One of the most memorable moments in my 20 years working in the HIV field happened in a standing-room-only meeting hall in Vienna at the International AIDS Conference in 2010. This was the moment that the clinical trial CAPRISA 004 announced proof-of-concept for prevention of HIV among women using a vaginal microbicide (1% tenofivir gel). The entire room broke out in a standing ovation and tears of joy. Finally! A prevention tool that could allow a woman to protect herself in sexual encounters, regardless of the desires and wishes of her sexual partner. Five years later, microbicides have not yet come to fruition. But pre-exposure prophylaxis (PrEP) holds the same great promise.
Worldwide, young women are 1.6 times more likely to be infected with HIV than their male peers. Prior to 1999, females represented 11.7% of all positive HIV test reports. By 2006, this figure had risen to 27.8%, the highest percentage since the start of the epidemic. The two main modes of infection for women are heterosexual contact and injection drug use, both interpersonal domains which are often controlled by a male partner. It makes sense that women would be keen to use PrEP.
But here are five ways that PrEP may not be as "empowering" for women as we would hope; ways in which PrEP's promise may be limited by gender inequity.
- PrEP plays into the medical establishment's control over women's bodies. All of the viable antiretroviral-based prevention options will be at least somewhat invasive, could have side effects, and require administration and monitoring by a physician. We have to remember that among women living with HIV in Canada, 31% are Aboriginal women, and about 36% are among African, Caribbean and Black women. A history of colonization and unethical treatment by governments, health systems and researchers has left a legacy of profound distrust of any health innovations being offered to Black or Aboriginal communities.
- Women may not have the autonomy to take advantage of PrEP. Whether a woman is able to use any prevention product is a complex balance of whether she perceives herself to be at risk, understands how a product works, how she anticipates her partner will react, if she can afford to access the necessary services and prescriptions, and how much control she actually has over her sexuality and fertility. Women sometimes need to hide their sexual and reproductive health strategies from their male partners. However, some women face adverse consequences from their male partners if discovered, as the products might be seen as an affront to men's power and the traditional gender norms. Indeed, studies have found a significant link between intimate partner violence and low PrEP adherence. And if women do disclose their desire to use PrEP, the negotiations will be no different than condom use in raising doubts about fidelity and trust.
- Our PrEP advocacy efforts have largely ignored women. In Canada, there has been significant buzz around PrEP and most of the early uptakers are white gay men. But unfortunately, this has had the unintended effect of creating homophobic associations with PrEP. In order to make PrEP work for women, they need to perceive themselves to be at risk for HIV, be aware of PrEP, see it as something for them, and have affordable access to it. They also need providers who are knowledgeable and willing to prescribe PrEP. PrEP is not common conversation outside of gay communities and HIV organizations. In Canada, very little attention with regard to HIV overall -- let alone PrEP issues -- is focused on women.
- Not all women who need PrEP want to make babies. One of the key benefits of PrEP is the ability to safely conceive within serodiscordant couples, also known as PrEP-ception. Conversations on -- and implementation of -- PrEP use by women should include all women at risk, not just those who want to conceive. Women have a right to choose PrEP as a tool for "fucking without fear," if that's what they want, without being subjected to slut-shaming, and with the primary focus on their own health and autonomy. Our messages to women have to be consistently sex-positive.
- Adherence challenges show up in our vaginas. Not only are there relationship challenges of taking PrEP for some women (see #2 above), our genital tissues are more sensitive to less-than-perfect adherence. PrEP, when taken daily, is just as effective in women's bodies as in men. However, longer and more consistent dosing is required to achieve protective levels of PrEP in vaginal tissue than in rectal tissue. While taking two doses per week can result in the accumulation of a protective level of drug in rectal tissue, continuous daily use is required to achieve a protective drug level in the vagina. We need to make women aware of that.
We need complementary, but different, PrEP organizing strategies for specific populations most affected by HIV in Canada. Women have a right to stay negative and to protect themselves from HIV autonomously, without relying on their partners, and without the sole purpose being safe conception. As HIV advocates and educators, let's make sure our PrEP awareness-raising and promotion efforts are inclusive for everyone who would benefit. And let's make sure that we are not ignoring or reinforcing gender inequities in our PrEP advocacy.
San Patten is a consultant based in Halifax, Canada, who specializes in HIV policy, program evaluation, organizational development and community-based research. She is a big proponent of biomedical tools as part of a comprehensive toolkit to prevent HIV, including their potential role in reducing the social-structural inequities that create vulnerability to HIV.