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But transactional sex is not the only risk for women in developing countries; simply being married puts women at greater risk for HIV infection. Despite slogans like “B faithful,” social norms often push married men to engage in multiple, concurrent partnerships, putting their wives and each of their sexual partners at increased risk for HIV. Young married women in developing countries are at particularly high risk. In rural South Africa, for example, these women are 75 percent more likely to be HIV-positive than sexually-active unmarried girls. Few women feel that they have the right to ask their husbands to use condoms, even if they know their husbands are not being faithful; others might feel requesting condom use is acceptable, but fear the consequences. Since women can neither rely on condoms nor insist on refraining from sex, women have virtually no means by which to protect themselves.
Understandably, women are beginning to show interest in a microbicide. Several recent studies have shown that a majority women in developing countries would be willing to purchase a microbicide, even if it costs more than a condom. A 2002 survey showed that 68% of women in Kenya and 58% of women in Brazil would be willing to pay twice as much for a microbicide as for a condom because it would give them more direct control over their sexual health. In 1998, a survey by the European Union’s HIV/AIDS Programme in Developing Countries showed that 25% of sexually active women in France and more than 70% of women in urban areas of the Cote d’Ivoire and South Africa believe that a vaginal microbicide would be very useful. In the sub-Saharan countries, more than 50% said they would be willing to pay up to five times the price of a condom for an effective microbicide.
Microbicides have generated considerable interest in the United States as well. The Alan Guttmacher Institute found in a 1998 national survey that 23% of women in the U.S. are worried about contracting HIV or STDs and would be interested in using a microbicide. Another 17% said they would be interested even though they were not particularly worried about contracting HIV or an STD. In this same study, 9 out of 10 of all women who said they were interested reported that the reason a microbicide was appealing was the idea that it would allow them to control their protection rather than having to rely on their partners to do so. One third of the women also cited that they were interested in microbicides because condoms were uncomfortable or impractical. Considering the existence of a growing market of 21.3 million US women, investment in a microbicide could reap significant returns.
If a microbicide is in such demand, why hasn’t one been developed? Early failures in microbicide development are one explanation. In vitro studies in the early 1980’s suggested that Nonoxynol-9 (N-9), a spermicide that had been available since the 1950’s, killed the HIV virus. By the early 1990’s adding N–9 to sexual lubricants and condoms became the norm. However, researchers in 2000 demonstrated conclusively that N-9 does not, in fact, prevent HIV, and indeed actually increases an individual’s susceptibility to HIV when used frequently because it is a detergent that can irritate the skin and create small sores. N-9 was also found to be unsafe for anal sex when applied rectally. For these reasons, the CDC soon issued a statement in strongly recommending that N-9 not be used for STD or HIV prevention. The federal government called for warning labels on all N-9 products in 2004. Public health advocates such as WHO and the CDC, however, maintain that N-9 is a viable contraceptive for women at low risk for HIV.
Several other factors contribute to the lack of funding for microbicide development. Poor women (especially in developing nations) and gay men would benefit most from an effective microbicide. Both groups are marginalized in most societies, and women especially may lack the resources with which to purchase a microbicide. Consequently, both groups are seen as low priority in the eyes of investors and pharmaceutical companies. Because investors presume that microbicides will make them little profit, microbicide development has received insufficient attention.
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