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Culture & Acceptability

There is a growing body of knowledge and literature about microbicide acceptability and use based on data from early clinical trials as well as studies designed specifically to examine acceptability (for example, Coggins, et al. 2000; Elias and Coggins 2001; Bentley, et al. 2000; Hammett, et al. 2000; Hart, et al. 1999).

Almost universally, women express enormous interest in microbicides.

In general, acceptability studies have underscored the urgent need for and interest in a woman-controlled method of HIV prevention.

Research shows that users desire both contraceptive and non-contraceptive forms of microbicides. Some women --especially in developing countries-- have a need for products that will protect them from infection but still allow conception. Other women prefer a dual-acting product that can protect against unwanted pregnancy and infection at the same time.

Product preferences vary woman to woman rather than culture to culture.

Formulation preference studies also suggest that no one formulation or delivery device will meet the needs and preferences of all women. Some prefer gel applied with an applicator; others may opt for film, suppository, or sponge. Research indicates that perceived safety and effectiveness are more important than most product attributes in defining a woman's willingness to use a microbicide. Ultimately, a constellation of products with a range of qualities --formulation, packaging, and indications-- will be able to meet the needs of a wide range of users.

Many women may choose to inform their partner about microbicide use.

While many women like the idea of a product that could be used without a partner's knowledge, most say they would want to involve their partner in the decision, or would tell him for fear of repercussions if he "found out" (Box 3).

Nonetheless, a microbicide offers substantial advantages over a male condom. First there is a significant difference between securing a partners' "passive acquiescence" to microbicide use as compared to their "active participation" in condom use.

One of the barriers to using male condoms, is that their use must be "negotiated" at each act of intercourse. This requires couples to interrupt the sexual encounter and requires them to "talk" about sex and risk. With microbicides, a woman can inform her partner once of her intention to use the product, and then take matters into her own hands.

Microbicides and Dry Sex

In some parts of the Sub-Saharan Africa, women routinely use various cleaning and drying agents before sex in order to dry or tighten the vagina. This practice --known as "dry sex" evolves from the belief that men prefer a tight, dry vagina. In some instances, sexual lubrication is also associated with promiscuity.

Dry Sex refers to a range of practices (wiping; inserting herbal and other preparations) to cleanse, dry, or tighten the vagina.

There has been widespread concern among researchers and policymakers that microbicides would not be acceptable in areas with a norm of dry sex. Early findings from microbicide studies suggest that microbicide use may be acceptable even in areas where dry sex is considered to be the norm. Feedback from women involved in clinical trials in these regions suggests that many women find the extra lubrication adds to sexual pleasure.

It remains uncertain whether women will be able to use lubricating agents when male partners expect "dry sex" and vaginal wetness can be perceived as a sign of infidelity or infection. However, the research findings do underscore the importance of conducting research to test assumptions about what would or would not be acceptable, and continuing to conduct clinical trials and supplementary studies to gather information on user perspectives based on actual product use.

Men's attitudes toward microbicides

Men's views and experiences are also likely to powerfully influence microbicide use, so it is important to consider their preferences, and ways to address concerns they may have (Coggins, et al. 2000; Van de Wijgert, et al. 1999; Pool, et al. 2000; Ramjee, et al. 2001). In general, men are supportive of efforts to develop microbicides, although few acknowledge a need for "their" women to use such products, and many express concerns about women using products without their male partners' permission. It is important to continue to explore ways to present information and products to men in a way that makes clear their own responsibility for helping to ensure the health of their partners and families.