Emelita L. Wong

Hormonal contraceptive use, cervical ectopy, and the acquisition of cervical infections

Background and Objectives: Several previous studies have suggested that hormonal contraception could be associated with increased risk of cervical infections. However, few high-quality prospective studies have examined this relationship. Goal: The goal of this study was to measure the effect of oral contraceptives (OC) and depot-medroxyprogesterone acetate (DMPA) on the acquisition of cervical chlamydial and gonococcal infections. Study: Women attending 2 reproductive health centers in Baltimore, MD, were enrolled into a prospective cohort study. Participants were 15 to 45 years and were initiating OCs or DMPA or not using hormonal contraception. Interviews, physical examinations, and testing for incident cervical infections were conducted at 3, 6, and 12 months. Results: The analysis included 819 women. Most were single (77%) and nulliparous (75%); 43% were black. Median age was 22 years. During the study, 45 women acquired a chlamydial or gonococcal infection (6.2 per 100 women-years). DMPA use (hazard ratio [HR], 3.6; 95% confidence interval [CI], 1.6–8.5), but not OC use (HR, 1.5; 95% CI, 0.6–3.5), was significantly associated with increased acquisition of cervical infections after adjusting for other risk factors. Cervical ectopy was not an important mediator of cervical infection risk. Conclusions: DMPA use, but not OC use, appeared to be significantly associated with increased acquisition of cervical chlamydial and gonococcal infections.

Female condom introduction and sexually transmitted infection prevalence: results of a community intervention trial in Kenya.

ObjectiveTo measure the impact on sexually transmitted infection (STI) prevalence of a female condom introduction and risk-reduction program at Kenyan agricultural sites. DesignWe conducted a cluster-randomized trial to determine whether a replicable, community-level intervention would reduce STI prevalence. MethodsSix matched pairs of tea, coffee and flower plantations were identified. The six intervention sites received an information/motivation program with free distribution of female and male condoms, and six control sites received only male condoms and related information. Participants were tested for cervical gonorrhea and chlamydia by ligase chain reaction on urine specimens, and vaginal trichomoniasis by culture, at baseline, 6 and 12 months. ResultsParticipants at intervention (n = 969) and control sites (n = 960) were similar; baseline STI prevalence was 23.9%. Consistent male condom use was more than 20% at 12 months. Consistent female condom use was reported by 11 and 7% of intervention site women at 6 and 12 months. Unadjusted STI prevalence was 16.5 and 17.4% at 6 months, and 18.3 and 18.5% at 12 months, at the intervention and control sites, respectively. Logistic regression models confirmed the null effect of the female condom intervention. ConclusionsFemale condom introduction did not enhance STI prevention at these sites. It is unclear which aspects of the intervention – STI education, condom promotion, case management – were associated with decreased STI prevalence from baseline to follow-up.

Long-term use of the female condom among couples at high risk of human immunodeficiency virus infection in Zambia

Background: Few studies have measured female condom use for more than a 6‐month period or among persons at high risk of STD. Objective: To measure long‐term use of the female condom among couples at high risk of HIV infection and to evaluate the effect of female condom use on unprotected coital acts. Study Design: Ninety‐nine Zambian couples with symptomatic sexually transmitted diseases (STD) received female condoms, male condoms, and spermicides and were counseled to use either condom plus spermicide for each coital act. Couples were followed up at 3‐, 6‐, and 12‐month visits. Barrier contraceptive use was measured prospectively by coital log. Results: Among the 99 couples enrolled, 51, 38, and 30 couples were successfully followed up for 3, 6, and 12 months, respectively. Female condoms were reportedly used in 24%, 27%, and 23% of coital acts and by 86%, 79%, and 67% of the returning couples during each time interval. Higher‐level female condom users used male condoms less often but had fewer unprotected coital acts (5% vs. 14%; p < 0.05) than lower‐level female condom users. Conclusion: A majority of couples at high risk of HIV infection used the female condom in conjunction with other barrier methods over a 1‐year period. The addition of female condoms accompanied by appropriate counseling to the barrier method mix may reduce unprotected sex among couples at high‐risk of HIV infection.

A prospective study assessing the effects of introducing the female condom in a sex worker population in Mombasa, Kenya

Objective: To assess the impact and costs of adding female condoms to a male condom promotion and distribution peer education programme for sex workers in Mombasa, Kenya. Design: A 12 month, prospective study of 210 female sex workers. Methods: We interviewed participants about their sexual behaviour every 2 months for a total of seven times and introduced female condoms after the third interview. We also collected cost data and calculated the cost and cost effectiveness of adding the female condom component to the existing programme. Results: Introduction of the female condom in an HIV/AIDS prevention project targeting sex workers led to small, but significant, increases in consistent condom use with all sexual partners. However, there was a high degree of substitution of the female condom for male condoms. The cost per additional consistent condom user at a programme level is estimated to be

Temporal Trends in Sexually Transmitted Infection Prevalence and Condom Use Following Introduction of the Female Condom to Madagascar Sex Workers

2160 (£1169, €1711) (95% CI: 1338 to 11 179). Conclusions: The female condom has some potential for reducing unprotected sex among sex workers. However, given its high cost, and the marginal improvements seen here, governments should limit promotion of the female condom in populations that are already successfully using the male condom. More research is needed to identify effective methods of encouraging sex workers to practise safer sex with their boyfriends.

Randomised controlled trial on whether advance knowledge of prostate-specific antigen testing improves participant reporting of unprotected sex

We followed 1000 sex workers in Madagascar for 18 months to assess whether adding female condoms to male condom distribution led to increased protection levels and decreased sexually transmitted infections (STIs). For months 1–6, participants had access to male condoms only; in the final 12 months, they had access to male and female condoms. We interviewed participants about condom use every two months and tested for chlamydia, gonorrhoea and trichomoniasis every six months. Following six months of male condom distribution, participants used protection in 78% of sex acts with clients. Following female condom introduction, protection at months 12 and 18 rose to 83% and 88%, respectively. Aggregate STI prevalence declined from 52% at baseline to 50% at month 6. With the female condom added, STI prevalence dropped to 41% and 40% at months 12 and 18, respectively. We conclude female condom introduction is associated with increased use of protection to levels that reduce STI risk.

Randomised controlled trial of alternative male and female condom promotion strategies targeting sex workers in Madagascar

Objectives: To determine whether the process of informing research participants that they would be tested for the presence of a biological marker of semen exposure would reduce bias in their reports of unprotected sex. Methods: A randomised trial of 210 female sex workers from Mombasa, Kenya, was conducted, where half the group had advance knowledge (via the request for informed consent) that they would be tested for prostate-specific antigen (PSA) in their vaginal fluid before they reported on sex and condom use for the past 48 h. The other half were invited to participate (via additional informed consent) in the test for PSA after they had already consented to be questioned and reported on these sexual behaviours. A trained nurse instructed participants to self-swab to collect vaginal fluid specimens, which were tested for PSA using ELISA. Results: Reporting of unprotected sex did not differ between those with advance knowledge of the test for PSA and those without this knowledge (14.3% v 11.4%, respectively; p = 0.27). Surprisingly, more women with advance knowledge (15.8%) had discrepant self reports and PSA results than women without advance knowledge (9.1%); however, the difference was not statistically significant (OR 1.9; 95% CI 0.8 to 4.5). Conclusions: Knowing that one’s answers to a questionnaire could be verified with a biological marker of semen exposure did not make respondents more likely to report unprotected sex.

Use of male condoms during and after randomized, controlled trial participation in Cameroon.

Objectives: To assess whether individual clinic-based counselling as a supplement to peer education for male and female condom promotion leads to greater use of protection and lower STI prevalence among sex workers in Madagascar already exposed to intensive male condom promotion. Methods: In two public dispensaries in Madagascar, a total of 901 sex workers were randomly allocated between two alternative male and female condom promotion interventions: peer education only, or peer education supplemented with individual clinic-based counselling. Participants were followed for 12 months. Every 2 months they made clinic visits, where they were interviewed on condom use. Peer educators counselled all participants on condom use as they accompanied their assigned participants to study visits. Participants assigned to receive the supplemental intervention were counselled by a trained clinician following study interviews. Participants were tested and treated for chlamydia, gonorrhoea and trichomoniasis every 6 months. We used logistic regression to assess whether the more intensive intervention was associated with reduced STI prevalence. Use of protection with clients and non-paying partners was assessed by study arm, site, and visit. Results: There was no statistically significant association between study arm and aggregated STI prevalence. No substantial differences in levels of reported protection were noted between study groups. Conclusions: This study found little evidence for gains from more thorough clinical counselling on male and female condom use. These findings suggest that less clinically intensive interventions such as peer education could be suitable for male and female condom promotion in populations already exposed to barrier method promotion.

Hormonal contraception and area of cervical ectopy: A longitudinal assessment

Background and Objective: This study evaluated patterns of long-term use of male condoms among partners of 966 Cameroonian women who received eight intensive, monthly counseling sessions about condoms and sexually transmitted infection testing and treatment. Method: An interrupted time-series design was used with study participants reporting condom use and other covariates at enrollment, monthly for 6 months during the randomized, controlled trial, and at approximately 14 months after the trial. Results: Consistent condom use began decreasing while women were still receiving monthly condom use counseling, with every month in the trial associated with an odds ratio of 0.96 (95% confidence interval [CI], 0.94–0.99) of consistent condom use and dropped substantively after the trial with a 0.39 (95% CI, 0.26–0.59) odds ratio in a logistic regression analysis. The incidence of unprotected coital acts as each month passed increased by 3% (95% CI, 1–4%) with no statistically significant change during the condom use follow-up survey as indicated in a zero-inflated Poisson regression model for unprotected coital acts. Condom use in a coital act was 0.84 (95% CI, 0.78–0.92) less likely during the follow-up survey than during the trial. Conclusion: Only a few women sustained consistent condom use throughout the study period and for more than 1 year after. It is important to continue documenting the impact of condom promotion in a rigorous manner and to identify content and delivery of counseling that will lead to sustained condom use beyond the intervention period.

Adolescents use of maternal and child health services in developing countries.

BACKGROUND The effect of combined oral contraceptives (COCs) and depot-medroxyprogesterone acetate (DMPA) on the area of cervical ectopy is not well understood. STUDY DESIGN From 1996 to 1999, we recruited women not using hormonal contraception from two family planning centers in Baltimore, MD. Upon study entry and 3, 6 and 12 months after the initial visit, participants were interviewed and received visual cervical examinations with photography. Ectopy was measured from digitized photographs and was analyzed both continuously and categorically (small [≤0.48 cm(2)] vs. large [>0.48 cm(2)]). RESULTS Of 1003 enrolled women, 802 returned for at least one follow-up visit. At 12 months, the numbers of women using COCs, DMPA or no hormonal method at least 50% of the time since the prior visit were 230, 76 and 229, respectively. After multivariable adjustment, COC use (vs. no hormonal use) was associated with large area of ectopy (odds ratio [OR]: 1.8, 95% confidence interval [CI]: 1.0-3.3). No significant relationship was observed between DMPA and large area of ectopy (OR: 0.5, 95% CI: 0.2-1.3). The incidence of large area of ectopy by contraceptive exposure (COC, DMPA or no hormonal method) was 17.4 (CI: 11.8-24.6), 10.9 (CI: 4.4-22.4) and 4.6 (CI: 2.2-8.4) per 100 woman-years, respectively. CONCLUSIONS Use of COCs, but not DMPA, was associated with large area of cervical ectopy. Area of ectopy at baseline was the strongest predictor of area of ectopy at follow-up.