1. Dual Protection = prevent pregnancy + avoid STI/HIV
This presentation describes dual protection – the process of preventing both pregnancy and STI/HIV infection. █
Note to facilitator:
Additional information on dual protection can be found in the Participant Manual, page 31. The Counseling Tool (flip book) also includes information on page 16 that providers can use with clients to counsel them about ways to avoid both pregnancy and STIs/HIV.
Photo credit: Richard Lord
August Contraception for Clients with HIV

2. Options using family planning:
Ways to Avoid Both Pregnancy and STIs/HIV
Options using family planning:
Condoms
Male condoms
Female condoms or 
Condoms
and
another family
planning method
For example: 
Any family
planning method
with
uninfected partner 
Other safe forms of intimacy
Some other options: 
Dual protection – avoiding pregnancy and STIs/HIV – can be achieved in several ways:1 █
First, consistent and correct use of condoms is very effective for contraception, and condoms are the only method that also protects against STIs/HIV. When using this option, emergency contraception should be available to prevent pregnancy should a condom accident occur. █
Second, using male or female condoms plus another family planning method – also known as dual method use – provides increased protection from pregnancy. █
Third, any contraceptive method can be used if two individuals are uninfected and each one has no other sexual partners. If a couple is discordant, the uninfected partner is at risk of HIV infection. If both partners are HIV-positive, there is some risk of reinfection with a different strain of HIV. █
Some additional options include sexual intimacy that is satisfying but does not transmit STIs or HIV – which means avoiding contact with a partner’s semen or vaginal secretions. █
Finally, delaying or avoiding sexual activity, also known as abstinence, is another safe choice. If a client chooses option 4 or 5, advise the client to keep condoms on hand should sex occur.
On the next several slides, we will discuss option 2, dual method use, in more detail. █
Note to facilitator:
When discussing option 2, reinforce that male and female condoms should not be used together. When discussing option 4, clarify that it does not include anal or oral sex without condoms, which many people dangerously believe is safe because it cannot lead to pregnancy and health workers and educational materials almost never mention it. Unprotected anal sex is especially risky, with the highest risk for STI/HIV transmission; it is also quite common, as many people use it as a traditional family planning method. Oral sex has a much lower risk of HIV transmission than anal or vaginal sex, but there is still a risk of transmission of other STIs. The risk of STI/HIV transmission is greatly reduced by using condoms during anal and oral sex.
Reference:
1. World Health Organization (WHO), Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs/INFO Project (CCP). Decision-Making Tool for Family Planning Clients and Providers. Baltimore, MD and Geneva: CCP and WHO, 2005. 
Delay or avoid having sex
Source: WHO and JHU/CCP, 2005.
August Contraception for Clients with HIV

3. Why Encourage Dual Method Use
Use condoms to protect against STIs/HIV plus another method for increased protection against pregnancy.
Reduces:
Risk of unintended pregnancy
Transmission of HIV between partners
Risk of acquiring or transmitting other STIs
To review, dual method use refers to a couple using a condom to protect against STIs/HIV plus using another method for increased pregnancy prevention. █
Dual method use helps to reduce:
The risk of unintended pregnancy, especially for individuals who need reliable protection from pregnancy that is not partner dependent
The transmission of HIV between partners, including the transmission of a different strain of HIV to a partner already infected with HIV
The risk of acquiring or transmitting other STIs █
Dual method use may not be easy to achieve. It requires ongoing support and encouragement by providers. █
Dual method use requires ongoing support and encouragement by providers.
August Contraception for Clients with HIV

4. Counseling about Dual Method Use
Users of other methods may be less likely to use condoms.
Encourage clients to consider:
Limitations of a single-method approach
Their individual risk of pregnancy
Whether partners have HIV or other STIs
The negative consequences that may result
Dual method use is an effective way to prevent both unintended pregnancy and STIs, including HIV. But studies have suggested that women with HIV who use more effective contraceptive methods are less likely to use condoms, even with a noninfected partner.2 █
These study results reinforce the importance of providers helping clients to understand the benefits of dual method use by considering the following:
The limitations of a single-method approach
Their individual risk of pregnancy and the implications of an unintended pregnancy
Whether their partners have HIV or another STI
The negative consequences of acquiring or transmitting HIV, especially as resistant strains of the virus emerge
When counseling about dual method use, the provider is responsible for helping clients determine what method(s) will be effective for them and how confident they are that a partner will use condoms. Providers must also help clients consider what adjustments may need to be made over time because as personal situations change, a client’s need for protection may change as well. █
Reference:
2. Diaz T, Schable B, Chu SY. Relationship between use of condoms and other forms of contraception among human immunodeficiency virus-infected women. Obstet Gynecol 1995;86(2):
Source: Diaz, 1995.
August Contraception for Clients with HIV

5. Counseling about Dual Method Use
continued ...
Teach clients:
To negotiate condom use
How to use condoms
Importance of using condoms consistently and correctly with all partners
Because clients often find it difficult to negotiate condom use with their partners, it is important for providers to teach skills for negotiation of condom use and the correct use of condoms. This is typically done using demonstrations and role-plays to simulate some of the more challenging obstacles clients may encounter when negotiating with their partners. When possible and with the client’s consent, partner or couple counseling on the importance of condom use can also be an effective approach. █
Men who may have intercourse with multiple partners should be counseled to use condoms even when a female partner is using another method of contraception. The advice to use condoms in addition to another method is particularly important for discordant couples. However, concordant couples, where both partners are HIV-positive, should also use condoms to avoid STIs and superinfection with another HIV strain.
Next, we will discuss other contraceptive methods that could be used either alone for pregnancy prevention or in combination with condoms for dual protection against pregnancy and STIs, including HIV. █
Discussion question:
In addition to discordant couples, describe other situations where dual method use may be appealing to an individual client or couple.
Photo credit: William Finger/FHI
Encourage dual method use for all clients with HIV who wish to protect themselves.
August Contraception for Clients with HIV

6. Safer Sex Methods and Demos
Male Condom
Female Condom
Dental Dams