Two cheers for microbicides

This year's biggest success in HIV prevention research was undoubtedly the CAPRISA 004 study on pre-exposure prophylaxis (PrEP) microbicides gel for women. The unveiling of the study results at the recent International AIDS conference in Vienna made it the toast of the town and raised the spirits of HIV/AIDS researchers, policy-makers and advocates everywhere, given the sad string of serious pitfalls and setbacks -- scientific, economic, and political -- endured over the last years. Against that dismal backdrop, a gel that over a 30-month period, used before and after sex, protected women from getting HIV by 39% sounds like manna from heaven. Colleen Farrell over at the Bioethics Forum has a good brief description of the CAPRISA study and some of its implications and limitations.

However, even one assumes that the study results will be replicated and confirmed, it is still hard not to be somewhat pessimistic about the challenges of implementing this HIV prevention strategy in the field. On paper, it has fine feminist credentials: it is female-controlled way of preventing women from getting HIV from (all-too-often-wayward) men. In reality, there are bound to be challenges to adherence, when women are not repeatedly reminded to use the gel, and particularly if men dictate when sex occurs (not an hour from now, but now). This blogger does not personally have a vagina, but can imagine that inserting gel into it before and after sex is not a particularly erotic or pleasant experience, even if doing so might be lifesaving, particularly in high HIV-prevalence settings. (Fortunately pill and other forms of PrEP are currently being tested.) In addition, I am not sure anyone knows what the long-term health effects of intermittent use of antiretroviral drugs for HIV prevention purposes are, since this is (as Ferrell puts it) a new frontier. And we are not even talking yet about the usual problems of distributive justice in developing countries -- universal access to PrEP for safe sex purposes will be a long time coming, in countries where there is still no universal access for drugs for prevention of mother-to-child transmission or for antiretroviral treatment.

Of course, we already have a pretty vivid idea of what doing nothing in the face of the HIV/AIDS epidemic amounts to. Pessimism can and only should go so far. So researchers have to soldier on, even if they come up with interventions that provide spotty protection and whose implementation raises ethical problems right, left and center. CAPRISA 004 seems to have provided an important weapon for the long and ugly battle ahead.