The primary objective of this presentation is to explore whether the advent of the HIV pandemic has any bearings on contraceptive method use, especially in countries most seriously affected by HIV/AIDS. The related objectives include: (1) evaluating overall trends in contraceptive use; (2) examining discontinuation of use by method and reason; (3) discerning reliance on oral contraceptives and condoms by level of HIV epidemic; and (4) assessing oral contraceptive and condom use, including the implications for fertility regulation of a major switch from the former to the latter.
Data and Methods
The presentation is based on published data and forthcoming reports on levels and trends in contraceptive use, by the UN Population Division, together with UNAIDS data on countries by the level of HIV prevalence. In addition, data from Demographic and Health Surveys (DHS) are used for 16 developing countries with information on the contraceptive calendar. The life table method was used to estimate the cumulative 12-month probabilities of the discontinuation of use.
With 61% of couples using a contraceptive method in 19981, contraception, a novelty three decades ago, has become the norm in much of the world. Contraceptive use in developing countries has increased from 9% in 1960–19652,3 to 59% in 19981. Overall, the method mix (that is, the relative percentage of couples relying on various methods) has not changed significantly in spite of the increase in number of contraceptive methods that have become available.
In spite of the impressive gains made in the overall use of contraceptives1–6, the continuation of use remains low, except for IUD7. Over 40% discontinue the spacing method within the first year after initiating the use in 18 developing countries included for an in-depth analysis of contraceptive use dynamics. The 12-month cumulative probability of discontinuation was 60% for the condom, compared with approximately 52% for withdrawal and injectables. The comparable figure for IUD was 16%. The 12-month discontinuation as a result of the failure of the method or the user was high for periodic abstinence (22%) and withdrawal (15%) compared with 10% for the condom, 7% for the OC, 3% for injectables and 2% for the IUD. Except for IUD, methods (the pill and injectables) rated for low failure rates were characterized by high discontinuation as a result of side-effects or method-related health concerns. For example, 46% of injectable users discontinued within the first year since starting the use because of method-related health concerns or side-effects. Among the six (IUD, the OC, injectables, the condom, periodic abstinence and withdrawal), IUD was found to be the method with the least discontinuation because of failure or method-related health concerns7.
Since 1983, the use of the OC and the condom has increased in developed countries. However, the use of the OC has recently declined whereas the use of the condom remains largely unchanged in developing countries1–6. In Africa, the region most affected by HIV/AIDS, there has been no increase in condom use among married women, whereas the use of the OC has dropped and of injectables has increased. OCs and injectables are the two most commonly used methods in Africa1.
The emergence of HIV/AIDS seems to have had no significant bearings on contraceptive use patterns among married or cohabiting couples in developing countries. Condom use among married couples in developing countries continues to be low, and shows only a modest increase in recent times. The level of condom use8 among married couples in countries classified by UNAIDS with a generalized HIV epidemic9 remains lowest, whereas it is high and increasing in countries with concentrated HIV epidemic.
Among the six countries (Botswana, Lesotho, South Africa, Swaziland, Zambia, and Zimbabwe) hardest hit by the HIV/AIDS epidemic, with HIV prevalence of 20% or higher in the general population, only users in Zambia make a relatively greater (14%) use of the condom than in the other five countries where its use remains 5% or less1. Overall, two in three users in the six countries rely on the OC or injectables compared with only 4% who rely on the condom.
A more in-depth comparative analysis of the OC versus condom users in 16 developing countries8 shows that the overall 12-month discontinuation of use is higher (56%) among condom users compared with OC users (43%). Discontinuation as a result of method or user failure is also higher among condom (9%) than OC (6%) users. However, condom users are better able to mitigate the consequences of failure and the abandonment of use with fewer unwanted births or pregnancies (27%) compared with OC users (33%), and more reported abortions (spontaneous or induced) among the former (21%) than among the latter (14%). Condom users in these countries are found to be more urban, better educated and more likely to want to stop further childbearing, yet experience more method or user failure than OC users. A major shift from the use of oral contraceptives to condoms is unlikely to result in an increasing number of unintended pregnancies, caused mainly by the behaviour of condom users who are more likely to switch to another method. Moreover, most (80%) of the unintended pregnancies result from the non-use rather than from the failure to use the method. Overall, increased condom use among married couples remains a major policy/programme challenge.
From the family planning perspective, the vigorous promotion of condoms as a method of family planning within marriage does not represent a serious threat to the goal of reducing unwanted childbearing and abortion. From the HIV prevention perspective, however, condom use within marriage remains low and is characterized with low continuation and high failure. Note that all of the above discussion relates to contraceptive use among married or cohabiting couples. The dynamics of contraceptive use, especially of condom use, may be different among unmarried sexually active men and women.
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