The Acceptability of a Vaginal Microbicide Among South African Men

As the HIV epidemic enters its third decade, women bear the burden of infection. In sub-Saharan Africa, where heterosexual HIV transmission is the dominant mode of infection, the number of infected women is startling. It is estimated that there are 12 infected women for every 10 infected men. The escalation of HIV infection among women is largely because women's position in society is inferior to men's. Women are often unable to make informed choices about their sexual health and unable to negotiate the use of condoms. UNAIDS has made an urgent call for the development of female-controlled methods to protect against male-to-female HIV transmission. These methods include female condoms and vaginal microbicides. A key concept in the development of a vaginal microbicide or any new product is its acceptability. The aims of this article are to assess the acceptability of a vaginal microbicide to men, and the degree to which men might prefer microbicide use to condom use.

From June to August 1999, the researchers recruited 95 men from a Durban STD clinic; 98 men from the general population of Cape Town; and 50 male university students from Pretoria (total: 243 men). Prior to being interviewed, the men received a brief demonstration of a vaginal gel, Col 1492 (Advantage 24). Those who wished to were allowed to feel the gel. Previous experience with sex workers suggested that men who visited them had a preference for dry sex, hence the importance of demonstrating the volume of the product to be inserted into the vagina. (Researchers in 11 sub-Saharan countries have documented the traditional practice of inserting drying substances into the vagina. One of the main reasons women cite for these practices is to enhance sexual experience through sensations of vaginal dryness, tightness or warmth.)

Sixty-two percent of the men knew that using a condom could prevent HIV infection, but 58 percent disliked using condoms. With respect to who should take responsibility for condom use, 52 percent of the men from STD clinics, 41 percent of the men from the general population, and 29 percent of the students felt it was the man's responsibility to initiate condom use.

The large majority of men in each group (77-87 percent) would like their partners to use a vaginal microbicide if one became available. Men in all three groups preferred a microbicide to a condom (82 percent vs. 18 percent). Approximately two-thirds of men said they would not like a product to increase lubrication in their partner's vagina.

Twenty-nine percent of men said the HIV epidemic in South Africa was not of serious concern. "Another of our findings that is of serious concern is that heterosexual anal sex practices appears to be prevalent among men," the authors wrote. "Our findings indicate a pressing need to develop microbicides that can be used for both vaginal and rectal application."

"Our findings suggest that should microbicides become available, men would be willing to use them as their primary method of protection from HIV and other STDs," they wrote. Despite acknowledging that women have a right to protect themselves from STDs, men indicated a need to be involved in the decision to use a microbicide. Several potential microbicides -- both contraceptive and non-contraceptive -- are being investigated in human trials. Men in the study reported a greater need for a non-contraceptive product than a contraceptive one, which is consistent with the major role of fertility in many African countries.

The amount of lubrication provided by the product will play an important role in its acceptance in South Africa and other countries where dry sex is practiced. "It may be useful to involve men in clinical trials currently underway to test potential microbicides, not only to ascertain safety of the product on the male genitalia, but also to determined both short-term and long-term acceptability of the product," the authors concluded. "Efficacy of the product will depend on both consistent and correct use, a key component of which is acceptability of the product among potential users."

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