"My husband doesn't beat me. Can I still use this microbicide?"

by Rebekah Webb

In her April 11 posting to the IRMA blog, Jo Robinson has raised some very timely questions about how microbicides are defined and how they might be 'marketed'.

There has been some debate among advocates about the strategy of pitching microbicides as something to be used by negative women vaginally - and moreover - secretly to protect themselves from infection from their male partners. First of all, the idea that you can control the use of any product is of course flawed. But deeper than that the assumption behind this - as Jo outlines - is that all men care nothing for women - or worse are sexual predators - and this does seem like not only an extreme view, but also one that entrenches the idea of women being passive and helpless - the 'innocent victims' concept. Most of us agree that this is a very narrow way of defining microbicides and one that could seriously backfire on efforts to improve sexual health because it pitches women against men and entrenches gender inequality rather than transforming it. It gives the impression that gender identities are fixed - what about those with multiple gender identities or transgendered individuals?

I do think it is entirely appropriate to focus on the needs of a particular group or constituency within society, and to talk explicitly about women's - or a subset of women's - specific needs.

We know from experience that women's issues tend to get lost - I am sure many minority groups feel the same way. Talking about women's needs does not in any way take away from the needs of other groups - they are not in competition. However, as Jo highlights, we may want to re-visit our basic assumptions about who will use microbicides and why and be sure that we are not going down a cul-de-sac instead of into an open field in which everyone can benefit from greater HIV protection.

The Global Campaign for Microbicides (GCM) has for some time now moved away from talking about covert use (we still think that for some women this will be a critical factor, but we don't think it will be true for most women). Those interested might like to refer to our factsheet on messaging around microbicides, which sets out our policies on the kind of language that is helpful and not helpful in advancing the microbicides cause. We are continually in the process of refining and developing this language and welcome such input from advocates everywhere.

There is clear and overwhelming evidence that the vast majority of women around the world are not given the right to express their sexual needs and rates of violence against women are unbelievably - unacceptably - high. But I think that we can talk about this without going down the essentialist path (i.e. the stereotyping path). As we all know, the number of people who are really sexual predators is very small - but what you commonly have is a breakdown in communication between men and women, with men thinking that they have to act aggressively in order to be true to their gender identity, and who resort all too quickly to physical expressions of their feelings. In addition, you have the societal view that to be a man is to be sexually active, to be a woman is to be sexually passive. Programs that improve communication between the sexes are the real magic bullet but they are thought to be too time-consuming and complex.

Ideally, microbicides - just like the more successful of the microcredit initiatives in Bangladesh - would best be introduced in the context of programs addressing sexual/domestic violence so that as you empower women you don't expose them to greater health risk. You encourage dialogue as you say and end up with a better result for all concerned. Such an example is the IMAGE project in South Africa, which by combining HIV prevention with awareness raising around domestic violence resulted in a 50% reduction in intimate partner violence within 2 years. It can be done.

It is very tempting in the microbicides world to employ simplistic messages to engage donors - using the cliches and catchphrases and the like which policymakers respond to. As soon as you talk about women's empowerment, the vast majority of policymakers (here in Europe but I am sure elsewhere) will nod and say of course!

However, there definitely needs to be a more concerted effort to create a discourse around microbicides that is much more nuanced and which we can use with communities - people have referred to this as a two track messaging system. I think it is possible to create a language which can suit both the purpose of 'fundraising' and of introducing microbicides to key audiences in a way that paves the way for introduction and use.The other reason given for using the 'this is for (negative) women' card is down to the evidence that giving men birth control is not the best way to get planned parenthood. The invention of the Pill which put the power of contraception in women's hands has had a massive impact on the social and economic development of nations around the world - and where it is still not available, we see the impact. Recent research in Scotland into creating a contraceptive pill for men was scrapped just last year because in surveys, women said that they would not trust men to take it! Given this context, the idea to give women something they can use has considerable weight from a public health standpoint.

Nonetheless I agree with Jo that positive women -and men- will be more likely to know about risks to their partners and want to use microbicides. So however useful it is to talk about preventing HIV in the same terms as the prevention of pregnancy, we need to remember that the analogy of the Pill can only go so far.

What we have to balance is that women have immediate practical health needs which a microbicide would help them with. But they also have needs which microbicides may not help them with if we don't address the above issues - and which may mean that microbicides don't reach their potential. I think ensuring that microbicides meets these broader needs around transforming gender relations will be critical to their uptake and success.

Rebekah Webb is the European Coordinator for GCM, a member of IRMA, and lives in Brussels, Belgium.