Wherever HIV is found, one constant is the differential gendered impacts on men and women. Millions of women lack the social and economic power to insist on existing HIV-prevention measures such as condoms, abstinence, or mutual monogamy. Biomedical prevention technologies are exciting for their potential to allow individuals to protect themselves, regardless of the desires and wishes of their sexual partner.
In October 2014, I had the opportunity to participate in the HIVR4P Conference (the first international conference dedicated to biomedical HIV prevention research). I found myself gravitating to the sessions on PrEP for women, and Multi-Purpose Prevention Technologies (or MPTs), led by enthusiastic researchers and women's health advocates. Female-initiated MPTs would allow women, in one or more combinations, to:
- Avoid infection from HIV;
- Prevent and possibly treat other STIs; and/or
- Avoid unwanted or unintended pregnancy
With 11 rings, 11 gels, two pills, two films and one diaphragm in development (pre-clinical and clinical), MPT research is a hot field of biomedical research. The only currently available MPT is -- you guessed it -- the condom (male and female), and both kinds require the tacit cooperation, if not outright participation, of the male partner.
One key promise of MPTs is that they will allow women to take control over their own sexual and reproductive health decisions. But I can't help but wonder about the difference between putting prevention and contraception 'in women's hands'versus 'on women's shoulders.' What do we mean by 'empowerment'? Some of the "yeah, but..." questions and caveats that come to mind for me include:
- Sure, the oral contraceptive pill had an enormous impact on (some) women's equality starting in the 1960s. But it also set responsibility for contraception squarely on the shoulders of women. As the women's health movement has documented, the so-called side effects from birth control pills include blood clots, depression, nausea, fatigue, migraines, and lack of sex drive. One reason that there's no male birth control pill is that these side effects were seen as unacceptable for men (but tolerable for women). MPTs could also further entrench women's responsibility for sexual health, rather than promoting a shared responsibility. In other words, MPTs provide another way to make sex consequence-free for men.
- Some critical voices say that MPTs play into the medical establishment's control over women's bodies. All of the viable MPTs will be at least somewhat invasive, could have side effects, and require administration and monitoring by a physician. A history of unethical treatment by governments, health systems, and researchers has left a legacy of profound mistrust of any health innovations being offered to Black communities. Colonization has left the same legacy of distrust and alienation from the medical establishment, government and research institutions amongst Canada's Aboriginal peoples.
- Whether a woman is able to use any prevention product is a complex balance of whether she perceives herself to be at risk, understands how a product works, how she anticipates her partner will react, and how much control she actually has over her sexuality and fertility. Thus, use of NPTs, while technically under a woman's control, may not be possible in the face of limited decision-making power.
- Women around the world sometimes need to hide their sexual and reproductive health strategies from their male partners. Women around the world secretly use contraceptives, and are also looking for ways to take control of preventing HIV when they cannot trust their male partners to take the initiative. However, in some cases, women could face adverse consequences from their male partners if discovered, as the products might be seen as an affront to men's power and the traditional gender norms. And if women do disclose their desire to use an MPT, the discussions will be no different than condom use in raising doubts about fidelity and trust.
However promising, HIV prevention advocates should not take for granted that these technologies will directly translate into sexual empowerment for women. So, how do we create advocacy messages that support MPTs but also acknowledge their limitations in terms of women's 'empowerment'? Here are some key messages that we can try to stick to:
- MPTs would be part of a prevention spectrum, not "a magic bullet"
- We avoid portraying women as victims
- We know that technological tools cannot replace women's empowerment
- We recognize that user-initiated prevention doesn't necessarily imply covert prevention
- We include discussion of the female condom as an important HIV-prevention option and support increased access to and use of female condoms
- We recognize the need for complementary, but different, organizing strategies in different parts of the world.
There are still many gaps remaining in women's HIV prevention. While we work hard to put HIV prevention tools in the hands of women, those tools can only do so much in chiseling away underlying gender inequities. And women-initiated technologies shouldn't come with the expectation that women will shoulder all the burden of sexual and reproductive health for her and her male partner.
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