title: Optimizing HIV prevention for women: a review of evidence from microbicide studies and considerations for gender-sensitive microbicide introduction.
abstract: BACKGROUND
  Microbicides were conceptualized as a product that could give women increased agency over HIV prevention. However, gender-related norms and inequalities that place women and girls at risk of acquiring HIV are also likely to affect their ability to use microbicides. Understanding how gendered norms and inequalities may pose obstacles to women's microbicide use is important to inform product design, microbicide trial implementation and eventually microbicide and other antiretroviral-based prevention programmes. We reviewed published vaginal microbicide studies to identify gender-related factors that are likely to affect microbicide acceptability, access and adherence. We make recommendations on product design, trial implementation, positioning, marketing and delivery of microbicides in a way that takes into account the gender-related norms and inequalities identified in the review.
  
  
  METHODS
  We conducted PubMed searches for microbicide studies published in journals between 2000 and 2013. Search terms included trial names (e.g. "MDP301"), microbicide product names (e.g. "BufferGel"), researchers' names (e.g. "van der Straten") and other relevant terms (e.g. "microbicide"). We included microbicide clinical trials; surrogate studies in which a vaginal gel, ring or diaphragm was used without an active ingredient; and hypothetical studies in which no product was used. Social and behavioural studies implemented in conjunction with clinical trials and surrogate studies were also included. Although we recognize the importance of rectal microbicides to women, we did not include studies of rectal microbicides, as most of them focused on men who have sex with men. Using a standardized review template, three reviewers read the articles and looked for gender-related findings in key domains (e.g. product acceptability, sexual pleasure, partner communication, microbicide access and adherence).
  
  
  CONCLUSIONS
  The gendered norms, roles and relations that will likely affect women's ability to access and use microbicides are related to two broad categories: norms regulating women's and men's sexuality and power dynamics within intimate relationships. Though norms about women's and men's sexuality vary among cultural contexts, women's sexual behaviour and pleasure are typically less socially acceptable and more restricted than men's. These norms drive the need for woman-initiated HIV prevention, but also have implications for microbicide acceptability and how they are likely to be used by women of different ages and relationship types. Women's limited power to negotiate the circumstances of their intimate relationships and sex lives will impact their ability to access and use microbicides. Men's role in women's effective microbicide use can range from opposition to non-interference to active support.
  
  
  CONCLUSIONS
  Identifying an effective microbicide that women can use consistently is vital to the future of HIV prevention for women. Once such a microbicide is identified and licensed, positioning, marketing and delivering microbicides in a way that takes into account the gendered norms and inequalities we have identified would help maximize access and adherence. It also has the potential to improve communication about sexuality, strengthen relationships between women and men and increase women's agency over their bodies and their health.
authors.affiliation: Research Utilization Department, FHI 360, Durham, NC, USA; edoggett@fhi360.org.
authors.forename: Elizabeth G
authors.initials: EG
authors.lastname: Doggett
authors.affiliation: Social and Behavioral Health Sciences Department, FHI 360, Durham, NC, USA.
authors.forename: Michele
authors.initials: M
authors.lastname: Lanham
authors.affiliation: Research Utilization Department, FHI 360, Durham, NC, USA.
authors.forename: Rose
authors.initials: R
authors.lastname: Wilcher
authors.affiliation: Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, London, UK.
authors.forename: Mitzy
authors.initials: M
authors.lastname: Gafos
authors.affiliation: CAPRISA, Nelson Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa.|Department of Epidemiology, Columbia University, New York, NY, USA.
authors.forename: Quarraisha A
authors.initials: QA
authors.lastname: Karim
authors.affiliation: Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: Lori
authors.initials: L
authors.lastname: Heise
mesh_terms: D000282:Administration, Intravaginal; D000328:Adult; D000890:Anti-Infective Agents / Q000008:administration & dosage*; D005260:Female; D015658:HIV Infections / Q000517:prevention & control*; D006801:Humans; D007398:Interpersonal Relations; D008297:Male; D012725:Sexual Behavior; D012747:Sexual Partners; D014622:Vaginal Creams, Foams, and Jellies / Q000627:therapeutic use
chemical_list: D000890:Anti-Infective Agents; D014622:Vaginal Creams, Foams, and Jellies
keywords: HIV prevention; gender; gender norms; microbicides; woman-controlled methods