An array of potential formats for microbicides: gel, ring, cream… exist also in suppository and foam.

Reacting to a peripheries post on microbicides, Cheryl Overs commented “These [definition of microbicides] are a hint of the skewed propaganda about microbicides and an insight into the absence of consideration of how they will affect the millions of sex workers worldwide. Sex workers will lose any hope of using a 99% effective product against STIs, HIV and unwanted pregnancies, condoms” adding that, “The idea that sex workers will buy and use a combination of different products for different orifices/sex acts is absurd. Especially when one of those products will still have to be a condom.” Cheryl is summing up various concerns expressed in the “Sex work and the new era of HIV prevention and care” report she produced for the Asia Pacific Network of Sex Workers (APNSW).

The report, available online, addresses the significant changes that have happened recently in the field of HIV prevention and HIV care and treatment and their implications for sex workers. The section on microbicides is well written and provides an accurate and comprehensive picture of the basic science, opportunities and what interests us here, challenges of using microbicides for sex workers.

It is important to keep in mind that microbicides are still in development and that there are no microbicides preventing HIV infection to date.

The first challenge faced by sex workers is around condom migration or condom abandonment, which means condom use decreasing in favour of increasing microbicides use. This could happen because the sex worker decides or prefers to use microbicides rather than condoms, but could also be imposed by customers (because they prefer it “raw”) or business owners (because they will provide a commercial advantage). The immediate problem is that microbicides are not expected to be as effective as condom for preventing HIV infection, therefore, “if a female sex worker who currently has 70% of her vaginal sex acts protected by a condom changes to a 70% effective microbicides, her risk of getting HIV by vaginal sex would rise.” The reality is that microbicides may be even less effective than this and therefore the risk of HIV infection would increase even more. The less immediate problem is that this challenges the “women-initiated” discourse about microbicides when it comes to sex workers.

The power of microbicides: For whom, at what price and under whose control?

The second challenge is around the cost of using an HIV prevention method that a) is not as effective as condoms in preventing HIV infection and therefore will still require purchasing or obtaining condoms, b) does not prevent a whole lot of other STIs, and c) does not have contraceptive properties and therefore does not prevent a major hindrance for sex workers, pregnancy. Also, as microbicides are to date not designed with anal sex in mind, different products would be needed for different sexual activities. This means that sex workers would need a costly toolbox of HIV prevention methods at hand which will add to the existing financial burden of buying condom and lubricants particularly when NGOs or donors do not fill the “condom” gap for lack of means of because of ties preventing them to work with sex workers (that’s where PEPFAR comes into mind).

Finally there a several issues around use or misuse of the product, ranging from skimping (to save on cost), dosage, adherence and frequency of use and eventually resistance for second generation microbicides that will contain antiretrovirals (ARV).

The report is raising fundamental questions around microbicides and their use by sex workers. As basic and clinical research are already moving at a fast pace toward second generation microbicides (ARV based) which use will even be more limited, this report is a timely reminder of all those who should benefit from developing HIV prevention strategies that works. People vulnerable to HIV infection will only benefit of new products and strategies if these are designed with end-users in mind.In this regards, sex workers (men and women) are on a par with women in sub-Saharan Africa, men who have sex with men (MSM), and injecting drug users (IDU).

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