]oc;.\s PRINCIPLES & PRACTICE

Transcription

1 ]oc;.\s PRINCIPLES & PRACTICE The Efect of Birth Control Methods on Sexually Transmitted Disease/HWRsk Mary Lee O Connell, RN, MSN, FAACE Awareness of the effects that birth control methods have on the enhancement or protection against risk of sexually transmitted diseases (STDs) and human immunodeficiency virus (HIV) is very important. Health care providers must be aware of these effects to advise clients about birth control. This article reviews the literature about the effects of birth control methods on STD/HIV risk. JOGNN, 25, ; Accepted: December 1994 N o highly effective method exists to protect a woman against pregnancy and infection (Cates 8r Stone, 1992a). Despite this dual need, the effectiveness rates of birth control methods reflect only pregnancy prevention, not the prevention of sexually transmitted disease (STD) and human immunodeficiency virus (HIV). A woman cannot make an informed choice of a birth control method without first understanding the separate risks of pregnancy and STD/HIV infection. She has a much higher risk of contracting an infection than of becoming pregnant. Even on the day a woman s risk of pregnancy is highest, the day before ovulation, the risk of contracting gonorrhea from an infected man is four times greater than the risk of pregnancy (Cates &Stone, 1992a). Although the risk of pregnancy exists only during part of a woman s cycle, the risk of infection exists throughout the cycle. Any barrier method failure, at any rime in a woman s cycle, may expose her to the risk of STD/HIV infection. Many STDs act in synergy with HIV infection to enhance the transmission of both (Centers for Disease Control and Prevention, 1992a). This article reviews the research on birth control methods and risk of STD/HIV infection. Women account for the largest increase in HIV infection through heterosexual contact (Guinan, 1992). As of March 1993, heterosexual exposure accounted for 50% of accumulated cases among women ages years and 49% of accumulated cases among women ages years (Centers for Disease Control and Prevention, 1993). Women should be mindful that a birth control method s failure to protect from an STD may increase the risk of HIV infection. Sterilization, combined oral contraceptives, Norplant, Depo-Provera, and the IUD offer the greatest pregnancy prevention; however, they provide no protection from STD/HIV. Health practitioners have the opportunity to develop educational programs that give women a more complete picture of their risk of STD/HIV infection. For example, sterilization, combined oral contraceptives, Norplant (Wyeth-Ayerst Laboratories, Philadelphia, PA), Depo- Provera (The Upjohn Company, Kalamazoo, MI), and intrauterine devices (IUDs) offer the greatest pregnancy prevention but provide no protection from STD/HIV. Health education programs can emphasize the difference between prevention of pregnancy and prevention of STD/HIV. Such education can incorporate current research on how a woman s choice of birth control methods can decrease her risk of infection. Combined Oral Contraceptives Combined oral contraceptives may increase the risk of STD/HIV infection (Center for Population Research, 1991). The increased risk of STD/HIV infection may be caused by the cervical ectropion induced by oral contraceptives. Cervical ectropion extends the columnar epithelium from the cervical canal to the outer portion of the cervix. Because the chlamydia1 and gonococcal organ- 476 J O C N N Volume 25, Number 6

2 Birth Control Methods E. STD/HIV Risk isms selectively invade columnar epithelium, the outer cervix has an increased risk of infection (Cates & Stone, 1992b). The Contraceptive Evaluation Branch of the U.S. National Institutes of Health questioned the relationship of oral contraceptive use and STD/HIV infections. Its supported research determined that oral contraceptive users were more likely to be carriers of subclinical chlamydia and gonorrhea than were nonusers and should be screened routinely for STDs (Center for Population Research, 1991). Oral contraceptive users also might have an increased susceptibility to HIV infection. Estrogen and progesterone modify the cell-mediated immune system. The inhibition of cell-mediated immunity increases susceptibility to HIV infection (Center For Population Research, 1991). Plummer et al. (1991) found that oral contraceptive use was associated independently with the acquisition of HIV-1 in a group of highly exposed prostitutes. None of the subjects reported anal intercourse or intercourse during menses. When also controlling for condom use, genital ulcers, and chlamydia trachomatis infection, oral contraceptive use remained associated with an increased risk of HIV-1 infection. Cates and Stone (1992b) examined the conflicting conclusions of studies on the association between oral contraceptive use and HIV infection. They determined that Plummer et al. (1991) correctly adjusted for measurable potential confounders and thus was the best of the studies conducted to date. They concluded that because the pill and other hormonal contraceptives have a crucial role in international family planning programs, additional research on oral contraceptives must have the highest priority. Health care practitioners should continue to emphasize to women that oral contraceptives will not protect them from STD/HIV infection. Education and counseling can emphasize that clients who are not in a mutually monogamous relationship have an increased risk of STD/ HIV infection. These women might consider using oral contraceptives to prevent pregnancy and a condom with a spermicide to decrease the risk of STD/HIV infection. Norplant and Depo-Provera Norplant and Depo- Provera, progestin-only contraceptives, provide effective pregnancy prevention but do not decrease the risk of STD/HIV infection. Depo-Provera, depo-medroxyprogesterone acetate (DMPA), is the most commonly used injectable progestin. Norplant and DMPA both cause menstrual cycle disturbance, which is the most frequent reason for discontinuing each method (Hatcher et al., 1994). Norplant and DMPA users who rely on tampons during the bleeding disruptions may be increasing their risk of STD/HIV infection. Any extended use of tampons, particularly on the light flow days, can cause vaginal dryness and irritation. These microabrasions may increase a woman s risk of STD/HIV infection. The increased bleeding associated with Norplant and Depo-Provera may increase the female-to-male transmission of HIV infection. Theoretically, the increased bleeding episodes associated with both methods and the long-term amenorrhea accompanying DMPA use might increase the risk of STD/ HIV infection. The European Study Group on Heterosexual Transmission of HIV (1992) determined that sexual contact during menses increased the female-to-male transmission of HIV infection. The study group also found that male-to-female transmission risk is greater for women 45 years of age and older. The low estrogen that increases the fragility of the genital mucosa in perimenopausal women also might occur as a result of long-term DMPA use. Research is necessary to determine the longterm effects of low estrogen in women using DMPA and Norplant. Practitioners also can support research on progestin s effect on the immune system and HIV infection. They can continue to counsel women about the extent of Norplant and DMPA s bleeding disruptions and the absence of STD/HIV protection. Women using these contraceptives should be aware of their risks of STD/HIV infection and the need for periodic examinations. Intrmterine Devices The IUD provides effective pregnancy prevention but does not decrease the risk of STD/HIV infection. Women who use an IUD may have an increased risk of pelvic inflammatory disease and HIV infection. The increased risk of pelvic inflammatory disease occurs during the first 3 weeks after insertion; subsequently, such increased risk is minimal. However, the effect of the IUD on the uterine lining may increase the risk of HIV infection. Increased bleeding or spotting also may increase female-to-male HIV transmission (Hatcher et al., 1994). Condoms Effectiveness rates for latex condoms measure pregnancy prevention, not the prevention of STD/HIV infection. Pregnancy failure rates are estimated to be for women ages years (Harlap, Kost, & Forrest, 1991). Although condom failure can result in pregnancy at only one time of the month, any condom failure can increase the risk of STD/HIV infection. Further study is needed to determine the effectiveness of condoms and spermicides when used in combination. Rosenberg s (1992) mathematical analysis of condom effectiveness determined that using condoms alone reduced the risk of gonorrhea by almost 50%. A similar Julv/August 1996 J O C N N 477

3 P R I N C I P L E S & P R A C T I C E Condoms alone may not prevent STD/HIV infection and should be used in combination with a spermicide. analysis of spermicidal studies determined that when used alone, spermicides reduced the risk of gonorrhea by only 50% (Rosenberg, 1992). Barrier contraceptives provided only limited protection to the women in a study by Kjaer et al. (1990). In the study, the researchers examined the relationship of condom and diaphragm use to cervical human papillomavirus and herpes simplex infection. These researchers inferred that the infection risk remained because not all of the women used the condoms or diaphragms during the entire act of sexual intercourse or during every intercourse. The Contraceptive Evaluation Branch recommends that condoms be used as protection from HIV infection for those at low risk. They conclude, however, that for clients at high risk whose partners are infected with HIV, there is uncertainty about the efficacy of condoms in preventing HIV infection (Center for Population Research, 1991). This uncertainty suggests a need to understand the causes of condom failure. Albert, Hatcher, and Graves (1991) found that many condom breakages were associated less with the action of ejaculation and more with the vaginal environment. Their study determined that 64% of the women with drier vaginas experienced breakages before ejaculation. After childbirth, during breastfeeding, and before and after menopause, women often experience decreased vaginal lubrication. These women may be at greater risk for condom breakage and STD/HIV risk unless additional lubrication is used. Lubricants can lessen vaginal dryness, but those with an oil base can damage latex condoms and increase the risk of pregnancy and infection. Some spermicides and many vaginal hormone and yeast medications can cause latex degeneration (Hatcher et al., 1994). Manufacturers and health care practitioners should provide easy-to-read instructions on the products indicating whether to use or avoid use with condoms. Health care practitioners should inform clients (a) that condoms alone may not prevent STD/HIV infection and (b) that condoms should be used in combination with a spermicide. Further research is necessary to determine the effectiveness of condoms when used with different forms of spermicides. Sper micides The Contraceptive Evaluation Branch reports that spermicides, usually nonoxynol-9, provide less-than-perfect protection from STDs, particularly the viruses (Center for Population Research, 1991). There is also concern that spermicides may irritate the vaginal lining or rectal mucosa (Center For Population Research, 1991). The active ingredient in most spermicide preparations, nonoxynol- 9, is a detergent. It can irritate or cause cracks in the vaginal mucosa and provide a portal of entry for HIV infection. Two forms of spermicide, spermicidal suppositories and tablets, have additional potential to increase risk of infection. Both preparations require minutes to dissolve after being placed in the vagina. If they are not dissolved, they are less effective and cause a gritty sensation and friction that can irritate the vagina or penis, thereby increasing the risk of infection (Hatcher et al., 1994). Contraceptive Foam Many women believe that contraceptive foam containing nonoxynol-9 is more effective than other spermicide products. However, there are no published efficacy studies comparing various spermicide products (Hatcher et al., 1992). Foam can be used alone or combined with a condom or a diaphram. The Boston Women s Health Book Collective (1992) recommends using foam in combination with a condom for maximum contraceptive and STD prevention effectiveness. Contraceptive sponge The amount of nonoxynol-9 in the contraceptive sponge and its 24-hour use put women who use it at a greater risk of irritation and potential STD/HIV infection. Although a single dose of foam, jelly, or suppository contains mg of nonoxynol-9, the sponge contains 1,000 mg (Medical Economics Data, 1993). Because the sponge is designed for 24 hours of use, sponge users are exposed to a large amount of spermicide for long periods of time. A randomized trial of the nonoxynol-9 sponge, with a control group using a placebo, determined that it was ineffective in preventing HIV infection among prostitutes in Nairobi (Kreiss et al., 1992). The two groups in the study were similar in age, duration of prostitution, percentage of sex partners using condoms, and use of oral contraceptive pills. None of the subjects reported practicing anal intercourse or oral sex. Women using the contraceptive sponge were 3.3 times more likely to develop vulvitis and genital ulcers than women in the control group. The percent of women using the sponge infected with HIV was 56%, compared with 41% of the placebo group (Kreiss et al., 1992). Although the results of the study by Kreiss et al. (1992) cannot be generalized to women at low risk who are not exposed to large amounts of spermicide, they suggest the need for further research. Frequent contraceptive sponge use may increase the risk of HIV infection because of mechanical trauma, irritation from the high dose of spermicide, or both. Because the effect of HIV prevention for spermicides remains uncertain, the use of spermicides without condoms cannot be recommended 478 J O G N N Volume 25, Number 6

4 Birth Control Methods & STD/HIV Risk for the prevention of HIV infection (Stone & Peterson, 1992). Health care practitioners can help women using the contraceptive sponge to reduce the potential for infection. They can advise women to remove the sponge 6 hours after the last intercourse. By removing the sponge before the 24-hour maximum, women can lessen the potential for vaginal dryness and irritation. Diaphragm and Cervical cap The diaphragm and the cervical cap, combined with spermicide, provide pregnancy prevention but protect only the cervical opening from STD infection. Their role in preventing HIV infection remains undetermined (Cates, Stewart, & Trussell, 1992). Diaphragms and cervical caps always must be used in combination with a spermicidal cream or jelly. Women using diaphragms and cervical caps should be advised that any irritation from the spermicide can provide a portal of entry for HIV infection. Health care providers can suggest that women remove the cervical cap or diaphragm as soon as the instructions recommend, to lessen the risk of irritation from the spermicide. Women who use a diaphragm or cervical cap should be mindful that latex deterioration can increase their risk of pregnancy and STD/HIV infection. They should be advised that any vaginal medication, whether prescription or nonprescription, may damage the latex. Women can be encouraged to ask practitioners if a vaginal medication can be used with the diaphragm or cap and whether they should abstain from intercourse during the treatment. Sterilization Contraceptive sterilization is effective in preventing pregnancy but provides no STD/HIV protection. One third of American women rely on sterilization; 25% have had tuba1 ligations, and 11% have partners who have had vasectomies (Harlap et al., 1991). The Centers for Disease Control and Prevention (1992b) noted that sterilized women often do not perceive the need for barrier methods to protect them from STD/HIV infection. Although 45.7% of nonsterilized women reported never using a condom, 78% of women who were sterilized reported never using one. Women who rely on sterilization may have a greater risk of STD/HIV infection. Because these women do not visit health practitioners as often as those who require renewals of oral contraceptives, they may be at risk from an undiagnosed STD. Practitioners can assess their clients plans for STD/HIV protection as a part of the sterilization counseling. Reminders by mail or telephone can encourage women to return for periodic examinations. Hysterectomy After a hysterectomy, women may not perceive the need for STD/HIV protection or periodic examinations. Ap- proximately 1.7 million women had a hysterectomy during the years 1988 to Women ages years had the highest rates: hysterectomies per 10,000 women (Wilcox et al., 1994). As indicated, women ages 45 years and older have a greater risk of male-to-female transmission of HIV (European Study Group on Heterosexual Transmission of HIV, 1992). These women need further education. Health care providers must assess each woman s knowledge of her surgery and determine if her ovaries also were removed. Even if the ovaries are left in place, damage to the ovarian blood vessels can lessen estrogen production. After hysterectomy, 40% to 50% of premenopausal women reported symptoms of insufficient estrogen production (Stewart, Guest, Stewart, & Hatcher, 1987). If women do not receive hormone replacement therapy, the dryness can increase susceptibility to vaginal irritation, injury, and STD/HIV infection. Practitioners can advise women to use (a) water-soluble lubricants to lessen vaginal dryness and (b) condoms combined with spermicides to lessen STD/HIV risk. Women also may need reminders that a regular pelvic examination and Papanicolaou smear test are still necessary to diagnose asymptomatic STDs. Implicationsfor Practice Health practitioners have the opportunity to promote sexual health by emphasizing that pregnancy prevention and STD/HIV protection are not one and the same. They should emphasize to their clients that many STDs facilitate the transmission of HIV infection. The organisms that cause genital ulcers, the herpes simplex virus, syphilis, chancroid, gonorrhea, chlamydia, and trichomoniasis are associated with higher levels of HIV infection (Hatcher et al., 1994). Preventive health care and early diagnosis can lessen this risk. Practitioners can help each client choose a method of birth control that meets her individual needs. For women in a mutually monogamous relationship, pregnancy prevention may be their only need. For women who are not in a mutually monogamous relationship, pregnancy prevention and STD/HIV prevention may need to be addressed. These women may consider using combined oral contraceptives, Norplant, Depo-Provera, or the IUD to prevent pregnancy and a condom and spermicide to protect from STD/HIV infection. Health care practitioners can give women information about their options and risks. They must take the lead in expanding HIV prevention programs to include funding for education, testing, and treatment for the other STDs that can increase the risk of HIV transmission. Practitioners can emphasize how consistent and correct use of barrier methods can improve their effectiveness and lessen STD/HIV risk. By understanding how a method can fail, clients can review their use of the method and plan preventive strategies to lessen the risk of failure or reevaluate their contraceptive choice. The health care practitioner s ongoing relationship with the July/August 199G J O G N N 479

5 P R I N C I P L E S C P R A C T I C E client offers additional opportunity for assisting her in reevaluating contraceptive choices when relationships change and pregnancies occur. Conclusion Contraceptives differ in their effectiveness in decreasing STD/HIV risk. This difference has important implications for clinical practice. Health care practitioners must encourage preventive health care and early diagnosis of STDs to lessen HIV risk. They also must support research on the relative effectiveness of individual and combined barrier contraceptive methods in decreasing STD/HIV risk. When presenting programs to promote sexual health, practitioners should continue to emphasize the difference between pregnancy prevention and STD/HIV prevention. References Albert, A. E., Hatcher, R. A., & Graves, W. (1991). Condom use and breakage among women in a municipal hospital family planning clinic. Contraception, 43, Boston Women s Health Book Collective. (1992). The new our bodies, ourselves. New York: Simon & Schuster. Cates, W., Jr., Stewart, F. H., & Trussell, J. (1992). The quest for women s prophylactic methods: Hope vs. science. American JournalofPublic Health, 82, Cates, W., Jr., & Stone, K. M. (1992a). Family planning, sexually transmitted diseases and contraceptive choice: A literature update-part I. Family Planning Perspectives, 24, Cates, W., Jr., &Stone, K. M. (1992b). Familyplanning, sexually transmitted diseases and contraceptive choice: A literature update-part 11. Family Planning Perspectives, 24, Center for Population Research, National Institute of Child Health and Human Development. (1991). Contraceptive Evaluation Branch and Contraceptive Development Branch Reports to the National Advisory Child Health and Human Development Council. Washington, DC: U. S. Government Printing Office. Centers for Disease Control and Prevention. (1993). HIV/MDS surveillance report, 5(1), 1-10, Centers for Disease Control and Prevention. (1992a). Sexually Transmitted Disease Surveillance, 1991, U.S. Department of Health and Human Services, Public Health Service. Atlanta: Author. Centers for Disease Control and Prevention. (1992b). Surgical sterilization among women and use of condoms-baltimore, Morbidity and Mortality Weekly, 41, European Study Group on Heterosexual Transmission of HIV. (1992). Comparison of female to male and male to female transmission of HIV in 563 stable couples. British Medical Journal, 304, Guinan, M. E. (1992). HIV, heterosexual transmission, and women. Journal of the American MedicalAssociation, 268, Harlap, S., Kost, K., & Forrest, J. D. (1991). Preventingpregnancy, protecting health: A new look at birth control choices in the United States. Alan Guttmacher Institute: New York. Hatcher, R. A., Stewart, F., Trussell, J., Kowal, D., Guest, F., Stewart, G. K., & Cates, W. (1992). Contraceptive technology (15th ed.). New York: Irvington. Hatcher, R. A., Trussell, J., Stewart, F., Stewart, G. K., Kowal, D., Guest, F., Cates, W., Jr., & Policar, M. S. (1994). Contruceptive technology (16th ed.). New York: Irvington. Kjaer, S. K., Engholm, G., Teisen, C., Haugaard, B. J., Lynge, E., Christensen, R. B., Moller, K. A., Jensen, H., Poll, P., Vestergaard, B. F., De Villiers, E. M., & Jensen, 0. M. (1990). Risk factors for cervical human papillomavirus and herpes simples virus infections in Greenland and Denmark: A population-based study. American Journal of Epidernology, 131, Kreiss, J., Ngugi, E., Holmes, K., Ndinya-Achola, J., Waiyaki, P., Roberts, P. L., Ruminjo, I., Sajabi, R., Kimata, J., Fleming, T. R., Anzala, A., Holton, D., & Plummer, F. (1992). Efficacy of nonoxynol 9 contraceptive sponge use in preventing heterosexual acquisition of HIV in Nairobi prostitutes. Journal of the American Medical Association, 268, Medical Economics Data Production Co. (1993). Physicians desk reference for nonprescription drugs (14th ed.). Montvale, NJ: Author. Plummer, F. A., Simonsen, J. N., Cameron, D. W., Ndinya- Achola, J. O., Kreiss, J. K., Gakinya, M. N., Waiyaki, P., Cheang, M., Piot, P., Ronald, A. R., & Ngugi, E. N. (1991). Cofactors in male-female sexual transmission of human immunodeficiency virus type 1. Journal of Infectious Diseases, 163, Rosenberg, M. J. (1992, May). What s new in barrier contraceptives: Effectiveness of male and female methods. Paper presented at STD Update 92, Association of Reproductive Health Professionals, Tysons Corner, VA. Stone, K. M., & Peterson, H. B. (1992). Spermicides, HIV, and the vaginal sponge. Journal of the American MedicalAssociation, 268, Stewart, F., Guest, F., Stewart, G., & Hatcher, R. (1987). Understanding your body. New York: Bantan Books. Wilcox, L. S., Koonin, L. M., Pokras, R., Strauss, L. T., Xia, Z., & Peterson, H. (1994). Hysterectomy in the United States, Obstetrics and Gynecology, 83, Address for correspondence: Mary Lee O Connell, RN, MSN, FACCE, 4524 Cheltenham Drive, Bethesda, MD Mary Lee O Connell is an educator specializing in maternal-child nursing and women s health. She teachesparents and higb school and college students and works with pregnant homeless women in tbe Washtngton, DC, area. She is currently a student in the Women s Health Nurse Practitioner Program at tke Untversity of Maryland. 480 J O C N N Volume 25, Number G