Dual-purpose promotion. Many promotions stress dual benefits of condom use (219, 234). A growing number of family planning programs are providing information and counseling about STIs and are promoting condoms for STI prevention as well as for contraception. Still, there is a long way to go. A study among clinics in nine African countries found that only 2% to 36% of new clients were informed that condoms are an effective method of preventing STIs (359).

Offering people a choice of reasons to use condoms encourages use (171). In Ghana focus-group research found that women felt more comfortable talking with their husbands about using condoms for family planning, even if the women themselves were also concerned about disease (31, 426). In Zimbabwe women said that discussing contraception was a good negotiating point for using condoms (424).

DKT International/PSI

As in Ethiopia, many condom promotions stress the dual benefits of condom use—preventing STIs and unintended pregnancies. Offering people a choice of reasons to use condoms increases use.

In general, consistent use of condoms as a secondary method declines as the effectiveness of the primary contraceptive method increases (174, 472). In the US, condom use fell among women who adopted Norplant implants or Depo-Provera injectables. Notably, the decrease was concentrated among women with one partner, while condom use among women with multiple partners rose (126).

Many couples find it difficult to use two contraceptive methods (237). Some providers now recommend that all users of condoms and other barrier methods should have emergency contraceptive pills (ECPs) available as a backup method. ECPs, however, do not prevent STIs (48).

Linking STI prevention and family planning programs. In most countries family planning programs and STI-prevention programs conventionally have operated separately, with different objectives, different reasons for promoting condoms, different outlets, and even different audiences and clientele. Attention to condoms to prevent HIV/AIDS has grown largely outside family planning and maternal and child health (MCH) programs, many of which have been concerned that their reputation could be tainted by involvement with AIDS and other STIs.

Nevertheless, as condoms have been more widely promoted for dual protection, linking family planning and STI programs has become more acceptable. Many observers have urged better linking or integration of the two (49, 105). The 1994 Cairo International Conference on Population and Development (ICPD) Program of Action asserted, "Family planning programs work best when they are part of or linked to broader reproductive health programs" (542).

While the differences in the two kinds of services may make integration difficult (12, 84, 294), many observers conclude that benefits outweigh difficulties (51, 52, 294, 328, 334, 545, 554). Still, a recent analysis of five African countries found that single-purpose nongovernmental family planning programs are often more efficient than integrated government reproductive health care programs. The researchers conclude that programs need to adapt to the local situation (514).

Shortages of funding and institutional and staff reluctance often impede integration (554), but in several countries family planning and maternal and child health programs have successfully added STI prevention to their activities. In Nepal, for example, worry about the possible stigma of STIs has proved groundless (12).

Elsewhere, increased publicity about condoms for AIDS prevention has improved the image of condoms and thus increased their use for contraception as well. In Mexico, Jamaica, and Brazil, surveys found that including messages about AIDS in family planning communication did not change the image of the condom as a family planning method (102, 176). Also, in Colombia a 3-month radio campaign promoted condoms for AIDS prevention and mentioned the Asociación Pro-Bienestar de la Familia (PROFAMILIA), the family planning organization. Surveys found that the image of condoms improved, and attitudes toward PROFAMILIA remained positive (36, 385).

The Jamaica Family Planning Association (FAMPLAN) has added safe sex counseling and HIV prevention in its family planning clinics, rural outreach services, and programs for migrant and factory workers and youth. FAMPLAN condom packaging stresses the dual benefits of condoms and the use of two methods (481). After one year of operation, the integrated program distributed 213,000 condoms in 1994 compared with 60,000 in 1992, the year before integration (481).

Integration must be carefully considered because integrating diagnosis and treatment of STIs with family planning services is not necessarily the most effective way to reduce the prevalence of STIs. Focusing instead on preventing STIs by promoting and distributing condoms and by advocating safe sexual behavior, particularly among high-risk groups, is recommended for programs supported by USAID (553).