Men's attitudes toward vaginal microbicides and microbicide trials in Zimbabwe

International Family Planning Perspectives, Mar 1999 by Khumalo-Sakutukwa, Gertrude N, Coggins, Christiana, Dube, Sabada E, Et al

Context: Vaginal microbicides, if shown to be safe and effective, might be useful for the many Zimbabwean women at risk for HIV and sexually transmitted diseases (STDs) who fail to negotiate condom use with their sexual partners. Because Zimbabwean men have authority around sexual issues, their attitudes toward microbicides may determine whether such a method will be adopted and used.

Methods: Five focus-group discussions were held with urban and rural Zimbabwean men to determine their attitudes toward communication about sex, HIV risk-reduction strategies, traditional vaginal practices, vaginal microbicides and their wives ' participation in microbicide trials.

Results: Several men indicated that they might prefer microbicides to condoms, if they are shown to be safe and effective. Some men expressed a concern about microbicides being spermicidal, and, because there is a cultural preference in Zimbabwe for "dry sex, "some men expressed concern that microbicides may cause excessive lubrication of the vagina. Both urban and rural men were willing to use condoms or microbicides with girlfriends and prostitutes, but not with wives. A few men conceded that the secret use of microbicides by their wives might be possible, but that they would be angry if they learned of it. Most men said that they would be supportive of their wives' participation in microbicide trials, if they are asked for permission first and if proper medical care and insurance coverage are provided.

Conclusions: If they prove to be safe and effective, microbicides might become widely used in Zimbabwe, particularly if they do not substantially lubricate the vagina or act as contraceptives. Social acceptance will be more likely if researchers directly inform men about these products and seek male permission for their female partners to enroll in microbicide trials.

International Family Planning Perspectives, 25(1):15-20

The people of Zimbabwe are highly aware of AIDS, modes of transmission of HIV and HIV prevention strategies, but they do not act on their knowledge at similarly high rates, particularly if they are married.l According to the 1994 Zimbabwe Demographic and Health Survey (DHS), more than twothirds of urban women and men reported knowing that the transmission of HIV can be prevented by the use of male condoms.2 However, of the women who had intercourse with a spouse in the four weeks preceding the survey, only 7% reported having used a male condom at least once during that period. In contrast, during the same time period, condoms were used by 38% of women who had had intercourse with a partner who was not a spouse.

Being monogamous is not an effective HIV prevention strategy for all Zimbabwean women, as their male partners are not always faithful to them. Eleven percent of married men reported having extramarital liaisons during the four weeks preceding the DHS survey, as did 0.2% of married women. In addition, 7% of men reported that they had paid for sex during the same time period.

It seems unlikely that in the near future levels of male condom use, abstinence or adherence to mutually faithful relationships will increase so significantly in Zimbabwe that the HIV epidemic will be slowed or stopped.3 Given the previous success of female-controlled methods of contraception such as oral contraceptives and injectables in Zimbabwe,* female-controlled methods of HIV and sexually transmitted disease (STD) prevention may be more successful than male-controlled methods. Such methods may include vaginal microbicides, which could be applied directly inside the vagina in the form of a gel, film, sponge, foaming tablet or suppository.

A safe vaginal microbicide that effectively protects women from HIV is not currently available. Clinical trials have demonstrated that commercially available spermicides containing nonoxynol-9 can reduce the risk of both gonorrhea and chlamydial infection,4 but the evidence regarding their effectiveness against HIV is inconclusive.5

Several newly developed vaginal microbicides have shown activity against HIV in vitro and in animal tests, but these either are still under development or have only recently entered safety testing in humans. Examples include BufferGel (an aqueous gel with sufficient buffer capacity to acidify approximately three times its own volume in human semen), protegrins and defensins (which are naturally occurring antibiotic peptides isolated from white blood cells), breast milk lipids (which have antibiotic properties), plant extracts, a Lactobacillus crispatus suppository, sulfated polysaccharides (which block pathogen entry) and antiretroviral compounds.6

A potential advantage of vaginal microbicides over all other female-controlled barrier methods (such as the diaphragm, female condom and cervical cap) is that women may be able to use them without their male partner's knowledge, cooperation or consent. However, such products may have some disadvantages as well. For example, in Zimbabwe, a widespread cultural belief holds that the vagina should be dry and tight.7 To achieve this, many