The Centers for Disease Control and Prevention recently reported that HIV related deaths declined by 48.4% between 2010 and 2018, and that there was a 23% decline in seroconversions between 2010 and 2019. Unfortunately, Black people and women continue to make up the bulk of reported deaths and new infections each year.
This latest data supports the understanding that if HIV is to be eliminated, Black women and marginalized people must be empowered against infection. New data indicate that the best way to do that is to provide people with numerous harm-reduction options.
A Nov. 17 webinar called, “HIV Prevention Pipeline: Putting Desire & Choice in the Science,” offered a deep dive into the data behind some of the latest prevention and harm reduction options. The webinar, which was produced by AIDS Foundation Chicago, Midwest AIDS Training and Education Center, and IRMA, featured Craig Hendrix, M.D.—a professor of medicine at Johns Hopkins University School of Medicine—speaking at length about the latest possibilities of delivering PrEP to people, with data from surveys and investigations backing up his reports on the most appealing options. The event was moderated by Jim Pickett, the senior director of prevention advocacy and gay men's health at AIDS Foundation Chicago.
The most compelling fact to emerge from the presentation was that having access to more options for using PrEP—beyond taking a daily pill—made it a more attractive choice to people.
Different Forms of PrEP Appeal to Different People
It might strike some as obvious, but when it comes to harm reduction and sex, people need a range of choices that fit into their lifestyles without causing inconveniences, if they are going to willingly use those options consistently and correctly.
Women who use PrEP have greater autonomy over their sexual health than those who rely upon their sexual partners to agree with using safer sex options, such as condoms. But taking a pill does not appeal to everyone, which only reinforces the need for choices.
Similarly, given the recent finding that the long-acting injectable, cabotegravir, is easier for women to use in order to maintain adherence, it is important to remember that not all people are comfortable with needles. Whether a drug offers the best protection against seroconverting or not, if it is not desirable—or makes a patient feel uncomfortable—it is not likely to be used.
Appealing Percentages According to the Options
Hendrix found in a study that included people living in South Africa and Zimbabwe that preferences for HIV prevention tools varied widely between the two countries. Nearly the same percentage of women from the two countries preferred using a vaginal ring containing the anti-HIV medication dapivirine (28% of women from South Africa, compared to 29% of women from Zimbabwe). But when it came to using long term-inserts, vaginal films, and gels, the percentages of preferences were at polar opposites.
Vaginal films, which dissolve directly into vaginal fluid and decrease the dilution of antiviral properties, were found to be easy to use, portable, low cost, and with minimal vaginal discharge or impact on sexual activity, while also providing privacy for users. The ultimate finding was that they were acceptable among African and U.S. women, accompanied by a quote that determined that they were “as simple as getting out of the shower, putting it in, and then moving on. Almost like brushing your teeth.”
Medication + Douching = a Behaviorally Congruent Product
Hendrix highlighted the use of behaviorally congruent products as a potential game changer in protecting people from HIV. He explained that these products “take advantage of existing sexual behaviors and products that are used very commonly in the context of sex in some populations, but not all.”
A look at behaviorally congruent health products included fluoridated drinking water and toothpaste, vitamin-fortified bread and milk, sexual lubricant—which was used by 85% of men who have sex with men (MSM), though fewer than 40% of women—and douches, which were used by just under 75% of MSM and 22% to 56% of women. The understanding is that there are numerous means for delivering harm-reducing drugs to protect users from HIV that have not yet been fully explored.
Of all of these products, rectal douching was found to be the most effective as a delivery method. Though lube is commonly used between same-gender-loving men, it was not a viable solution because its active ingredients did not end up in the desired places—the colon and rectum—during studies with gloved hands.
Rectal douching as a prevention method was found to be superior even to daily oral pill use, with the bulk of people surveyed responding favorably to using the product prior to engaging in sex. In this prevention method, the rectal douche included preventative medication. Again, this was supported by the fact that rectal products were already used as part of sexual preparation and did not require any change in behaviour.
A survey conducted on Grindr in 2018 found that 95% of insertive gay and bisexual men supported their partners using a medicated rectal douche; 98% of those who already used douches reported that they were likely to use the microbicide douches; 94% of those who did not currently douche reported that they were likely to use this option.
Additionally, on-demand products such as medicated douches were found to provide effective protection within one hour, versus the necessary level of protection achieved via oral dosages only after four to seven days. In that regard, medicated douching and high-dosage, on-demand products were incredibly effective for people who engage in anal sex, though the need for other options remains, because—as was pointed out repeatedly throughout the webinar—different harm-reduction tools appeal to different people, and douching is not for everyone.
This perspective on the need for options was reinforced by Hendrix’s summation: Poor adherence limits efficacy; PrEP effectiveness increases with choice; not enough focus has been given to desirable harm-reduction options for sexual health; and it is necessary to combine protection with desire and behaviorally congruent options in order to protect the most people possible against HIV.