A session at the Mexico AIDS conference discussed the difficulty of getting policy makers to look anywhere except at randomised controlled trials (RCTs). Although the outstanding researcher Nancy Padian has carried out such a trial, those who oversee these trials insisted that the experimental group be instructed to use a male condom as well as the diaphragm, while the control group used the condom only. Unsurprisingly, many experimental participants and who could blame them? rejected this instruction, and used the diaphragm alone. The trial was rated a failure, because theexperimental group and the control group ended up with exactly the same number of new infections (and pregnancies).
Careful study of the findings of Nancy Padians randomised control trial of the diaphragm suggests that the diaphragm probably did act as harm reductive. Thus the efficacy of the diaphragm was suggested by the findings that although many of those in the experimental group abandoned the condom and used the diaphragm alone, the two groups achieved equally good results. Almost since the epidemic began, some of us have wondered if the vaginal diaphragm might not have a harm reduction role in protecting women.
Used by generations of women as an alternative to the male condom in preventing pregnancy, it did reduce, although not absolutely prevent, conceptions. It also gave some protection against other sexually transmitted infections. As an understanding of HIV emerged it could be argued that the diaphragm gave protection to the cervix, the site of many of the cells that are infected by the semen.
The degree of protection the diaphragm achieves is uncertain but its known merits have been neglected for too long.
The evidence for protection given by the male condom never included RCTs that examined the protection they give to women. In fact, the trials only traced the protection from sexually transmitted infection that they gave to sailors spending their time ashore. In recent years, however, reports of male condom use still not RCTs among discordant couples have been persuasive that consistent use gives protection for both partners. Meanwhile, as we well know, many women cannot convince their male partners to use a male condom or allow a female condom.
This is the rationale behind the enormous ongoing efforts to find a microbicide. It would be very important if, having no reasonable alternative, we could advise women: first, try and get your partner
to use a male condom or try to use a female condom if these propositions fail, discretely insert your diaphragm as a tool for harm reduction. Every woman should be fitted with a diaphragm and shown how use it.
Who would oppose this simple option?
Theorists who argue against the diaphragm are afraid that women will abandon the male or female condom. However, surely we cannot deprive women of the diaphragm alternative when so many people are failing to use anything at all. Shouldnt women be educated and empowered to make their own choices?
Zena Stein is an epidemiologist at the School of Public Health, Columbia University.
Ida Susser is an anthropology professor at City University of New York and adjunct
professor, Department of Socio-Medical Sciences School of Public Health,
Columbia University. Marion Stevens manages the Treatment Monitor at the Health
Systems Trust. |
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