The following is a guest blog post by Jim Pickett, chair of International Rectal Microbicides Advocates (IRMA) and director of Prevention Advocacy and Gay Men’s Health at the AIDS Foundation of Chicago.
Since 2005, our network of more than 1,000 scientists, advocates, policymakers, and funders from six continents that makes up International Rectal Microbicide Advocates (IRMA), has advocated for the accelerated research and development of safe, effective, acceptable and accessible rectal microbicides for the women, men, and transgender individuals around the world who engage in anal intercourse. In addition to pushing for scientific activity, IRMA works to confront the institutional, socio-cultural and political stigma around the public health need for rectal microbicide research, to increase funding and commitment within the field, and is the only global coalition with a focus on promoting the development of rectal microbicides. IRMA América Latina y el Caribe (IRMA ALC) and IRMA Nigeria help advance IRMA’s work in South America, the Caribbean and Africa.
Unprotected anal intercourse is 10 to 20 times more likely to result in HIV transmission compared to unprotected vaginal intercourse. Condoms are not always accessible, or desirable. And while condoms, when used consistently and correctly, are very, very good at preventing HIV, they aren’t good at all if they aren’t used. Because condoms are limited in these ways, people are excited and energized around the idea of a gel or a lubricant that could be applied rectally and provide a level of protection in the absence of condoms. Most people who have anal intercourse tend to use some form of lubrication. If that lube could safely inhibit HIV transmission, we’d surely have a potent new prevention tool, and one with a high level of acceptability. Importantly, it would be an option controlled by the receptive partner. It is possible a rectal microbicide could also be delivered in the form of a rectal enema or a douche.
About a decade behind vaginal microbicide development, the rectal microbicide field has completed two small Phase I safety trials and is currently conducting a third Phase I trial testing a rectal formulation of tenofovir gel. On the heels of the groundbreaking results from the South African CAPRISA 004 microbicide trial that showed a tenofovir-based gel could provide protection against HIV when applied vaginally, it is critical for the entire field – community members, advocates, scientists and policy makers – to prepare for advanced-stage effectiveness trials of rectal microbicides. In fact, the National Institutes of Health-funded Microbicide Trials Network is currently developing a protocol (MTN 017) for a Phase II rectal microbicide safety trial that would take place at sites in Thailand, South Africa, Peru and the United States, with a launch date sometime in 2012.
Africa needs more of our attention in terms of rectal microbicide advocacy. While IRMA has hundreds of active African members across the continent, until recently rectal microbicides have simply not been part of the larger HIV prevention discussion in Africa. This is partly due to the denial of anal sex among heterosexual men and women and the pervasive homophobia that has denied and criminalized the very existence of gay men and other men who have sex with men (MSM). It had long been incorrectly assumed that the primary (read: only one that matters) means of HIV transmission on the continent was through unprotected vaginal intercourse. The truth is much more complex than that – unprotected anal intercourse DOES play a role in the African epidemic – a significant percentage of heterosexual Africans most certainly engage in anal intercourse, and gay men and other MSM exist in every country, and in most, bear a much higher HIV burden when compared to the general population.
IRMA’s efforts have thankfully flipped the script. Leading scientists, including luminaries like Dr. Salim Abdul Karim, Principal Investigator of CAPRISA 004, are now openly acknowledging the need for safe, effective, acceptable and accessible rectal microbicides for African women and men, to complement a similar need for expanded access to existing prevention interventions, vaginal microbicides, oral prevention, vaccines, and other innovative tools to combat the epidemic. The IRMA Nigeria chapter of our network includes some of the most dynamic advocates we have anywhere in the world, and it is their leadership that helped bring about such an awakening.
IRMA’s newly-launched Project ARM, or Africa for Rectal Microbicides, aims to expand African mobilization and enhance community capacity around rectal microbicide advocacy in order to ensure broad participation in research activities and well-informed community input into the development of an African rectal microbicide agenda. The end goal is expanded rectal microbicide research and advocacy activities in Africa – including clinical trials. And of course, when rectal microbicides become available, we want them to be within arm’s reach of every single human being on the continent who wants to use them.
In December of this year, Project ARM will bring African community advocates, scientists, policymakers, and other key actors together to discuss anal sex in Africa and craft an African rectal microbicide agenda at a meeting in conjunction with the ICASA 2011 conference in Addis Ababa, Ethiopia.
There is a great need for culturally competent educational materials with an African context. As part of Project ARM activities, IRMA is working with Population Council – which has provided seed money for pre-production activities currently underway – to develop a 15-minute video as a tool to provide education on anal intercourse and to create awareness around rectal microbicide development in Africa. The plan is to screen a rough-cut of the video at the December meeting, obtain feedback, and finalize the video in the first quarter of 2012. We have yet to identify a funder to pay for production, testing, and post-production activities, but we are optimistic we can find the support necessary.
We recognize a discussion around gay men, MSM, anal sex between men and women, and rectal microbicides can be a very fraught, and even dangerous, one in Africa. These conversations are about nothing less than life and death – they ARE dangerous in a number of ways. But all Africans, all people at risk for HIV, regardless of their identity, gender, profession or sexual expression, deserve an array of tools to protect themselves. We won’t make those tools a reality if we whisper too softly.
Where there is a will, there is a way. We see Project ARM as both the will, and a way forward. Will you join us?