In the 20 years since HIV first revealed itself, the epidemic has forced the reproductive health field to look beyond condoms, toward new approaches such as microbicides. But will women (and men) use them? In this issue of International Family Planning Perspectives, Gita Ramjee and colleagues offer some insights into this question, by reporting on South African men's reactions to a potential microbicidal product [see article]. Most said they wanted their partners to be protected from the risk of contracting HIV or some other sexually transmitted infection, but the majority also disliked using male condoms. Support for a woman's use of a microbicide was strong, especially among younger and more educated men, yet most men said they would want to be involved in the decision to use such a product. Finally, a number said they would object to a microbicide if it increased vaginal lubrication, as this would interfere with sexual pleasure. The authors conclude that South African men "may not be completely happy with women's autonomy in choosing a microbicide," a situation that reflects "some of the entrenched cultural attitudes prevalent in many developing countries."
Until microbicides are developed, however, condoms remain the chief protection from STDs. [see article], Martine Collumbien and coauthors estimate the unmet need for condoms in four coastal districts of Orissa, a state in eastern India. Estimates based on data from a 1998 survey indicate that men aged 18-35 used about 2.8 million condoms, mostly with their wives. Few men report having extramarital or premarital sex, but overall just 15% of nonmarital sexual encounters were protected by condoms. Estimates of the unmet need for condoms in Orissa range from 2.3 million per year (under the most conservative assumptions) to nearly 60 million (if all marital sex acts were protected by condom use).
While it is important to protect adolescents and young adults from contracting STDs as a result of high-risk sexual behavior, they may be difficult to reach with prevention messages. Parents and other adult family members are well-placed to do this, but it is not clear how willing they are to advise youth to use condoms or seek out care. Ilene Speizer and colleagues [see article] report on survey data collected from adults in Lomé, Togo, on their attitudes toward adolescent sexual behavior. Adults' perspectives often differed by gender, with women voicing more conservative attitudes than men, especially with regard to contraceptive use among adolescents and unmarried couples. Men seemed more open than women to offering youth information on sexuality. However, women were significantly more likely to have communicated with a daughter about reproductive health. Thus, in Togo, female teenagers appear to have greater access to reproductive health information from the parent with the more conservative attitudes about sex.
Elsewhere in this issue, Stella Babalola and coauthors [see article] examine the effects of a family planning promotion campaign in Cameroon. Called the Gold Circle initiative, it was designed to promote improvement in the quality of family planning services in four countries, including Cameroon. After clinic quality was improved in a variety of ways, a public information campaign was conducted. More than one in three women surveyed were aware of the Gold Circle initiative, half of whom knew about it through television. Women exposed to the campaign were significantly more likely to intend to use family planning. In addition, service statistics suggest that the campaign led to an increased demand for family planning services at Gold Circle clinics.
In Bangladesh, a new reproductive health strategy is being implemented that will required women to come out of their homes to receive reproductive health services, rather than rely on workers who come door-to-door. Sidney Schuler and coauthors report in this issue [see article] on how clients, communities and program staff are adapting to these changes. Their findings illustrate some of the challenges that providers face in trying to implement radical policy changes in a short time, particularly when the changes entail increased costs for clients.
Elizabeth Ward and colleagues [see article] study a sample of family planning clients in Jamaica to identify risk factors for common STDs and to investigate the accuracy of several different screening approaches for detecting STDs. More than one in four were diagnosed with at least one STD. A modified version of a World Health Organization algorithm for detecting STDs among asymptomatic women performed poorly; in contrast, approaches involving risk scores (in which values are assigned to each risk predictor and a woman's risk score is the sum of these values) or a rapid risk assessment (involving a combination of scores and a urine dipstick test) were easier to perform and more predictive of STD infection.
Finally and reluctantly, we announce the departure of Michael Klitsch, who has been executive editor of International Family Planning Perspectives since 1995. Mike's connection to the journal goes back to 1980, when he joined the staff as an assistant editor. In the intervening years, Mike developed a deep commitment to the sexual and reproductive health field and a vast knowledge of the professionals working in the field. While we will miss his expertise and enthusiasm, we wish him well in his new role as senior editor/writer at EngenderHealth.