Prevention for women needs more than just lip service

HIV incidence among women between 15 and 49 is increasing in South Africa while rates in other groups decline. Prevention needs more than lip service to reverse this deadly trend. With more than 2.5 million people now on antiretroviral (ARV) treatment, an increasing national focus on treatment and adherence means that women-centred prevention strategies are being neglected.

Disappointing findings that vaginal microbicide gel is not effective in preventing HIV highlights the urgent need for research into a range of HIV prevention options that will fit more easily into the lives of women. We must step-up the procurement and promotion of female condoms and create the demand for this life-saving product.

With gender based violence at epidemic levels and encouraging Pre-Exposure Prophylaxis (PrEP) research findings (a CDC trial in Botswana, for example, found that PrEP reduced the risk of heterosexual transmission of HIV by roughly 63% in the study group overall), we must identify at-risk women and start trialling PrEP treatment.

According to the World Health Organisation, some studies suggest that women using progestogen-only injectable contraception may be at increased risk of HIV acquisition. Thorough counselling on hormonal contraception must therefore be given to women across South Africa, especially HIV positive women. We must ensure that healthcare workers are properly trained to discuss the benefits and risks of all forms of contraception and how they interact with HIV and AIDS.

Perhaps most importantly, addressing the structural drivers of HIV – inequality and discrimination, stigma, unemployment, poverty, poor educational opportunities and gender based violence – must form a critical part of the country’s prevention agenda.

We call for ZERO for women and girls in the NSP (2017 – 2021).

South Africa’s women and girls need a range of prevention technologies and strategies which address their diverse realities and integrate with their lives – we need more than lip service.

Where is the ZERO for women and girls?

Women and girls carry the bulk of the HIV burden in South Africa where 6.4 million people are estimated to be living with HIV or AIDS. Women are both more at risk of infection and more likely to be caring for those affected.

While HIV incidence is declining overall, it has increased among women aged 15-49. HIV incidence is highest in young women aged 15-24 at 2.3%, making up a quarter of all new infections. Females have a significantly higher HIV prevalence (percentage of people living with HIV) than males, estimated at 36% among women aged 30-35, compared to 25.6% among men in the same age group.

Getting to zero new infections is the big global goal but we are very far from it, particularly for women. Our National Strategic Plan’s target is to reduce new infections by 50%, with no specific targets for women and girls.

More recently, UNAIDS launched its ambitious 90-90-90 strategy – 90% diagnosed, 90% on treatment, 90% virally suppressed – to end the AIDS epidemic by 2030 but it makes no mention of specific targets for women and does not recognise them as a key at-risk population.

With the focus now firmly on treatment as prevention, the effort to develop effective prevention methods that fit into the lives of women is slowing. More research and funding for research is critically needed in this area to give women more control over their sexual and reproductive health and reduce their risk of becoming infected.

Poor access to services for marginalised women – such as sex workers, rural women and lesbian, bisexual and transgender women – is still an issue. The sexual and reproductive health and rights of women and girls need to be understood and addressed. All the prevention tools in the world will mean nothing if they are not used. We need to create the demand for sexual and reproductive health services for all women, particularly marginalised women.

The reality is that we are very far from zero for women. Real and ambitious targets for women and girls will help us to get there. We call for ZERO for women and girls in the NSP (2017 – 2021).

Join us and raise your voice for women and girls >

More research needed: statement on microbicide study results

The SANAC Women’s Sector would like to thank the researchers that pioneered this important study. As a women’s interest group we honour all the women who participated in this study, their partners and families who supported them during the trail. The FACTS 001 trial participants are the heroes in this case we cannot be more grateful for their commitment and endurance during this period. We also are extremely proud that the LEAD research teams on this trial are all women well-known for their passion and commitment for prevention methods that focus on women.

The Tenofovir gel, designed to reduce risk for HIV and Herpes Simplex (HSV) viruses presents an opportunity for a woman-controlled intervention, in a context where this is desperately needed. Herpes infection is an established risk factor which increases risk for HIV infection in exposed women, and behavioural interventions such as Stepping Stones have an impact in the reduction of HSV (Jewkes et al., 2008).

The results  of a confirmatory trial of 1% Tenofovir gel used before and after sex announced at CROI yesterday proved not effective in preventing HIV in women when used before and after vaginal sex. FACTS 001 was conducted in South Africa with 2,059 women between the ages of 18-30 enrolled in the study and most were single and lived at home. The results of the trial report that the use of the gel by study participants was not optimum and hence no reduction of HIV in the intervention arm was recorded.

The findings of this study should be studied within the broader context of health behaviours and adherence among young women. Consistency in use of HIV prevention methods, including barrier methods remains a problem (Shai, Jewkes, Nduna, Levin, & Dunkle, 2010). Similarities can be drawn between condom use and the use of the gel. Both need to be administered before and after sex; with a condom put on before sex and carefully removed after sex. The gel is also applied before and after sex. What this means is that the user should have access to the product at a point of possible sexual encounter. It is this scenario that creates a challenge for some.

With biomedical interventions allegiance and adherence are critical for effectiveness to be achieved; however, for many young women, sexual encounters are often unplanned and unpredicted, though anticipated and expected. It is precisely this was should guide the development of HIV prevention interventions.

One positive aspect of this process is that at least this intervention was tested. Results, though not favourable, are reported and challenges associated with its failure will be interrogated. This is the correct step and should be a platform for us to use to advocate for delivery of interventions that are evidence based. Though we are all disappointed now; this scientific exercise will save millions of Rands that should, frankly, not be spent on interventions that do not have a public health effect. For instance, with condoms, the public-wide effects of condom use in preventing HIV infections does not have scientific base. There is no report of randomised controlled trials to demonstrate the effects of condoms on the country’s HIV incidence. At an individual level, yes, condoms work and should be promoted, vigilantly. However, consistently spending millions of Rands on a technology that does not dent HIV incidence on the most at risk group remains questionable.

Young women are the group highest at risk for HIV in South Africa. Male condoms present similar challenges to this ge’ and yet support for male condoms is unwavering. The commitment shown by the South African government for research development in the field of HIV/AIDS should be applauded. This is a great shift from our history as women and for HIV. However the question remains: is it fast enough to keep up with the continued new infections among women 16-24? Can South Africa afford the 365 000 new infections among this age group annually? Hence we remain concerned about the slow pace our government is moving in relation to implementing proven options that work for women. Female condoms and their accessibility, oral PrEP (Pre-Exposure Prophylaxis) has proven to work in many countries. We urge our government and the National Department of Health to prioritize the access and policy around these options.

Vuyseka Dubula, a HIV positive mother to an eight year old girl said

“…the possibility of a microbicide gave me hope that my daughter will not have the same challenges as I did…”

She needs choices and that is what we need, choices for women in this prevention basket.

Perhaps we can reiterate a couple of lessons to be learnt by us all, in particular, scientists who are at the forefront of the development of HIV prevention technologies:

  • Technologies that work for longer than at every sexual act, could be the answer for young women.
  • Clandestine technologies that you do not need to insert before and after sex with your partner’s knowledge, are preferred by young women.
  • Interventions that are not perceived, or experienced, to interfere with fertility and the menstrual cycle, are more easily welcomed.
  • The technology should also be easily accessible.
  • The product is proving to be not in-sync with women’s living conditions and lifestyle demands of this age group. Researchers need to develop biomedical interventions with women than interventions for women.
  • Young women are faced with poverty, unemployment, social inequality, violence, rape or unsolicited sex, poor health services or access to health, poor housing and many other socio-economic factors. These have an influence on how women participate in research and clinical trials.
  • Whilst efforts to involve communities in research are a feature in the design and conduct of trials, a lot more needs to be done to understand how these affect participation of women in trials.
  • A multi-sector approach in a trial community context is important when trials are designed and implemented to ensure that the above factors are considered as much as possible.
  • As much as resources are put in research infrastructure, equally, resources are needed in community involvement before and during the conduct of clinical trials.

The fact that the gel is not a practical method for women is an issue that we need to give urgent attention to. The trial participants are a snap shot of the picture of HIV in South Africa. This shows clearly that we cannot continue to look for solution for woman without taking socio-structural factors into consideration. We need to seriously give attention to who is this young woman 16-24 and we hope that research will give some answers. We look forward to the results of the RING and ASPIRE studies that will be released in 2015/2016.

We demand more research with a focus on young women and girls. The current status quo cannot continue.

References

Jewkes, R., Nduna, M., Levin, J., Jama, N., Dunkle, K. L., Puren, A., & Duvvury, N. (2008). Impact of Stepping Stones on incidence of HIV and HSV-2 and sexual behaviour in rural South Africa: cluster randomised controlled trial. British Medical Journal, 337(7666). doi: a506 10.1136/bmj.a506

Shai, N. J., Jewkes, R., Nduna, M., Levin, J., & Dunkle, K. (2010). Factors associated with consistent condom use among rural young women in South Africa. AIDS Care, iFirst.