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Power and Prevention

October 2000

For poor countries unable to afford anti-HIV treatment, prevention remains the foremost tool against HIV. Still, many barriers exist for people -- especially women -- trying to prevent HIV and other sexually transmitted diseases (STDs).

Not only are women biologically more susceptible to contracting HIV, but they also face social barriers that prevent their access and use of available prevention methods. The recognition of gender-related constraints for HIV prevention has led to the demand for female-controlled and initiated methods of protection. Below is an update of two advances in this field.


The Female Condom: Reality or Farce?

In recent years, a great deal of attention has been paid to the female condom. The theory is that the condom provides women with more control in protecting themselves and/or their partners from HIV and STD infection (as opposed to the male condom). The question is whether the female condom really works as intended. Apparently, the answer depends on who you ask.

Reports from Brazil, Thailand, South Africa and Zimbabwe show a general acceptability among women (including HIV-positive women) of female condoms. They suggest that, when combined with education about using it correctly, there is a strong likelihood of the female condom being included in a woman's sexual activity, providing a woman-initiated method for preventing pregnancy and the transmission of STDs and HIV.

The cost of the female condom prohibits many women around the world from using them (they cost ten times as much as male condoms). This leads many to question whether poor women will be able to access them.

The safety and effectiveness of re-using the condom is also being examined. Because the female condom is made of polyurethane and is quite strong, some researchers believe that re-use may be possible. The main issue is figuring out a safe method for cleaning and storing it after each use.

It's recommended to use a new condom each time, while many educators agree any use is better than none.

Not everyone is sold on the female condom. Aside from its expense, its critics say that its visibility and noisiness requires the buy-in of male partners. Unfortunately in the sessions, little attention was devoted to the role of men in the use of female condoms.

Previous observations in the US and Canada suggest that heterosexual couples who can negotiate safer sex often prefer the male condom. Because the female condom is so "obvious," it's unlikely that women who cannot negotiate safer sex in their relationships will have any greater success with the female condom.

Some women report ongoing problems with cervical pain related to consistently using the female condom. Proponents and educators agree that, over time and with good education, women get better at inserting the condom correctly and complaints of discomfort or pain decrease significantly.


Making Microbicides Happen

A potentially more realistic method of female-controlled and initiated prevention may be microbicides. These substances (gel, cream, sponge, vaginal ring or vaginal wipe that kill pathogens) are being studied to see if they can reduce transmission of sexually transmitted diseases when applied to the vagina or rectum. Microbicides might be able to prevent STDs, including HIV, but allow for pregnancy.

The effect of microbicides works for both partners, so that STD infection is prevented as with barrier methods (like condoms). Microbicides are generally inexpensive and can be used with far less of the partner's cooperation. There is even the possibility of using a microbicide mouthwash for oral sex. Sounds great, right?

The problem is that development of microbicides has been slow, partly because public interest in them is low. So, while many products are currently under research, only three are in late-stages of development.

One substance that held much promise (nonoxynol-9) has just been determined to increase likelihood of STD infection. Microbicide researchers and advocates agree this news is a setback, but they're encouraged by promising research of other approaches. These include specific anti-HIV therapies that have a basis for inhibiting HIV entry when used on the skin.


The Bottom Line on Power and Prevention

Not only are female-controlled STD and HIV prevention devices (including those that allow for pregnancy) long overdue, they are absolutely necessary to save the lives of women around the world. Although there's enormous interest in the female condom, it's unclear how to turn this interest into protected sex.

Microbicides may be a better alternative, but for now that's a theory, not a fact. More money and research are needed. Many researchers believe that -- with sufficient investment (including from pharmaceutical companies) and political involvement -- a microbicide could be developed within five years. To make this happen, advocacy for a real commitment to invest in microbicide research must occur on a global level.

Still, we need to be realistic. Five- and ten-year time frames have been promised repeatedly by vaccine researchers over last 20 years with no real success yet. And microbicide research faces some of the same problems that hold up vaccine researchers.

We must remain focused on the underlying goal: to find a way to achieve female-controlled prevention -- today -- by whatever means necessary.


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