Okay, so abstinence hasn’t worked very well, featuring more in conversations than in bedrooms. Male condoms mean trusting men both to display foresight and to eat the proverbial “banana with its peel on”, while female condoms are scarce, awkward and apparently noisy. A vaccine against that quick-change-artist, the Aids virus, is science fiction — and likely to remain that way for a long time.
Enter an unlikely hero: The Blob.
The Blob is a microbicide, a smallish dab of transparent gel, cream or lotion, which comes in narrow plastic push-tubes, miniature toothpaste-type tubes or sponges and flexible plastic vaginal rings soaked in the stuff.
Many microbicides, including a traditional herbal medicine from India, are just at the beginning stages of an exhausting marathon of tests. Others drop out along the way. The lemon and lime juice profiled in last week’s Mail & Guardian, for example, only works at concentrations so strong that it damages the lining of the vagina, thereby opening the door to the Aids virus. You’d be better off making lemonade, while waiting for scientists to isolate the active ingredient and contain it in something less destructive.
The most exciting news is that five dramatically different microbicides have passed their laboratory and animal safety trials with flying colours. They’re currently undergoing the final hurdle: effectiveness tests among tens of thousands of women volunteers across Africa and Asia, many of whom have results due two years from now.
Some of these volunteers are illiterate. Many are poor. None are ignorant, because they have to survive an intensive educational campaign on the potential risks and dangers before giving their written informed consent and being enrolled in what is quite possibly one of the largest human experiments in history.
Some are married, some are single and some are sex workers. Some use it with a condom, others without. Some have children. Others don’t. They have to give up large chunks of time in order to travel to clinics repeatedly for testing and analysis, they often have to undergo embarrassing medical examinations and discussions and they can’t be paid to do the work for fear that they might then distort the information.
All the participants are brave, because they understand that if the science is to benefit others, not all of them will get the real thing. Some will be given a placebo — a gel that looks like the real thing and does nothing to protect them from Aids. There is no other way to make absolutely sure of the results, which are double-blinded so that no type of well-intentioned bias from staff or volunteers can manipulate the outcome.
Interestingly, many of the women who fall pregnant claim to be using condoms as well, so either the condoms are not very successful or their recollection is at fault. Either way, as a result, researchers need to test The Blob on vast numbers of women.
Researchers have learnt from previous mistakes and are getting better at conducting ethically sound research in poverty-stricken areas where government health services may be patchy and residents desperate.
Many of the microbicides sound like robots in Star Wars movies: C31G, HPTN035 and PRO2000/5. Some of the research has progressed to the point where The Blob in question has a little trademark symbol after its name, like the seaweed-based Carraguardâ„¢, whose main ingredient is a stabiliser also found in ice cream and hand lotions. Carraguard used to be known as PC-515.
The names are clunky, but the actual experiment is relatively simple: insert, have sex with your partner, remove and discard applicator. Don’t wash your private parts immediately after sex. Do not use other products, commercial or traditional. Repeat every time you have sex.
It’s painstaking, time-consuming, horrendously expensive research to conduct. “You’ve got to be mad to be doing one of these,” Professor Janet Darbyshire of the United Kingdom Medical Research Council cheerfully admitted at this week’s Microbicides 2006 conference in Cape Town. “There are so many issues!”
Dr Salim Abdool Karim, director of the Durban-based Centre for the Aids Programme of Research in South Africa, agreed. “It’s a task of madness,” he told more than 1 000 delegates at the bi-annual meeting. And he smiled.
The scientists won’t admit it on record, but they’re getting excited by the possibility that some day soon we will have an inexpensive way to prevent Aids and many other sexually transmitted viruses and bacteria. And it’s something that will work for women who haven’t been tested and don’t want to know their HIV status. Prevention, for the disease with no cure, may soon be on the shelves next to the Sunlight soap and the Tampax.
Both the researchers and their volunteers persist in this crazy, Herculean task for a good reason.
“Women are falling in love,” said Symon Wandiembe of the Uganda Research Unit on Aids. “They are falling in love with microbicides. We should not let this love fail.”
What’s in it for me?
Mothers
Some of the most interesting research under way suggests that microbicides can be tailored so that the Aids virus is deactivated as the sperm makes its way up the vagina. In other words, women who want to start a family may not have to run the risk of contracting Aids at the same time. Ever the worry-warts, scientists fret that men may try to use the eventual creation of commercial microbicides to wriggle out of using condoms. The ideal will probably be to use both. Latex is going to be with us for a long time.
Women who haven’t been tested
This is the big one. Many women don’t want to know their HIV status, although the number should decline as they see people living with anti-retroviral drugs. In the meantime, using an inexpensive gel that helps to protect you against a number of other unpleasant diseases such as herpes and might also improve your sex life, seems like a win-win situation.
Researchers at the microbicides conference this week in Cape Town — the first time they’ve met on the African continent — warn that women should not stop insisting on condoms if at all possible. Even a microbicide that only works half the time could make a huge dent in the spread of the epidemic. And women who are HIV-positive may find a microbicide that protects them against re-infection without compromising their immune systems.
Teenagers
South Africa is one of the few countries in the world where teenage girls are allowed to participate in microbicide tests. Matshediso Mtshweni of the Setshaba Research Centre in Soshanguve, Pretoria, says the decision was not taken lightly, but noted that teenagers above a certain age may legally access contraception and abortion. Girls participating in research under way in Pretoria, Cape Town and Durban have to be over the age of 16 and already be sexually active and they do not have to inform their parents or ask for permission.
Any girls currently not sexually active are told to stay that way and are not allowed to enrol in the programme. Sexually active girls are encouraged to use condoms and have themselves tested. Although the programme has been criticised as immoral, the Global Campaign for Microbicides has research suggesting that females in microbicide tests use condoms more than their friends do. In fact, since about a third of South Africa’s women are infected with HIV by their early twenties, it may be immoral not to try to find a preventative method. As many of the girls have adult lifestyles already, it appeared that recruitment at shopping malls, clubs and taverns was more successful than at schools.
Gay Men
Microbicides — gels that work in the vagina — may well also work “up your arse”, as one activist described it at the Cape Town conference. In fact, a fairly significant percentage of women in a number of tests under way report both vaginal and anal sex, so everybody may benefit. Gay men may also find an unexpected benefit to using a gel that helps to fight off Aids, herpes and gonorrhea: it works as a lubricant. Just this once, women appear to be ahead of men in the funding race: the United States National Institute of Health has granted $16,5-million for rectal microbicide research. This is only 6% of the money spent on vaginal microbicides. But if you want to put it all in perspective, that’s only 1% of what’s been spent on the search for an HIV vaccine, which may not be ready for decades and may well be extremely expensive. Which in turn pales beside the money spent bombing Iraq …
Businesspeople
There are going to be some fabulous commercial opportunities opening up in patents, marketing and distribution. If Durex can make money from the frequent sale of small numbers of condoms, think of how much money there is to be made from microbicides. And don’t believe the grumbling that the first-world economies won’t come to the party because Aids doesn’t really affect them: have you seen the astronomical infection rates in the United States for chlamydia (which can make you infertile) and the human papilloma virus (which can give you cervical cancer)?
Expect to see the same products marketed here for Aids and there for other sexually transmitted diseases. With any luck, the products will be prominently displayed at the cashier’s till next to the sweeties and magazines. Meanwhile, countries have learnt from the anti-retroviral battle how to lobby for reduced fees for patents. And the good news about having several different lines of microbicidal research being tested simultaneously is that it should keep the eventual cost low because no one company can monopolise the market. — Christina Scott