Biomedical tools for HIV prevention, also known as new prevention technologies (or NPTs), are often touted as tools that will give women greater control over HIV prevention. But will these tools actually empower women? Here, we explore this question and some reasons for optimism and skepticism.
In Canada and around the world, many women are at a disadvantage socially and economically. These disadvantages mean that women are often at risk of HIV infection because they lack the power to negotiate the use of HIV prevention measures, such as condoms, abstinence and mutual monogamy. In addition, all women are biologically more susceptible to HIV infection through heterosexual sex than men for several reasons. Firstly, women are exposed to more HIV during sex than men because the volume of semen is usually greater than the volume of vaginal fluid and because semen contains a higher concentration of HIV. Secondly, more of a woman's mucous membranes are exposed to HIV because the surface area of the vagina is greater than that of the penis. Finally, HIV has more time to cause infection in women because semen can remain in prolonged contact with the vagina following unprotected sex.1,2
"Abstinence and condom use may be impossible for women to enforce. Fidelity is of no use unless it is mutual, and men's faithfulness very often lies outside of women's control."3
Efforts are underway to develop several new technologies to prevent HIV, including microbicides, vaccines, post-exposure prophylaxis (PEP), pre-exposure prophylaxis (PrEP) and HIV treatment as prevention. In recent trials, some of these NPTs have proven successful.
These new technologies may have the ability to expand the HIV prevention toolkit, giving women more options to protect themselves from HIV. When thinking about the potential value of NPTs, a helpful analogy is the range of contraception options available to women (see figure). Currently available contraceptive options are considerable and each woman can choose a method based on her personal needs and preferences. Similarly, potential new HIV prevention options would greatly expand women's options for HIV prevention and provide a range of timing options (before, during or after sex) and modes of use (oral, topical or injectable), thus allowing each woman to choose the right option for her.
Just as women have very different preferences for birth control, women would also have options for preventing HIV transmission. In other words, the more options to choose from, the better, because there will never be a "one-size-fits-all" option that is acceptable to all women.
Will these new NPTs increase women's control over HIV prevention?
One of the main arguments for the potential of NPTs to provide women with more control over HIV prevention is that women could use NPTs without the consent or even the knowledge of their male partners (this is sometimes called covert use). Therefore, NPTs may help women who experience problems negotiating safer sex and are less empowered to insist on condom usage -- such as women who do commercial sex work and women in coercive relationships.4 While NPTs such as PrEP and microbicides are not likely to provide the same amount of protection as condoms, some protection is better than none in cases where the male partner refuses to use a condom.5
Also, unlike condoms, many NPTs would not have to be used in "the heat of the moment" and therefore may make negotiating safer sex easier for women. Biomedical research is shifting from focusing on prevention methods that need to be used at the time of the sexual encounter to methods that can be used before and/or after sex.6 It may be easier for women to negotiate these methods than to convince a male partner to use a condom during each and every sexual encounter.
Another key benefit of NPTs for women is that they could allow women to conceive while at the same time protecting against HIV infection. The primary HIV prevention method currently available -- condoms -- does not allow for safer conception between serodiscordant couples (where one is HIV positive and one is HIV negative). Developing HIV prevention tools that would allow for conception while still reducing the risk of HIV infection would have a significant advantage for serodiscordant couples wanting to have a child.
Prevention methods such as condoms and abstinence are not always realistic options for women, especially those who are married, who want to have children or who are at risk of sexual violence. A safe and effective microbicide, PrEP or HIV vaccine could provide women with more options for protecting themselves from HIV infection.
While there are reasons for optimism, NPTs may not be the panacea for women's equality and empowerment that they are sometimes thought to be.
Even if NPTs become available and even though the use of NPTs would technically be under a woman's control, it may not be possible for many women to use an NPT.6,7 Whether a woman decides to use an NPT is a complex process.8 Her decision will be based on several factors: Does she think she is at risk of HIV infection from her partner? Does she understand how the NPT works? Can she afford the NPT? What does she anticipate her partner's reaction to be? Does she have enough autonomy to make her own decisions about her sexual and reproductive health? Finally, some studies have shown that, just as with condoms, many women are unlikely to use NPTs with their regular partners. The reasons given include the perception that an NPT could reduce their own or their partner's pleasure and the concern that their partner may interpret NPT use as a sign of mistrust.8-10
Although NPTs could theoretically provide women with more control over HIV prevention and allow women to use prevention methods discreetly, the use of some NPTs may not be all that easy to hide. For example, an attentive male partner might notice the extra lubrication or a different sensation from a microbicide, or find his partner's stash of PrEP pills. In some cases, if women are discovered using prevention products, they could face adverse consequences, even violence, as the products might be seen as an affront to men's power and the traditional gender norms.9,11,12 So, although NPTs could offer women more choices, there is no guarantee that they will empower women.
A woman may also face negative consequences if she does decide to negotiate NPT use with her partner. For example, broaching the topic of NPTs with their male partners might signify mistrust and/or infidelity.12,13 Also, if women tell their male partners about their use of an NPT, men may decide that they no longer have to use condoms, which could increase women's risk of HIV transmission since NPTs are not as effective as condoms.8,10 This effect is known as risk compensation.
NPTs could also further entrench women's responsibility for sexual health, rather than promoting a shared responsibility. Women are already primarily responsible for birth control, and NPTs could add to the burden on women to make sex "consequence-free" for their male partners.8
A lot can be learned from our experience with the female condom, which is currently the only female-initiated prevention tool currently available.14 Although touted as a tool that would empower women, the female condom has generally not lived up to its expectations for various reasons including difficulties with covert use, poor acceptability among some women, and its relatively high cost.
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