5 ways that PrEP highlights gender inequities in HIV
One of the most memorable moments in my 20 years working in the HIV field happened in a standing-room-only meeting hall in Vienna at the International AIDS Conference in 2010. This was the moment that the clinical trial CAPRISA 004 announced proof-of-concept for prevention of HIV among women using a vaginal microbicide (1% tenofivir gel). The entire room broke out in a standing ovation and tears of joy. Finally! A prevention tool that could allow a woman to protect herself in sexual encounters, regardless of the desires and wishes of her sexual partner. Five years later, microbicides have not yet come to fruition. But pre-exposure prophylaxis (PrEP) holds the same great promise.
Worldwide, young women are 1.6 times more likely to be infected with HIV than their male peers. Prior to 1999, females represented 11.7% of all positive HIV test reports. By 2006, this figure had risen to 27.8%, the highest percentage since the start of the epidemic. The two main modes of infection for women are heterosexual contact and injection drug use, both interpersonal domains which are often controlled by a male partner. It makes sense that women would be keen to use PrEP.
But here are five ways that PrEP may not be as “empowering” for women as we would hope; ways in which PrEP’s promise may be limited by gender inequity.
- PrEP plays into the medical establishment’s control over women’s bodies. All of the viable antiretroviral-based prevention options will be at least somewhat invasive, could have side effects, and require administration and monitoring by a physician. We have to remember that among women living with HIV in Canada, 31% are Aboriginal women, and about 36% are among African, Caribbean and Black women. A history of colonization and unethical treatment by governments, health systems and researchers has left a legacy of profound distrust of any health innovations being offered to Black or Aboriginal communities.
- Women may not have the autonomy to take advantage of PrEP. 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, if she can afford to access the necessary services and prescriptions, and how much control she actually has over her sexuality and fertility. Women sometimes need to hide their sexual and reproductive health strategies from their male partners. However, some women 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. Indeed, studies have found a significant link between intimate partner violence and low PrEP adherence. And if women do disclose their desire to use PrEP, the negotiations will be no different than condom use in raising doubts about fidelity and trust.
- Our PrEP advocacy efforts have largely ignored women. In Canada, there has been significant buzz around PrEP and most of the early uptakers are white gay men. But unfortunately, this has had the unintended effect of creating homophobic associations with PrEP. In order to make PrEP work for women, they need to perceive themselves to be at risk for HIV, be aware of PrEP, see it as something for them, and have affordable access to it. They also need providers who are knowledgeable and willing to prescribe PrEP. PrEP is not common conversation outside of gay communities and HIV organizations. In Canada, very little attention with regard to HIV overall—let alone PrEP issues—is focused on women.
- Not all women who need PrEP want to make babies. One of the key benefits of PrEP is the ability to safely conceive within serodiscordant couples, also known as PrEP-ception. Conversations on—and implementation of—PrEP use by women should include all women at risk, not just those who want to conceive. Women have a right to choose PrEP as a tool for “fucking without fear,” if that’s what they want, without being subjected to slut-shaming, and with the primary focus on their own health and autonomy. Our messages to women have to be consistently sex-positive.
- Adherence challenges show up in our vaginas. Not only are there relationship challenges of taking PrEP for some women (see #2 above), our genital tissues are more sensitive to less-than-perfect adherence. PrEP, when taken daily, is just as effective in women’s bodies as in men. However, longer and more consistent dosing is required to achieve protective levels of PrEP in vaginal tissue than in rectal tissue. While taking two doses per week can result in the accumulation of a protective level of drug in rectal tissue, continuous daily use is required to achieve a protective drug level in the vagina. We need to make women aware of that.
We need complementary, but different, PrEP organizing strategies for specific populations most affected by HIV in Canada. Women have a right to stay negative and to protect themselves from HIV autonomously, without relying on their partners, and without the sole purpose being safe conception. As HIV advocates and educators, let’s make sure our PrEP awareness-raising and promotion efforts are inclusive for everyone who would benefit. And let’s make sure that we are not ignoring or reinforcing gender inequities in our PrEP advocacy.
San Patten is a consultant based in Halifax, Canada, who specializes in HIV policy, program evaluation, organizational development and community-based research. She is a big proponent of biomedical tools as part of a comprehensive toolkit to prevent HIV, including their potential role in reducing the social-structural inequities that create vulnerability to HIV.
Currently in Ontario, PrEP is targeted to men who have sex with men (MSM) and I don’t seen PrEP being useful for women in my region who are most at risk for HIV, due to several issues. Cost is the major one–most women, earning 73.5 cents for every dollar a man earns, and often at part-time jobs, are not in a position to afford an expensive drug. PrEP is not widely available by prescription in Ontario, and many women are surviving without benefits which would cover the drug in other provinces.
The second issue concerns taking something systemically for HIV prevention. This implies a high level of sexual activity to justify the daily effort including side effects (although Truvada is supposed to be well tolerated) and the cost. Most women are already dealing with the ‘slut shaming’ stigma around being sexually active. In addition, For MSM PrEP is supposed to be paired with condoms…but negotiating condom use is a big issue for women. So how can PrEP work around such barriers? And why would women who are not highly sexually active take a daily medication…just in case?
You don’t mention the recently concluded monthly vaginal microbicide ring trials, announced last month (The Ring Study and ASPIRE). Presentations at the 3rd International Workshop on Women and HIV (Toronto, 2013) suggested that this combination of contraception and microbicides is a better emotional fit for women. Pregnancy prevention can be seen by both partners as a desirable action; the prevention of HIV offers a hidden benefit, and the month-long duration of the ring helps with adherence.
If I were funding HIV prevention technologies for women, this is where I would concentrate my efforts–not on PrEP.
Great points, Devorah.
Yes, re: the current cost of PrEP – I mention in #2 above that PrEP access for a woman will depend on “if she can afford to access the necessary services and prescriptions.”
For your concern about women not wanting to take a daily pill to prevent HIV “just in case” – I think this is a similar issue that we experienced around contraception. ‘The pill’ was faced by the same questions around slut-shaming and implications of being very sexually active. Many women take a daily oral contraceptive even if they are not sexually active, “just in case” they get some action 🙂
I make the same point above in #2 that we need to make prevention options more sex-positive and resist connotations that PrEP user = slut. I also raise the same concern you do around sexual negotiation: “And if women do disclose their desire to use PrEP, the negotiations will be no different than condom use in raising doubts about fidelity and trust.”
I totally agree with you that the multi-purpose ring is super-exciting and much needed. But it’s not available yet and probably won’t be for many years. So, for this (word-limited) blog, I chose to focus on PrEP which is an option that is currently available (acknowledging of course the affordability/accessibility concerns).
Thanks for your work in advocating for HIV prevention women!