1. Are Dual-Method Messages Undermining
STI/HIV Prevention?
Ann O’Leary
Senior Behavioral Scientist
National HIV Prevention Conference
August 17, 2011
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
Place Division name here

2. Why recommend use of dual methods?
□ Many teens and young women are at risk for both of two
events:
■ Unintended pregnancy
■ Among low-income women, 62% of pregnancies were unintended
■ 410,000 births among teens in 2009
■ Sexually transmitted infections (STIs), including HIV
■ 38% of teen girls; 44% of black girls, had an STI in 2009
 Condoms are extremely effective against STIs and HIV
 Condoms are less effective against pregnancy than HC
* All references available upon request of O’Leary, 2011 paper

3. Why recommend use of dual methods (cont.)?
 In theory, the use of hormonal contraceptives and
condoms together should prevent both of these adverse
effects of sex
 Thus, guidelines from “Healthy People” and the World
Health Association recommend counseling young
women to use HC and condoms.
 But how many do?
* All references available upon request of O’Leary, 2011 paper

4. Do women use dual methods?
□ Review of literature reveals few teens and young women
use hormonal contraceptive (HC) and condoms:
■ In 2009, YRBS showed the following rates of dual-method use:
■ 10.7% of whites
■ 3.6% of blacks
■ 3.9% hispanics
■ Even among dual method users, consistent use is not common
■ In general, younger women use condoms alone and, when a
committed relationship is established, they use HC alone
* All references available on request of O’Leary, 2011 paper

5. Problems with multiple messages
□ The second of two may not be processed cognitively
□ If primary concern is addressed (most frequently
pregnancy) other risk reduction method may be foregone
(risk compensation)
 Condom negotiation with partner may be more difficult if
partner knows HC is being used.
* All references available on request of O’Leary, 2011 paper

6. How effective are interventions to increase
dual method use?
□ Literature review suggests promoting dual use is difficult.
Interventions that have been tested have yielded:
□ Inconsistent results
□ Null results
□ Non-sustained results
* All references available on request of O’Leary, 2011 paper

7. Who are successful dual method users?
□ Relationship characteristics:
□ Single, young, in uncommitted relationship
□ At lower risk-fewer partners
□ Motivations for use:
□ More concerned about HIV/STI
□ Among teens, STRONG desire to avoid pregnancy
* All references available on request of O’Leary, 2011 paper

8. A proposed RCT
□ Two arms:
□ Use HC and condoms
□ Use condom s only
Provide all participants with condoms and emergency
contraception (EC)
* All references available on request of O’Leary, 2011 paper

9. Messages for proposed RCT arms
□ Two arms:
□ “I recommend that you use a hormonal contraceptive to prevent
pregnancy, and condoms to prevent sexually transmitted
disease, including HIV.”
□ “I recommend that you use condoms to prevent pregnancy and
sexually transmitted disease, including HIV.”
* All references available on request of O’Leary, 2011 paper

10. A proposed RCT (cont.)
□ Hypotheses:
□ Fewer sexually transmitted diseases in condom-only arm
□ More use of EC, possibly pregnancy, in condom-only arm
We could also identify the characteristics of successful dual-
method users and successful condom-only under conditions of
controlled messaging so that messages can be tailored to
women with different profiles
* All references available on request of O’Leary, 2011 paper

11. Is this RCT ethical?
□ Some think no:
□ Randomization removes women’s free reproductive choice
□ It is wrong to randomize some women to an inferior form of birth
control
* All references available on request of O’Leary, 2011 paper

12. Is this RCT ethical? (cont.)
□ Responses to these arguments:
□ Randomization will occur only after informed consent;
participants are free to discontinue study or make own
reproductive choices irrrespective of participation.
□ It may also be morally problematic to prescribe hormonal
contraception to women who are at risk for STI/HIV.
* All references available on request of O’Leary, 2011 paper

13. Summary
□ Dual protection is routinely recommended to teens and
young women.
□ Most of these women do not use dual methods.
□ Use of hormonal contraceptives is associated with non-
use of condoms.
□ The possibility that dual-method recommendations are
adding substantially to the societal burden of STI/HIV
compared with condom-only recommendations is an
empirical question that can be answered via a
randomized controlled trial.
* All references available on request of O’Leary, 2011 paper

14. Email address:
aoleary@cdc.gov

15. The views presented here are those
of the author and do not reflect
necessarily represent the official
position of the CDC.