To protect against AIDS, all women who are not sure whether they or their partners are infected should use condoms during every act of sexual intercourse (see Population Reports, Condoms Now More than Ever, H-8, September 1990). If a woman's partner will not use a condom, she should at least use a spermicide. Any couple whose sexual relationship has not been or will not continue to be a long-term, mutually faithful one faces a risk of exposure to HIV. Women who have more than one sexual partner or whose partners have more than one partner are not the best candidates for IUDs in any case. Nonetheless, any such woman using another effective method of family planning to prevent pregnancy should be encouraged to continue it even while she uses condoms and spermicides to prevent HIV infection (231). HIV can spread from a woman to her fetus during pregnancy. Therefore preventing pregnancy is especially important if a woman or her partner is likely to be infected.

Available evidence does not show that IUD use makes a woman more susceptible to HIV infection, but little research has been done to date. An Italian case-control study concluding that IUD use increased a woman's risk of being infected by an HIV-positive sexual partner (616) had serious methodological flaws (629). An analysis in Kenya that took account of other methods used found that current or past use of IUDs, injectables, and oral contraceptives did not affect the chances of being HIV-positive, and use of condoms reduced the chances (613).

There also has been little research on whether IUDs pose any special risk to a woman already infected with HIV. In practice, a WHO scientific group recommending eligibility criteria for various family planning methods concluded that HIV infection or high risk for HIV infection, as with other STDs, rules out IUD use (565). HIV testing should not be required for women who want IUDs, however (599). Both the WHO scientific group and the IPPF International Medical Advisory Panel recommend that IUDs be removed from HIV-positive women (565, 599).

There are no reports that HIV has been transmitted to a woman during IUD insertion or that a health care provider has been infected with HIV while inserting an IUD in an infected woman. Still, reports in Kenya suggest that concern about HIV transmission has affected providers' practices. While many providers are more scrupulous about infection-prevention procedures when inserting IUDs, fear of AIDS may also be creating reluctance to insert IUDs (633).

The same clinic procedures that protect both clients and health care providers against other infections also can protect them against HIV infection. To avoid any risk of infecting a client during IUD insertion, providers should see that all instruments are high-level disinfected before each use (see sidebar, Infection Prevention for IUD Insertion and Removal). To avoid any risk of transmission from a client to a health care provider, standard procedures for preventing blood-borne diseases such as hepatitis B should be followed. Providers should:

• Wear latex or plastic gloves if hands might come in contact with blood, body fluids, or mucous membranes;
• Change gloves after each client;
• Wash hands immediately and thoroughly after any direct contact with blood, body fluids, or mucous membranes and after removing gloves;
• Take care to avoid pricking or cutting themselves with a syringe or other instrument that might have blood or body fluid on it; and
• Clean up blood spills with disinfectant immediately (396, 435, 635).