Do women in the U.S. really need a microbicide? Good question. It seems to me that most of us -- whether in Vietnam or in Texas -- could use some form of protection that would allow us to control our risk for HIV and other STIs without depending upon a partner. This being the case, an ideal microbicide -- one a woman could use ahead of time; that provided near 100 percent protection and was not apparent to her partner -- would be welcomed. As one woman said to me, "I want something I do not have to ask him if we can use. I am always scared that he is going to say no and then what am I going to do?" Many women are afraid that their partner will refuse to wear a condom. Others are afraid that they will be harmed either physically or emotionally if they insist on using condoms. In some relationships, simply suggesting the use of a condom can cause suspicion, rejection and even violence. A good microbicide would help alleviate some of these women's fears and hopefully reduce their risk of getting HIV.
Condoms offer excellent protection, but too often they are not used and women cannot control their use. Studies have shown very low use of male condoms even in favorable circumstances. The lack of enthusiasm for male condoms makes microbicides a potential option for men as well, including gay men. Ideally, microbicides should be capable of protecting the insertive and the receptive sexual partner, making them attractive for men who have sex with men as well as for any man who does not want to use condoms because of the loss of sensitivity and intimacy.
But any microbicide now on the horizon probably won't offer perfect protection. Most likely, when the first microbicide does become available, it will still have to be used in combination with another form of prophylaxis to provide an individual with a high degree of reliable protection from HIV. The Global Campaign for Microbicides says, "Even when microbicides reach the market, it is unlikely that they will match the efficacy of male and female condoms for HIV prevention. Logically, it is safer to keep a virus from coming into contact with one's body than it is to try to disable it once is there."
There are also concerns that women will not use or will stop using other prophylactics when they start using the microbicide and will therefore increase their risk of getting or spreading disease. The other side of that argument is that for the women who most need a microbicide, condoms were never a good option to begin with. At least with a microbicide, women who cannot use condoms will have some opportunity for protecting themselves from sexually transmitted infections, including HIV. It is better to have some type of protection than none at all, which is the situation now faced by too many women.
Despite the need for an effective microbicide, it will be several years before we get one, and there will be little chance for getting a microbicide without continued advocacy from scientists, governments, and especially the men and women who will be using them.
In the United States, the word microbicide still does not resonate with some of the very women who are perceived to most need options for protecting themselves from HIV. In discussions with a number of women age 20 to 55 in my town, the majority of them could not even define the term microbicide, let alone explain how they would be used. It is disturbing that scientists and advocates are struggling to get a microbicide to market for consumers who do not yet understand its relevance to their lives. In a group in Dallas, Texas, an activist gave a talk to help a group of HIV-positive women understand the use of microbicides. After the presentation, one of the participants said to me, "What was that about? I am not going to use that while having sex -- no way." Obviously this means that we need to begin reaching out to women who will eventually be using microbicides, even while we are trying to get a product past Phase II trials. We must begin to advocate for ourselves. The advocacy of women legitimizes the need for more research to produce an effective microbicide.
How do we get more women involved in the campaign for a microbicide? How can we get more women empowered to protect themselves from disease? Education is a start. We must find a way to get information to women in communities where microbicides will be most beneficial -- communities where the risk is greatest. This includes HIV-positive women, teenage girls at Planned Parenthood clinics, transgendered women, college students, sex workers, homeless women, and married women showing up in domestic violence shelters. In addition to providing people with information, we must teach the importance of advocacy. Historically, the women who could benefit the most from a microbicide (or female condom, or needle exchange, or responsive medical care, and so on) have been the least active in advocacy. The reasons are the same as why women need a microbicide in the first place. Getting women involved will be difficult if we do not talk about microbicides in a way that resonates with their experience. This means it is our job to pay attention to the realities of sexuality, economic, geographic, and family differences regardless of whether we're talking with rural women, poor women, sex workers, married women or lesbians about this issue.
The power in relationships between men and women is too often unequal. Women tend to have less power in relationships than men -- and not only in India and Africa, which is what people usually talk about when discussing microbicides -- but here in Texas as well. As a result, many women learn that speaking up on the job, in school, at home, or in a relationship, can have negative consequences. The inability to control the method of prophylaxis used during sex and the resulting risk of disease is a symptom of this lack of power.
Of course, none of these problems will end with the creation of a microbicide, however we may see the tide begin to turn. Another participant from a local Dallas support group said, "I want a relationship where I do not have to worry about the fight over condoms. I get tired of always having to ask him to put one on. I really hope someone will create something that I can use for my own protection." As women begin to have more control over their sexual health, the balance of power in their relationships might begin to change. This shift could have consequences for how women operate in relationships and society. Hopefully, the most dramatic change will be a reduction in the growing number of women who test positive each year for HIV and other sexually transmitted infections.
Eventually, a microbicide will appear that benefits women. Having additional protection against HIV and STIs would be a great breakthrough, but another important benefit will be if it helps women gain more control in their relationships and their lives.
Back to the GMHC Treatment Issues September 2003 contents page.