A young AIDS patient in Africa

Global HIV data- tragically- confirms what women's health, rights, and social justice advocates have said for a decade. Social, economic, and sexual vulnerability of women-particularly young women and girls- harms their health and increases their risk of HIV and other sexually transmitted diseases (STDs). Existing prevention strategies have largely failed to address this vulnerability, focusing on abstinence, mutual monogamy and male condom use- none of which are easily controlled by women. The faces of HIV and AIDS in the world today are increasingly those of young women, many of whom are married, many of whom contracted the virus during adolescence.

Predictably HIV/AIDS is rapidly becoming a woman's epidemic. Approximately 14,000 people become infected with HIV everyday. Half of them are women. A vast majority of women had only one mode of exposure to HIV – sex with their male partners. Women are biologically more vulnerable to STD including HIV/AIDS. Women are twice as likely as men to contract HIV from unprotected intercourse. Vaginal membranes are exposed to infectious fluids for hours after sex. Younger women are at greater risk because the immature cervix is more vulnerable to damage and infection. STD often go undetected, and therefore untreated, in women. STD increase women's vulnerability to HIV. In addition, untreated STI can lead to infertility, ectopic pregnancy, infant mortality and cervical cancer.

Gender inequalities prevent many women from being able to protect themselves. Millions of women lack the social and economic power to insist on HIV prevention measures such as condoms, abstinence or mutual monogamy. Male and female condom use requires the tacit cooperation, if not outright participation, of a woman's male partner. HIV risk escalates among adolescent girls because of their physical vulnerability and susceptibility to rape, forced marriage, trafficking, economic dependence and coercion. Violence, coercion, and economic dependency render millions of women of all ages unable to 'negotiate' condom use or to abandon partners who put them at risk. Millions live in societies that permit them no role in sexual decision making, condone male infidelity and assign to women the burden of shame and stigma associated with infectious disease.

But there is always hope that not only gender inequity might change for the better, and women and men will recognize, appreciate and respect the rights of each other, but women will have more meaningful role to play in decision making, and will be empowered enough to access, afford, use and negotiate the use of STD/HIV prevention options with their partners. This struggle shall indeed be a long one.

Some dedicated advocates, scientists and donors are working to develop microbicides— gels, tablets, or other intra-vaginal products a woman could use to reduce her risk of getting HIV through sex. Microbicides are still being researched, and will require significant political will, public investment and popular demand before they become available.

Microbicides are substances that can substantially reduce the transmission of HIV and other sexually transmitted infections (STI) when applied vaginally and, possibly, rectally. Epidemiological models suggest that a microbicide with 60% efficacy could avert 2.54 million HIV infections world-wide over 3 years.

Microbicides are not yet available, but are at different stages of research in a number of countries. They could be produced in a variety of forms: gel, cream, film, suppository, sponge or vaginal ring. Some would also be contraceptives, offering women a dual protection method. Others would not be contraceptive, enabling women to become pregnant without risking infection.

Many studies have reported that women who do perceive themselves at risk for HIV had little success in asking their husbands to use condoms. While condom promotion has encouraged men to use condoms with sex workers and casual partners, most men still refuse to use condoms with the wife or regular partner. Predictably, HIV cases are increasing rapidly among married, monogamous women in countries like India. Microbicides will certainly help these women to protect themselves from STI/HIV.

Many women want to get pregnant – for their own reasons and/ or to achieve the status and security that, in many societies, they can only attain through motherhood. Since condoms are contraceptive, women now have to choose between childbearing and HIV prevention. Microbicides offer a ray of hope here too, being developed into two variants: contraceptive and non-contraceptive, which will make it possible for women to conceive without exposing herself to the risk of HIV transmission.

Microbicides must be safe for all potential users – sexually active women and men, pregnant women, HIV positive women, adolescents – and for vaginal and rectal application. They must also be compatible with condoms and other barrier methods. Potential mechanisms of microbicide action include:

killing or inactivating the virus by disrupting the surface membrane (surfactants) or boosting the vagina's natural defences (acidifying agents).

Preventing the virus from binding to it's target cells (adsorption inhibitors)

Blocking replication of the virus once it has entered cells.

There are about 60 possible microbicides in the pipeline. Six potential products are likely to enter Phase 3 large scale multi-centric clinical trials soon to assess effectiveness in prevention of vaginal transmission of HIV. These products include the surfactant (Savvy), the acidifying agent (buffer gel), and the adsorption inhibitors (PRO 2000, dextrin sulphate, carageenan and cellulose sulphate).

There are also some barriers to widespread support for microbicides. Morally conservative and patriarchal social norms make it difficult to confront the reality of a sexually transmitted epidemic. A culture of silence around women's sexuality enhances the stigma associated with seeking information or interventions about self-protection.

Much progress has been made on microbicides but many challenges remain. Badly needed is a significant increase in investment from both the public and private sectors.

Another challenge is to involve men and try to address the unequal power equation between a man and a woman, thereby increasing the understanding of each other's need, and collectively demand:

HIV prevention must address women's needs and vulnerabilities.

Women need education, economic opportunity and social support.

Women need gender equality in order to protect their health and rights.

Women need HIV and STI prevention tools they can control.

Women need microbicides…