Monday, March 01, 2004

Putting HIV Prevention In Women's Hands

Just as fairy tales do, policy debates about HIV prevention tend to end with marriage - "and they lived happily ever after." Teenagers should abstain until marriage (if you are conservative) or use condoms until marriage (if you are liberal). But of course, only in fairy tales do people's life stories end with marriage, and an article in yesterday's New York Times illustrates that the risk of HIV infection doesn't end there either:
Teenage brides in some African countries are becoming infected with the AIDS virus at higher rates than sexually active unmarried girls of similar ages in the same areas, the director of Unicef and other United Nations officials said here on Saturday. [...]

The officials said the findings pointed to an inadequacy in programs that focus on abstinence among teenagers as a main means of preventing H.I.V. infection because they failed to take into account fully the risk of transmission in marriage.

The young brides are apparently acquiring H.I.V., the AIDS virus, from their husbands, who tend to be many years older and were infected before marriage, the officials said.
The head of UNAIDS suggests promoting condom use in marriage, an idea which seems to me to be a non-starter. A sixteen-year-old girl married to a much older man is unlikely to have sufficient personal power to insist on condom use. It's no coincidence that HIV rates among women are highest in cultures which emphasize female submission - those women have great difficulty negotiating safer-sex practices within their relationships. Most African countries have no laws against marital rape, leaving married women with no legal right to protect themselves from their husbands. And even when brutality is not at issue, most married people - especially in traditional cultures - intend to have children. For that reason alone, condoms simply will not be widely accepted within marriage.

Requiring HIV testing at marriage might be helpful, although, as this article explains, many marriages are not registered with the government. But widespread male infidelity in marriage limits the degree to which women are protected by premarital testing.

So, if married women aren't protected by the much-lauded ABC approach (Abstain, Be faithful, use Condoms), what hope do they have? Microbicides. Microbicides are chemical products - usually delivered as a lubricant gel or a vaginal suppository - which either kill HIV or block it from cell entry. They're probably not quite as effective as barrier methods, but have substantial advantages anyway: women can use them without their partners' knowledge; they don't reduce sexual sensation; and they don't interfere with pregnancy.

Microbicide research has historically been underfunded. The former director of UNAIDS said in 2002 that microbicide research is "a classic case of market failure. The profit incentive for a first generation microbicide simply isn't there." But in the past few years, governments and foundations have managed to scrape together enough money that we're now, finally, looking at several promising lines of research.

Right now, many people's ability to protect themselves from HIV depends, not on what they do, but on what they can convince their partners to do. (This applies to gay men as well as to women.) Microbicides could change that - but as they near FDA approval, expect to hear conservatives focus on their failure rates, as they've done with condoms. Then ask those conservatives what they would tell a seventeen-year-old Zimbabwean girl whose parents have just married her to a forty-year-old trucker who spends months on the road sleeping with who-knows-who. Fidelity in marriage is great, but no one's life should depend on it.