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Pickett Fences: Mind the Gap

Microbicides for the Coot ... and the Boot

July/August 2004

Jim Pickett

This year, six vaginal microbicides are expected to enter into Phase III clinical trials, recruiting thousands of women who will be testing the efficacy and safety of these products. In the form of creams, gels, lubes or suppositories, vaginal microbicides will either kill or immobilize HIV, block HIV infection by creating a barrier between the virus and the cells of the vagina, or prevent the HIV infection from taking hold after it has entered the body.

The best vaginal microbicide(s) will employ two or more of the above mechanisms for extra effectiveness. By 2010, we could very well see one or more of these products on the market.

There are a total of 62 vaginal microbicide candidates in the development pipeline; 18 of which are in Phase I, II, or III clinical trials. The other 44 candidates are in pre-clinical development.

So, that's all fine and good for the coot (i.e., vagina.) And c'mon people, give us three cheers for the coot! It's about time women had some prevention options they could control, that wouldn't rely on some stupid man. Let's be clear, there is not a society on the planet that can be proud of its males in terms of how they behave (and misbehave) in heterosexual relationships. For women throughout the world, the strongest predictor for their own HIV risk is being married or involved in a committed relationship. Their perception of fidelity from their partners won't protect them from a man who has a different concept of fidelity, trust and direct, honest communication.

All hail vaginal microbicides! They can't get here too soon.

But hey, what about the boot (i.e., booty, butt, ass, culo, can). Just where are we at with rectal microbicides, which would be similar to vaginal products but would protect our precious triumvirate of anus, rectum and colon during anal intercourse? When will Booty Butter be on the shelf of your favorite grocer? How many products are in development?

None. Yet. Key word -- yet.

Also know that in the United States, about seven times more heterosexual women have anal sex in comparison to the number of gay men who do. In fact, about 1/4 of all American women have had anal sex, and they are unlikely to engage in this activity with condoms. A study done by UCLA found that 35-48% of gay men reported having unprotected anal sex in the last year.

Can't we just use vaginal microbicides for the booty? If they work for the coot, why not the boot? Um, no, it doesn't work like that. The vagina is a very different environment from the Holey Trinity my dears.

For one, it is an enclosed pouch, where the rectum is essentially one big, open tube (think Holland Tunnel.) From anus to rectum to colon we're talking about two feet, right up to the spleen. Hello!

The epithelium of the rectum is only one cell layer thick and very fragile, the vagina is a much tougher customer with seven cell layers. The rectum is very vascular, very lymphatic, very vulnerable to infection, and any trauma (such as that caused by anal penetration) may facilitate HIV transmission. And even with the Holland Tunnel on the inside, the anus is very tight and micro-abrasions occur in even the most gentle and loving of sexual intercourse.

Another couple of interesting rectal tidbits are that HIV is present in the rectal mucosa of an HIV-positive person and that the cells in the wall of the rectum and colon are actually designed to take up foreign particles and transport them to immune cells inside the body to be destroyed. HIV diabolically takes full advantage of this system. With the rectum we also need to be mindful of fissures, fistulas, ulcerations, hemorrhoids, and human papilloma virus (HPV).

So no, we can't use vaginal microbicides in the rectum, though they definitely need to be made safe for the rectum, even if they won't be effective (first do no harm.) And while there is pre-clinical research happening in this area, no, we don't have any rectal candidates yet. But it doesn't have to be that way.

Research has shown that a vaginal or rectal microbicide that is only 60% effective could prevent as many as 2.5 million deaths worldwide over three years if only 20% of people with access used it 1/2 the time they did not use condoms.

What this means is that we got to get busy. We have to begin advocating for the booty. Gay men and heterosexual women need to mind the gap, we need to talk about anal sex at dinner parties and on golf courses. We need to be involved in the pre-clinical research, like giving up some rectal tissue samples for scientific study, or attending a focus group about anal sex practices.

We must ask for, no -- demand, Booty Butter. And we can't make the asking while tittering behind our monogrammed handkerchiefs.

And we have to be patient. There are significant challenges to developing an effective rectal microbicide, challenges that are as much about human physiology as they are about politics and culture. We cannot be dissuaded or dismayed. Many gay men are already foregoing condoms for a host of reasons. We know women often don't use protection during anal sex. Wouldn't it be marvelous to be able to provide these lovely ladies and gentlemen with something to keep their bootys happy and healthy?

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To read more of Jim Pickett's columns, click here.

This article was provided by Positively Aware. It is a part of the publication Positively Aware. Visit Positively Aware's website to find out more about the publication.
See Also
More Analysis and Views on Microbicides

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