Dual Protection Against Pregnancy and STIs

Dual protection is the use of strategies that prevent both unintended pregnancy and sexually transmitted infections, including HIV. Only condoms protect against both, but condoms alone are followed by pregnancy in about 13 of 100 women in the first year of typical use. The usual solution is a condom with a highly effective method, or condoms with prompt access to emergency contraception.

Why it matters. Most hormonal methods and IUDs give no protection against HIV, chlamydia, gonorrhoea, syphilis, trichomonas, herpes or HPV. Patients choosing the most effective pregnancy prevention are often those with the least condom use.

Dual protection strategies.

• Condoms alone (external or internal), used consistently and correctly.

• Condoms with another contraceptive method (the dual method).

• Condoms with emergency contraception available for failures.

• Condoms with HIV pre-exposure prophylaxis where HIV risk is substantial.

Risk assessment. Ask about number of partners, new partner in the last 3 months, partner with other partners, STI symptoms in the patient or partner, transactional sex, injecting drug use, partner living with HIV and condom use frequency. Assess pregnancy risk at the same time.

Method effectiveness against STIs.

Hormonal methods and HIV acquisition. Current evidence does not show that any hormonal method increases HIV acquisition. Patients at high HIV risk can use any method and should be counselled on condoms and pre-exposure prophylaxis.

IUDs and infection. The IUD does not cause pelvic infection in patients without cervical infection. The small increase in risk is in the first 20 days after insertion and relates to existing infection. Insert an IUD in patients with low STI risk; in high-risk patients screen first without delaying asymptomatic patients when testing is unavailable.

Counselling.

• Offer both condoms and the chosen contraceptive method in the same visit.

• Demonstrate external condom use on a model; show how to insert an internal condom.

• Explain that a condom is applied before any genital contact and used for every act.

• Discuss how to raise condom use with a partner; role-play responses.

• Give condoms to take away.

HIV testing and prevention.

• Offer HIV testing at every visit when status is unknown or risk is ongoing.

• Oral pre-exposure prophylaxis: tenofovir disoproxil fumarate 300 mg with emtricitabine 200 mg (or lamivudine 300 mg) orally once daily, started after a negative HIV test and continued while at risk. No interaction with hormonal methods.

• Long-acting options where available: cabotegravir 600 mg intramuscularly at months 0 and 1 then every 2 months; lenacapavir 927 mg subcutaneously every 6 months; dapivirine vaginal ring 25 mg replaced every 28 days.

• Post-exposure prophylaxis after sexual exposure or violence: tenofovir disoproxil fumarate 300 mg, lamivudine 300 mg and dolutegravir 50 mg orally once daily for 28 days, started within 72 hours.

STI screening and vaccination. Test for syphilis, chlamydia, gonorrhoea and hepatitis B where risk exists. Treat symptomatic STIs the same day. Offer hepatitis B and HPV vaccination.

Backup for condom failure. Offer emergency contraception when a condom breaks, slips or is used incorrectly and pregnancy is not wanted.

Common errors.

• Assuming a patient with a long-acting method no longer needs condoms.

• Presenting condoms as unreliable and discouraging use.

• Using spermicides as protection against STIs.

• Treating a patient with cervicitis and an IUD by removing the device without cause; treat the infection and remove the device only if there is no improvement in 48 to 72 hours.

Special groups. People living with HIV need dual protection to prevent transmission and acquisition of other STIs; undetectable viral load on treatment prevents sexual transmission, but pregnancy prevention still needs a contraceptive method. Adolescents, sex workers, men who have sex with men and patients in serodiscordant relationships need active dual protection counselling. Survivors of sexual violence need emergency contraception, post-exposure prophylaxis and presumptive STI treatment.

Referral and escalation. Refer for HIV treatment and partner services, and for sexual violence care at the same visit.