By Sarah-Jane CollinsApril 17, 2012
Women can’t always control condom use — and for decades that has been one of the greatest challenges in the fight against HIV/AIDS. It still is. But that could be changing.
When it comes to the AIDS epidemic, women are suffering from a lack of agency. That message so familiar to Australians, "If it's not on, it's not on," is virtually useless in many societies, where social structures simply don't allow women to refuse unprotected sex.
In sub-Saharan Africa, which accounts for some 70 per cent of global cases of HIV/AIDS infection, women make up about 60 per cent of all cases. Clearly these women need new ways to protect themselves.
In 1990, South African epidemiologist and advocate Zena Stein published a paper calling for a complete rethink of our approach to the problem. She argued that "to prevent AIDS, both men and women need to be empowered". She questioned the lack of funding for solutions such as gels, foams and creams that women could apply and control without men's input.
Stein compared HIV/AIDS prevention to the way women gained reproductive freedom through contraception advances such as the pill: Family planning research shows that pregnancy prevention became effective only when women were given the means to control it. Likewise it must follow, Stein said, that women must have the power to individually safeguard against HIV/AIDS.
Finally, twenty two years after Stein's paper, we may be getting there. In just the past 18 months, new research shows promising developments that may give women the power to protect themselves from the disease.
At a global conference underway this April in Sydney, scientists and advocates are discussing the latest research. Among them there is a sense that the landscape has changed.
Keynote speaker Salim S Abdool Karim, a professor from the University of KwaZulu-Natal in South Africa, told Microbicides 2012 delegates on April 15 that, for the first time, the conference was taking place where scientific evidence is indicating real success.
"We now have the defining moment in HIV. We now have the possibility to really talk about impacting on this epidemic in a very substantial way," he said.
Since the publication in late 2010 of a breakthrough paper on the use of a microbicidal gel called Tenofovir — a study Karim led at the Centre for the AIDS Program of Research in South Africa — the discussion about HIV/AIDS public health outcomes has shifted rapidly.
The South African Tenofovir gel trial found a 39 per cent reduction in new HIV cases overall, though the outcome was better for women who used the gel regularly: there was a 54 per cent reduction for the group of women who were using the gel more than 80 per cent of the time. A second study of HIV prevention methods, involving more than 5,000 women in South Africa, Uganda and Zimbabwe, late last year chose to stop testing the gel, however, as it was showing no real difference to infection rates.
Karim told the conference it was impossible to know why the two studies had produced such disparate results. Still he found plenty to be positive about in the research.
And a third trial testing the effectiveness of the gel is underway in South Africa; its results should be back in 2014.
Antiretroviral drugs also are seen as a possible way to prevent further infection. These drugs already are used to treat people who are HIV-positive. But in the US, the Food and Drug Administration is considering changing the restrictions on use of the drugs, allowing people who do not have HIV to take them as a preventative measure.
Studies using anti-retroviral drugs (involving both heterosexual and man-to-man sexual contact) suggest possible solutions, whether in the form of an implant, oral pill or gel, that could be reliably effective.
A study of couples across nine countries in which one partner was HIV-positive, showed promising results when antiretroviral drugs were taken by the partner who was not infected. And a multinational study of men who have sex with men and transgender women, published in November 2010, showed similar effectiveness.
Karim said the constellation of new research presents hope that a workable solution is not too far away.
"We have a huge game-changer now, where antiretrovirals… are highly effective. And in fact what we've seen is a change in the discourse. UN AIDS is now talking about zeros," he said. A world without further HIV infections might only have been dreamt of two years ago, let alone when the virus first emerged 31 years ago.
Hundreds of scientists and advocates who are working in the HIV/AIDs field have traveled to Sydney for the conference —and, they are all upbeat.
Manju Chatani, from the AIDS Vaccine Advocacy Coalition (AVAC), says the conference is the best opportunity to "skill up" advocates who work in the countries and regions worst hit by the AIDS epidemic so that they can more effectively push for change — whether that be changing community attitudes, educating, gaining support from government or simply awareness-raising.
"It's a really interesting conference to come to, because it's not just about the scientific updates on microbicide trials - this field was born out of advocacy by women's groups really looking for options for women, so there's always been a strong element of advocacy around it," she told The Global Mail.
"We're in a very different era right now, where we can actually start talking about implementation," she said, enthused about the latest research, "because the treatment-prevention trials show that early treatment can prevent transmission."
She is adamant that arresting the spread of HIV is not possible without enabling women to make independent decisions about protecting themselves.
"The real key is actually putting prevention in women's hands. Because if you look at what we have now as prevention mechanisms, we have condoms — requires a man to use it. We have female condoms — requires negotiation with a man to use it. We have abstinence. [Chatani laughs.] We have faithfulness, and whether you're faithful or not has no bearing on what your partner decides to do. So all these mechanisms are not practical for women," she says.
In AVAC's December 2011 report, titled The End?, executive director Mitchell Warren says the AIDS epidemic can be over "in our lifetime".
"We now have the tools that if used strategically… can control the epidemic and eventually bring it to an end," he writes.
Global health initiatives are incorporating microbicides and antiretroviral treatments into their prevention programs.
Last November United States Secretary of State Hillary Clinton gave a speech that advocated for an AIDS-free generation:
"Our efforts have helped set the stage for a historic opportunity, one that the world has today: to change the course of this pandemic and usher in an AIDS-free generation.
"Now, by an AIDS-free generation, I mean one where, first, virtually no children are born with the virus; second, as these children become teenagers and adults, they are at far lower risk of becoming infected than they would be today thanks to a wide range of prevention tools; and third, if they do acquire HIV, they have access to treatment that helps prevent them from developing AIDS and passing the virus on to others."
The speech heavily emphasised the importance of recent scientific advances and the need to enable women to have better control over protection.
It was followed closely by US President Barack Obama's World AIDS Day remarks on December 1, 2011, that were similarly positive.
"Few could have imagined that we'd be talking about the real possibility of an AIDS-free generation, but that's what we're talking about," he said.
What happens next is by no means certain, but what seemed entirely out of reach just 18 months ago is now openly discussed by some of the most influential players in international health and aid.
As Salim Abdool Karim puts it: "When we were [at] this conference in 2010 no one would even have mentioned the word zeros. Everyone would look at you and say, 'What are you talking about, you've smoked something.' Well, now we're seeing talk about zeros. Zero infection [and] zero AIDS-related deaths."