Friday, April 11, 2008

Let's Hear Those Voices! Let's Have Choices for Everyone Who Needs Them!

Why should we prioritise the needs of one group of people over the needs of other groups of people?

by Jo Robinson

I’ve enjoyed some of the fall out discussions from the International Microbicides Conference in Delhi, that have appeared in my inbox via several lists. It’s got me thinking a bit, particularly about how we communicate messages around microbicides, and how we talk meaningfully about microbicides, without reinforcing stigma and prejudice of those living with HIV, and other marginalised groups of people.

I’ve been picking up on this message that has been around for a long time, that the primary target audience for an HIV microbicide is HIV negative women living in Africa, and other places where HIV prevalance among the general population is high. Nothing wrong with that you might argue, but... IS THERE something inherently wrong with it?

My initial introductions to the microbicide field were in 2001, and shortly after I attended my first International Microbicides Conference in Antwerp, Belgium, in 2002. At or around this conference the International Partnership for Microbicides (IPM) was launched, and it was all very exciting news. I was a new fresh young microbicide activist - There were a few of us back then, as opposed to the enormous movement that has been created today I’m pleased to say!

We lapped up messages, had fantastic discussions, started working on materials to disseminate, and hooked up with Global Campaign for Microbicides (GCM) and realised we had in GCM an organisation that wanted to work in partnership, and was interested in a diverse range of voices from the community.

But that was six years ago and a lot of work has happened in the field, and times have changed. HIV has I’m sad to say, advanced in our communities, HIV prevention work has advanced, messages have changed with the times. Things have moved on, so how do we stay up to date and on the edge? How do we make sure that people at the cutting edge of HIV prevention and sex and relationships stay at the centre of community mobilisation around microbicides? How do we make sure our voices are heard globally when we don’t work for an international organisation or have a marketing budget? Well, the IRMA blog is a very welcome opportunity to share some of our thoughts I think.

So, are microbicides still for HIV negative women only? Well, the work that IRMA is doing clearly challenges that notion in different ways. What springs to my mind when we prioritise one group of people’s needs over another is that in HIV prevention terms this makes no sense whatsoever. Playing people off against each other is distrastrous for the health and wellbeing of people in different communities.

Why should we prioritise the needs of one group of people over the needs of other groups of people?

It doesn’t seem very human rights-based, does it? It’s counter-intuitive to me to think about a hierarchy of needs. Most people that are living with a prevalence of HIV that is high among their communities or sexual networks, have pressing needs around HIV transmission – either avoiding passing HIV, or avoiding getting HIV, so let’s try and focus on the needs of all of them and try to hold them all in mind – plenty of others will try to divide us. I’d like to see us be a little bit more united. The great thing about the microbicides movement is that here is an issue and a product or set of products that are of interest to us all, and as such they have the potential to unite us all in favour of a common goal, namely promoting the health and wellbeing of people with HIV and communities affected by HIV.

Here in the UK, we have moved on a lot in the past six years. Our HIV prevention messages are now much more targetted at people with HIV as well as those that do not have HIV. We have had to carefully avoid messaging that excludes people with HIV because we’ve found that that reinforces stigma and prejudice, often making it harder for those people to negotiate the type of sex they want – be it protected or unprotected, and that’s the last thing we want to do. The vast majority of people with HIV are highly motivated to avoid passing on HIV, but it doesn’t mean they do not have a variety of complex sexual health needs and a large need for support around sex and relationship issues.

I question if we should be so blatent in our messaging and thinking about microbicides as a tool that will “primarily” help a particular group of people.

Women without HIV might well be the “targets” of something new, but will they actually be the first to use it? I suspect that gay men in their droves will be picking up any new microbicide product, because using lube for sex is so common among men (and women) who have anal sex (and much less common in comparison among people who have vaginal sex).

The people that will be most interested in a new HIV prevention tool will also be living with HIV themselves. Time after time I’ve been around people with HIV who are motivated around HIV prevention, and want to take advantage of anything that will make passing on HIV less of a “big issue to worry and think about” when they have sex with partners that don’t have HIV. For some, condoms, work, but choice would be nice!!

So, I think we should be careful if we think about hierarchies of communities and needs. Why are HIV negative women more deserving? Because there are more women getting HIV than men? Well, HIV prevalence in certain communities of men who have sex with men in a range of cities around the world is on a par with prevalence in some of the high HIV prevalance countries in Africa for example, so let’s think about prevalence in a broader way, and target our resources where they are equally needed.

If I were thinking about messaging around microbicides in the gay community, would I want to prioritise the needs of receptive men or “bottoms” rather than “tops” or “insertive” men?

Do they have different needs? Should I say, this is primarily for the “bottoms”, but, oh, yeah, we best make sure we at least tell the “tops” about it? I suspect what we’d want to do is make sure we had included everyone, because sex usually takes two or more people! I’d want to see microbicides as a uniting factor for the community, because they will help insertive partners as much as they will help receptive partners.

Many have argued that women need something that they can use without their partners knowing, but practically speaking, this is probably counter intuitive to many women, as much as it will be intuitive to some. Many have argued that violence, coercision and power dynamics all have their part to play in why we must develop something that HIV negative women can hide from (the assumption goes) their HIV positive male partners. Whilst this might be important to some women in some situations, it’s a lot more complex than this I suspect for many, and this type of story if we buy into it reinforces the message that HIV positive men are in some way predatory and only interested in unprotected sex at any cost– surely a stereotype that we ought to be fighting, rather than reinforcing?

In the relationship workshops I’ve been priveleged to run, with women and men with HIV, most talk about love, trust, caring about each other and intimacy, and that negotiating and talking about the sex they want is a problem, and it’s not a problem that will go away unless they have choices and strategies to deal with it.

If a microbicide gives me other choices, and is something I can use whether we talk about it or not, that’s a good thing. But why is an HIV negative women’s need more important than an HIV positive man’s right to have different choices around how to avoid passing on HIV? Where is the group that is demanding a microbicide because it will expand options for straight men with HIV? Or gay men who are insertive partners during in sex? After all, there are plenty of women out there arguing that we should have better male condom distribution schemes, - even though they won’t necessarily be putting them on themselves!

So many different audiences, so many different voices, but let’s here those voices!

What’s my marketing message going to be?

What message would you give men with HIV when it comes to microbicides?

“Fumbling around with a condom? Why not take it as it comes with a gel!”

[Please feel free to comment and keep this important discussion going!]

1 comment:

Seth said...

Thanks for this great article. I've always had an issue with prioritizing the needs of different groups. I wrok in teh field of public health and the main focus has always been women's health and women's right- women's vulnerability, etc. with such little attention paid to how to involve men in HIV prevention, gender rights, family planning, etc. Clearly men also transmit and get infected by STIs and need to be involved in global sexual health programs! The same is true for MSM... the great thing about IRMA is that it strives to ensure all are protected not just one subset - clearly studies show that everyone, not just gay men have anal sex, thus a rectal microbicide would be beneficial to all groups, not just women or men. Obviously certain groups are left out from using vaginal microbicides, manly MSM. The development of vaginal microbicides is so important, however other groups cannot be forgotten in the process of development. Those working on the AIDS vaccine aren't saying... lest's only make the vaccine effective in HIV negative women. Clearly, MSM rates are on the rise again and things such as crytsal meth and stigam against MSM will only continue to fuel this trend.

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