Studies are currently underway to test the effectiveness of diaphragms to protect women against HIV and other STIs, including a large trial based at the University of California, San Francisco (P.I. Padian N). Once widely used for pregnancy prevention, the diaphragm has been replaced by more effective hormonal methods and is often viewed as out-moded. If proven effective as a STI-prevention device, any successful reintroduction of the diaphragm will depend largely on providers, certainly as long as the diaphragm must be fitted. Provider recommendations and practices are an essential component of access to prescription methods, and their perceptions will be important in determining whether the diaphragm regain use. The objective of this study is to evaluate providers' perceptions of the diaphragm and their willingness to integrate it into the choice of methods they recommend for prevention of HIV/STIs and pregnancy. We propose to investigate preferences for different approaches to HIV/STI counseling in Southern Africa and the United States, where women have widely divergent disease risks and fertility intentions, through in-depth interviews and survey research. As little research has been conducted in this area, a qualitative component is necessary to inform the larger survey study and to interpret findings, particularly for country-specific conditions. In the interviews and survey, we will assess provider attitudes, knowledge and prescribing practices of the diaphragm, since biases and lack of familiarity could hinder acceptance of the method. We will also document the extent of training that currently exists on the diaphragm as part of family planning. We will measure providers' willingness to prescribe the diaphragm at different levels of efficacy for different types of clients. The interviews will investigate providers' specific concerns about diaphragm promotion, and their perceptions of the appropriate place for diaphragms within counseling strategies. The providers will be asked to assess clinical scenarios, and judge the suitability of various counseling messages for each case. The messages will range in complexity, from simple to hierarchical, and will include 1) HIV/STI-prevention messages; 2) pregnancy prevention messages; and 3) combination HIV/STI and pregnancy prevention messages. We will analyze how provider selection of a suitable message for each case changes with varying levels of diaphragm efficacy, client disease risk, and different country conditions, including HIV prevalence. We will compare results across nurses and physicians providing reproductive health care. It is critical to work with providers at the inception of the diaphragm effectiveness trial, so that in anticipation of positive results, we can move quickly to policy and dissemination. Without a concerted plan to bring providers the latest information in the most effective, usable form, the diffusion of new knowledge in this area is likely to remain slow and highly variable. As the diaphragm effectiveness results become available, data from this proposed study will position us to design counseling interventions and to address provider education and training needs.
