Use of two contraceptive methods (dual-method use) refers to using condoms plus another modern method of contraception. The latter method is usually hormonal (like birth control pills) or a non-hormonal intrauterine system. Unprotected sex results in disease and death in many areas of the world due to HIV/STI. Millions of women, especially in lower-resource areas, also have an unmet need for preventing unplanned pregnancy. We examined studies of dual-method use, which can better prevent pregnancy and protect against HIV and other sexually transmitted infections (STIs).
Through January 2014, we did computer searches for studies of programs to improve use of dual-methods. We wrote to researchers to find missing data. Studies examined a behavioral intervention for improving dual-method use. The educational program had to address preventing pregnancy and HIV/STI by using condoms plus another modern contraceptive. The intervention was compared with a different program, usual care, or no intervention.
We only found four studies to include. Three were randomized trials and the fourth was a pilot study for one of the included trials. The programs differed from one another. They included computer-delivered sessions tailored for each person; phone counseling added to clinic counseling; and case management plus a peer-leadership program. In the latter study, more women in the intervention group reported regular use of dual methods, namely birth control pills plus condoms, than the control group. The pilot study reported a trend toward more regular dual-method use for the intervention group compared to the control group. The other two trials did not show any major difference between the study groups in reported use of dual methods or in test results for pregnancy or STIs.
We found few programs to improve use of dual methods, and only one showed an effect. The reports gave enough information on how the interventions were conducted. The studies had adequate follow-up periods of 12 to 24 months. However, the overall quality of results was low, mainly due to study design and losing many women to follow up.
We found few behavioral interventions for improving dual-method contraceptive use and little evidence of effectiveness. A multifaceted program showed some effect but only had self-reported outcomes. Two trials were more applicable to clinical settings and had objective outcomes measures, but neither showed any effect. The included studies had adequate information on intervention fidelity and sufficient follow-up periods for change to occur. However, the overall quality of evidence was considered low. Two trials had design limitations and two had high losses to follow up, as often occurs in contraceptive trials. Good quality studies are still needed of carefully designed and implemented programs or services.
Dual-method contraception refers to using condoms as well as another modern method of contraception. The latter (usually non-barrier) method is commonly hormonal (e.g., oral contraceptives) or a non-hormonal intrauterine device. Use of two methods can better prevent pregnancy and the transmission of HIV and other sexually transmitted infections (STIs) compared to single-method use. Unprotected sex increases risk for disease, disability, and mortality in many areas due to the prevalence and incidence of HIV/STI. Millions of women, especially in lower-resource areas, also have an unmet need for protection against unintended pregnancy.
We examined comparative studies of behavioral interventions for improving use of dual methods of contraception. Dual-method use refers to using condoms as well as another modern contraceptive method. Our intent was to identify effective interventions for preventing pregnancy as well as HIV/STI transmission.
Through January 2014, we searched MEDLINE, CENTRAL, POPLINE, EMBASE, COPAC, and Open Grey. In addition, we searched ClinicalTrials.gov and ICTRP for current trials and trials with relevant data or reports. We examined reference lists of pertinent papers, including review articles, for additional reports.
Studies could be either randomized or non-randomized. They examined a behavioral intervention with an educational or counseling component to encourage or improve the use of dual methods, i.e., condoms and another modern contraceptive. The intervention had to address preventing pregnancy as well as the transmission of HIV/STI. The program or service could be targeted to individuals, couples, or communities. The comparison condition could be another behavioral intervention to improve contraceptive use, usual care, other health education, or no intervention.
Studies had to report use of dual methods, i.e., condoms plus another modern contraceptive method. We focused on the investigator’s assessment of consistent dual-method use or use at last sex. Outcomes had to be measured at least three months after the behavioral intervention began.
Two authors evaluated abstracts for eligibility and extracted data from included studies. For the dichotomous outcomes, the Mantel-Haenszel odds ratio (OR) with 95% CI was calculated using a fixed-effect model. Where studies used adjusted analysis, we presented the results as reported by the investigators. No meta-analysis was conducted due to differences in interventions and outcome measures.
We identified four studies that met the inclusion criteria: three randomized controlled trials and a pilot study for one of the included trials. The interventions differed markedly: computer-delivered, individually tailored sessions; phone counseling added to clinic counseling; and case management plus a peer-leadership program. The latter study, which addressed multiple risks, showed an effect on contraceptive use. Compared to the control group, the intervention group was more likely to report consistent dual-method use, i.e., oral contraceptives and condoms. The reported relative risk was 1.58 at 12 months (95% CI 1.03 to 2.43) and 1.36 at 24 months (95% CI 1.01 to 1.85). The related pilot study showed more reporting of consistent dual-method use for the intervention group compared to the control group (reported P value = 0.06); the investigators used a higher alpha (P < 0.10) for this pilot study. The other two trials did not show any significant difference between the study groups in reported dual-method use or in test results for pregnancy or STIs at 12 or 24 months.