If condoms are over 90 percent effective, when used constantly and consistently, in preventing the spread of HIV, then why do we need more options in our prevention toolbox? Why aren't condoms working? This very blunt question was posed by Jim Pickett, chair of the International Rectal Microbicide Advocates (IRMA), to audience members at a discussion and video presentation entitled "The Bottom Line on Rectal Microbicide Research." Hosted by Gay Men's Health Crisis (GMHC) on Jan. 23, 2013, the presentation dealt with what will someday be another tool for prevention, though it is currently only in trial phases -- rectal microbicides.
A microbicide is a product applied topically in the vagina or rectum that can offer protection against HIV and other sexually transmitted infections (STIs), and can potentially be used for contraception. It would be available as a gel, lubricant, douche, or an enema and would provide protection in the absence of condoms or used together with a condom. This presentation focused almost exclusively on rectal microbicides and how they can be used as a prevention method among gay men to stop the spread of HIV and other STIs -- and when it comes to advocacy in this growing field, Pickett is one of the world's top minds.
IRMA was founded in 2005 by four people from four agencies in the U.S. and Canada. It is currently comprised of around 1,200 advocates, scientists, funders and policymakers. Their mission is to support the development and research of safe, effective rectal microbicides for all who need them. They work primarily to increase and diversify funding (currently, 97 percent of funding comes from the federal government), increase research activities, make lubricants safer (Pickett noted that, currently, the U.S. Food and Drug Administration approves lube without human trials, instead it is often tested in rabbit and guinea pig genitalia only), increase access to lubricants, and increase knowledge around lubricants and their uses.
So anyway, why do we need more prevention tools? Pickett, who is also director of prevention advocacy and gay men's health at the AIDS Foundation of Chicago, asked his provocative question about condoms quite early in the presentation. The audience responses were varied, but extremely illuminating. One person said that sex is based on pleasure, and condoms come with an inherent diminished pleasure. Some people said that condoms mean only one person (usually the insertive partner) is responsible for prevention. Someone mentioned lack of access and cost prohibitions. Others mentioned stigma against condoms. For all these reasons and more, there must be more options in the prevention toolbox. Pickett noted that many future options will supplement, not replace, condoms -- as it should be.
Though there are plenty of ways to implement microbicides, including a dissolving, "breath strip"-type application, microbicides will most likely be delivered through behaviors that people already use during sex, such as a douche, an enema or a lubricant. Pickett noted that, with advances in prevention, scientists often try to find ways to insert prevention into what people are already doing around sex.
Pickett went on to illustrate that the anus is a peculiar cavity for the transmission of HIV. While a vagina has 40 cell layers, the anus only has one, and right behind the rectal tissue is a good portion of the body's CD4 cells, waiting to be infected. As such, anal sex is a higher risk activity. Also, so far, only about 100 human beings in the U.S. have been in clinical trials as part of rectal microbicide research, while thousands have been in vaginal microbicide trials.
The next trial on the horizon, about which Pickett was especially excited, is a global study of 186 gay men and transwomen from Peru, Puerto Rico, the U.S., Thailand and South Africa. Dubbed MTN-017, the study will be cut into three eight-week periods: One eight-week period will have the participants try applying the gel daily, the second portion will have participants insert the gel before and after sexual intercourse, and the third eight-week period will have them use the once-daily pre-exposure prophylaxis (PrEP) pill, Truvada (tenofovir/FTC). The order in which each trial volunteer follows each eight-week period will be randomized; so, for example, some will start with daily gel use, while others may start by taking Truvada. The study is designed to examine whether the gel is safe and acceptable to use, how it compares to Truvada in terms of adherence, and which method participants prefer. Pickett also showed a video produced by IRMA that talks about microbicides and microbicide research. The video is embedded near the beginning of this article.
Finishing off the presentation, Pickett said, "HIV is a swamp. Condoms drain it only part of the way." He also commented on how paradigms are shifting in HIV prevention. Using an apt analogy, he noted that music used to be listened to on big boomboxes. They were cool. They still have some retro, vintage nostalgia cred today, but music can now be listened to on tiny devices that can also pay for your meals and call your parents, among many other uses. Such will be the way of HIV prevention, according to Pickett -- "We're in the boombox phase of HIV prevention," he said -- and 10 years from now, what we use as prevention will look very different. He acknowledged that there will be hesitation among people who can't think of anything else besides the almighty condom. "The safer sex paradigm has shifted. We're used to saying 'Always use a condom, 100 percent of the time.' It is very hard for us to think about these new options."