By the end of 1998, approximately 33 million people around the world were living with HIV/AIDS, with young adults in the midst of their productive and reproductive years as the most affected. Preventing new HIV infections in women of reproductive age and their partners is a crucial response to the HIV/AIDS epidemic. Women need practical options to protect themselves from unwanted pregnancy and STDs other than HIV infection. They also need access to health services for the management of reproductive tract infections. So far, consistent and correct use of condoms is the only effective strategy to protect individuals from HIV/STDs.

Women can protect themselves from HIV/STDs and unwanted pregnancy by using dual protection. Dual protection involves a mechanical barrier alone or in combination with another contraceptive, such as hormonal contraceptives (pills, injectables and implants), intrauterine device (IUD) or sterilization. The most important mechanical barrier methods are the male and female condom. Other barrier methods include the cervical cap, the diaphragm and spermicides. Although oral contraceptives, injectables and implants are highly effective in preventing pregnancy, they offer no protection against HIV/STD transmission. Hormonal contraceptives and IUDs need to be used with condoms, whenever a risk of HIV/STD exists.

Dual protection is strongly recommended, when there is a need to protect against HIV/STDs and pregnancy. However, in developing countries, important obstacles remain.  Services are often not available, especially to rural populations, and traditional cultures may not encourage contraception. Women often do not have the power to negotiate condom use with their partners, even when they know they are at risk of HIV/STD infection. In addition, research findings indicate that the consistent use of another highly effective method of contraception is negatively correlated with consistent condom use and may adversely affect the ability of a woman to protect herself against HIV/STDs.

Although studies on pregnancy prevention are limited and no clinical studies on HIV prevention have been reported so far, the female condom is expected to be highly effective in preventing unwanted pregnancy and HIV/STDs. An important advantage of the female condom is that its use is less dependent on male co-operation. The higher cost and lower availability may, however, limit its usefulness, especially in developing countries. The issue of re-use also leaves concerns about the risk of STDs and the impact on contraceptive effectiveness.

The cervical cap and the diaphragm are barrier methods that protect against pregnancy. Some protection against gonorrhoea and chlamydia is also likely. Protection against HIV transmission is unclear as no study has been conducted so far and should not be presumed.

Spermicides are available in the form of a film, tablets or foam. When used in sufficient concentrations in laboratory settings, spermicides containing nonoxynol-9 inactivate sperm. However, the pregnancy rate during the first year of use is higher than for condom use. Repeated and high dose use of nonoxynol-9containing spermicide can also cause vaginal lesions, which may increase the risk of HIV transmission.

Microbicides kill micro-organisms (bacteria, protozoa and viruses), while virucides specifically kill viruses. Nonoxynol-9 effectively inactivates HIV in laboratory settings, but these results have not been replicated during actual use. However, it may offer some protection against gonorrhoea and chlamydia. The effect of chlorhexidine and other microbicides on HIV transmission are currently under study.

If measures against HIV/STDs and unwanted pregnancies are to be effective, partners must be able to communicate between themselves about sexuality, including protective measures. In many countries this is currently not the practice. Health workers may need to facilitate the discussion between partners by counselling couples and support them in using dual protection. This will require communication skills and the availability of relevant educational material.

Women often lack decision-making power to protect, when facing the risks of unwanted pregnancy and STDs, including HIV. There is an urgent need for innovative preventive methods, especially for women. Greater involvement of men is required to protect women against HIV/STDs and more work needs to be done to identify and address men's specific needs.

In many countries sex between men exists and requires special attention because it involves high risk of HIV transmission. Among safer sex practices for men having sex with men is the consistent use of condoms (male and female). This will in particular require the availability of condoms in situations where males are forced to stay together for longer periods, such as prisons.

People living with HIV have special needs. They may require counselling and support about their infectiousness, future fertility and ways to prevent unwanted pregnancy, preferably as a shared responsibility between partners. Access to effective contraception is essential but may not be sufficient. Further research on contraceptive methods for those already infected needs to be undertaken. Increased research efforts are needed in the development of non-spermicidal microbicides, which would allow pregnancy, while also protect against HIV/STDs. This is also important for discordant couples with a desire to have offspring. This issue is addressed by the campaign on microbicide development, as discussed in a Special Article by Lori Heise.

Consistent and correct use of condoms remains the main strategy to protect against HIV/STDs and pregnancy. The female condom and vaginal microbicides (when available in the future) would be good alternatives. There is an urgent need for research to increase the effectiveness and user-satisfaction of those methods. In the meantime, reproductive health programmes should focus on improving the quality and utilization of integrated reproductive health services, including counselling and support to couples.

Jantine Jacobi, Medical Officer Reproductive Health, World Health Organization, P.O. Box 3444, Windhoek, Namibia; Tel: 264-61203-2333; Fax: 264-61229-090; e-mail: jacobi@un.na