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Are Dual-Method Messages Undermining STI/HIV Prevention?
1. Are Dual-Method Messages Undermining
STI/HIV Prevention?
Ann O’Leary
Senior Behavioral Scientist
National HIV Prevention Conference
August 17, 2011
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
Place Division name here
2. Why recommend use of dual methods?
□ Many teens and young women are at risk for both of two
events:
■ Unintended pregnancy
■ Among low-income women, 62% of pregnancies were unintended
■ 410,000 births among teens in 2009
■ Sexually transmitted infections (STIs), including HIV
■ 38% of teen girls; 44% of black girls, had an STI in 2009
Condoms are extremely effective against STIs and HIV
Condoms are less effective against pregnancy than HC
* All references available upon request of O’Leary, 2011 paper
3. Why recommend use of dual methods (cont.)?
In theory, the use of hormonal contraceptives and
condoms together should prevent both of these adverse
effects of sex
Thus, guidelines from “Healthy People” and the World
Health Association recommend counseling young
women to use HC and condoms.
But how many do?
* All references available upon request of O’Leary, 2011 paper
4. Do women use dual methods?
□ Review of literature reveals few teens and young women
use hormonal contraceptive (HC) and condoms:
■ In 2009, YRBS showed the following rates of dual-method use:
■ 10.7% of whites
■ 3.6% of blacks
■ 3.9% hispanics
■ Even among dual method users, consistent use is not common
■ In general, younger women use condoms alone and, when a
committed relationship is established, they use HC alone
* All references available on request of O’Leary, 2011 paper
5. Problems with multiple messages
□ The second of two may not be processed cognitively
□ If primary concern is addressed (most frequently
pregnancy) other risk reduction method may be foregone
(risk compensation)
Condom negotiation with partner may be more difficult if
partner knows HC is being used.
* All references available on request of O’Leary, 2011 paper
6. How effective are interventions to increase
dual method use?
□ Literature review suggests promoting dual use is difficult.
Interventions that have been tested have yielded:
□ Inconsistent results
□ Null results
□ Non-sustained results
* All references available on request of O’Leary, 2011 paper
7. Who are successful dual method users?
□ Relationship characteristics:
□ Single, young, in uncommitted relationship
□ At lower risk-fewer partners
□ Motivations for use:
□ More concerned about HIV/STI
□ Among teens, STRONG desire to avoid pregnancy
* All references available on request of O’Leary, 2011 paper
8. A proposed RCT
□ Two arms:
□ Use HC and condoms
□ Use condom s only
Provide all participants with condoms and emergency
contraception (EC)
* All references available on request of O’Leary, 2011 paper
9. Messages for proposed RCT arms
□ Two arms:
□ “I recommend that you use a hormonal contraceptive to prevent
pregnancy, and condoms to prevent sexually transmitted
disease, including HIV.”
□ “I recommend that you use condoms to prevent pregnancy and
sexually transmitted disease, including HIV.”
* All references available on request of O’Leary, 2011 paper
10. A proposed RCT (cont.)
□ Hypotheses:
□ Fewer sexually transmitted diseases in condom-only arm
□ More use of EC, possibly pregnancy, in condom-only arm
We could also identify the characteristics of successful dual-
method users and successful condom-only under conditions of
controlled messaging so that messages can be tailored to
women with different profiles
* All references available on request of O’Leary, 2011 paper
11. Is this RCT ethical?
□ Some think no:
□ Randomization removes women’s free reproductive choice
□ It is wrong to randomize some women to an inferior form of birth
control
* All references available on request of O’Leary, 2011 paper
12. Is this RCT ethical? (cont.)
□ Responses to these arguments:
□ Randomization will occur only after informed consent;
participants are free to discontinue study or make own
reproductive choices irrrespective of participation.
□ It may also be morally problematic to prescribe hormonal
contraception to women who are at risk for STI/HIV.
* All references available on request of O’Leary, 2011 paper
13. Summary
□ Dual protection is routinely recommended to teens and
young women.
□ Most of these women do not use dual methods.
□ Use of hormonal contraceptives is associated with non-
use of condoms.
□ The possibility that dual-method recommendations are
adding substantially to the societal burden of STI/HIV
compared with condom-only recommendations is an
empirical question that can be answered via a
randomized controlled trial.
* All references available on request of O’Leary, 2011 paper