Earlier this week, researchers announced the results from a large HIV prevention trial among African women. What they found was both disappointing and instructive: none of the prevention methods tested in the study made a difference in HIV infection rates, because few women actually used them as directed.
Women and girls have been at the center of the HIV prevention research agenda for more than a decade. Women account for half of new HIV infections worldwide, in part because there are too few prevention options that they can control.
But the latest trial results show that we still have a lot to learn about what women really want and need in HIV prevention. The women in the trial are telling us something that is true for every group at risk for HIV: to help more people avoid infection, we need to offer prevention tools they will actually want, demand and use.
The trial, known as VOICE, included over 5,000 women in South Africa, Uganda and Zimbabwe. It examined two HIV prevention strategies. One involves taking a daily pill and is known as oral pre-exposure prophylaxis (PrEP). The other is a vaginal gel, or microbicide, also meant to be used daily in this particular trial. Both contain a commonly-prescribed antiretroviral (ARV) drug called tenofovir.
The VOICE results reinforced what we know from previous studies -- namely, that tenofovir-based gel and pills can only help reduce HIV risk if they are actually used. In earlier trials of these options among heterosexual women and men, and gay men and transgender women, more consistent use of the products corresponded to higher levels of protection from HIV.
While most of the women in the VOICE trial came for their regular clinic visits and tests, they did not use the study products consistently enough to gain any benefit. In fact, fewer than 30 percent had evidence of the study drug in their bloodstream. And compared to both older and married participants, young, unmarried women were much less likely to use their study products and much more likely to acquire HIV.
Clearly HIV prevention is never just biomedical -- behavior is key. Using an HIV prevention tool every day can be a daunting challenge for many people. It may be especially difficult in societies where HIV is heavily stigmatized or for people who are treated -- as women and girls often are -- as being less deserving of care and protection.
At a more basic level, daily PrEP and vaginal gels may just not fit into the realities of many people's -- especially young people's -- lives. This is not only true for women. Another study published last week showed that young gay men in the U.S. also struggled to adhere to daily PrEP. Their most commonly cited reason was "being away from home," a sign of the mobility and uncertainty that marks many young people's lives.
After years of exciting news on the biomedical prevention front, the VOICE results underscore that it is time to get serious about the behavioral side of new HIV prevention options.
First, it means figuring out how to identify those who are most likely to use and benefit from PrEP and other emerging options. We know daily PrEP can make a potentially life-saving difference for many women and men at risk for HIV right now, and we have a responsibility to reach them with new methods and with the support they need to use them.
My organization, AVAC, is repeating its call for a comprehensive package of demonstration projects that can help practitioners and program designers determine how to deliver and support the use of PrEP for those women and men at-risk who are able to use a daily option. These studies are critical, but few are planned or underway so far.
Second, we need to redouble research into additional options that women can control, want and use. Several promising approaches are already being studied, including vaginal rings and injections that may only need to be administered every month or quarter, as well as less-than-daily dosing schedules of pills or gels, which may be preferable to some. In addition, research and development resources are urgently needed for combined contraceptive and HIV prevention methods, which would address many women's needs more comprehensively.
Similarly, research to find HIV vaccines, which would overcome many of the issues around adherence, also needs an aggressive push. Vaccine research has been complex and challenging, but it is at its most promising point in decades.
For many women, especially in Africa, the need for action on these fronts is even greater than ever. In the VOICE study, almost 6 percent of women became infected with HIV during each year of the trial, a much higher percentage than researchers had anticipated based on past data. Among unmarried women under age 25, the rate of infection was even more alarming with nearly 1 in 10 women infected each year.
We need to listen to the women of VOICE and other recent studies. That means designing prevention options based on a deeper understanding of women's reproductive and sexual health needs and desires, their perceptions of their personal risk for HIV infection, and their willingness and ability to use the products on offer.
On International Women's Day this Friday, we can honor the thousands of women around the world who are partners in the search for new options, by making real our commitments to women's health and well-being. We owe it to the millions of women and girls who remain threatened by HIV worldwide to work with them to develop and deliver prevention options they truly want, need and can use.