The EmpoweRING Future of PrEP

Over half of the 35 million people living with HIV/AIDS around the world are cisgender women*. Here in the United States, AIDS is often problematically conceptualized as a “gay men’s disease,” yet women account for one fourth of all new HIV infections. The majority of infections (84%) among women are attributed to “heterosexual sex,” or more accurately, receptive vaginal or anal sex with cisgender men. Women of color represent 4 out of every 5 new infections among women, despite the fact that these women make up only 27% of all women in the country.

Given these disparities, women need access to strategies for HIV prevention – customized, tailored protective options that put these women in control. Until recently, besides completely abstaining from sex, women’s only option for HIV prevention during sex was to use a barrier like condoms. Condoms don’t work well for everybody, and they place the responsibility and power in the hands of the person wearing the condom. HIV-negative individuals who want to conceive with an HIV-positive partner have had to use expensive options like sperm washing in order prevent HIV transmission to the HIV-negative partner or the baby.

That is, until 2004, when the U.S. FDA approved Truvada™ for use as PrEP, which stands for pre-exposure prophylaxis, to prevent HIV infection. Truvada is a pill containing two anti-HIV medications, tenofovir and emtricitabine, and it is over 90% effective at preventing HIV infection when taken daily as prescribed by a doctor. However, the challenge with Truvada for PrEP (or any pill, for that matter) remains adherence: the reality is, it works best when you take it every single day. That can be hard to remember, to afford, or to fit into one’s life for a variety of reasons. Even though Truvada is very safe overall, the 10 percent of people who do experience side effects (like headaches, nausea, or diarrhea) may decide that Truvada is not right for them.

It’s also important to keep in mind that HIV prevention may not be the first thing on women’s minds when it comes to having safer sex. Often, preventing pregnancy is a common first priority of not only cisgender women, but any people of reproductive age who were assigned female sex at birth (intersex folks, gender nonconforming and non-binary people, and transgender men who can get pregnant and are having sex that could lead to pregnancy may need or want contraception too). Over the years, the contraception toolkit for these individuals has expanded to include a wide range of hormonal and non-hormonal, short-term and long-acting options for birth control, so that each individual can figure out which method works best for them and their body. (Didn’t realize there are so many options? Check out Bedsider.org’s interactive graphic for more information.) Isn’t it about time that we had the same breadth of options to prevent HIV infection? And what if we could combine these options to form a single product that works to prevent both HIV and pregnancy at the same time?

That’s exactly the thinking behind the Microbicide Trials Network’s study, MTN 028. Together with its sister study MTN 027, this study represents the first time the safety of a vaginal ring for HIV prevention has been tested. Eighteen total 18-to-45-year-old participants assigned female sex at birth were recruited for MTN 028 at Bridge HIV in San Francisco. These participants were asked to insert and wear a vaginal ring containing two anti-HIV medications for four weeks, with check-up visits during that time and for one week after the ring is taken out. The researchers hoped to learn not only about safety (i.e., whether there are any side effects of the ring) but also about participants’ opinions of the ring, like how comfortable it was to use. This information will prove invaluable in determining whether a vaginal ring could be “the next Truvada,” and even whether this ring could be combined with contraceptive rings (like NuvaRing™) in the future.

If the results from MTN 028 are promising, future research studies may also assess the safety of the ring in people who were not assigned female sex at birth but do have vaginas, like some transgender women. Additional research will also be needed to find out whether the vaginal ring is safe for people taking testosterone, since use of this hormone in people born with vaginas can cause physiological changes to the vagina. More forms of PrEP are also being developed and studied, including microbicidal lubricants, douches, and injectable medications. Some focus groups conducted among cisgender women in the US have indicated that injectable PrEP might be the most attractive option, but many women said they would use any form of PrEP. Just like with contraception, different options work for different people, making each one worth pursuing.

In the powerful words of Stephen Lewis in his famous “AIDS Has a Woman’s Face” speech at the 2004 Microbicides Conference: “The idea that women will have a way of re-asserting control over their own sexuality, the idea that they will be able to defend their bodily health, the idea that women will have a course of prevention to follow which results in saving their lives, the idea that women may have a microbicide which prevents infection but allows for contraception, the idea that women can use microbicides without bowing to male dictates – indeed the idea that men will not even know the microbicide is in use … these are ideas whose time has come.”
 
*A cisgender woman is a person who was assigned female sex at birth and self-identifies as female. For the purposes of this article, from this point onward “women” will refer specifically to cisgender women.

By Laura Potter

Sources
US Women & PrEP Working Group: A coalition of women from leading AIDS and women’s health organizations
Women and PrEP: A Q&A with Dr. Judy Auerbach
Knowledge, Attitudes, and Likelihood of Pre-Exposure Prophylaxis (PrEP) Use Among US Women at Risk of Acquiring HIV
Speech by Stephen Lewis, UN Special Envoy on HIV/AIDS in Africa at the 2004 Microbicides Conference

October 2015