Understanding negotiation and use of female-controlled barrier methods American Public Health Association 135th Annual Meeting and Expo November 3-7 2007 Washington DC Marieke van Dijk, MD, Regional Associate Co-investigators: Diana Lara Sandra García Daniel Grossman Jhoanne Muñoz

Overview Background Methodology Results Conclusions Female condom Diaphragm Use Negotiation Acceptability

Female-controlled barrier methods Women suffer from serious consequences of STI’s (PID, ectopic pregnancy, infertility, cervical cancer) Vulnerable populations (e.g. sex workers) more affected and often unable to negotiate male condom use Renewed interest in diaphragm and women-friendly microbicides

Methodology Two study sites in Dominican Republic (Puerto Plata and Santiago) In-depth interviews with 18 female sex workers 22 male sexual partners (7 regular partners, 15 new clients) Analysis of transcriptions by two researchers Regular partners: boyfriends, husbands (no paid sex), regular clients (paid sex) Even distribution among PP and S Male respondents recruited through sex establishment where most sex workers worked whoparticipated, they would bring a client Regular partners through NGO’s DR: 60.000 female sex workers , sex work is very common, larger cities and tourist areas, DR does not explicitly criminalize sex work. Sex workers have higher prevalences of NG (2-6% general pop: 0,8%), CT (15-16%, general pop. 7.2%) and HIV (7-12%, general pop. 2,8%. (report 2003) All with counselling 30 male and 30 female condoms, 1 diaphragm 243 sex workers completed study Group 1: 1st month only male and female condoms, 2nd month also diaphragm Group 2: all methods at 1st visit 4 months; monthly follow-up interviews by trained staff on experiences Recruited with help of three local NGO’s: COIN, CEPROSH and MODEMU, work with sex workers and people living with HIV; also worked with public health services of the DR that usually perform routine STI checks on sex workers| Criteria: working in sex industry, self-identified as sex worker Recruited from direct and indirect sex establishments

Results Regular partners: boyfriends, husbands (no paid sex), regular clients (paid sex) Even distribution among PP and S

The female condom (FC) Regular partners: boyfriends, husbands (no paid sex), regular clients (paid sex) Even distribution among PP and S

FC: Use 12 women were frequent users (good experiences) 2 had difficulties inserting it All 22 men had at least one experience with the female condom

FC: Negotiation Three strategies: Give both options (male and female condom) Negotiate the female condom when men refuse male condom Use the female condom secretly 3 of the 7 women who use it secretly, did this only with clients, not with regular partners Possible because often drunk

FC: Acceptability – men’s attitudes According to women: Reluctance, but they accept after explanation They like it, as they don’t need to use a male condom They get angry and mistreat the women According to men: High satisfaction with female condom! 3 of the 7 women who use it secretly, did this only with clients, not with regular partners

FC: Advantages According to men: According to women: Protection against all diseases, including HIV (12) Comfortable (male condom is tight) Feel more ‘free’, more natural According to women: Women feel protected (18) Beneficial for their business (6) They have ‘the control’ (5) Protection against pregnancy (4) Comfortable (3) No rests of lubrication gel inside of vagina (1) protection against all diseases, including HIV (18) Stronger, thicker material; it cannot break (6) men: Stronger material (12) It covers ‘all’ (2)

FC: Disadvantages According to women: According to men: Looks ugly (5) Strange noise while having intercourse (2) Excess of lubricant gel (2) ‘Penile misrouting’ (2) Irritation of the skin (1) According to men: Unfamiliar method, more confidence in male condom (3) Ugly because big size, visible outside ring Penis went between outer ring and vaginal wall

The diaphragm Regular partners: boyfriends, husbands (no paid sex), regular clients (paid sex) Even distribution among PP and S

Diaphragm: Use 10 women reported frequent use Often tried out with regular partner first (5) 3 women had problems inserting it 1st time 3 women non-compliance with 6 hrs interval after intercourse 2 women accepted sex without male condom 8 men had experience with the diaphragm (1 client, 7 regular partners) 10 frequent use (good experiences) Without condom: 1 husband and 1 client

Diaphragm: Negotiation Regular partners Were told about use diaphragm (before or after intercourse) Secret use Clients Insert it before going to work or before intercourse in the bathroom

Diaphragm: Acceptability - men’s attitudes According to women: They accept after explanation of method They like it, as they don’t need to use a male condom They get angry and mistreat the women According to men: OK, but not very safe 3 of the 7 women who use it secretly, did this only with clients, not with regular partners Men’s reactions (when told) according to women:

Diaphragm: Advantages According to men: Protection against pregnancy (5) Protection against diseases, including HIV (3) No need to use male condom (2) According to women: Back-up method against diseases (10) Can be used without knowledge men (10) Can be used during menstruation (6) Comfortable (5) Protects against pregnancy (2) when men refuse use male condom or when condom breaks

Diaphragm: Disadvantages According to women: Pain, irritation, discomfort (6) Lack of confidence in protection against diseases; does not protect against HIV (4) Has to be left in vagina for six hours (3) Some men can feel it (3) Problems according to men: Lack of protection

Conclusions Introduction female-controlled barrier methods improved women’s options to have protected sex Acceptability of female condoms is high for women and men Diaphragm use seems higher with regular partners than with clients

Conclusions (cont.) More data are needed on condom migration after introducing female-controlled barrier methods Strategies are needed to disseminate information on female-controlled barrier methods among clients and regular partners

THANK YOU! mvandijk@popcouncil.org.mx Acknowledgements: Ibis Reproductive Health PSI USAID – DR Leticia Fernandez Hector Jerez Francisco Paz Local partners: CEPROSH COIN MODEMU Profamilia