During the era where the female condom was still not available, a review of 10 studies where STD protection from male condoms was compared to STD protection from women's methods, such as the diaphragm and spermicides, demonstrated that women used female methods more often than they were able to negotiate male condom use with a partner. Even though the efficacy of the female methods was lower than for a male condom, women still increased their protection against STDs at more impressive rates than those among women reporting partner's use of a male condom; the explanation was that male condom use was much less systematic, and therefore less protective.

The Philadelphia Women's Health Sister Studies examined whether increasing protective options for women would increase their chances of protecting themselves and reduce disease rates. Its prevention message was based on the New York State AIDS Institute's "Hierarchy of Protective Options for Women" policy.

The global HIV/STD crisis for women is rooted in their almost universal underprivileged status. Women's economic dependency on men, resulting from societal gender roles that allow only limited educational and vocational opportunities for women, also spawns serious relational power imbalances that threaten women's health and welfare daily. Women are often not the ones to make the decision about contraception or disease prevention - if women force the issue, they risk violence or abandonment. Thus, women face a continuous calculation of tradeoffs as they try to keep themselves and their children healthy and safe, often choosing the least of multiple evils. Unsafe sex with a partner, for example, might be chosen over the spectre of isolation, lack of resources and homelessness.

Public health messages exclusively exhorting male condom use tend to ignore the realities of women's roles and relationships with male partners. Although the female condom has been available since 1992 and women's barrier methods such as the diaphragm, the cervical cap and spermicides have been studied since the 1970s, they have not been promoted to women to increase their protection against HIV/STD infection. For most women, increasing chances of protection means moving from zero protection to something.

In the male condomonly group, the educational message included male condom usage and negotiation skills. In the female condomonly group, women received information on  the body, skills for female condom use and raising motivation and comfort levels in using it.

Finally, in the hierarchy group, the women were taught skills in the use of each method (female condom, male condom, diaphragm, cervical cap, spermicides), the relative effectiveness of the different methods (the methods were organized vertically, from most to least efficacious against STD/HIV), and how to insert a barrier method.

The hierarchy arm stressed two points: one, among protection options, female and male condoms are the most protective when used properly and consistently, and therefore should be used when at all possible; two, some protective option is better than using nothing. Free protection supplies were distributed throughout the study.

The percentage of women retained in the study at 6 months was the poorest for the singlemessage arms: 51% for the female condom and 58% for the male condom arm, as compared with 75% for the hierarchy. This difference in women appearing for follow-up was attributed to the relative lower acceptability, on a population basis, of a restricted method policy.

Across all subgroups, large and statistically significant changes were seen in the proportion of protected vaginal sex acts with a main partner, from intake to followup. Using any method which attempts to adjust for loss-to-follow-up, such as imputing missing follow-up protection values based on intake values of protection, results in a higher overall level of protection for the hierarchy arm. This is because intake levels of protection for the hierarchy arm were similar enough to those of the female condom only and male condom only arms.

Because the hierarchy arm defined protection as protection from any method, the study looked at the level of condomprotected acts. Women overwhelmingly reported use of condoms, even if they had not done so at study intake. Eleven women (13% of the followup sample) reported no condom use, of whom 5 (6%) used spermicide as their sole method of protection (no one reported exclusive use of diaphragm or cervical cap).  Of the 34 hierarchy women who reported no condom use at intake, 76% reported use of either male or female condom at study end. By comparison, of the 40 women who reported any condom use at intake, 3 women, or 8% reported no use of either male or female condoms in the last followup interval . In summary, there was no evidence to support the notion that exposure to greater choice for women resulted in less condom use.

   This study also confirmed findings of many female condom studies already conducted. Eighty-six percent of women were interested in trying the female condom after the first counselling session. At six months, 51% of women were still using the female condom. The most wellliked aspects were: high level of protection, its natural feel, and woman's control. Dislikes included: insertion, appearance and the inner ring.

Finally , in initial analys es of labora toryco nfirme d diseas e recurr ence rates amon g the 292 subjec ts, there was a nonst atistic ally signifi cant 20% lower rate of recurrence (of trichomonas, early syphilis, chlamydia, or gonorrhoea) among hierarchy women (15%), as compared with women assigned to either of the single message arms (18.5%).

The study confirmed that women find a message that includes multiple methods of protection more acceptable than one which restricts method choice (e.g., male condom only). On a population level, a choice message produces the best behavioural change, which can be expected to translate into reduced disease rates. This study has important implications for women's prevention interventions and, hopefully, will spur increased adoption of a risk reduction or "choice" approach as both a sound and urgentlyneeded public health response to the HIV crisis among women.

Erica L. Gollub, University of Pennsylvania, Treatment Research Centre, Department of  Addiction Studies, 3900 Chestnut Street, Philadelphia, PA, USA, 19104; Tel: 1- 215-823-4533; Fax: 1-215-823-6080; e-mail: Gollub_E@research.trc.upenn.edu