The report contains the recommendations of a meeting of experts convened last October by the World Health Organization's (WHO's) Department of Reproductive Health and Research (RHR) and the CONRAD Program. The experts also concluded that spermicides containing nonoxynol-9 do not protect against two other common sexually transmitted infections -- cervical gonorrhea and chlamydia.

Nonoxynol-9 has been used over the past half-century in a wide range of spermicidal products—vaginal gels, creams, foams, suppositories, sponges, and films, used alone or with other contraceptive devices, such the diaphragm. It is the main ingredient in at least 18 spermicides sold over the counter throughout the world. Estimated numbers of women of reproductive age using spermicides vary from country to country, from less than 1% in Asia to nearly 17% in some Latin American countries. In the United States, about 11% of women use these products.

In the 1970s and 1980s, laboratory tests showed that nonoxynol-9 could inactivate the organisms that cause gonorrhea, chlamydial infections, and other sexually transmitted infections, as well as HIV. These findings fueled hopes that it could function as both a contraceptive and a microbicide.

But clinical trials conducted to date do not support these hopes. On the contrary, two studies mentioned in the report point to an increased risk of STIs (sexually transmitted infections), including HIV infection, in women using nonoxynol-9 products.

Dr. Henry Gabelnick, director of CONRAD, emphasized “the failure of nonoxynol-9 to provide protection against HIV and other STIs should not lead to the conclusion that microbicides are not possible but should instead accelerate research to find safe and effective products.” CONRAD is a non-governmental organization administered through EVMS. Its mission is the development of new technology for fertility regulation and prevention of sexually transmitted infections that is appropriate for developing countries.

Scientists are working on some 60 promising compounds, of which 11 have reached the clinical testing stage, but a lack of funds and interest by large pharmaceutical companies is slowing progress. Although the potential market is large — an estimated 340 million cases of curable reproductive tract infections occur each year — most cases are in resource-poor, developing countries.

One possible reason for the increased risk of STIs in women using nonoxynol-9 products is that nonoxynol-9 can disrupt the epithelium, or cell wall, of the vagina, thereby potentially facilitating invasion by an infective organism.

The frequency of this epithelial disruption seems to depend on the intensity of use of the product — from 18% of women using the product every other day to 53% using it four times a day, in one study.

“Women who have multiple daily acts of intercourse should be advised to choose another method of contraception,” the experts concluded. However, they added, for women who do not use spermicides frequently and who are not at a high risk of HIV infection, spermicides that contain low doses of nonoxynol-9 are “probably safe.”

"Nonoxynol-9 clearly does not prevent HIV infection and may even favor infection if used frequently," said Dr. Tomris Turmen, executive director of family and community health at WHO. "There is an urgent need to develop a microbicide which can substantially reduce the transmission of sexually transmitted infections, including HIV, and which can be used by women."

Regarding the use of spermicides for contraception, the report concluded that, when used alone, nonoxynol-9 is only moderately effective for pregnancy prevention but better than no contraceptive method at all.

"Although far less effective than the pill or intrauterine devices or injectable or implantable contraceptives, nonoxynol-9 spermicides offer some advantages," according to Dr. Tim Farley, who heads RHR's reproductive tract infection team. “They are readily accessible as over-the-counter products, available just about everywhere in the world and they are under the woman's control.”

Nonoxynol-9 is sometimes added to male condoms as a lubricant. The experts found no evidence that nonoxynol-9-lubricated condoms provided any more protection against pregnancy or sexually transmitted infections than condoms lubricated with silicone, used as a lubricant for the majority of condoms available in developing countries. Since nonoxynol-9 may cause some adverse effects, the experts recommended that such condoms should no longer be promoted, but noted, “it is better to use a nonoxynol-9-lubricated condom than no condom.”

There is also concern about the use of lubricants containing nonoxynol-9 in anal intercourse. The evidence reviewed by the experts suggested that an "increased risk of infection soon after the application of products containing nonoxynol-9 seems quite likely."

While spermicides containing nonoxynol-9 remain a contraceptive option for women at low risk of HIV infection, they are substantially less effective in preventing pregnancy than most other methods. Women at risk of HIV infection who want contraception should be informed that consistent and correct condom use is highly effective for pregnancy prevention and prevention of sexually transmitted infections, including HIV infection.