The Context of HIV Risk Among Drug Users and Their Sexual Partners

ecause it covers more tissue area (Nowak 1993). As mentioned above,
the presence of the female condom is obvious to the male; thus, issues of
trust remain potentially problematic.
An issue that has become the subject of much debate but woefully little
research is the recommendation that women use spermicide alone when
the protection afforded by a condom is not a possible option (Cates et al.
1992; Rosenberg and Gollub 1992; Stein 1992). These would be
situations in which women perceive themselves as helpless to prevent
unprotected encounters, as in cases of rape and domestic violence. (Of
course, these events would have to be predictable for the woman to be
able to insert the spermicide). Indeed, many service providers in the
community are recommending this measure, which obviously does not
depend upon male cooperation. Arguments in favor of this
recommendation include the in vitro virucidal effects of nonoxynol-9
(North 1990), and the speculation that the lubrication afforded by
spermicidal gels may prevent tearing of the skin during episodes of
coerced sex. However, because frequent use of nonoxynol-9 has been
shown to disrupt the outer lining of the cervix and vagina in some women
(Niruthisard et al. 1991), it is possible that transmission may be
facilitated in some cases by this strategy. Indeed, in an experimental
study in which commercial sex workers in Nairobi were randomized to
receive either a nonoxynol-9–containing sponge or placebo cream, no
effect on HIV seroconversion was observed (Kreiss et al. 1992). This
study has been criticized as flawed in design and nongeneralizable in
results (Rosenberg and Gollub 1992); however, it suggests the need for
conservativism in recommending this prevention strategy. Furthermore,
some intervention specialists express concern about giving complex or
mixed messages, particularly given the extreme paucity of data regarding
the effectiveness of this strategy.
GENERAL ISSUES IN PREVENTION OF AIDS IN AT-RISK
WOMEN
Prevention efforts may not reach the women most in need, as many innercity
women are isolated and not attached to community agencies.
Individualized outreach by trusted others is the most effective way to
recruit disenfranchised women, particularly Hispanic women. When
possible, integration of AIDS prevention intervention with ongoing
trusted services already part of women’s lives is likely to enhance
maintenance of change. Emotional support for the client on the part of
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