Women account for more than half of all people living with HIV worldwide. In sub-Saharan Africa, young women are twice as likely to have HIV as young men. It is clear that women are disproportionately affected by the virus. Women’s vulnerability to HIV stems not only from a higher biological risk than men, but also from violations of women’s human rights, gender inequalities and marginalization.
USAID, through the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), is committed to expanding the array of woman-controlled HIV prevention methods so that women and girls can better protect themselves from infection. In 2010, the CAPRISA 004 trial, funded in part by PEPFAR through USAID, provided the first proof of concept that a vaginal microbicide made of tenofovir gel could protect women against HIV infection when used appropriately. Microbicides are substances applied vaginally or rectally to protect users against HIV infection. This scientific breakthrough presented the global health community with a potential new, female-initiated tool in the fight against HIV.
With these encouraging findings and continued clinical trials to test microbicides, we now need to look ahead toward their meaningful introduction and use. Through this process, we will recognize potential barriers to successful roll out, and identify ways to mitigate those barriers. Are women interested in using microbicides, and if so, how easy will it be for women to access them? To what extent do women want to communicate with their male partners about microbicides? How accepting are men to women’s choices about HIV prevention? To what degree are policies supportive of women’s microbicide use?
One of our implementing partners, FHI 360, foresaw these concerns and acted. Under the USAID-supported Preventive Technologies Agreement, FHI 360, with support from Sonke Gender Justice in South Africa, conducted gender analyses in South Africa and Kenya, two countries where microbicide development work makes its future introduction likely. Gender analyses are systematic processes used to identify and understand gender differences. They examine how gender norms and inequalities affect relationships and power dynamics between men and women, as well as women’s access to resources, their rights, their opportunities, and their health practices and outcomes. In South Africa and Kenya, FHI 360 implemented this analysis to understand gender-related barriers to women’s microbicide use, identify solutions, and prepare for a gender transformative introduction
Of FHI 360’s findings, there are three key takeaways we would like to highlight:
1. Promoting microbicides to all women, not just most at risk populations, will be important to avoid stigmatizing the product. People in both countries cautioned against promoting this HIV prevention method as a niche product for specific populations, fearing that targeted promotion of microbicides might stigmatize the method and lead to microbicide rejection by the populations who could benefit from it the most.
2. Balancing women’s autonomy and male partner engagement in microbicide introduction is crucial. Women have the right to choose whether they inform their partners of their microbicide use, and health providers need to support women in making the decision that is appropriate for them. At the same time, educating men about microbicides may help increase acceptability and adherence and foster couples’ communication about sex and HIV protection. Microbicide introduction programs must take care to position women as the gatekeepers to their male partner’s involvement.
3. Sex sells. Many believed that microbicide promotion should focus on sexual benefit and pleasure in order to increase its appeal. By highlighting these positive aspects of the gel, which were identified throughout earlier microbicide trials, people may be more likely to adopt this HIV prevention method.
FHI 360’s gender analyses filled critical gaps in understanding that will enable public health practitioners to introduce this HIV-prevention method most successfully. As USAID and PEPFAR move closer to creating an AIDS-free generation, we recognize that gender analyses are a vital practice in order to better understand the communities with which we engage, strengthen the impact of our programs, and empower women and girls to protect their health and achieve their fullest potential.