Prevention technologies: Sensitive to populations that need them most?

"There is no doubt that we need more HIV prevention options - current options don't work especially for people like us," says Gulab, a transgender living with HIV in Chennai. "And this is the only possible reason to motivate me to advocate for new prevention options."

Gulab argues that 'perfect' technologies that disregard social realities don't necessarily deliver results, and it is extremely important for the most vulnerable people to be able to use these technologies to realize the public health potential later on. So it is all the more important to engage the most vulnerable communities, such as men who have sex with men (MSM), as research proceeds, so that upcoming technologies are not only technically effective, but also sensitive to the needs of the populations that need them most.

Gulab cites the example of the male condom, which if used correctly and consistently, is a best practice method of HIV prevention. But social realities are different and large numbers of people are unable to use male condoms for a range of reasons, and it is for these very people that we need to get more prevention options. Even if we hand over male condoms, it will not necessarily result in an increase in protected sex acts because the underlying factors are ignored completely. So, Gulab says, we also need to work simultaneously to reduce social disparities that put people in disadvantaged situations and increase their risk of HIV exposure.

As HIV prevention research advances in India, various clinical trial sites are gearing up for clinical trials of prevention technologies by the National AIDS Research Institute (NARI) in Pune, and by the Tuberculosis Research Centre (TRC) in Chennai. St John's Medical College in Bangalore is another emerging clinical trial site in Karnataka state.

Fortunately HIV prevention efforts have borne fruit in Pune, and, with HIV incidence going down, other cities with higher HIV incidence are being developed for multi-centric phase III clinical trials of microbicides and HIV vaccines.

Although these new options may not be 100 percent effective, Gulab argues that it is not justifiable to wait endlessly for the "perfect method" and allow HIV to spread unabated. Rather we need a wide range of different options to prevent HIV transmission today.

Amit, who works with MSM populations in Mumbai, says it is important to understand the 'fatalism' with which we live our lives.

"We grow up confronting different challenges, and for the MSM community confronting one's own sexuality is an immense realization. It's a process that doesn't happen overnight. We often become regressive when it comes to health-seeking behaviour. Health literacy I guess is a huge issue, across populations, and not only limited to MSM," says Amit.

Amit participated in female condom acceptability trials several years ago, and he feels that it is a step forward, and addresses the needs of people who aren't able to use male condoms. He adds that breaking the proverbial silence on issues around sex and sexuality with his male partners, has helped them tremendously in empowering themselves in not only realizing the HIV prevention needs, but also have put them in better positions to negotiate male and female condom use with each other.

So now, despite the fact that female condom supplies are not reaching him, he continues to use male condoms, which he wasn't doing before the female condom acceptability trial.

Amit firmly believes that as research for new prevention technologies goes forward, it is imperative to couple it with realistic initiatives to increase health literacy aimed at increasing health-seeking behaviour of individuals.

Many transgenders and MSM in India are seldom in a position to negotiate male condom use with their partners. Moreover, due to the criminalization (Section 377 of Indian Penal Code) as well as the social stigma attached to anal sex, it is important to understand that the social conditions under which it happens are very disempowering for receptive partners in particular. It puts them at risk of not only sexually-transmitted infections (STIs), including HIV, but also at grave risk of violence, coercion and abuse.

Volunteers at a community-based-organization (CBO), Bharosa Trust, have been working consistently on HIV prevention among MSM and strongly feel that unless legal reforms accompany HIV prevention research and social perceptions about MSM change, it will be hard to imagine an enabling environment for MSM population to have safer sex.

These volunteers (name withheld on request) argue that even with free distribution of existing HIV prevention options, the majority of their community members are seldom able to use male condoms consistently. Unless strategies to address legal as well as social reforms, for example to stop criminalization of anal sex and reduce stigma associated with same-sex behaviour, new HIV prevention technologies (including vaccines and rectal microbicides currently under research), might have similar accessibility issues with these populations and continue to remain beyond the reach of the very populations that need them most.

Bobby Ramakant-CNS