Having choices is definitely something to celebrate. It not only makes our lives easier, it also keeps more of us safe. Research from family planning shows that the more contraceptive options people have, the more likely they are to choose one and actually use it. More contraceptive options equal fewer accidental pregnancies. It makes sense that HIV prevention can and should work the same way.
It's time to start talking about all the proven HIV prevention options as viable and important. We can stop ranking them as better or worse and view them instead as complementary pieces of the puzzle. If I happen to like pre-exposure prophylaxis (PrEP) with some female condoms on the side and you prefer condoms all the time with post-exposure prophylaxis (PEP) as a back up if necessary, then congratulations to both of us.
After figuring out who you want to have sex with and how you like to do it, the next decision is how to stay safe while doing it. Having several effective choices on the menu is something to celebrate -- and to demand as a universal right for everyone. September 16 is Global Female Condom Day -- so let's use that occasion to take a walk through some of the newer methods of HIV prevention for women and receptive sex partners.
The Female Condom: Good News for Receptive Sex Partners
Access to more forms of HIV prevention is especially great news for receptive sex partners (aka bottoms, in this case referring to those who are receiving a penis in their vagina or anus.) For way too long, women have been advised to refuse to have sex with a male partner who refuses to use condoms. This advice is not reality-based for most women because (a) they wanted to have sex, too and (b) refusing, in many relationships, results in an ugly fight, possibly accompanied by violence, abandonment or other punishment. So, very often, when men or tops refuse condoms, women or receptive partners cross their fingers and hope for safety. We all deserve better options than that.
The female condom was our very first receptive-partner-initiated form of HIV prevention. Unfortunately, its introduction on the market was so low-key and underwhelming that many people have either never heard of female condoms or else associate them only with tacky late-night-talk-show humor. On Saturday Night Live's Weekend Update, it was described as fitting snugly over a wine glass. Female condoms cost more than male condoms and, due to lack of widespread demand, aren't always on store shelves when people want to by them. Lower cost, public education and better marketing would solve those problems by stimulating demand.
Envision the vagina as a flower with long petals, like a lily or tulip, that folds up at night. It can stretch as widely as necessary (think childbirth) but folds itself together when at rest. So why do people see the size of the female condom as threatening? It simply lines the vagina internally, providing thin, silky, lubricated, heat-transferring protection during sex. Once accustomed to it, many prefer it to the last-minute rush and constriction of a male condom.
After all, here is a tool that people can put in up to eight hours ahead of time, giving themselves excellent protection from HIV, other sexually transmitted infections and pregnancy. It can be used vaginally or anally and does not decrease sensation for the insertive partner (a frequent complaint about male condoms). And it's super-helpful for men who sometimes experience erectile dysfunction -- because no erection is needed to use it.
The female condom (used by anyone of any gender) is simply another choice -- like choosing whether to drive or fly when you are going on a trip. Each has its advantages. If you fly, it's quicker. If you drive, you can take everything you want with you. Or choosing what to have for dinner. If you have a big salad, you can enjoy feeling virtuous and healthy. If you choose (insert favorite, less healthy entrée here), you'll get total, absolute deliciousness. Both options benefit you in different ways. And you get the privilege of picking what you want at the time.
PEP: The Effective Emergency Option
We have had PEP for HIV prevention since 1988 when it was approved for use by health care workers and other first responders who experienced on-the-job HIV exposures from blood. PEP involves taking antiretroviral treatment (ART) for 28 days after exposure to reduce the risk of acquiring HIV. In 2005 the CDC issued its first guidelines for "non-occupational" PEP, the same short course of ART but used after non-work-related exposures. Access to nPEP can vary widely, depending where you are. The New York State Health Department recognizes its value following "blood and body fluid exposures, including sexual and needle-sharing activities," after sexual assault, when mixed-status couples experience condom slippage, breakage or lapse in use, or for other blood or body fluids exposure. PEP has to be started within 72 hours of the exposure to be effective, and recipients receive HIV testing before treatment, after completing their four-week treatment and at 12 weeks to see if they have seroconverted.
Because of the significant cost involved and the potential risk of side effects from the ART drug combination, it is "only be used when the potential benefits of taking nPEP outweigh its risks." Many providers are reluctant or refuse to prescribe it if they think someone is routinely requesting it after the fact instead of using HIV prevention tools in advance. Nevertheless, it is an effective emergency option that everyone deserves to know about and have access to if they need it.
PrEP: A Huge Breakthrough, Especially for Women and Bottoms
When PrEP was approved by the FDA in 2012, it became (among other things) a bridge to ongoing protection for people who accessed PEP in an emergency and then realized they also needed reliable, ongoing protection. Now they can be advised that they have the option of transitioning directly from PEP (when completed and if they remain HIV negative) to PrEP for their ongoing protection. This can be a vitally important transition to safety for some people.
The advent of PrEP was a huge breakthrough, especially for women. Now we have a pro-active HIV prevention method women can use if their partners refused to allow condom use of any kind. For the first time, women and receptive partners can protect themselves from HIV without ever discussing it with a partner. So why is it, given that there are roughly equal numbers of men and women in the U.S. who could benefit from using PrEP, that 89% of all new PrEP prescriptions in the U.S. are being written for men? The answer is that most women who could likely benefit from PrEP don't even know that it exists.
As with the female condom in the 1990s, most people (including federal public health officials) still don't see PrEP as something women urgently need to know about. It is not being promoted to women, and people don't demand things they've never heard of. This is not OK.
PrEP and Female Condoms: A Sexy Couple
PrEP and female condoms work well in tandem to increase people's protective options. According to current data, it takes up to three weeks for PrEP to build up to protective levels in vaginal tissue, although the time to protection in rectal tissue only takes five to seven days. PrEP is also less "forgiving" for vaginal sex than it is for anal sex. Rectal protection can likely be maintained even if the user forgets a pill here and there. But vaginal protection levels can drop more quickly, putting women and trans men who receive vaginal/front hole sex who miss pills at higher risk.
Enter the female condom, wearing her little white cape! She is perfectly designed to protect women and trans men just getting started on PrEP, and those who may forget to take a pill now and then. Like a belt and suspenders, one option works if the other one slips. And it's great to be moving into a time when we have enough alternatives that we can mix and match the best combinations for ourselves.
Two big barriers to sexual pleasure and health are the lack of tools for protection and lack of knowledge that such tools exist. Women, in particular, have suffered from this since the beginning of time. Modern contraception was an enormous breakthrough in making sex safer for women. But one woman in ten of those married or in long-term partnerships still don't have access to modern contraception. And that ratio grows when the "single" women who also need protection are added.
All of us deserve to have pleasurable, consensual, safe, satisfying sex that is shaped only by our own and our partners' imaginations. Celebrating the growing range of HIV prevention options can bring us closer to that goal.
Anna Forbes is a Washington, D.C.-based writer, organizer and activist working in HIV/AIDS since 1985. Now an independent consultant focused on women's needs with regard to HIV, her current and recent clients include the Sero Project, SisterLove, GNP+, the Positive Women's Network - USA, the International AIDS Society, IAVI, UN Women and the Global Network of Sex Work Projects.