Have we learned what we need to know to deliver microbicides?

ROME — The first day of this Sixth IAS Conference I attended a satellite session “From Proof to Delivery: Scaling Up HIV Prevention for Women: The Challenge of Delivering the First Microbicide in Africa.” The promise of microbides and “treatment as prevention” are proving to be the biggest stories of this conference — new prevention tools showing highly positive results.

Demonstrators in the IAS Media Centre in Rome 

demand fast action on a microbicide.

(Photo by David J. Olson)

This is perhaps the most encouraging moment in the long, and often frustrating, history of HIV prevention, and I believe there is not a person here that is not tremendously excited about the potential these technologies hold for its future. Exactly a year ago, at the Vienna International AIDS Conference, we heard the results of the CAPRISA trials in South Africa  and how effective the product had proven to be.

A year later, I am struck by how the conversation has moved far beyond mere effectiveness and now focuses on the delivery, marketing and pricing of the eventual product, and how we will get women to use it correctly. It is amazing that the conversation has moved so dramatically in only 12 months, and wonderful that we are thinking about these issues now, years before we are likely to have a product on the market. This augurs well for thinking this through properly and getting it right.

But I noticed something missing from this conversation — both in the event I attended here in Rome and more broadly . That is, there was much talk of the need to deliver the product through multiple channels — presumably including the private sector, although that was not explicitly mentioned — and much talk about the need for finding innovative ways of doing that.


But I heard little mention of the role of the private (commercial) sector in all of this (apart from several references to Gilead, the manufacturer of Tenofovir gel, the active ingredient in the microbide tested in CAPRISA). And I heard no reference at all to social marketing which is really what the speakers were talking about when they emphasized the need to find innovative delivery strategies. For over four decades, social marketing has proven its ability to deliver a variety of products (condoms, contraceptives, bednets, vitamins) to a variety of places (grocery shops, bars, street vendors) and by innovative means (Coca-Cola delivery trucks, boats and peer educators ranging from sex workers, hairdressers, soldiers, adolescents and prisoners).

So we are hardly without experience in this area, though none of this was acknowledged in the event, despite the clear and repeated need for innovative strategies. Perhaps that was because, despite the presence of 13 speakers from the scientific and research communities, there was not one person from the private sector or the social marketing world.

Pretty much everyone assumes that once the microbicide is introduced, it will be an instant hit and women will snap it up. I fervently hope that it is so, but I think it would be a mistake to assume that. One woman in the audience raised this uncomfortable possibility, by reminding us of the female condom, another female-controlled device introduced to much acclaim almost 20 years ago which has not realized its potential.

Why was that? Do we really understand the reasons? Certainly, it’s a more obtrusive product that was off-putting to some men (and women), there were pricing issues and some donors did not provide the funding required to make it a success. But do we truly understand the lessons of the female condom, and other unsuccessful health products, so that we do not repeat them with a microbicide? I am not sure we do.
Fortunately, we still have time. So let’s absorb those lessons, let’s recruit the private sector and social marketing as critical partners in our efforts to find innovative strategies for delivering a microbicide, once it is on the market, and ensure that it is used correctly.