., A Situ-
ation Analysis of the Maternal and Child Health/Family Planning
(MCH/FP) Program in Botswana,Gabarone, Botswana: Ministr y of Health
MCH/FP Unit, Family Health Division, and New York: Population Coun-
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Health Services in Africa: Findings from Situation Analysis Studies, New
York: Population Council, 1998; Becker J and Leitman E, Introducing
sexuality within family planning: the experience of three HIV/STD pre-
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Network, 2001, 20(4):4–7; Askew I et al., Demand for and cost-effec-
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2. O’Reilly KR, Dehne KL and Snow R, Should management of sexu-
ally transmitted infections be integrated into family planning services:
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3. Shelton JD, Prevention first: a three-pronged strategy to integrate
family planning program efforts against HIV and sexually transmitted
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152; Cates W, Jr., and Stone KM, Family planning, sexually transmit-
ted diseases and contraceptive choice: a literature update—Part 1, Fam-
ily Planning Perspectives, 1992, 24(2):75–84; and Cates W, Jr., Contra-
ception, unintended pregnancies, and sexually transmitted diseases:
why isn’t a simple solution possible? American Journal of Epidemiolo-
gy, 1996, 143(4):311–318.
adoption, we recently implemented intervention activities
that target male partners of clinic clients. As Yoruba culture
generally considers the male to be dominant in regard to
family matters, the ultimate effectiveness of dual protection
will rest with enlisting the support of male partners.
The lack of comparison family planning clinics not exposed
to the intervention limits our ability to conclude definitively
that the changes in providers’ counseling were related to
the intervention. However, since dual protection was in-
troduced only by ARFH and the female condom is avail-
able only in the study clinics, providers had limited potential
to be exposed to dual-protection concepts outside of the
study. Further, we cannot be certain that providers’ aware-
ness of being observed by the research staff did not influ-
ence their behavior. However, most reports of similar ob-
servation methodologies suggest that after an initial reaction,
people who are being observed return to their typical be-
havior patterns. Finally, each service provider was observed
with multiple clients, and most provided counseling at both
baseline and Time 2. Therefore, assessments of provider
practices in the observations are correlated, which would
lead to inflated standard errors and p-values. This issue is
of minor importance in our current analysis, however, as
its focus is on the changes in the overall experience of clients
rather than on changes at specific clinics.
ARFH staff had been concerned about sustaining dual-pro-
tection services in the clinics after project funding ends. Al-
though an unlimited supply of female condoms has not
been assured at the time of this report, other elements im-
portant to sustainability are in place. Most important, the
commitment of the providers to the goals of dual-protec-
tion programming will help ensure that the counseling in-
tervention will continue. Clinic managers’ participation in
project planning and management has helped to ensure
that top-level staff members have bought into the program.
Support of dual-protection services, in terms of the flip
charts, brochures and posters, are in place. Dual-protec-
tion concepts are now being incorporated into other ARFH
projects and consultant services, including work with pri-
vate medical practitioners and in youth projects with the
Oyo State Ministries of Health and Education.
The problems reported here are probably indicative of
the usual provider difficulties in dealing with changes in
fundamental family planning service provision and of the
difficulties of providing clinic services in a low-resource en-
vironment. Despite these problems, substantial changes
have been made, and we expect that they will continue to
be implemented.
Dual-protection services increased condom uptake in the
participating Ibadan family planning clinics, mainly as a
result of female condom introduction and through dual
94 International Family Planning Perspectives
4. Miller K, Jones H and Horn MC, Indicators of readiness and quali-
ty: basic findings, in: Miller K et al., eds., Clinic-Based Family Planning
and Reproductive Health Services in Africa: Findings from Situation Analy-
sis Studies, New York: Population Council, 1998.
5. Stein Z, Family planning, sexually transmitted diseases, and the pre-
vention of AIDS—divided we fail? American Journal of Public Health, 1996,
6. Mantell JE et al., The acceptability of the female condom: perspec-
tives of family planning providers in New York City, South Africa, and
Nigeria, Journal of Urban Health, 78(4):658–668.
7. Askew I, Fassihian G and Maggwa N, Integrating STI and HIV/AIDS
services at MCH/family planning clinics, in: Miller K et al., eds., 1998,
op. cit. (see reference 4).
8. National AIDS Control Programme, Annual Report 2001, Abuja, Nige-
ria: Ministry of Health, 2001.
9. World Bank Institute, Confronting AIDS: Public Priorities in a Global
Epidemic, Washington, DC: World Bank Institute, 1997.
10. National Population Commission, Nigeria Demographic and Health
Survey 1999, Calverton, MD, USA: ORC/Macro, 2000; Orubuloye IO,
Caldwell JC and Caldwell P, Perceived male sexual needs and male sex-
ual behaviour in Southwest Nigeria, in: Caldwell JC et al., eds., Towa rds
the Containment of the AIDS Epidemic: Social and Behavioural Research,
Canberra, Australia: Health Transition Centre, Australian National Uni-
versity, 2000; Orubuloye IO et al., The role of high-risk occupations in
the spread of AIDS: truck drivers and itinerant market women in Nige-
ria, in: Orubuloye IO et al., eds., Sexual Networking and AIDS in Sub-Sa-
haran Africa: Behavioural Research and the Social Context, Health Tran-
sition Series, Canberra, Australia: Health Transition Centre, Australian
National University, 1994, No. 4; Caldwell JC et al., The social context
of AIDS in Sub-Saharan Africa, in: Orubuloye IO et al., eds., Sexual Net-
working and AIDS in Sub-Saharan Africa: Behavioural Research and the
Social Context, Health Transition Series, Canberra, Australia: Health
Transition Centre, Australian National University, 1994, No. 4; and
Messersmith LJ et al., Who’s at risk? Men’s STD experience and con-
dom use in Southwest Nigeria, Studies in Family Planning, 2000,
11. Mantell JE et al., Introducing the female condom through the pub-
lic health sector: experiences from South Africa, AIDS Care, 2000, 12(5):
12. Mantell JE and Weiss E, Dual protection against unwanted preg-
nancy and HIV/STDs, Sexual Health Exchange, 1999, No. 3, p. 8; and
Mantell JE, Weiss E and Scheepers E, The female-initiated protection
paradigm: promoting dual protection within family planning services,
unpublished manuscript, 1997.
13. Miller R et al., The Situation Analysis Approach to Assessing Family
Planning and Reproductive Health Services, New York: Population Coun-
cil, 1997.
14. Becker J and Leitman E, 1997, op. cit. (see reference 1); and Abdel-
Tawab N et al., Integrating issues of sexuality into Egyptian family plan-
ning counseling, New York: Population Council, 2000.
15. Abdool Karim Q, Abdool Karim SS and Preston-Whyte E, Accessi-
bility of condoms to teenagers at family planning clinics in Durban.
Part II: A provider’s perspective, South African Medical Journal, 1992,
82(5):360–362; Feldblum P et al., Female condom introduction and
sexually transmitted infection prevalence: results of a community in-
tervention trial in Kenya, AIDS, 2001, 15(8):1037–1044; Mqoqi N et
al., The National Introduction of the Female Condom and Emergency Con-
traceptive Pills Program, Pilot Phase—Final Report, Johannesburg, South
Africa: Reproductive Health Research Unit, Chris Hani-Baragwanath
Hospital, 2000; and Mantell JE et al., 2000, op. cit. (see reference 11).
16. Nutley T, National public sector introduction of the female con-
dom in South Africa, paper presented at the USAID Technical Update
on the Female Condom, Dec. 18, 2001, Washington, DC.
17. Mantell J et al., The impact of male gender roles on HIV risk in south-
west Nigeria, paper presented at the annual meeting of the American
Public Health Association, Atlanta, GA, USA, Oct. 21–25, 2001.
Contexto: Debido a la creciente epidemia del VIH en el Afri-
ca Subsahariana, es necesario integrar con urgencia todos los
esfuerzos que se realizan para prevenir el VIH y las infecciones
transmitidas sexualmente (ITS) y la promoción del uso del con-
dón, a los servicios de planificación familiar.
Métodos: Se introdujeron servicios de consejería en materia de
doble protección—la protección simultánea contra el embarazo
no planeado y el VIH y otras ITS—junto con la oferta del condón
femenino en seis clínicas de planificación familiar en Ibadán,
Nigeria. Para evaluar la promoción de la doble protección ofre-
cida por los proveedores, se observaron en forma estructurada la
interacción entre las clientas y los proveedores, se llevaron a cabo
entrevistas a los proveedores y recabaron estadísticas de servicios
clínicos, además de otros métodos cualitativos y cuantitativos.
Resultados: Después de recibir capacitación intensa, los pro-
veedores ofrecieron consejería sobre la doble protección a la ma-
yoría de las clientas y demostraron el uso del condón femenino
al 80% de las clientas nuevas observadas. Aumentaron signifi-
cativamente las discusiones con clientas sobre su comportamiento
sexual con su pareja, sobre la relativa capacidad de los diversos
anticonceptivos para prevenir la infección del VIH, y sobre la
manera de influenciar al pareja que use el condón. Igualmente,
aumentaron los esfuerzos de evaluar el riesgo de las ITS. La in-
teriorización por parte de los proveedores acerca de la impor-
tancia de la prevención del VIH/SIDA fue crucial para la pro-
moción y mantenimiento de la iniciativa de la doble protección.
Aumentó la compra de condones, desde el 2% de todas las visi-
tas a las clínicas de planificación familiar en 1999 al 9% entre
enero y junio de 2001. Este aumento se debió principalmente al
aumento del uso del condón femenino, utilizado en forma in-
dependiente o junto a otros anticonceptivos.
Conclusiones: La integración de la consejería en materia de
doble protección y el suministro del condón femenino en los ser-
vicios de planificación familiar parece ser una iniciativa via-
ble; es igualmente posible la aceptación por parte de los pro-
veedores de los objetivos de la doble protección. Si bien los
proveedores y las clientas son un factor clave para transformar
la planificación familiar para ofrecer servicios de doble pro-
tección, también la actitud y el comportamiento de los hom-
bres deben ser considerados seriamente para lograr éxito con
esta iniciativa de doble protección.
Contexte: L’escalade de l’épidémie du VIH en Afrique subsa-
harienne crée un besoin urgent d’intégration des efforts de pré-
vention du VIH et autres infections sexuellement transmissibles
(IST) et de la promotion du préservatif dans le cadre des ser-
vices de planning familial.
Méthodes: Les conseils sur la double protection—la protection
simultanée contre des VIH/IST et la grossesse non planifée—et
l’offre du préservatif féminin ont été introduits dans six cliniques
de planning familial d’Ibadan, au Nigéria. L’observation struc-
turée des échanges entre clientes et prestataires, les statistiques
de prestations dans les cliniques et les interviews de prestataires
ont servi, entre autres méthodes qualitatives et quantitatives,
à évaluer la promotion de la double protection par les presta-
Promoting Dual Protection in Family Planning Clinics
95Volume 28, Number 2, June 2002
taires et clientes représentent les intervenants clés de la trans-
formation du planning familial vers les services de double pro-
tection, il faudra tenir compte des perceptions et comportements
des partenaires masculins des clientes dans l’évaluation du suc-
cès de l’initiative.
Funding for the study described in this article was provided by the
U.S. Agency for International Development (USAID) through the
Horizons Program, an operations research project implemented by
the Population Council in partnership with the International Cen-
ter for Research on Women, the Program for Appropriate Technol-
ogy in Health, the International HIV/AIDS Alliance, the Univer-
sity of Alabama at Birmingham and Tulane University. Additional
funding for intervention activities was provided by the World AIDS
Foundation. The opinions expressed are those of the authors and
do not necessarily reflect the views of USAID or the World AIDS
Foundation. The authors greatly appreciate comments on earlier
drafts from Martin Gorosh, Robert Miller and Zena Stein. They
also acknowledge statistical consultation from Bruce Levin and
Cheng-Shiun Leu.
Author Contact:
taires du planning familial.
Résultats: Après formation intensive, les prestataires offraient
des conseils de double protection à la majorité de leurs clientes
et démontraient l’usage du préservatif féminin à 80% des nou-
velles clientes observées. La discussion du comportement sexuel
des clientes et de leurs partenaires, de la capacité relative de
protection contre le VIH offerte par différents contraceptifs et
de la manière de négocier l’usage du préservatif, a augmenté
significativement, de même que l’évaluation des IST. L’intério-
risation par les prestataires de l’importance de la prévention
du VIH/sida s’est avérée essentielle à la promotion et à la du-
rabilité de l’initiative sur la double protection. Les achats de
préservatifs ont augmenté, d’un point de référence de 2% de l’en-
semble des consultations de planning familial en 1999 à 9%
entre janvier et juin 2001. Cet accroissement est dû principa-
lement à l’acceptation du préservatif féminin, utilisé seul ou en
combinaison avec un autre contraceptif.
Conclusions: L’intégration des conseils de double protection
et de l’offre du préservatif féminin dans les services de planning
familial semble praticable, de même que l’acceptation par les
prestataires des objectifs de la double protection. Si les presta-
... But it is lower than studies conducted in Bungoma County, Kenya (38%.5) [20]; Nigeria (45%) [21]; and United States of America (47%) [22]. This difference might be because of regional variation and variation in guidelines of reproductive health and health policy of the country. ...
Full-text available
Introduction. A dual contraceptive method is the usage of any modern contraceptive method with male or female condoms which could lower sexually transmitted diseases and unwanted pregnancy. Ethiopian standard utilization of dual contraceptive is low. The hassle is more severe for HIV/AIDS-infected people. Therefore, this review was aimed at assessing dual contraceptive utilization and factor associated with people living with HIV/AIDS in Ethiopia. Method. International databases (PubMed/MEDLINE, Hinari, Embase, African Journals Online, Scopus, and Google Scholar) and Ethiopian university repository online have been covered in this review. Microsoft Excel was used for extraction, and the Stata 14 software program was used for analysis. We detected the heterogeneity between studies using the Cochran Q statistic and I2 test. Publication bias was assessed by funnel plot and Egger’s and Begg’s tests. Result. The overall prevalence of dual contraceptive use among people living with HIV/AIDS was 27.73% (95% CI: 20.26-35.19) in Ethiopia. Discussion with the partner (OR: 3.78, 95% CI: 3.08-4.69), HIV status disclosure to the spouse/partner (OR: 2.810, 95% CI: 2.26-3.48), post diagnosis counseling (OR: 5.00, 95% CI: 3.71-6.75), schooling in secondary and above education (OR: 3.78, 95% CI: 2.41-5.93), partner involvement in counseling (OR: 2.76, 95% CI: 1.99-3.82), urban residence (OR: 2.84, 95% CI 2.03-3.94), and having no fertility desire (OR: 4.01, 95% CI 2.91-5.57) were significantly associated with dual contraceptive use. Conclusion. Dual contraceptive utilization among people living with HIV/AIDS was found to be low in Ethiopia. This will be a significant concern unless future intervention focuses on rural residence, involvement of the partner in post-diagnosis counseling, encouraging the people living with HIV/AIDS to disclose HIV status, and discussion with the partner. Providing counseling during the antenatal and postnatal period also enhances dual contraceptive use.
... Training for service providers needs to include the role that the female condom can play in dual protection, how counselling services can effectively be provided and a review of programme implementation issues likely to arise. 1,35 These successful interventions encourage a ''practice makes perfect'' attitude, and do not over-complicate female condom use. They incorporate information about anatomy, sexuality, communication and negotiation skills; they respect women and provide opportunities for them to develop a sense of self-efficacy and self-confidence in using female condoms and self-worth about protecting themselves and their partners. ...
Although the female condom has been introduced into over 90 countries since 1997, it has only been accepted in sexual and reproductive health programmes as a mainstream method in a few. This paper describes introductory strategies developed by Ministries of Health and non-governmental organisations in Brazil, Ghana, Zimbabwe and South Africa, supported by UNAIDS, and the manufacturers of the female condom, which have significantly expanded the number of female condoms being used. These projects have several key similarities: a focus on training for providers and peer educators, face-to-face communication with potential users to equip them with information and skills, an identified target audience, a consistent supply, a long assessment period to gauge actual use beyond the initial novelty phase, and a mix of public and private sector distribution. Female condom programmes require the sanction, leadership and funding of governments and donors. However, the non-governmental and private sectors have also played a major role in programme implementation. To ensure successful introduction of the female condom, it is crucial to involve a range of decision-makers, programme managers, service providers, community leaders and women's and youth groups. The rising cost of inaction and unprotected sex in the spread of HIV and AIDS force us to recognise the high cost of not providing female condoms alongside male condoms in family planning and AIDS prevention programmes. Résumé Le préservatif féminin a été introduit dans plus de 90 pays depuis 1997, mais rares sont ceux où il a été accepté comme méthode primaire dans les programmes de santé génésique. Cet article décrit les stratégies d'introduction préparées par les ministères de la santé et des ONG au Brésil, au Ghana, au Zimbabwe et en Afrique du Sud, avec le soutien de l'ONUSIDA, et les fabricants de préservatifs féminins, qui ont nettement accru l'utilisation de ces préservatifs. Les projets ont plusieurs similitudes: une priorité à la formation des prestataires et des éducateurs pairs, une communication personnelle avec les utilisatrices potentielles pour les informer et les former, un public cible identifié, un approvisionnement régulier, une longue période d'évaluation pour estimer l'utilisation réelle après la nouveauté du début, et une distribution partagée entre secteur privé et public. Ces projets exigent l'approbation, l'impulsion et le financement des gouvernements et des donateurs, mais les ONG et le secteur privé ont également joué un rôle majeur dans leur réalisation. Pour une introduction réussie, il faut associer différents décideurs, gestionnaires de programmes, prestataires de services, chefs communautaires et groupes de femmes et de jeunes. Le coût croissant de l'inaction et de relations sexuelles non protégées dans la transmission du VIH nous force à reconnaı̂tre qu'il serait onéreux de ne pas fournir des préservatifs féminins parallèlement aux préservatifs masculins dans les programmes de planification familiale et de prévention du SIDA. Resumen El condón femenino ha sido introducido en más de 90 paı́ses desde 1997, pero en la mayorı́a de ellos no ha sido aceptado como un método corriente en los programas de salud sexual y reproductiva. Este artı́culo describe las estrategias para la introducción del condón femenino desarrolladas por los Ministerios de Salud y organizaciones no gubernamentales en Brasil, Ghana, Zimbabwe y Sudáfrica, con el apoyo de UNAIDS y los fabricantes del condón femenino, las cuales han aumentado significativamente el número de condones femeninos en uso. Dichos proyectos comparten varios aspectos claves: un enfoque en la capacitación de los proveedores de servicios y los educadores de pares, comunicación directa con los usuarios potenciales, grupos destinatarios identificados, abastecimiento constante, un perı́odo largo para medir el uso más allá de la fase inicial, y distribución mixta entre los sectores públicos y privados. Estos programas requieren la sanción, liderazgo y financiamiento de gobiernos y donantes. Los sectores no-gubernamentales y privados también han jugado un papel importante en la implementación de los programas. Para asegurar la introducción exitosa del condón femenino, es preciso involucrar una gama de personas responsables de adoptar decisiones, administradores de programas, prestadores de servicios, dirigentes comunitarios, y grupos de mujeres y jóvenes. Las consecuencias de la inacción y el sexo no protegido exigen que reconozcamos el alto costo de no proveer el condón femenino junto con el condón masculino en los programas de planificación familiar y prevención del SIDA.
... 16 Availability of drugs and laboratory facilities are also crucial, as are the other central pillars of successful STI service delivery -partner notification and treatment and condom promotion. 17,18 Fourthly, although not all reproductive tract infections in women are sexually transmitted, the need for attention to RTIs which are not sexually transmitted is often sidelined. This is a crucial distinction, however, as the population of women needing treatment for endogenous and iatrogenic RTIs may be different from (or overlap) the population needing STI treatment.* ...
... Many of the definitions of dual protection found in the literature tend to be limited to only one type of dual protection, usually the use of condoms for disease prevention and birth control pills for contraception, 9 or less often condoms with other contraceptives. 10,11 Some authors assume that because use of the contraceptive pill is so common, it would be easiest just to add condoms. However, in addition to having to keep a supply and use a condom each time for sex, the pill must be taken every day at around the same time of day, making this combination one of the most demanding forms of dual protection possible. ...
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Although non-barrier contraceptive use has become a global norm, unprotected sex in relation to sexually transmitted infections remains the norm almost everywhere. Dual protection is protection from unwanted pregnancy, HIV and other sexually transmitted infections, and is a form of safer sex for heterosexual couples that is more needed than practised or understood. This paper draws on a review of the literature in family planning, obstetrics and gynaecology, and AIDS-related journals from 1998 to early 2005. Definitions of dual protection, found mainly in family planning literature, are very narrow. Condoms remain the mainstay of dual protection, but the aim of this paper is to provide an expanded list of dual protection methods to show that there is a range of options. These include non-penetrative sex and the increasing use of condoms with the back-up of emergency contraception on the part of young people. The fact that people may fail to use dual protection consistently and correctly is not a valid reason not to promote it. It is never too late for those providing family planning and STI/HIV prevention services to start promoting condoms and dual protection. In the long-term, the development of highly efficacious and highly acceptable methods of dual protection is an urgent research priority, starting with a wider range of condoms that will appeal to more people. Résumé Bien que l’emploi de contraceptifs non mécaniques se soit généralisé dans le monde, les relations sexuelles non protégées par rapport aux IST demeurent la norme presque partout. Une double protection permet d’éviter une grossesse, et la transmission du VIH et d’autres IST ; c’est une forme de sexualité sans risque pour les couples hétérosexuels trop peu pratiquée ou comprise. Cet article analyse des articles publiés dans les revues sur la planification familiale, l’obstétrique, la gynécologie et le SIDA, de 1998 au début de 2005. Les définitions de la double protection, trouvées essentiellement dans les revues sur la planification familiale, sont très étroites. La principale méthode de double protection demeure le préservatif, mais l’article souhaite donner une liste élargie afin de montrer qu’il existe une gamme d’options, notamment les relations sans pénétration et l’utilisation accrue de préservatifs complétée par une contraception d’urgence pour les jeunes. Que la double protection ne soit pas toujours utilisée de manière suivie et correcte n’est pas une raison valable pour ne pas l’encourager. Il n’est jamais trop tard pour que les responsables des services de planification familiale et de prévention des IST/du VIH commencent à promouvoir les préservatifs et la protection double. À long terme, le développement de méthodes très efficaces et acceptables de double protection est une priorité de la recherche, à commencer par un éventail plus large de préservatifs qui plairont à davantage de gens. Resumen Aunque el uso de anticonceptivos que no son de barrera se ha vuelto la norma mundial, el sexo sin protección en relación con las infecciones de transmisión sexual (ITS) continúa siendo la norma en casi todas partes. La doble protección –protección del embarazo no deseado, el VIH y otras ITS – es una forma de que las parejas heterosexuales tengan sexo más seguro, que es más necesitada que practicada o entendida. Este artículo se basa en una revisión de artículos sobre la planificación familiar, obstetricia y ginecología, en revistas relacionadas con el SIDA desde 1998 hasta principios de 2005. Las definiciones de la doble protección, encontradas principalmente en el material sobre la planificación familiar, son muy estrechas. El condón continúa siendo el pilar, pero el objetivo de este artículo es proporcionar una lista más amplia de los métodos de doble protección para mostrar que existe una variedad de opciones. Entre éstas figuran el sexo no penetrador y el uso en alza del condón con el respaldo de la anticoncepción de emergencia por parte de los jóvenes. El hecho de que las personas quizás no usen la doble protección de manera sistemática y correcta no es una razón válida para no promoverla. Nunca es muy tarde para que aquéllos que proporcionan servicios de planificación familiar y de prevención de ITS/VIH empiecen a promover el condón y la doble protección. A la larga, el desarrollo de métodos de doble protección de alta eficacia y aceptación es una urgente prioridad de investigación, comenzando por una mayor variedad de condones que atraerá a más personas.
... An operations research study in Nigeria, in which patient education on STIs and selfrisk assessment were made central features of the family planning consultation, also found promising preliminary results, with the proportion of visits resulting in acceptance of condoms (mostly the female condom) increasing from 2% to 9%. 62 Operations research studies undertaken in Zimbabwe 10 and Kenya 11 also attempted to systematically re-orientate family planning and antenatal care services so that they included both STI education and screening. They did this through training staff, guaranteeing drug supplies and developing a standardized checklist to guide staff through all components during the consultation (including a full history, clinical and pelvic examination, 23-question risk assessment, and education on STIs and HIV/AIDS). ...
Approximately 80% of HIV cases are transmitted sexually and a further 10% perinatally or during breastfeeding. Hence, the health sector has looked to sexual and reproductive health programmes for leadership and guidance in providing information and counselling to prevent these forms of transmission, and more recently to undertake some aspects of treatment. This paper reviews and assesses the contributions made to date by sexual and reproductive health services to HIV/AIDS prevention and treatment, mainly by services for family planning, sexually transmitted infections and antenatal and delivery care. It also describes other sexual and reproductive health problems experienced by HIV-positive women, such as the need for abortion services, infertility services and cervical cancer screening and treatment. This paper shows that sexual and reproductive health programmes can make an important contribution to HIV prevention and treatment, and that STI control is important both for sexual and reproductive health and HIV/AIDS control. It concludes that more integrated programmes of sexual and reproductive health care and STI/HIV/AIDS control should be developed which jointly offer certain services, expand outreach to new population groups, and create well-functioning referral links to optimize the outreach and impact of what are to date essentially vertical programmes.
... The proportion of women using dual method is lower in the present study compared to the findings of studies done in Tigray (59.9%), Ethiopia, Kenya (38.5%), and Nigeria (45%) [32,44,45].. The discrepancy between study reports could probably be due to sociodemographic and cultural differences of the study populations, presence of quality, integrated sexual and reproductive health and ART services in Kenya and Nigeria. ...
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Background: Mother to child transmission is responsible for 90% of child infection with human immune deficiency virus (HIV). Dual contraceptive use is one of the best actions to prevent mother's human immune deficiency virus transmission to her child and partner. This study aimed at assessing the prevalence and factors associated with dual contraceptive use among sexually active women on antiretroviral therapy in Gondar City, northwest, Ethiopia. Methods: An institution based cross sectional study was conducted in Gondar City public health facilities from December 1 to 31, 2018. Systematic random sampling technique was utilized to include 563 study participants. Data were collected by interview using a structured questionnaire. Descriptive analysis was made to compute mean, median and proportion. Finally, multivariable logistic regression model was fitted to identify the factors associated with dual contraceptive method utilization. Analysis was performed by using Statistical Package for Social Sciences (SPSS) software version 20. Results: The overall prevalence of dual contraceptive method utilization among sexually active women on antiretroviral therapy was 28.8% (95% CI: 24.9, 32.7). Women aged 35-49 years (Adjusted odds ratio (AOR): 6.99; 95% CI: 3.11, 15.71)), who lived in urban areas (AOR: 4.81; 95% CI: 2.04, 11.31), attended secondary and above education (AOR: 4.43; 95% CI: 1.92, 10.22), and disclosed HIV status to sexual partners (AOR: 9.84; 95% CI: 3.48, 27.81) were more likely to use dual contraceptive method. Conclusion: In this study, the proportion of women who utilized dual contraceptive method was low. Age, place of residence, educational status and disclosure of HIV status were factors associated with dual contraceptive use. Therefore, providing education about the advantages of disclosing HIV status to sexual partners and strengthening of counseling about the advantages of dual contraceptive use will be helpful in enhancing the use of dual contraceptive method among sexually active women on antiretroviral therapy.
... This low acceptability of the FC includes pervasive male partner objection [3,4]. However, studies suggest levels of protected sex increase when FCs are added to the available method mix [5][6][7][8][9]. Zambia is an important context for new contraceptive options, as the population experiences both a high unmet need for family planning (27.1%) and an HIV prevalence of 18% in urban areas [10]. ...
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During a mass media campaign accompanying the launch of the Maximum Diva Woman's Condom (WC) in Lusaka, Zambia, a cluster-randomized evaluation was implemented to measure the added impact of a peer-led interpersonal communication (IPC) intervention on the awareness and uptake of the new female condom (FC). The WC and mass media campaign were introduced simultaneously in 40 urban wards in April 2016; half of the wards were randomly assigned to the treatment (IPC intervention) with cross-sectional surveys conducted before (n = 2,364) and one year after (n = 2,430) the start of the intervention. A pre-specified intention-to-treat (ITT) analysis measured the impact of randomization to IPC at the community level. In adjusted ITT models, there were no statistically significant differences between intervention and control groups. Due to significant implementation challenges, we also conducted exploratory secondary analyses to estimate effects among those who attended an IPC event (n = 66) using instrumental variable and inverse probability weighting analyses. In addition to increases in FC identification (IPC attendees had higher reported use of any condom, improved perceptions of FC's, and were more likely to have discussed contraceptive use with their partner as compared to non-attendees). The introduction of a new FC product combined with an IPC intervention significantly increased general knowledge and awareness in the community as compared to media alone, but did not lead to detectable community level impacts on other primary outcomes of interest. Observational evidence from our study suggests that IPC attendance is associated with increased use and negotiation. Future studies should explore the intensity and duration of IPC programming necessary to achieve detectable community level impacts on behavior. Trial Registration: AEARCTR-0000899.
... In sub-Saharan Africa, marital relations are generally regulated by fidelity and intimacy [37], and condoms are generally perceived as an HIV-preventive device used, not as a contraceptive method [38]. Condom use has been promoted by health staff and media to prevent HIV infection from high-risk partners [39,40]. By using HECs, condoms are more likely to be perceived as a device for HIV prevention and stigmatized, and so condom use may become unacceptable, especially in marital sex. ...
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Background: Women of reproductive age are at the highest risk of both HIV infection and unintended pregnancy in sub-Saharan Africa. Highly effective contraceptives (HECs) such as hormonal injectable and implants are widely used in this region. HECs are effective for preventing pregnancies. However, unlike condoms, HECs offer no protection against HIV. Dual-method use, or the use of condoms with HECs, is an ideal option to reduce HIV risk but is infrequently practiced. Rather, women tend not to use condoms when they use HECs and increase their HIV risk from their sexual partners. However, it remains unknown whether HIV status affects such tendency. Given the increasing popularity of HECs in sub-Saharan Africa, this study examined the association between the use of HECs and condom use among HIV-positive and negative women. Methods: A cross-sectional study was conducted among 833 sexually active women aged 18-49 years, recruited from six clinics in Siaya county, Kenya. From March to May 2017, female research assistants interviewed the women using a structured questionnaire. Multiple logistic regression analysis was conducted to examine the association between HEC use and consistent condom use in the past 90 days, adjusting for potential confounders. It was also examined with regular partners (husbands or live-in partners) and non-regular partners, separately. In addition, a sub-sample analysis of HIV-negative or unknown women was conducted. Results: In total, 735 women were available for the analysis. Among the women, 231 (31.4%) were HIV-positive. HIV-positive women were more likely to use HECs than HIV-negative or status unknown women (70.1% vs. 61.7%, p = 0.027). HEC use was significantly associated with decreased condom use with a regular partner (adjusted odds ratio (AOR) = 0.25; 95% CI 0.15-0.43, p<0.001) and a non-regular partner (AOR = 0.25; 95% CI 0.11-0.58, p = 0.001). However, compared with HIV-negative or status unknown women, HIV-positive women were more likely to use HECs and condoms consistently with a regular partner (AOR = 6.54, 95% CI 2.15-20.00, p = 0.001). Other factors significantly associated with consistent condom use included partner's positive attitude toward contraception, partner's HIV-positive status, high HIV risk perception, and desire for children in the future. Conclusion: Dual-method use was limited among HIV-negative women and women who had HIV-negative partners due to inconsistent condom use. The use of HECs was significantly associated with decreased condom use, regardless of partner type and their HIV status. Due to this inverse association, HIV-negative women may increase their HIV risk from their sexual partners. Therefore, interventions should be strengthened to reduce their dual risks of HIV infection and unintended pregnancy by promoting dual-method use. Family planning services should strengthen counseling on the possible risk of HIV infection from their sexual partners and target not only women but also their partners, who may play a key role in condom use.
... Moreover, uninfected infertile couples engaging in unprotected sex in a monogamous relationship would constitute DP; but this is unlikely for many youths as these age-groups have high fecundity, form fragile relationships, and often engage in casual sex [25,26]. DP can also be achieved through effective contraception using a barrier method, such as, correct and consistent use of male/ female condoms [27][28][29][30]; however, condom-only are associated with high pregnancy rate because of imperfect use [31,32]. ...
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Background: A less risky sexual behaviour for sexual and reproductive health among HIV positive women is essential for their well-being and that of their sexual partners and children. The aim of this study was to assess the frequency of dual contraception method use and factors associated among HIV positive women follow-up at the treatment center unit (TCU) at Yaounde Central Hospital (YCH). Methods: It was a transversal study done for 6 months at YCH. A sample of 294 HIV positive women among 322 who came for consultation and received their treatment during our study period was included. Data collection was by face-to-face questionnaire administration. Data were analysed using Epi-infos software. Multiple logistic regression was done to find an association between the outcome and predictor variables with statistically significant level of p < 0.05 and CI of 95%. Results: Prevalence of DCM use was 33.3%. Multivariate logistic regression showed that DCM utilization was associated with age > 35 [(AOR = 0.29, 95% CI (0.14-0.60], sexual frequency (AOR = 0.25, 95% CI (0.10-0.60)], parity and gravidity of less than 3, (AOR = 0.29, 95% CI (0.14-0.58) and (AOR = 0.28, 95% CI (0.12-0.65)] respectively and no past history of abortion [(AOR = 0.24, 95% CI (0.10-0.56)]. All were protective factors. Conclusion: DCM use prevalence among HIV positive women was low. Age > 35 years, one or more than one sexual intercourse per week, parity and gravidity of less than 3 and no past history of abortion were associated with DCM use.
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CONTEXT: The high prevalence of sexually transmitted infections (STIs) and their role in HIV transmission have made integrating STI prevention and management into existing family planning and antenatal care programs a goal in most resource-poor countries, especially in Sub-Saharan Africa. However, little is known about how integrated ser- vices can best be configured, and what impact they have on prevention of infection and unwanted pregnancy. METHODS: The literature is reviewed to examine what is and is not known about integration and to identify priority areas to be addressed through research. RESULTS: The feasibility and effectiveness of strategies that focus on the addition of either STI prevention services or detection and treatment activities are uncertain. An urgent need for research exists in three areas. The first is the devel- opment and testing of strategies that, instead of adding STI-related activities to existing family planning and antena- tal care programs, seek to reorient the goals of routine consultations toward protection against the dual risks of un- wanted pregnancy and infection and involvement of clients in deciding the outcome of the consultation. Second, strategies that reach male partners and facilitate access by adolescents to sexual and reproductive health services need to be developed and tested. Finally, prospective, preferably randomized studies need to be carried out to test and compare the impact of alternative integration strategies on population-level indicators of behavior and health. CONCLUSIONS: Strategies for integration of services need to be rigorously tested to ensure that they are both feasible and effective before they are implemented. International Family Planning Perspectives, 2002, 28(2):77-86
Acknowledgements We would like to extend our thanks to the entire staff from BEMFAM/Brazil, ASHONPLAFA/Honduras, and FAMPLAN/Jamaica, and particularly, to those who participated in the discussions, in-depth interviews, and focus groups that assisted in preparing this publication.
This article presents a three-pronged strategy for prevention of HIV/AIDS and sexually transmitted infections (STIs). The enormous misfortune caused by HIV/AIDS and STIs provides compelling grounds for enlisting the support of family planning and related health program efforts against these diseases. The dynamics of STI transmission support a three-pronged prevention strategy aimed at high transmitters at men and at the general population. While ultimate success will require support from a number of other segments of the health community and from the broader society family planning and related health efforts can contribute much especially by building ongoing prevention activities. Reducing STIs and HIV/AIDS on a broad scale even a global one will not be easy. But it can happen if there is a primary preventative strategy.
Many STD/HIV-prevention programs worldwide assume that individuals' risk of acquiring sexually transmitted diseases, including HIV infection, is highest in the context of commercial sex. To address this assumption, research conducted in urban Southwest Nigeria combined qualitative and quantitative methods to examine men's sexual behavior, condom use, and STD experience in different types of sexual relationships (marital, casual, and commercial). Logistic regression analysis of survey data indicates that number of sexual partners and sex with sex workers are positively and significantly related to STD experience. Follow-up in-depth interviews with clients of sex workers indicate, however, that these men are actually more likely to report having contracted an STD from a casual sex partner than from a sex worker. Men are most uncertain about their vulnerability to STDs with casual partners. Men's condom use is highest in commercial sex, inconsistent in casual relationships, and lowest in marriage. STD/HIV-prevention programs need to address the range of sexual relationships and the meanings and behaviors associated with them.
An extensive review of what is known about efforts to integrate prevention and treatment services for sexually transmitted infections (STIs) into family planning services found that all too little empirical evidence is available. This paper summarises the key findings of the review, discusses the need for additional information on forms of integration and how they are working, and makes recommendations on gathering the type of information that will allow countries to decide whether and how to integrate these two public health services for women. One area of need is operations research, in which interventions to improve reproductive health through the provision of integrated services can be explored and evaluated. Another important focus is on modelling and costing studies that could help to clarify under what conditions integration of family planning and STI services, and what type of integration, may be most beneficial in specific settings and for specific clinic populations. Further, it highlights the need for descriptive studies of examples of integration that are already in place or developing, several of which are in progress. Finally, the paper argues that, even when full programmatic integration is undesirable or not planned, some specific activities that can mutually reinforce the goals of both family planning and STI/HIV programmes can be undertaken. Among these, the authors plead for urgent attention to one specific task of integration in family planning services - the promotion of dual protection among those at risk of both STI/HIV and unwanted pregnancy, an important task of any integrated FP/STI/HIV service provision.
This study assessed the ability and preparedness of staff at family planning clinics in Durban to assist in AIDS prevention by promoting condom use among teenagers. Staff at 12 randomly selected clinics were interviewed to assess their attitudes towards teenagers seeking condoms, the information imparted on AIDS and condom use, constraints faced in delivering services, and their perceived role in controlling the spread of AIDS. Despite their awareness of AIDS, those interviewed perceived their role to be that of promoting contraception. Condoms were perceived as a poor choice of contraceptive and their use was discouraged. The pamphlets dispensed along with condoms were thought to provide adequate information about condom use. Information on AIDS was given only if the clinic attender initiated discussion on the subject. Most of the clinic staff were keen to discuss other issues during their consultations, but felt constrained by the large numbers of people they had to attend to and the lack of adequate facilities. If family planning services are to play a role in controlling the spread of AIDS, the first step must be to make this function part of the overall policy. For there to be effective counselling on AIDS prevention, in-service training of current staff is required, as well as more staff and improvements in facilities to ensure greater privacy.
Couples who use contraceptives not only protect themselves against unwanted pregnancies, but also may reduce their risk of becoming infected with a sexually transmitted disease (STD). No currently available method, however, is highly effective in protecting simultaneously against pregnancy and infection. Thus, couples who place high priority on minimizing both risks may have to use two methods. The need for contraceptive methods that provide effective protection against both pregnancy and STDs has been intensified by the HIV epidemic, but progress has been slowed by the lack of integration between the STD and family planning fields. The first part of this two-part article discusses the similarities and differences between the two fields, examines the impact of STDs on contraceptive use and services, and reviews the scientific literature dealing with the effects of condoms, spermicides and barrier-and-spermicide methods on the risk of STD transmission. Part II (which will appear in the next issue) examines what is known about the effects of oral contraceptives, the IUD, tubal sterilization and abortion on reproductive tract infections. The second part also includes a discussion of the trade-offs involved in choosing a contraceptive and presents estimates of the first-year rates of unplanned pregnancy and gonorrhea infection (given an infected partner) that would occur among women using various contraceptive methods.