Three decades after the full onset of the global HIV tragedy, science appears to finally be developing preventative measures, including microbicides that would thwart infections in the first place, according to individuals at an international conference in Sydney this week.
Now, however, the challenge is to put the solution into the hands of those most susceptible to the disease. Despite safe and effective HIV prevention options such as male and female condoms among others, and considerable research and development of new HIV prevention technologies, new HIV infections continue to occur daily, according to information provided at the International Microbicides Conference.
“Every woman and man irrespective of where they live, or their age, race or tribe, loves to be protected from HIV as they go about their reproductive lives,” Milly Katana, a featured speaker, told the conference. “We have made many missteps since the onslaught of the HIV epidemic in the 19th century in the Congo Basin forests and the highlands of Eastern Africa, the bustling cites of the Americas and Europe. Some of these missteps we have made unintentionally; and we beg to be forgiven. Others we made intentionally in the quest of being self-centered or in an attempt to conform to scientific precisions or culturally induced biases.”
Although Ugandans have contributed meaningfully in the development of an antiretroviral drug (AZT or Zidovudine) for public health sake, it took more than 15 years for some of these very people to get access to the life-extending drug. Such delays are missteps that shouldn’t have happened. The ARV therapy is still inaccessible to many people living with HIV in need of it.
“What I am saying now is to draw lessons from our recent past as we develop a product that is intended to be used by poor or young women who may not have financial stability yet are at risk of contracting HIV,” said Katana, a representative from the Wisdom Centre in Uganda. “We might have a very exciting opportunity in the form of microbicides (currently under research), to put in the hands of women for HIV prevention.
“As we build the boat, we should also be talking about how we are going to sail in it,” she continued. “It should not be like we build the boat today and then realize later on that there is no water to sail it in. We should be talking about what form the product will take, what distribution channels shall we use (once microbicides become available after research and development), for whom are we making these products for and whom we need to engage at this point in time to get this potentially successful product into use.”
Microbicides offer an opportunity to salvage the situation, she continued. For women living with HIV, there has been some hope in the form of treatment. The stakes regarding prevention of HIV among women are very high. Very exciting work is currently underway with some promising breakthrough results, Katana told the conference. Women do not have as much information on microbicides today, however, as they did when the products were first proposed.
Lessons from recent history include delayed operationalization of successful interventions ranging from ARVs for therapeutic purposes to prevention technologies like safe medical male circumcision and condoms which are until now still faced with accessibility hurdles. As early as 1986, studies showed that circumcision reduced the incidence of HIV among male clients of female sex workers in Pumwani neighborhoods of Nairobi. However it took almost 25 years to start rolling out male circumcision as a prevention technology.
Some considerations for getting the products available to women and men should employ both conventional and non-conventional marketing strategies. However this should be with a distinctive perspective as these are no ordinary consumer products such as soft drinks. Access strategy should address short term and long term measures. Short term measures should focus on post-trial access for women who participate in trials that indicate protective effects of the products.
“It is outright injustice for women that participate in the clinical trials having to wait for years before they can get the products that they helped in testing. The long term access strategy can be summarized into 4 Ps: the product, price of the product, the place of outlet and promotion details” Katana told the conference.
“The highest burden of HIV is in developing countries. The most vulnerable individuals are young women who may have little independence in terms of not only their sexuality but also housing. The product therefore should be easy to store in very basic forms that accord the majority of the users the necessary privacy while maintaining the potency of the products,” she said. “For example, a product that may need refrigeration makes privacy lost as young women do not own personal fridges. The point of use should also be independent of the sexual activity. This is because most women have minimal negotiation power over their sexuality. In addition, the products should have minimal monitoring requirements so that their use is less dependent on specialized personnel who are in very short supply the world over.”
There is also the question of price. It is total injustice, she said, to imagine that women will be forced to bear the costs of production and research as well as give profits to the producers. “These are products that should be produced in the interest of public health. It is therefore now that the public sector must start strategizing on how to finance the products so that they are affordable to the users. With more than 2 million people infected with HIV annually, it is criminal to deny any woman access to a protective product simply because she can’t afford its cost.”
The distribution must also target where individuals can easily get access to the products. Private engagements should be launched so as to leverage the wide distribution networks for consumer goods, with women understandably eager to obtain microbicides alongside their daily groceries in market stalls.
In addition, Katana added, “research should be directed at coming up with products that have minimal storage complexities so as to make them available through a wide range of outlets. Similarly, policy engagements need to start now so that most of the foreseeable distribution hurdles are addressed before products leave the production lines.”
Some of the hurdles include licensing requirements and clinical monitoring. Inasmuch as the products are so far thought to be ARV based, products should require minimal or no clinical monitoring requirements.
“In order to facilitate access, products that will turn the tide of the HIV epidemic should address misconceptions related to their use. This should be done in constant consultation with women who are going to use the products. Most of the trials that are currently underway have inbuilt education activities to address community concerns and myths, as well as provider biases. At the roll-out level, such misconceptions should be addressed even before the products leave the production lines as well as on an ongoing basis. This should involve clear messages for different sections of the population ranging from potential users, policy makers, the financiers, and the distributors. This is calls for a solid partnership between researchers, communities and public health policy makers including ministries of health, to identify such misconceptions so that strategies to address them start right away,” Katana said.
“The world, especially women, are desperate for a technology that will put the power for preventing new HIV infections in the hands of women,” Katana continued. “As research is under way, critical thinking must be made to come up with products that will not only be user friendly but affordable by all women irrespective of which part of the world they live in.”
(Bobby Ramakant is the Director for Policy and Programmes for Citizen News Service. He writes extensively on health and development for CNS. Email: firstname.lastname@example.org, website: www.citizen-news.org)