Until women take control of HIV prevention, it will be impossible to halt the global spread of HIV/AIDS, several speakers claimed at the 16th international AIDS conference in Toronto this week.
Of the 39 million people in the world currently living with HIV or AIDS, half are women. Of the 45 million new cases expected between 2002 and 2010, 70% are likely to be in women in the developing world, says UNAIDS.
Signalling an urgent need to prioritise methods of prevention that take control away from men, while acknowledging the remoteness of an effective HIV vaccine and the soaring costs of treatments, advocates urged greater investment in microbicide research.
Microbicide gels and creams can be applied before sex to prevent HIV and other sexually transmitted viruses from attaching to vaginal walls. Relatively inexpensive and easy to manufacture and distribute, they are designed to be used by women without the cooperation, consent, or knowledge of their partners.
Women’s health advocates said that women needed to control prevention methods, because they often lack the social and economic power to insist on abstinence, fidelity, and condom use in their partners—the tenets of the current ABC of HIV prevention policies.
According to a report in the San Francisco Chronicle (14 Aug, page A1) , Stephen Lewis, the UN special envoy for HIV/AIDS in Africa, said that “the search for a microbicide is one of the most important things the world is doing.” He called the spread of AIDS in vulnerable women in Africa “absolutely unbearable” and said that it will take “generations” to change male sexual behaviour in Africa to bring about equality. “I don’t think a microbicide can be discovered soon enough,” he added.
Announcing a new focus on microbicides for the Bill and Melinda Gates Foundation, Bill Gates said that for every one person receiving antiretroviral treatment between 2002 and 2005, 10 new HIV infections occurred. This amounted to an “unsustainable” $13bn (£7bn; €10bn) a year, every year, in treatment costs. He described microbicides as “the next big breakthrough in the fight against AIDS.”
Peter Piot, the executive director of UNAIDS, affirmed the need for a shift in focus from treatment to prevention during his keynote speech. “A top priority is to immediately double funding for microbicide research and development,” he said.
Sixteen candidate microbicides are in various stages of clinical evaluation. Five are in phase III trials, involving 27 000 women across Africa and India. Eight governments, including the United Kingdom’s, have joined the Bill and Melinda Gates and the Rockefeller foundations to fund research into microbicides to the tune of $160m, and more funds were pledged at the conference.
“This is a breakthrough for us . . . an outstanding show of support from donors,” Anna Forbes, the deputy director of the global campaign on microbicides, told the BMJ. “Products in the late stages of clinical testing and the rates of new infections in women have created a new sense of urgency to move forward with microbicide development,” she added.
Critics argue that developing microbicides alone will not tackle the underlying inequalities between the sexes that put women at risk. In a special session devoted to frontline responses by women, advocates called for strategies to boost women’s economic, social, and political power.
Dr Nafis Sadik, the United Nation’s special envoy for HIV/AIDS in Asia, said that policy makers in her region “are more afraid of women gaining autonomy and control over their sexuality and reproduction than they are of AIDS.” The sociocultural context that keeps women devalued and disempowered cannot be divorced from new attempts to tackle women’s ability to prevent HIV infection, she said.
Others worry that early projections are overly optimistic in suggesting that a microbicide that is 60% effective, could avert 2.5 million infections in its first three years of use.
A commentary published in last week’s Lancet to coincide with the conference, says that the science of HIV transmission is not yet well understood and that the effect of microbicides on pregnancy and possible future resistance to antiretroviral drugs is largely unknown (2006;368:431 and 424).
The Bill and Melinda Gates Foundation has funded the Microbicide Development Strategy , developed by an alliance of international scientists and donors, and released at the conference this week. It calls for a better understanding of the basic science, greater coordination between researchers and product developers, and better clinical trial capacity. It also says that there should be more funding from private and public partners, including the drugs industry.
“We have never seen microbicides as a magic bullet,” said Ms Forbes. Rather, the products were one of several methods to prevent HIV transmission that would increase women’s ability to protect themselves, she said.
The Microbicide Development Strategy is available at www.microbicide.org.
