Cervical Barrier Methods: Expanding Women's Options for HIV/STI Prevention 

HIV infection is a large and growing problem for American women, especially among African American and Latina women where prevalence rates are on the rise. When it comes to birth control methods, then, women need methods that protect against pregnancy as well as sexually transmitted infections (STIs) including HIV.

Condoms are the best method of HIV/STI protection for those who are sexually active, and condoms also prevent pregnancy—this is referred to as “dual protection,” but condom use requires a male partner’s consent and participation. The rise of HIV among women and the lack of female-controlled methods for dual protection have led researchers to investigate the potential of new and existing barrier methods for dual protection. The diaphragm is currently being studied as a possible candidate for female-controlled HIV/STI prevention.

Although there have not yet been any gold-standard trials of the diaphragm for the prevention of STIs, observational studies suggest that the diaphragm may offer some protection against chlamydia, gonorrhea, pelvic inflammatory disease (PID), and cervical cancer.

Health care providers cannot currently recommend diaphragm use for STI prevention based on this data, but more research may lead to changes in how the diaphragm is used.

The diaphragm is typically used with a spermicide, however the World Health Organization has concluded that although spermicides reduce the risk of pregnancy, they do not offer protection against HIV/STIs and should not be used by women at high risk of HIV/STI infection. For this reason, most current studies evaluating the diaphragm for HIV/STI prevention substitute spermicide with a lubricant gel (such as Replens® or K-Y® Jelly) or with a microbicide (a topical product that could prevent HIV/STIs when used vaginally).*

History, Pregnancy Prevention and Cervical Barrier Methods

Cervical barrier methods, such as diaphragms and cervical caps, are among the oldest known contraceptives. The diaphragm and cervical cap prevent pregnancy by blocking sperm from entering the uterus and fertilizing the egg. Today, cervical barriers are approved for family planning purposes and are safely and successfully used by women in the U.S. and around the world.

Women have relied on cervical barrier methods to prevent pregnancy for many centuries. Ancient texts dating to 1850 BC document the use of crocodile-dung and of fermented dough as cervical barriers. Romans covered the cervix with fruits, nuts, and wool to create a spermicidal barrier. In the mid-1800s scientists invented modern diaphragms and cervical caps. By the early 20th century, the diaphragm and other cervical barriers had become popular among European and American women. In the U.S, the birth control proponent Margaret Sanger advocated for physician-provided diaphragms and caps in order to circumvent laws banning over-the-counter forms of contraception such as condoms.

Cervical barrier methods are safe, effective contraceptives which are woman-initiated and woman-controlled. These methods are a good option for women who cannot, or chose not, to use hormonal methods such as birth control pills. Cervical barrier devices can be inserted up to six hours prior to intercourse, and therefore may be used without a sexual partner’s knowledge and don’t interrupt sexual activity. In contrast, other barrier methods require a man’s cooperation, which may be difficult for some women to negotiate. Cervical barrier methods are also reusable which makes them cost-effective. Despite their past popularity, however, use of cervical barriers has declined in recent years.

Using Cervical Barrier Methods

According to the 1995 National Survey of Family Growth, less than three percent of American women who use contraceptives choose diaphragms or cervical caps. Low usage of these methods is due in part to misperceptions among women and bias among health care providers.

Although inconvenience is often cited as a reason not to use these methods, Marie Harvey, a researcher at the University of Oregon, reports that women who are satisfied with the diaphragm cite three major factors:

• women’s confidence about their ability to use the method consistently and correctly
• ability to use the method without a partner’s knowledge
• ability to use a diaphragm without interrupting the sexual mood

While many women assume that the diaphragm is inconvenient, others have different, positive experiences. Whether or not cervical barriers are preferable also depends on the attitude and preference of the sexual partner. Many men opt for cervical barriers instead of condoms because they don’t interrupt sexual activity. Barrier methods also allow skin-to-skin contact where condoms do not.

Health care providers’ perceptions of their clients also influence diaphragm use. If providers think that the diaphragm can only be used successfully by women with certain socioeconomic or behavioral characteristics, they may not inform their patients about diaphragms or might counsel against their use. Ultimately, this limits women’s and men’s choices.

For example, a family planning nurse involved with a research project in New York City described the ideal diaphragm user as “someone who can stop and (insert) it in the heat of the moment.” Being responsible and having good self-control are other characteristics providers used to describe an ideal diaphragm user. However, research has shown that women with a wide range of circumstances and personal traits find the diaphragm to be an acceptable method of contraception and are able to effectively use the device.

Diaphragm users in the U.S. tend to be older, educated women. Regardless of whether this is a result of provider bias or women’s self-selection, educating women and providers about the method’s positive attributes could potentially lead to a change in usage patterns.

New Evidence About the Cervix

A growing body of research suggests that covering the cervix with a barrier like the diaphragm could play a key role in preventing the transmission of HIV and some STIs.

In a recent paper published in the journal AIDS, Tom Moench and colleagues point out that several factors make the cervix biologically more vulnerable to HIV/STIs than other areas of the female reproductive system. First, the delicate lining of the cervix is damaged more easily than the cell lining of the vagina. Second, recent evidence suggests that the cervix has a concentration of cells with HIV receptors, increasing its vulnerability to HIV infection. Finally, the cervix is the entryway to the upper genital tract, so covering the cervix also protects these areas from infection. In a project now underway in Southern Africa, researchers are evaluating the diaphragm’s effectiveness against HIV as well as women’s comfort level and acceptance of the diaphragm as a potential HIV prevention method.

Implications for American Women

Many women are at high risk of HIV/STIs for a combination of social, biological and economic reasons. Based on data collected in twenty-nine states by the Centers for Disease Control and Prevention between 1999 and 2002, heterosexually acquired HIV infections represented thirty-five percent of all new HIV cases and sixty-four percent of heterosexually acquired HIV infections occurred in females. In addition, young women accounted for eighty-nine percent of heterosexually acquired HIV infections among people between 13-19 years-old.

The CDC’s HIV prevention strategic plan (2001), estimates that African American women represented sixtry-four percent of new HIV infections among all women and Latinas accounted for eighteen percent, yet these two groups represent twelve percent and fourteen percent of the U.S. population respectively. Further, non-Hispanic black and Hispanic females are more likely than other females to be exposed to HIV because of the high prevalence of infection among non-Hispanic black and Hispanic males.

Race and ethnicity, however, are not themselves risk factors for HIV infection. African American and Hispanic women are also disproportionately affected by poverty, which is associated with an increased risk of HIV. Economic stability can influence a woman’s negotiating power in a relationship. Even if a woman suspects that her partner is at risk of HIV, she may be reluctant to negotiate condom use for fear that the man will leave her or withdraw financial support.

Limited access to HIV prevention education and misinformation also contribute to high rates of HIV among African American and Hispanic women. In general, African American and Hispanic women face challenges in gaining access to health care which is strongly influenced by insurance coverage and health system structures.

Researchers at the University of Oregon who interviewed groups of racially and ethnically diverse young women at risk of HIV/STIs found that seventy-two percent of the respondents would be more likely to use the diaphragm if it protected them against HIV. This finding suggests, once again, that female-controlled methods are in demand.

If current research shows that the diaphragm can reduce the risk of HIV, women will have an alternative prevention method which protects against both pregnancy and HIV/STIs.

* Microbicides are currently under development and are not yet available.

* Teresa Harrison, SM and Katy Backes, MPA are Project Managers at Ibis Reproductive Health a non-profit organization that aims to improve women’s health, choices and autonomy.