Despite the variety of contraceptives now available, it remains difficult for many women and couples to find a method that suits their needs. Women frequently find it necessary to make tradeoffs between contraceptive efficacy and freedom from side effects, or between protection against sexually transmitted infections and prevention of pregnancy. Available choices may be limited by medical conditions that contraindicate certain methods. Moreover, partners' individual needs and preferences and the dynamics of their relationship may affect not only which method is chosen, but whether a method is used at all. It is hardly surprising, then, that many couples do not practice contraception, and that those who do adopt a method often use it inconsistently or discontinue it altogether.

Given the high levels of pregnancy-related mortality and morbidity and the ever-increasing risk of HIV infection in many areas of the developing world, such responses to the dilemmas of contraceptive use have grave implications. Each article in this issue looks at factors that work against use of condoms and other contraceptives, and attempts to find ways of counteracting their effects.

In the lead article, Nancy Luke argues that stereotypical "sugar daddy" relationships—in which older, wealthier men provide money and gifts to much younger women in return for sex—are not as pervasive as they are generally assumed to be [see article]. Nevertheless, nonmarital relationships characterized by large age and economic disparities between partners are relatively common and are associated with reduced levels of condom use. Noting that this association is less evident when such disparities are smaller, Luke recommends efforts to increase women's relative power through improved negotiating skills; greater access to education, employment and information; and decreased need for material assistance.

Changes in women's menstrual bleeding patterns due to methods such as the IUD, the implant and the injectable are frequent causes of discontinuation. Elizabeth Tolley and colleagues show that 12 months after adopting their method, almost 70% of injectable users, 34% of IUD users and 10% of implant users from three public clinics in Cairo had discontinued [see article]. More than 40% of women who stopped using each method identified heavy or long menstrual bleeding as one of the most important reasons; lack of bleeding was cited by almost one-third of implant users. The study found only two factors that protected against bleeding-related discontinuation: Among IUD users, those whose husbands knew they had visited a clinic to obtain a method were less likely to discontinue; among implant users, the risk of discontinuation decreased with increasing age.

In Africa, where marriage is now sometimes cited as a risk factor for HIV infection, studies have commonly found that women are unable to ask their husband to use condoms, even if they suspect—or know—that he has other partners. Using data on matched partners in 238 cohabiting or marital relationships who had been individually interviewed in a household survey in KwaZulu-Natal, Pranitha Maharaj and John Cleland found that only 15% of men and 18% of women reported consistent or occasional use [see article]. The strongest predictor of condom use was a woman's perception that she was at risk of HIV infection from her partner. These findings, according to the authors, suggest that the belief that men's resistance to condom use within stable relationships cannot be overcome may be exaggerated.

Use of the female condom can be initiated by women, and therefore provides a way for women to protect themselves against HIV and other STIs. Using data from a survey of consumers exiting retail outlets in urban Zimbabwe, Dominique Meekers and Kerry Richter find that men and women who perceived the method as affordable and easy to use and those who had previously used a male condom were more likely to have tried the female condom [see article]. Consistent use with marital partners was negatively associated with reporting multiple partners in the past year, and positively associated with using the method for pregnancy prevention and having used a male condom. Consistent use with regular nonmarital partners was associated with perceived ease of use, perceived effectiveness for STI prevention, low HIV risk perception, and use for pregnancy and STI prevention. Because predictors of use vary according to type of relationship, the authors conclude that marketing efforts may need to position the female condom differently for different population groups.

Also in This Issue

Opinions on how to attack the AIDS epidemic have become highly polarized over the issue of condom use. In a Viewpoint, Steven Sinding argues that debates over whether to advocate condoms or urge abstinence and fidelity fail to recognize the complexity of sexual relations. The best way to save lives and protect health, he says, is to offer people a range of realistic options and encourage them to use whichever approach best fits their needs [see article].

—The Editors