Day 9 Digest (May 10, 2006)
Welcome to the 9th day of our discussion of Client and Provider Perspectives on Integration of Family Planning Counseling and HIV/AIDS Services.
In today's e-mail we include:
- Comments from Dr. Joachim Osur on Maureen Kwikiriza's question from yesterday.
- Comments from John Howson on questions from Arif Bashir, counselor, National AIDS Contol Programme, NIH, Islamabad (from Day#4)
- Some resources related to the question of the psychological reasons/beliefs for not wanting to use condoms and how this can be an important barrier to use which could be explored.
- A request to forum participants to send comments on Josephat Avoce's question to the group about how to measure whether people are using condoms to prevent unwanted pregnancies or HIV/AIDS/STIs or both
To participate in the discussion, you can:
- click reply to this e-mail
· send your to fphivintegration@ibp.wa-research.ch
· log into the forum website at http://my.ibpinitiative.org/Community.aspx?c=d1f835b2-0c72-420a-9ade-88186b49abe7 with the username and password you received.
Postings are also archived at http://www.fpandhiv.org/videoconference/cpieventpage.php along with all the resources mentioned in previous postings.
We look forward to continued rich and interesting discussions. Thanks again for participating!
Best regards,
HCP and INFO Teams
Response to Maureen Kwikiriza from Dr. Joachim Osur
Hi Maureen,
Thanks for your comments.
I want to say that HIV positive people, like anybody else, has a right to a satisfactory sexual life. With the advent of ARVs, the life of a PLWH is normalised and we should encourage them to do everything that goes with life, marriage and relationships.
Let me hasten to say that PLWHs must still be responsible and have protected sex.
What we are also seeing very frequently is the desire for PLWH to have children. This is very challenging and I do not have answers but it has been said that timed unprotected sex during ovulation in PLWHs whose viral viral loads is undetectable could possibly be tried though with some risks. Another posibility is insemination with washed sperms, again easier said than done.
What we need to seriously do is to create opportunities for PLWH to access FP so that they do not get unwanted pregnancies. Integration of services will achieve this.
Dr Osur
Comments by John Howson on questions from Arif Bashir
John Howson is Associate Director/Senior Technical Advisor for HIV/AIDS for te Health Communication Partnership (HCP). He represents the International HIV/AIDS Alliance in the partnership. He has worked in the area of HIV/AIDS, STI and reproductive health since 1990. Although originally he came from a clinical background as a nurse specialist and senior health adviser/counselor, for the last 8 years, his work has been focused on technical support to both incipient and well-established integrated HIV programs in developing countries, covering such technical areas as PMTCT, ART, prevention and mitigation programs, mostly in Southern, East and West Africa. For the last two years this has focused on the conceptualization, development and implementation of strategic, evidence-based and comprehensive HIV/AIDS communication programs, involving the participation of national governments, multi and bi-lateral agencies, civil society organizations, and championing the active participation of the most vulnerable members of society, including people living with HIV/AIDS. Within HCP, John takes the lead in liaison with the Office of HIV/AIDS at USAID-W and in ensuring that all HIV/AIDS programs under HCP are strategically focused on the targets set by the President’s Emergency Plan for HIV/AIDS, and other global initiatives such as the Global Fund, WHO’s 3 X 5 initiative, and the UNGASS targets.
1. If a couple cannot feel satisfaction when using the condom, then what should they use for HIV prevention. For FP they can use any other method but not for HIV.
One of the keys to successful use of condoms is good communication between the couple about what specific issues they are each experiencing with the use of the male condom, as this can at least identify how and where a solution might be sought. I think it is helpful here to distinguish between the satisfaction of the man and the woman. Some women do not like the feel of male condoms as this makes them feel less close to their partner, however and therefore the reduced satisfaction is more psychological than physical.
Men often report feeling less sensitivity and satisfaction when using a male condom. Although I know there are both religious and cultural taboos and restrictions against masturbation, men can often learn how to become more comfortable using condoms with their partners if they have practiced or practice using a condom on their penis, either alone or with their partner, during masturbation. This can help men get over the fear that the reduction in sensation may make them lose their erection as well as help relieve performance anxiety concerns they may have about having sex while using a condom.
It can also be helpful to put a small pea size drop of water-based lubricant onto the condom before rolling it down the erect penis, as this can increase sensitivity.
It is also important to ensure that the condom used is not too tight or too slack. Men tend to feel embarrassed about discussing the size of their penis, but not all men are made the same and condom manufacturers now make condoms that are designed for normal and larger shaped penises.
One of the keys to successful use of condoms is good communication between the couple about what specific issues they each experience with the use of the male condom, as this can at least identify how and where a solution might be sought.
Another alternative to the male condom is the use of the female condom. This is not made out of latex (rubber), but rather polyurethane, a plastic, and is therefore not vulnerable to tearing or being damaged by oil based lubricants. Although some people complain of a rustling noise from the plastic during intercourse, most men find it much more sensitive than using a male condom and many women prefer it also, as it covers more of the external genitals, and is also more sensitive for them. Some women also report that they feel less anxious about sex when using it, as they are controlling the method used. Unfortunately, it is more expensive than the male condom and not always as widely available.
2. I have met some clients who asked me that they do not release when they use condom, then what suggestion i should give them.
Again, I would encourage the man to try to practice masturbation while wearing a condom and see whether he is able to release wearing a condom this way. He may have to do this several times before he succeeds, then he can try intercourse again with his partner wearing a condom. He may want to invite his wife/partner to help him practice in this way.
Another alternative while he is practicing this method is to wear the condom for penetration and to help satisfy his partner, but to remove the condom from his penis and release on his wife’s abdomen or away from her body, depending on their preference, if he is still not able to release inside here while wearing the condom.
It would also be helpful to find out whether there is a psychological component to this anxiety. For instance, you may want to explore what he has learned about condoms and what his own views of them are. What does he feel about his semen not reaching his partner, but being left in the condom. This may sound strange, but for some men this may an issue that might be resolved through openly discussing his concerns.
3. Some clients tell me that they do not feel satisfaction with the use of condom, some time allergy problems come with the use of condom. Then what they should they use for safer sex, moreover they have also other sex partners.
I hope that the answers to the above questions help answer part of your question. It is true that some men feel less sensitivity when using a condom, but the disadvantages are often negated if men consider the advantages in terms of safety and protection from HIV and other STIs.
It is also true that some men are allergic to the latex (rubber) used to make the condoms and hypoallergenic condoms are available, that is, condoms are made for people who are allergic to them. Others are not allergic to the rubber but the lubricant, spermicide or powder used in the condoms. It would be important for the person to test different brands of condoms and see whether they have a reaction to them all. If they do have a reaction, they will need to wait until the inflammation and soreness settle before testing another condom. Alternatively, they could encourage their partner to use a female condom.
In the case where a married man has other sex partners apart from his wife and he is allergic to the rubber in condoms, he should be encouraged to limit his sexual contact with his other partners to non-penetrative sex, such a mutual masturbation, or encourage his partner to use a female condom.
Resources
Below we have listed some electronic resources on the psychological reasons/beliefs for not wanting to use condoms and how this can be an important barrier to use which can be explored in a variety of ways.
1. Attitudes toward condoms and condom use: a review.
Author: Ross MW
Source: International Journal of STD and AIDS. 3(1):10-6.
Abstract: The following topics are reviewed: condom use, attitudes toward condoms, reasons for failure to use condoms, personality and attitudes toward condoms, attitudes toward condoms and behavior, and changing attitudes toward condoms. The use of condoms varies across cultures. Prevention which emphasizes group subjective norms, personality, and interpersonal and situational barriers may influence condom use; intervention studies have not yet fully tested this hypothesis, however. What is known is that attitudes and use of condoms can be changed. Negative attitudes toward condom use include the perception of impaired pleasure, lack of availability at the appropriate time, coitus interruptus, and unnaturalness or unreliability. Positive perceptions may counterbalance the negative attitudes. In several military studies, it was found that lack of availability, perceived lack of risk, and influence of alcohol were the major reasons for failure to use. In many studies the reduction of pleasure is a dominant theme. Pharmacies were the preferred place of purchase. Among college students, condoms were viewed as minimizing a health risk but associated use with there being something wrong with their partner. A Dutch study found a reduced belief in the efficacy of condoms as a contraceptive but increased trust in the protection against AIDS. In a pre- and posttest of attitudes toward condom use among heterosexual couples, the findings were that attitudes could be modified and that information needs to relate to the context of sexual activity and sensorimotor arousal. The condom film with sexually explicit activity and instructions on condom placement was successful in generating a significant increase in positive attitudes toward condoms. Examining link between attitudes and behavior, however, is a necessary next step.
Participants in developing countries can request a copy of the full text of this article from POPLINE by clicking on this link and then on the "Add to Basket" link.
2. Title: Safer sex or pleasurable sex? Rethinking condom use in the AIDS era.
Author: Khan SI | Hudson-Rodd N | Saggers S | Bhuiyan MI | Bhuiya A
Source: Sexual Health. 2004;1:217-225.
Abstract: Condom use in Bangladesh is low despite nationwide family planning initiatives and HIV interventions. Fifty men aged between 18 and 55 years from diverse socio-demographic backgrounds and five key informants were interviewed in a qualitative male sexuality study. Refusal to use condoms is not only a personal choice, but pertains to relationships. The meanings of reduced bodily pleasure associated with condom use are socially constructed. Men's emotions and trust expressed through understanding of direct penile-vaginal contact and ejaculation inside the vagina as 'pure' and 'natural' sex oppose condom use. Sexual prowess in the form of prolonged intercourse without condoms, as depicted in Western pornography, was perceived as a 'real man's' sexual skill. Men sought to preserve a 'good man's' image by avoiding condoms, which symbolised promiscuous men in AIDS educational messages. Social dimensions of masculine sexuality, pleasure, eroticism and the emotional aspect of men's lives have to be addressed for effective condom promotion. (author's)
Participants in developing countries can request a copy of the full text of this article from POPLINE by clicking on this link and then on the "Add to Basket" link.
Josephat Avoce's question to the group
Josephat asked: "My questions relate to contraceptive methods and results of evaluation of dual protection in particular related to use of the condom alone. But if it is the condom alone, how can we know the proportion of people among those who used it as a method of dual protection, that is as protection from unwanted pregnancies on the one hand and the STIs/HIV/AIDS on the other hand.
In addition, what would have been the number of cases of unwanted pregnancies and infections with HIV avoided ascribable to the method of double protection for use of the condom only?
For programs which have done research on the condom as a method of dual protection, what methods of research and evaluation were used?"
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We invited a number of experts to respond to this question. We don't think we've yet found the 'best' response, but here are some ideas and suggestions. We would appreciate more suggestions from other forum participants.
Ushma Upadhyay, one of INFO's writers looked into the DHS data but could not find a question on the purpose of condom use. She did come across many research articles that analyze purpose of condom use. She suggested that forum participants take a look at this one from International Family Planning Perspectives, which used data from a survey to draw some conclusions about the purpose of condom use.
Title: Reasons for Condom Use Among Young People in KwaZulu-Natal: Prevention of HIV, Pregnancy or Both?
Author: Pranitha Maharaj (March 2006)
http://www.guttmacher.org/pubs/journals/3202806.html (full text)
Another one of INFO's writers, Vera Zlidar, suggested this article by Ward Cates:
Title: Dual protection against unintended pregnancy and sexually transmitted infections. What is the best contraceptive approach?
Authors: Cates W Jr; Steiner MJ.
Source: Sexually Transmitted Diseases. 2002 Mar;29(3):168-74
Abstract: In the midst of the global epidemics of both unintended pregnancy and sexually transmitted infection (STI), contraceptive options that provide dual protection are ideal. However, those contraceptives with the best record of preventing pregnancy under typical use conditions (sterilization, hormonal methods, IUDs) provide little if any protection against STI. Alternately, barrier contraceptive methods (specifically, condoms), which can reduce risks of many STIs, are associated with relatively higher pregnancy rates for most users than other contraceptives. This situation has produced a dilemma of those wishing to promote dual protection: whether to advocate use of two methods (one primarily to prevent pregnancy and the other primarily to prevent infections) or whether to emphasize use of condoms for both purposes. Data comparing these two approaches are limited and often contradictory. The authors discuss the underlying concepts of exposure to both pregnancy and infection, provide a broad overview of the effectiveness of contraceptive methods against these two conditions, present approaches to optimize dual protection, and propose several new directions for necessary research. In the absence of evidence-based recommendations, the authors believe clinicians should assist clients in assessing their likelihood of exposure to infection, either by prevalence of sexually transmitted infection in the community or by the specific risk factors of the client. If exposure is likely, particularly to the more serious infections such as HIV, the one-method approach should be given greater weight. However, in settings where unintended pregnancy is the greater concern, emphasizing the two-methods approach as a first option may be appropriate. (author's abstract) [ITEM #164876]
Participants in developing countries can request a copy of the full text of this article from POPLINE by clicking on this link and then on the "Add to Basket" link.