Rectal Microbicides: We Need Less Silence and More Science
At the opening session of the Microbicides 2008 Conference in New Delhi, India's Minister of Health and Family Welfare spoke about the importance of finding a safe and effective rectal microbicide (RM). Just hearing a public official talk about RMs was a significant victory for everyone fighting for them.
Rectal microbicides are products that could be available in the form of lubricants, creams, gels, douches, or enemas, and could be used to protect against HIV transmission when used during anal intercourse (AI). They do not exist yet, but researchers and scientists are working on them.
Around the world, almost all AI is unprotected. Compared to unprotected vaginal intercourse, unprotected AI is 10 to 100 times more likely to transmit HIV. Why? The lining of the rectum is more fragile than that of` the vagina, and the cells that are open to infection are closer to the surface. During AI, this lining may rupture, allowing HIV to break through and infect these cells.
Unfortunately, our knowledge of who is having anal sex, with whom, and in what context is not clear. W e do know that significant numbers of heterosexuals, gay men, and men who have sex with men (MSM) in developed and developing countries are acquiring HIV by engaging in this behavior.
However, by focusing almost exclusively on gay men, MSM, and the Western world (the Americas, Europe, and Australia) when thinking about the role of AI in the HIV epidemic, we fail to see that this is a behavior that also happens between women and men and could be playing an important role in the heterosexual epidemic.
Meanwhile, our policies tend to ignore the very existence of gay men and other MSM in Asia, Africa, and other parts of the developing world. This neglect costs lives. In its ground-breaking report Off the Map, the International Gay and Lesbian Human Rights Commission decried the wall of silence that surrounds AIDS and same-sex practices in Africa. The situation in developing countries outside of Africa is often much the same, with denial of male homosexuality and anal sex between women and men.
Very little research has examined the role of AI in the epidemic in developing countries. Studies in Senegal, Ghana, Kenya and Sudan, however, indicate that HIV rates among MSM are significantly higher than in the general population. This has also been demonstrated in most countries of Latin America, and in several countries and cities in Asia.
Many countries make anal sex a criminal act, and there is strong stigma, taboo, and homophobia associated with it. At the same time, there is a lack of clarity in the language we use to describe populations and the behaviors that put them at risk, so we do not fully understand the role of AI in the general epidemic. We tend to use sex acts as a way to identify populations -- equating gay men with anal sex, for instance. Phrases like "heterosexual transmission" assume we are talking about vaginal intercourse, and actually hide the fact that women and men who identify as heterosexual engage in anal sex. This lack of clarity and honesty in discussing how HIV is transmitted between all types of human beings is troubling. It means that a significant portion of the pandemic often described as "driven by heterosexual HIV infection" could actually be caused by unprotected AI.
Language matters. Inaccurate, overgeneralized descriptions of the epidemic affect how we design HIV/AIDS programs, whom we design them for, and the kind of research we do. Ignoring populations and behaviors means important voices are silenced, and it also means these vulnerable groups are not served by prevention programs.
These dangerous silences -- the denial of anal sex, and the denial of the existence of MSM -- among communities, funders, policymakers, and even key players in the microbicide community -- help to create the unfortunate circumstances we are in, namely, that the necessary resources have not been allocated to the research and development of safe, effective, and acceptable rectal microbicides. Funding for rectal microbicide research is a trickle compared to that for vaginal microbicide research.
So, when the top health official in India simply mentions the words "rectal microbicides," it really is a big deal. Ending the silence is the first step to getting the amount of funding we need to push the science forward. In addition, we need to push for more research into human sexual behaviors so that we have a better understanding of the epidemic, whom it affects, and how the virus is passed from person to person.
International Rectal Microbicide Advocates (IRMA), a network with over 600 members from 46 countries, released Less Silence, More Science: Advocacy to Make Rectal Microbicides a Reality at the Microbicides 2008 conference in India. This report, which can be found on IRMA's website (www.rectalmicrobicides.org) calls for a Global Rectal Microbicide Development Plan. It describes the global challenges to their development, lists key goals and strategies, and serves as a reference on rectal microbicide science.
"Rectal microbicides are an essential technology that could allow men and women to protect themselves, without fear, without shame, without taboo," says Ghana's Manju Chatani, Coordinator of the African Microbicides Advocacy Group and a member of the IRMA Steering Committee. IRMA calls for at least a five-fold increase in funding for rectal microbicide research by 2010 -- from $7 million a year to $35 million -- and states that governments and foundations from Europe, Canada, Australia, and the U.S. must invest in this critical, desperately needed prevention technology.
"This work is so incredibly important. Every day we don't move forward, thousands more get infected," said Dr. Peter Anton from UCLA, principal investigator for the world's first safety study of a rectal microbicide. "There is an ethical obligation here to advance the research and development of rectal microbicides, with good science and community awareness."
Anton presented several times at the Microbicides 2008 conference, sharing some interesting early data from his study of a gel called UC-781, which contains a non-nucleoside reverse transcriptase inhibitor (NNRTI.). The study was small and was designed to look at the gel's safety. While all the data are still not fully analyzed, Anton noted that there were possible signs of efficacy -- meaning that the product is not only safe, but actually may work to protect against HIV infection. We should know more in the next several months. Anton's slide presentations from the conference are all available on the IRMA site, and Gus Cairns provides a nice, concise summary of this study at www.aidsmap.com (search for UC-781 to find it.)
"It is imperative that morality not get in the way of protecting human beings and life; people of every sexual orientation have practiced anal sex since the beginning of time," according to Rick Jones of Amsterdam, representative from the Global Network of People Living with HIV/AIDS and a member of IRMA's Steering Committee. "The time for bigotry is over. We need to help those who are not infected stay that way."
Rectal microbicide advocacy includes you. If you only have a few minutes, you can be part of the solution. Visit the IRMA site and read a fact sheet, peruse a news item, or flip through a presentation to learn more. Sign up for IRMA's active email list to stay in the loop. And share the love! Pass along the IRMA web address to another advocate, researcher, policy maker, or potential funder. You too can help end the silence!
Jim Pickett, who chairs the International Rectal Microbicide Advocates and is Advocacy Director of the AIDS Foundation of Chicago, has been living with HIV for 13 years.
This article was provided by ACRIA and GMHC. It is a part of the publication Achieve. Visit ACRIA's website and GMHC's website to find out more about their activities, publications and services.