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Sexual Practices as Context: the Case of Microbicides

Scientists have been working for more than a decade to create microbicides, chemical agents typically in the form of gels or creams applied topically to the vagina or anus that will prevent unintended pregnancy and protect against the transmission of HIV and other sexually transmitted diseases (STDs). Scientists expect that a viable microbicide will be available soon, yet even once these products are scientifically proven to be physically safe and effective there remain serious logistical questions about how to make them accessible through adequate funding and supportive policies. In addition, attitudes, beliefs, and expectations about sex will determine whether or not individuals will actually use this new prevention technology. Studies examining the acceptability of microbicides and the factors that make their use more or less likely are underway.

The ongoing effort to develop viable and accessible microbicides stems from their potential as a woman-controlled method of HIV-prevention. Women are currently disproportionately vulnerable to HIV infection- in sub-Saharan Africa alone, 57 percent of adults with HIV are women, and young women ages 15-24 are more than three times as likely to be infected as young men.1 Social conventions and power imbalances within relationships render many women unable to negotiate abstinence, fidelity, or condom use with their sexual partners, but microbicides can be applied before sexual intercourse without the knowledge of a partner who might object. As covert family planning has long been a successful strategy for many women to circumvent partners' objections to contraception, it seems that women would likewise benefit from methods that protect against infection and that can be used in secret, if necessary.2 Recent studies, however, show that many women do not want to use microbicides without their partners' knowledge, either out of a desire for mutual honesty or out of fear of ramifications if discovered.

At the biannual international Microbicides conference held in Cape Town, South Africa in April 2006, Sara Whitehead, a medical epidemiologist working on a joint program between the U.S. Centers for Disease Control and the Thai government suggested that marketing a microbicide gel as a lubricant could help a woman negotiate its use more effectively than if the gel was for "disease protection." She added, "men may certainly be aware of what the product is supposed to do, and that it has an HIV prevention effect, but I think it makes the discussion, negotiation and decision making process much less awkward in some relationships if there are multiple purposes for the gel and you don't have to say which of the purposes is your main reason for wanting to use it."3

While such social marketing may be helpful by minimizing an association with AIDS (marketing condoms for family planning rather than HIV prevention has had some success), marketing microbicides as a lubricant poses another range of problems, especially in the context of communities where "dry sex," vaginal intercourse with little to no lubrication often requiring women to "dry" their vagina in some way, is the norm. Some men will associate the extra lubrication with infidelity or suspect a vaginal infection.4 For example, a recent study showed that in Zimbabwe, widespread cultural beliefs that women's vaginas should be "dry and tight" may interfere with the acceptability of vaginal microbicides. Furthermore, the Zimbabwean men make most decisions regarding sex, as in many places, and microbicide use seems dependent on their attitudes.5 Changing this sexual expectation would have positive implications for increased microbicide use and decreased HIV risk more generally, as dry sex is incompatible with condom use (without lubrication a condom is more likely to cause tears in the vaginal canal that increase risk infection).

Microbicides have been conceived as a means of mitigating the vulnerability of women that arises out of their disempowerment and widespread taboos about openly discussing sex or HIV/AIDS. But it turns out that in order for microbicides to live up to their potential, the global community must find ways to empower women and talk about sex. At the Microbicides conference in South Africa, Melissa May, spokesperson for the non-governmental organization Population Council, acknowledged that microbicides are "not going to be the silver bullet, the magic bullet," but they could be "another very important prevention tool in the fight against HIV/AIDS." She explained that, "as long as there is expanded dialogue and men and women can talk about sex openly," microbicides and condoms will be useful when used together to prevent the spread of HIV.6

To facilitate this necessary dialogue, the global community must first invest in social science research and pilot education and distribution projects in order to understand the social barriers to microbicide use. At the same time, comprehensive sexuality education programs can help to pave the way for microbicide acceptability by fostering the sort of dialogue May claims is necessary for the successful adoption of HIV prevention methods. Such programs offer not only facts about HIV/AIDS and pregnancy prevention but also opportunities for real conversation about the underlying norms and values-including ideas about gender equity-that shape relationships and sexual behaviors. With 15,000 people worldwide infected each day, the world clearly needs interventions that will immediately stem HIV transmission, in order for these to be effective, however, we must also work toward complex social changes without which we cannot hope to end the AIDS pandemic.

References

1. Comprehensive Sexuality Education is HIV Prevention, (DC: SIECUS ) accessed August 21, 2006, <http://www.siecus.org/inter/FS_WomenHIV-AIDS.pdf>
2. Cynthia Woodsong, "Covert Use of Topical Microbicides: Implications for Acceptability and Use," Perspectives on Sexual and Reproductive Health 36(3) (May/June 2004) accessed 6 July 2006, <http://www.guttmacher.org/pubs/journals/3612704.html>.
3. Global Challenges | Kaiser Daily HIV/AIDS Report Summarizes Research Presented at Microbicides Conference, Kaiser Network (27 April 2006), accessed 21 August 2006, <http://www.kaisernetwork.org/daily_reports/rep_index.cfm?DR_ID=36875>
4. Cynthia Woodsong, Covert Use of Topical Microbicides: Implications for Acceptability and Use (North Carolina : Family Health International, 2004).
5. HHM Janneke, et al, "Men's Attitudes Toward Vaginal Microbicides and Microbicide Trails in Zimbabwe," International Family Planning Perspectives 25(1):15-20 (March 1999).
6. Global Challenges | Kaiser Daily HIV/AIDS Report Summarizes Research Presented at Microbicides Conference