Thursday, April 17, 2008

Buy one vaginal microbicide get an anal one free!

by Jo Robinson
UK

[Many thanks to Rebekah Webb who responded to my posting on microbicides for all and to Seth who posted a comment in the comments section.]

This post comes on the back of thinking about your posts, and also something someone said in a training session to me yesterday. A gay guy who happened to be living with HIV said to me: “Well, I wonder if sex is different for gay men as opposed to straight women because women have to worry about pregnancy, and so do straight men, and for gay guys there’s just not that worry”. He continued to say that means you can “fuck like bunny rabbits and not really have to engage in such direct consequences as pregnancy”.

So are STIs and HIV comparable to the consequence of pregnancy – or are they fundamentally different in nature and scope and different as consequences of sex for most people? On a cultural and social level, pregnancies and STIs are very different in our minds and we need to be pretty clear to separate this out and do some social research around this in order to be clear where they sit in relation to each other. And they may well be different or similar in different cultures and contexts. This is obviously particularly important as we might have microbicides that may or may not act as contraceptive microbicides. I’m kinda hoping some social researchers see this and say, yes, we’ve done this neat piece of research – and put it on the IRMA site! The obvious question is also how do people see their risks from anal sex – an act which is pregnancy free usually!! Would women use a rectal microbicide when the only unintended outcome from anal sex is STIs and HIV– not pregnancy? Although many people would say well, HIV as an unintended outcome of sex is pretty serious, but most of us engage with HIV in a different way again to how we engage with the consequence of pregnancy.
Are you going to use a rectal and vaginal microbicide in the same session? The comedy of it – hang on a sec, I’ve just got to get the right one in, ah, no, I’ve mixed them up…lots of fun! Has anybody thought about this? How is it going to work practically?
If I’m thinking of consequences of anal sex…some have said that in some cultures and some situations many women and men have anal sex to avoid pregnancy risk associated with vaginal sex. My question would be where anal sex is not used as a pregnancy avoidance tactic, do women and men have anal sex at the same time (or one after the other) as having vaginal sex…in the same session? Are you going to use a rectal and vaginal microbicide in the same session? The comedy of it – hang on a sec, I’ve just got to get the right one in, ah, no, I’ve mixed them up…lots of fun! Has anybody thought about this? How is it going to work practically? To get people to engage in thinking about risk in this way is quite complex, and then to get them using two products, one for vaginal and one for anal sex – in the same session, well, that’s a lotta lube and a bit of concentration needed right there! I’ve heard it said many times that if a vaginal microbicide is licensed we’ll all be putting it up our bums next…and that statement has a fair amount of truth in it I think. It’s not that I’m not for microbicides – I really am! – I just like to think about the practicalities too…Two for the price of one? Buy one vaginal microbicide get a rectal one free? Same tube, split in half, for use as different ends?! – the marketing people will have a field day.

So both this guy’s comments and Rebekah and Seth’s got me thinking a bit about the realities of how we weigh up risks to our health before, during or after sex. Rebekah brings up the subject that a microbicide will help women with immediate health needs, presumably helping them to avoid STIs, HIV, and possibly pregnancy, or allowing women to get pregnant but avoid STIs and HIV. But do we women see these as immediate health needs? Do we always prioritise other needs before and during sex and then deal with the consequences afterwards? Do we prioritise our need for pleasure, for ease, for connection, for losing or abandoning ourselves to the moment, for worrying about whether a guy or girl will say no, if we say could you use a condom, or I’d like to use a microbicide…before and during sex, and then deal with the consequences and other emerging needs afterwards. So do we need something that’s going to help us with STIs and HIV after sex, rather than before?

What about people with HIV? If I’m trying to avoid pregnancy, but also avoid passing on HIV, then my vaginal and anal microbicide has to work for me too. Of course, some clever scientist might also come up with something that allows me to get pregnant but also avoid passing on HIV, and that would be very neat too. Options, options…
The answer is probably that we’re going to need both "before sex" and "after sex" options when it comes to expanding the microbicide product field.
The answer is probably that we’re going to need both "before sex" and "after sex" options when it comes to expanding the microbicide product field. If we look at how the contraceptive pill is used – it’s used quite differently whether women are in long term relationships or having shorter term relationships, or one night stands. In places in the world where women have access to the contraceptive pill, we have a number of options. Not only do we have a pill that we can take beforehand, but a pill that we can take afterwards. We are lucky because we have some choice around avoiding unwanted pregnancies which if we take the pill before we have sex, we can avoid an unintended outcome of the sex we have with guys. There is nothing like this for HIV…condoms are in the moment…which is different.

Many of us though will have had sex or know among our friends that it’s common to have sex particularly having a one off sexual encounter with someone, where we are not taking any contraception and if that sex is with a guy then there may be a risk of pregnancy. This risk often does not mean that people take precautions before they have sex, they look at their options afterwards…e.g. emergency contraception or “morning after pill” as most people call it is often top of the list for women to access in this situation. Often the need for a sexual health check up is pushed to the back of people’s minds, and they wait for symptoms – or not, and then presume that they have not picked anything up if they do not get symptoms.

For most women, we are taught that pregnancy is the most fearful consequence of unprotected sex with guys, and so in our minds, we prioritise our health and needs around this. Pregnancy is so tangible for us as an outcome of sex with guys that we have to do no thinking around it; if we want to avoid it we will access all available options to avoid it. But often that will mean that we do not avoid it in the present moment when we have sex, we either think about it before hand or take our pills during the month, or we think about it afterwards with emergency contraception helping us out. But STIs and HIV are different, we have to think about them more (they’re not as tangible as pregnancy in our minds) we ask ourselves have we or haven’t we been exposed to these things? I’ll have to wait longer for the test results…will I get symptoms? It’s more thinking…and that hurts our heads more.

So, in terms of a microbicide, what’s the ideal? Well, probably something that we could use after we have sex as much as one we could use before hand. (Both would be good). Have we thought about that? Have we thought about an agent that we could use – in the privacy of the bathroom after we’ve had sex – something that would protect us afterwards, or a day afterwards would be great.
We need something cheap, easily available, something to keep in your bathroom or under your bed ideally.
In the UK the only thing that will help you with avoiding HIV after sexual exposure is PEP – Post exposure prophylaxis (a month’s worth of HIV antiretroviral) available after sexual exposure – but only available through a hospital, and available only to those who have had a risky sexual exposure – that is defined by quite a few things having to be present. But a month’s worth of pills is not really going to be the answer for most. We need something cheap, easily available, something to keep in your bathroom or under your bed ideally.

How about packs of microbicides for use after sex? I know some of the microbicides are obviously designed to work during sex and for a bit afterwards…but how about something that will only work afterwards? How would that work? The science would be harder no doubt…but given the number of women that access emergency contraception or morning after pill in the UK, surely it would also be very popular in some parts of the world.

[Please continue the conversation - leave your comments here!]

1 comment:

Doreen said...

Interesting thoughts. Aside from having one microbicide for the vagina and another for the rectum; there is the gnarly problem that women have a vaginal opening so close to the anus--how do you keep those products apart? They will need to be designed not to migrate accidentally to the wrong orifice.

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