Microbicides: Addressing some key questions Lori Heise, Director Global Campaign for Microbicides

What is the Global Campaign for Microbicides? An international coalition of NGOs and advocates working collaboratively to: –Awareness: Mobilize political will for increased funding for microbicide research; –Access: Create a supportive policy environment for the timely development, introduction and use of new prevention technologies; and –Accountability: Ensure that as science proceeds, the public interest is protected and the rights and interests of trial participants, users, and communities are fully represented and respected.

The civil society arm of the microbicides movement….. Over 200 endorsing groups worldwide; Small core staffs in Washington DC and Brussels; Partner groups/coalitions in Canada, France, India, Ireland, Nigeria, South Africa, Spain, South East Asia, South Africa, Uganda, United Kingdom Emphasis on: –Capacity building for NGOs and advocates –Community and stakeholder involvement in clinical trials –Ethics of clinical testing –Gender, social science, and human rights

Overview Should we be concerned about introducing a method that is less efficacious than male condoms? If a microbicide were available, what public health benefit might we reasonably expect? Who would be the most likely beneficiaries of this method? What role can technology play in an overall HIV prevention agenda for women?

Confronting partial effectiveness Concern has been raised about introducing a method that is less efficacious than condoms Will individuals default from condoms to microbicides because they are easier to use (condom migration)? What should our counseling messages be?

Microbicides will be promoted as an adjunct and/or back-up to condoms, not as an alternative Prevention messages would shift to a hierarchy of options: –Use a male or female condom every time you have sex; if you absolutely can’t use a condom, use a microbicide –Use a microbicide with your condom for added pleasure and protection Shift to a “harm reduction approach”

A Balancing Act to Minimize HIV Risk condoms Up to 90% efficacy ? consistency of use microbicides 40-60% efficacy ? consistency of use

The Prevention Equation Level of protection conferred (the number of cases averted) depends on the product of three factors: u Efficacy of the method u Consistency of use within a partnership u Extent of use in a sub-population

The Prevention “Trade-Off” A 90% efficacious method (like condoms) used in 20% of sex acts, provides less protection than a: 70% efficacy used> 30% of the time 50% efficacy used> 40% of the time 30% efficacy used> 60% of the time

What do we know about likely use? Multiple studies document widespread interest –15 country qualitative study by ICRW –2 market studies: one global and one US In clinical trials and acceptability studies where women have experience using products, they articulate clear advantages to microbicides: –Easier to use than condoms –Allows skin on skin intimacy –Woman initiated

Covert use early emphasis of microbicide field Recent research suggests that most women would tell their partner some women afraid to risk others want partners involved “Passive acquiescence” versus “active involvement” Can be “negotiated” once rather than at every act of intercourse No need to talk about sex Allows skin to skin intimacy Can enhance pleasure Acceptability & Use Dynamics

Condom migration: should we be concerned?

Three lines of evidence suggest that introducing microbicides will lead to more protection rather than less  experience from family planning  data from intervention studies  insights from modeling More protection or less?

LSHTM Modeling Studies Under most circumstances, substantial migration can be tolerated without increasing risk of infection –either at the level of individuals –or among sub-populations Migration is potentially a problem only where condom use is high (>70%) and microbicide consistency is low (<50% of non-condom protected acts)

Condom Consistency BEFORE AFTER 30% 5% 50% 32% 70% 59% 90% 86% Reductions in condom consistency that an individual can tolerate without increasing her risk Microbicide HIV/STI efficacy = 50%; Used in 50% of acts not protected by condoms

Condom Consistency BEFORE AFTER 30% 0% 50% 0% 70% 37% 90% 79% Reductions in condom consistency that could be tolerated without increasing risk Microbicide HIV/STI efficacy = 50%; Used in 100% of acts not protected by condoms

Potential public health impact? A 60% efficacious microbicide introduced into 73 low income countries would avert 2.5 million HIV infections over 3 years in women, men and infants --Watts & colleagues, LSHTM Women newly infected with HIV (2004) 2.5 million Adult AIDS Deaths (2004) 2.6 million

This estimate conservatively assumes... Microbicides are effective only against HIV, not other STIs Microbicides are taken up by only 20% of individuals already in contact with services –women using modern contraception –sexually active youth in school –sex workers in contact with HIV prevention projects –IV drug users in contact with prevention services Those who use microbicides do so in 50 percent of acts where they do not use condoms

Take Home Messages Even a relatively low efficacy microbicide could have a large impact on the epidemic The magnitude of impact is strongly influenced by coverage and use Coverage Infections averted* 10% 1.4 million 20% 2.5 million 30% 3.6 million * over 3 years

Who will be the primary users/beneficiaries of microbicides? Single women? Women who sell sex? Married women? HIV positive women? Adolescents? Men?

Primary partnerships: The Achilles heel for women Globally, the majority of women contract HIV or STIs from a steady rather than a casual or paying partner Consistent condom use is universally difficult to achieve in emotionally close relationships (seldom more than 30%) For HIV, repeat exposure to a single infected individual may pose more risk than having several partners

Married girls have more frequent sex, are less likely to use condoms, and are more likely to have HIV+ partners Unmarried, sexually active Married Had sex in the last week Use condoms often/always HIV prevalence among male partners of adolescent girls HIV prevalence Source: Clark 2004 Sexually active girls aged 15 to 19 in Kisumu, Kenya

With Primary PartnerWith Casual or Outside Partner

Microbicides can begin the discussion about sex and power. But, it can’t end there. Changing the power balance between men and women is essential for real and sustained change. Microbicides: Where Gender, Technology & Sexuality Meet

Girls’ and Women's Protection Strategies Protection Technology Economic Opportunities Social Power Brady, Martha. Population Council, Conceptual Framework

Percent of ever-partnered women reporting physical and/or sexual violence by an intimate partner EverLast 12 months Bangladesh province Brazil province Ethiopia province Namibia city Peru province Samoa Thailand province Tanzania province Source: WHO Multi-Country Study on Domestic Violence and Women’s Health

She doesn’t want it Her husband mistreats her Bangladesh province Brazil province Ethiopia province Namibia capital Peru province Samoa Thailand province Tanzania province Percent of women interviewed who believe that a wife does not have a right to refuse sex if… Sexual Autonomy? Source: Who Multi-Country Study on Domestic Violence and Women’s Health

Who holds the purse strings on prevention? Source: McCauley et al Personal Savings Partner income 80% 15% 1% 65% Source of money for HIV test

A rights based agenda at a global level Global Coalition on Women and AIDS Priority Interventions Focus on young women and girls Secure women’s property and inheritance rights Reduce violence against women Keep girls in school Equalize access to HIV treatment Reduce burden on caregivers Expand women’s prevention options (microbicides & female condoms)

Experience from Family Planning Addition of each new method increases overall number of protected acts and decreases unintended pregnancies Adding a new contraceptive method to those available in an existing program increases prevalence by about 12 percentage points and decreases crude birth rate by 5.3 points (Ross,J & E. Frankenberg.1993 Findings from Two Decades of Family Planning Research. Population Council)

With condoms safer sex is his decision, We want to make it yours To download facts sheets & original reports visit: