Emergency postcoital contraception may be defined as the use of a drug or device to prevent pregnancy after intercourse. Unwanted pregnancy is common; worldwide, about 50 million pregnancies are terminated each year.1 It has been calculated that each year the widespread use of emergency contraception in the United States could prevent over 1 million abortions and 2 million unintended pregnancies that end in childbirth.2 A variety of different methods of emergency contraception are available (Table 1). The first to be described was high-dose estrogen, although currently the most widely used is a combination of estrogen and progestin. Recent interest in . . .

https://www.nejm.org/doi/pdf/10.1056/NEJM199710093371507?listPDF=true

Emergency Postcoital Contraception

The acquired immune deficiency syndrome (AIDS) epidemic is spreading fast in Africa in spite of the various efforts and resources put in place to prevent it. In Kenya, reproductive health programs have used the mass media and other communication interventions to inform and educate the public about the disease and to promote behavior change and healthy sexual practices. This effort has led to a discrepancy between awareness and behavioral change among people of reproductive age. In this article I examine the discrepancy in Kenya from a communications perspective addressing social cultural and related factors contributing to the lack of change in behavior and sexual practices. I draw on the theoretical framework of Grunig's model of excellence in communication, the importance of understanding and relationship building between programs and their stakeholders. Data were gathered qualitatively using focus groups and in-depth interviews among men and women in rural Kenya. Key findings indicate that although awareness of sexually transmitted diseases (STDs) including human immunodeficiency virus (HIV)/AIDS is high in Kenya, a majority of the population, particularly those in the rural communities, lack understanding of the communicated messages. They also lack the knowledge of other ways of transmitting HIV particularly among those not sexually involved. Cultural beliefs, values, norms, and myths have played a role in the rapidly increasing epidemic in the rural communities and yet HIV/AIDS communication programs have not addressed these factors adequately. I conclude that successful behavior change communication must include strategies that focus on increasing understanding of the communicated messages and understanding of the audience through application of appropriate methodologies. Building a relationship with the audience or stakeholders through dialogues and two-way symmetrical communication contributes toward this understanding and the maintenance of the newly adopted behaviors and practices.

/pdf/communication-for-hiv-aids-prevention-in-kenya-social-pzyptvgd1w.pdf

Communication for HIV/AIDS prevention in Kenya: social-cultural considerations.

Acceptability research is an important component of any product development process. As researchers move into a new, accelerated phase of vaginal microbicide development, it is important to take stock of the acceptability research conducted to date and determine future research priorities. In this paper, we review findings from acceptability research conducted to date in four categories: hypothetical product acceptability research, existing product research (spermicide acceptability studies), acceptability research within the context of clinical trials, and postmarketing acceptability research conducted around the female condom. Finally, we highlight areas where additional research is needed in light of recent progress in microbicide development and discuss a possible framework for the introduction and acceptability of new sexually transmitted disease (STD) prevention technologies.

Acceptability Research on Female-Controlled Barrier Methods to Prevent Heterosexual Transmission of HIV: Where Have We Been? Where Are We Going?

Background: Research on vaginal microbicides for HIV prevention is progressing rapidly; the first large-scale effectiveness trials were launched in 2004. The majority of candidate microbicides are formulated as gels, which will act as lubricants when used during sex. Preferences and practices regarding lubrication during sex, therefore, likely influence microbicide acceptability and use. Researchers seek to maximize consistent and correct use of candidate microbicides during clinical trials to enable valid estimates of product effectiveness, and if proven effective, microbicides will be widely used only if acceptable. Methods: We conducted a comprehensive literature review and interviewed 13 key informants from nine countries in Africa, Asia, Latin America, and North America. Results: We found that norms and practices regarding lubrication during sex exist in many different countries. Despite significant variation, common themes emerged. In the majority of countries, women's genital hygiene is highly valu...

Preferences and practices related to vaginal lubrication: implications for microbicide acceptability and clinical testing.

OBJECTIVES: This study examined whether past condom failure (breakage, slippage, or both) can predict future failure and evaluated other predictors of condom failure. METHODS: At each of 3 international sites, approximately 130 male condom users were enrolled and given 5 condoms to use for vaginal intercourse over a 3-week period. RESULTS: Men at increased risk (history of 1 or more condoms that broke or slipped off) reported approximately twice as many condom failures as those not in this group. Condom failure increased with the number of adverse condom use behaviors reported per participant. Opening condom packages with sharp objects and unrolling condoms before donning were associated with breakage. Unrolling condoms before donning and lengthy or intense intercourse were associated with slippage. Of background characteristics evaluated, having less education was associated with condom failure. CONCLUSIONS: These data suggest that a history of condom failure predicts future failure, a finding that may b...

Identifying condom users at risk for breakage and slippage: findings from three international sites.

75 participants in four community-based distribution programs of the Family Planning Association of Kenya 65 clients of two Profamilia clinics in Santo Domingo Dominican Republic and 60 clients of a research and family planning clinic associated with the University of Juarez in Durango Mexico completed a questionnaire and agreed to use spermicidal films and foaming tablets along with a latex condom during each act of intercourse for 14 days in Kenya and 21 days in the Latin American countries. The women were each given 15 foaming tablets 15 pieces of contraceptive film and 15 condoms. The investigators aimed to evaluate the acceptability of these two vaginal spermicides which may also protect against sexually transmitted diseases including HIV infection. The women preferred the spermicidal film over the foaming tablet: in Kenya 86% vs. 35% p < 0.001; in the Dominican Republic 60% vs. 46% p = 0.265; and in Mexico 97% vs. 73% p < 0.001. Their partners also had a preference for the spermicidal film: in Kenya 84% vs. 31% p < 0.001; in the Dominican Republic 29% vs. 21% p = 0.261; and in Mexico 59% vs. 46% p = 0.046. All the women in Kenya 69% of those in the Dominican Republic and 88% in Mexico mentioned something they liked about the film. The leading positive attributes were ease of use general feel or comfort and lack of side effects. On the other hand 25-33% of all women reported no positive attributes of foaming tablets. The most reported negative attributes of foaming tablets were that they were messy or too wet. Women in the Latin American countries were more likely to find that the film stuck to their finger during insertion than those in Kenya. They found the foaming tablets to be easier to insert than the film while women in Kenya found the film easier to insert (p < 0.001).

/pdf/acceptability-of-spermicidal-film-and-foaming-tablets-among-25f6btbokv.pdf

Acceptability of Spermicidal Film and Foaming Tablets Among Women in Three Countries

Family Health International staff used data from six studies (5711 condoms used by 1758 couples during vaginal intercourse at 13 sites) in the Dominican Republic Ghana Kenya Mali Mexico Nepal Sri Lanka and the US to examine slippage breakage and total failure rates. The 52-mm lubricated latex condoms were all manufactured by the same US company and came from six different manufacturing lots all of which passed the tensile test of the American Society for Testing and Materials and the airburst test of the International Standards Organization. Most couples (75-100%) at seven of the nine sites where marital status data were collected were married or living in union with their partner. Only 39% of those in the Dominican Republic and 46% of those in Mali were married or living in union with their partner. Breakage rates ranged from 0.6% in Sri Lanka to 13.3% in Ghana. At 11 sites breakage rates were less than 5%. Qualitative research identified four types of behavior associated with condom breakage: incorrect method of putting on the condom use of oil-based lubricants reuse of condoms and the duration and intensity of intercourse. Slippage rates ranged from 0 in Ghana to 9.3% in Kenya. About 66% of condom breaks occurred during intercourse or removal. 47% of the condoms that broke were broken at the tip or the closed end. 26% broke along the shaft. 27% broke near the open end. A secondary analysis conducted as part of one of the US studies revealed that a small portion of condom users comprise a disproportionate of condom failures. The factors linked to condom breakage were: couples with no condom experience in the last 12 months couples who did not live together at least one condom broke in the last year and couples with no more than 12 years of education. These findings suggest that most condom users use condoms correctly and therefore condoms protect them from pregnancy and sexually transmitted diseases.

/pdf/condom-breakage-and-slippage-rates-among-study-participants-1ad6ddf5hn.pdf

Condom breakage and slippage rates among study participants in eight countries.

Family planning (FP) clinics that plan to add sexually transmitted infection (STI) services should consider alternatives to modified WHO risk-inclusive algorithms for identifying infected women. A sample of 767 FP clients from Kingston Jamaica were interviewed and examined and specimens were obtained to detect the agents that cause gonorrhea chlamydia and trichomoniasis. Serum was tested to detect the bacteria that cause syphilis. Decision models for classifying women with STI were compared using clinical statistical criteria. Models included STI classifications based on the weighted sum of STI risk factors on the presence of two or more factors identified via an interview or on an interview augmented with a urine dipstick test (i.e. rapid risk assessment). These models were compared with a modified WHO algorithm originally intended for STI clients in Jamaica. Individual factors associated with gonorrhea chlamydia and trichomoniasis were urine leukocyte esterase dipstick test outcomes >1+ (indicating the likelihood of infection based on the concentration of white blood cell enzymes on a scale of negative trace 1+ 2+ and 3+) multiple partners in the past year friable cervix and age <25 years. An additional risk factor for cervical infection alone (gonorrhea or chlamydia) was spotting after sex. Reported vaginal discharge was not significantly associated with infection. For cervical infection the WHO risk-inclusive algorithm was least accurate (a positive predictive value of 14%) the weighted-risk algorithms were best (a positive predictive value of 23%) while the interview-alone and the rapid risk assessment were slightly less accurate (positive predictive values of 20%). The modified WHO risk-inclusive algorithm appeared inappropriate for asymptomatic women. The rapid risk assessment was easier to perform and more predictive. Urine leukocyte esterase dipstick tests may be useful when pelvic examinations are not feasible. The STI assessment models other than the WHO algorithm should be evaluated in other settings where STI prevalence is high or where patients are unlikely to seek further evaluation to better identify women in need of counseling further evaluation or treatment. (authors)

/pdf/strategies-for-detection-of-sexually-transmitted-infection-gyj9fl7a6m.pdf

Strategies for detection of sexually transmitted infection among family planning clients in Jamaica.

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Acceptability of Spermicidal Film and Foaming Tablets Among Women in Three Countries

Condom breakage and slippage rates among study participants in eight countries.

Strategies for detection of sexually transmitted infection among family planning clients in Jamaica.