Indian married men’s interest in microbicide use

Abstract

Research suggests that the HIV/AIDS epidemic has spread to monogamous women in India. Gender inequalities prevent women from asserting control over the circumstances that increase their vulnerability to infection. Men control most of the sexual decision-making. The present study explores views on use of microbicides by men and circumstances in which they might find microbicide use with their wives acceptable. Progressive in-depth interviews were conducted among 15 consenting men from Pune, India. Men felt that women with identifiable HIV risk, such as being a sex worker, having an HIV infected husbands or being educated; were more likely to use microbicides. Most high-risk men would permit or force their wives to use microbicides and had a higher intention to use microbicides compared with low-risk men probably due to perceived susceptibility. The majority of men with previous experience of microbicide use mentioned that privacy was important for gel use. Most low-risk men believed that they would be angry with covert gel use by their wives. They felt that covert use was impossible since their wives were under their control and they would notice the gel due to a change in their sexual experience. Low-risk men also opined that husband’s permission was not required if he was HIV-infected or having extra-marital sex. Some men stressed the need for exercising sexual control while women inserted gel before sex. Men’s risk-perception, knowledge about their safety concerns, as well as their behavior may affect acceptability of gel use, hence men’s involvement and cooperation is imperative for microbicide gel use by women in India.

Introduction

Globally, women represent a significant proportion of individuals living with HIV (UNAIDS, 2008). In addition to biologic susceptibility, women’s risk of HIV has been linked to socioeconomic and cultural factors that limit their control over sexual and reproductive health practices and options. Their inability to abstain from risky sexual encounters or negotiate condom use has been reported (Heise & Elias, 1995; Stein, 1990). For more than a decade, efforts to search effective HIV prevention options for women are ongoing. They include research on safety, acceptability and effectiveness of several vaginal microbicide products that women could use to prevent HIV acquisition from their HIV-infected partners. Although an efficacious microbicide is yet to be discovered the promising results of the CAPRISA trial in which tenofovir gel reduced HIV acquisition by an estimated 39% have ignited some hope (Karim et al., 2010). Some researchers have reported high levels of acceptability of microbicides among women participating in clinical trials worldwide (Braunstein & van de Wijgert, 2005; Joglekar, Joshi, Navlakha, Katti, & Mehendale, 2006; Joshi, Solomon, Mayer, & Mehendale, 2005). Studies have suggested that women feel the need to discuss use of vaginal microbicides with their male partners (Bentley et al., 2004; Rosen et al., 2008; Salter et al., 2008).

As the HIV pandemic is driven by heterosexual transmission in many parts of the world, it becomes critically important to understand the role that men may play in the acceptability and eventual use of new HIV prevention products. It has been reported that African men’s support for a new female-controlled HIV prevention product was countered by their concern that it could lead women to be more promiscuous (Bentley et al., 2004). Men’s concern about retaining control over their female partner’s sexuality was also reported in Uganda (Pool et al., 2000), South Africa (Ramjee, Gouws, Andrews, Myer, & Weber, 2001) and multiple sites in Africa involved in the Microbicides Development Programme trial of Pro 2000 gel (Montgomery et al., 2008).

In India, approximately 2.27 million people are estimated to be currently living with HIV/AIDS (National AIDS Control Organization, 2010). Researchers have reported high HIV prevalence among women in monogamous relationships (Gangakhedkar et al., 1997; Mehta et al., 2006; Tolley et al., 2006). As microbicides constitute a potential strategy for prevention of sexual transmission of HIV in India; men’s perceptions and preferences for a female-controlled HIV prevention method need to be explored. To date, the literature on men’s attitudes and experiences related to microbicide use is limited and almost no reports are available on male attitudes towards microbicides from India. This study aimed at assessing men’s attitudes towards vaginal microbicides, their relative preference over condom use, and their willingness to use microbicides with their partners. Specifically, we sought to understand the following: To what degree did men’s general support of women’s right to use a microbicide differ from their personal perspective on microbicide use? Were men who had “identifiable” risk any different from other men in terms of their own interest in future microbicide use? What factors best explained men’s general and personal interest in future microbicide use?

Methods

This study was reviewed and approved by the Ethics Committee of National AIDS Research Institute (NARI), Pune, India and the Protection of Human Subjects Committee (PHSC) of Family Health International (FHI). Between October 2003 and May 2004, 15 married men, participated in 33 sessions of in-depth interviews. Men with history of sexually transmitted infections (STIs) or with HIV infection were considered as “high-risk” and other as “low-risk”. Of the six high-risk and nine low-risk men, two and four were partners of past microbicide trial participants, respectively. They represented low socioeconomic urban population of Pune, India. Men were recruited only if their wives were participating in the ongoing microbicides acceptability study and agreed for their study participation. These couples were recruited with the assistance of health care providers and community-based partner organizations supporting clinical trials of the institute.

Informed consents were administered to participants and confidentiality of the information provided was assured. Trained same-sex interviewers conducted face-to-face interviews for each participant, each interview session lasting for 60–90 minutes. The first interview session focused on understanding participant’s household context, attributes, decision-making processes, and couple harmony; while more sensitive information about reproductive decision-making, HIV/AIDS risk and knowledge, and microbicide attributes was collected in the subsequent sessions.

The interviews were conducted in local languages (Marathi and Hindi) and later translated into English. An interview guide aided the discussion, which was tape recorded and later transcribed and translated. Incomplete information was captured and inconsistencies resolved in the subsequent interviews.

Data analysis

Data collection and coding were undertaken in parallel. The English translations were coded using the QSR.NUD*IST software program. Data analysis steps included an interactive process of reading and coding, which occurred simultaneously. Two researchers read and coded initial transcripts independently and then compared and resolved any discrepancies to develop a broad set of codes identifying major themes in the transcripts. Eventually one researcher coded the text. For each major theme, a detailed memo was constructed to identify sub themes, note patterns between subgroups (i.e., high/low-risk men, with/without microbicide experience) and describe potential linkages between thematic areas. Finally, specific quotations were chosen that communicated a commonly-held idea or an individual perspective well and adequately which are identified in () by the ID number of the individual who mentioned them.

Results

The mean age of the study participants was 35.4 years (range 28–42 years). Compared with their low-risk counterparts, high-risk men were several years younger, and married for shorter durations to women who were, on average, much younger than men. All low-risk and four of the six high-risk men were currently working. Five low-risk men were engaged in skilled work (laboratory technician, mechanic, tailor, furniture making, and factory worker). Most high-risk men had part-time employments as drivers, labourers, vegetable vendors, or petty manual jobs (Table 1).

Table 1.

Sociodemographic characteristics of male participants, by risk classification.

Sociodemographic variables	All (n=15)	High-risk (n=6)	Low-risk (n=9)
Age (mean)	35.4	34.0	36.3
Years of marriage	12.33	9.0	14.6
Partner’s age (mean)	28.54	24.7	30.9
Currently employed (%)	87	67	100
Average number of children		2.2	2.4
1–2 children	10	4	6
3 and more	5	2	3

Microbicides users

Men expressed a positive attitude towards a microbicide gel. However, ideas about who would most benefit from gel use showed variations. Most of the men considered sex workers or women partners among HIV-discordant couples as the likely microbicide users. However, a few men felt that housewives and uninfected women could also be the users, primarily to protect themselves from infection from their partners. For example, one low-risk man mentioned: “Women who go outside for business (CSWs) … mostly that type of woman will use it …” When probed about “other women”, he added: “ … those who have extra-marital relationships or if the husband/wife are suffering from AIDS … they will also use it” (#010).¹

Although one low-risk husband opined that even couples who were faithful to each other could consider using the gel, most men associated gel use with extra-marital sex.

Clandestine use

While about half the men believed that clandestine use of a vaginal gel by women might be possible for the short-term, few imagined it to be truly acceptable. When probed on whether a wife could decide on secret microbicide use, one low-risk 30-year-old carpenter (#018) suggested: “First she should collect all the information (confirm) that her husband is really guilty or not. If she comes to know that he is really wrong, at that time she can use the gel without his permission. But, it would be wrong to have a doubt if he is not wrong; she should discuss it with her husband”. One high-risk man mentioned that women might use the microbicide to protect their husbands from their own risky behavior: “If a wife uses it without telling her husband, he cannot do anything … Suppose she went out for sex and she uses gel. Then, it is useful to her as well as her husband”. On enquiry how the husband would react if he comes to know about this … the man said, “If husband is good, he will understand. But, if the husband is bad, he will shout at her” (#022).

Some men considered a wife’s secret use equivalent to admission of her extra-marital relationship. Several men suggested that it was the man’s role to tell his wife to use a microbicide: “It could be difficult (for a housewife to ask for it herself) because if her husband is good, then that woman will also be good and if that man is doing wrong … then he, himself, will tell her to use that product” (#018).

Ten of the 15 men explicitly stated that use of a microbicide product by women without first informing their partners was not acceptable to them. One high-risk driver (#046) mentioned that: “I can scold my wife … She should openly mention that ‘You are having this problem and I want to use the gel for my safety’”. A low-risk man imagined more severe consequences: “No, a woman should not use it without her husband’s permission, because it may lead to a break up of their marriage. If she does anything without her husband’s permission, then the husband can have doubts about her or (he may) beat her or leave her” (#018).

Interest in using a microbicide

Almost all high-risk men and the majority of low-risk men expressed some interest in using a microbicide, should one become available. All high-risk men agreed that they would permit their wives to use a microbicide, if asked. They felt that their wives could directly benefit from them. In contrast, low-risk men considered using microbicides only under certain circumstances. One low-risk man said: “There is generally no need to use microbicide. If I have extra-marital affairs, I will have fear in my mind, so I will force my wife to use the gel and if I have no outside (extra-marital) sexual affairs then I have no need to use it” (#010).

Microbicides, condoms and sexual pleasure

Most men, regardless of risk status, appeared to prefer a vaginal microbicide to condoms. This was largely related to men’s experiences and/or perceptions of sexual pleasure. Two high-risk men whose wives had participated in the microbicide trial reported that gel use increased sexual pleasure. One explained: “I felt interested to have sex. That madam (study counselor) told us it was compulsory to use condoms. But I had decided to have sex without condoms and did not use condom at all while having sex … It was very good. While having sex, we spent more time. Normally we spend around 10 15 minutes but after using this (gel), it went on for half an hour. That was a good experience; I had the mood and enjoyed sex” (#046). Another individual mentioned: “Two purposes can be fulfilled because of this gel. One is we get satisfaction and the other is we get protection” (#048). Similarly, one low-risk male partner of a microbicide trial female participant reported: “No I didn’t have any obstacles to sex after using the gel; rather, we got pleasure and happiness” (#025). Several other men with no previous experience with gel use reported that sexual pleasure would be a factor affecting its acceptability. Men appreciated gel use because it did not decrease sexual pleasure. Three of the six men with microbicide experience stated that the gel use did not affect sex one way or the other, mainly because of the compulsory condom use as per the clinical trial rules. A high-risk husband preferred gel over condoms, “because if a person uses condoms, he loses his mood … if this gel comes in the market, people will welcome it. But even then, … (I) will be a little worried about how safe it is. It will take time for people to be assured” (#046).

Conversely, two high-risk men indicated that they had more confidence in condoms than gel. For example, one insisted: “I would like to say that condoms are better than the gel (as they are) very easy to use. We just have to put it on the penis and after having sex the matter is closed” (#016).

Concern about side-effects

Several high-risk men and six low-risk men were initially concerned about the potential side-effects on them or their wives. Such concerns caused some men to pause while answering a question about participation of their wives in the study. None of the men with past microbicide experience reported any side-effects. Initially concerned that the gel use might cause him problems with urination or other skin problems, one male partner with a history of STI explained: “Once I had sex without using a condom …. I thought; let me see what happens because of the gel. Will I get some infection or anything like that? But I did not get any side effect … will my wife have any itching sensation or any boils? … But my wife did not have any trouble” (#046).

The need for privacy

Majority of men felt that microbicide use would be difficult in some circumstances; primarily because sufficient time and privacy were required for its sustained use. One participant mentioned, “If children are always with them, then how they can insert the gel … bed room should be separate, they must have privacy. But if they have only one room and all the family members are living together, then they will face problems” (#022). Despite these concerns, it seems that those who participated in the clinical trial found ways to adhere to gel use. One participant (#027) mentioned that despite having a big family the couple managed to use the gel.

Contraceptive and/or disease prevention properties

Some men recognized the value of having a microbicide gel that could also protect women from pregnancy. However, most men (particularly HIV-infected) felt that they would like a product that prevents them from getting HIV/AIDS yet enables women to get pregnant.

Access and cost

All the high-risk and some of the low-risk men preferred microbicides to be available at medical stores, while most low-risk men wanted them to be dispensed even at government hospitals. One high-risk husband of a microbicide user suggested that, “the medical store is a place where a man can get anything freely (without any hesitation), condom or gel” (#046). All men wanted products that are affordable and reasonably priced. Some even expected the product to be provided free of cost.

Discussion

Men in this study generally supported the development and introduction of female-initiated methods like topical microbicides. However, a man’s personal interest in using the product with a partner appeared contingent on specific and acknowledged risk of HIV within the couple setting. Within Indian married men and women, the importance of “evidence” to the process of identifying personal HIV risk has been described previously (Tolley et al., 2006). In some studies, women had suggested that discussing microbicide use with a partner could connote distrust and there was generally no conversation about sex within couples (Lambert, 2001).

Men in some of the previous studies have reported that, women may become more promiscuous following availability of vaginal microbicides (Bentley et al., 2004). In Zimbabwe and other African studies, most men commented that microbicides should be promoted but they strongly endorsed their use by women with their permission (Bentley et al., 2004; Coggins, Blanchard, & Friedland, 2000; van de Wijgert et al., 1999; Woodsong & Alleman, 2008). In the present study men justified covert use by women only with a solid evidence of her partner’s risky behavior. Men insisted that women should take permission from their spouses. Men from Durban in South Africa felt that both partners should take a joint decision to use microbicides (Ramjee et al., 2007), while in Zimbabwe, most men felt that women can protect themselves by avoiding sex with infected persons or using condoms (van de Wijgert et al., 1999). Srikrishnan and colleagues in southern India reported that 89% of men would allow non-primary partners to use microbicide whereas only 42% would allow their primary partners to use microbicides (Srikrishnan et al., 2001). Overall, there is strong evidence in support of high vaginal microbicide acceptability among men.

The present study has several limitations. First, the small sample size and restricted geographical focus clearly limit our ability to generalize findings to a larger population. In addition, our study explored microbicide acceptability within the context of heterosexual relationships and for vaginal use; men’s views on the acceptability of rectal microbicides within male or female relationships need to be clearly understood. Furthermore, men’s participation was contingent on their wives’ approval. Thus the interviewed men may have been in relatively more harmonious relationships with their wives. Nevertheless, our study aimed at addressing microbicide acceptability among men who were married, with and without identifiable risk and those whose wives had used a topical gel product during a phase 1 trial have helped to identify factors related to men’s acceptability and also some gaps in microbicide acceptability research.

The recent successes of microbicide trials have renewed momentum in the HIV prevention area (Grant et al., 2010; Karim et al., 2010). Elaborate and robust research studies will have to be planned to confirm recent findings, evaluate new vaginal microbicide compounds and potential combinations with anti-STI or contraceptive agents. Appropriate product-delivery mechanisms need to be developed and evaluated that facilitate their eventual acceptability and adherence in couple settings.

Our data suggests that women’s ability to negotiate product use could be facilitated if promotional materials emphasized the possibility of increased intimacy and sexual pleasure, as well as protection from disease. The efforts to educate people about vaginal microbicides should be couple-centric. Men with high-risk behavior should be made aware of lack of 100% efficacy of the vaginal microbicides and the need to use condoms for prevention of HIV acquisition. Regardless of beneficiary population, positioning a microbicide gel as a product for sexual health and possibly for enhancement of sexual pleasure among couples and not necessarily for high-risk individuals may be the best way to ensure that an effective product becomes accepted and used widely.