Executive Summary

Twenty years into the HIV/AIDS epidemic, the world still has only limited options for preventing the sexual transmission of the virus. We can extol the virtues of monogamy, encourage people to use the male or female condom, and expand treatment for sexually transmitted infections (STIs).

Individuals everywhere—especially women—need an expanded array of tools for enhancing their ability to protect themselves and their partners from HIV and STIs. Many women do not have the social or economic power necessary to insist on condom use and fidelity, or to abandon partnerships that put them at risk. In the same way that successful treatment regimens require triple and quadruple therapy, successful prevention requires multiple forms of intervention and complementary tools aimed at meeting the needs of different people.

One approach on the horizon that deserves increased public and private sector support is topical microbicides. Microbicides are agents that can prevent the transmission of HIV and other sexually transmitted pathogens when applied in the vagina or rectum. The successful development of a microbicide would provide a criticaladjunct to male and female condoms, as well as a needed complement to existing efforts to develop a therapeutic or prophylactic HIV vaccine. The search for safe, effective microbicides must persist in the face of vigorous research into an HIV vaccine. A microbicide is likely to become available more widely and more rapidly than a vaccine; will act at an earlier stage of infection; and may be able to interrupt the spread of other sexually transmitted pathogens, in addition to HIV (which an HIV vaccine would be unlikely to do).

Unlike those areas of science where the motives of profit and personal ambition are sufficient topropel innovation, microbicides will only become a reality if advocates mobilize sufficient politicalwill to garner substantial investment on the part of governments and private foundations.Because microbicides represent a new product class, they remain relatively unattractive toprivate investors who shy away from projects whose up-front development costs and marketpotential are difficult to quantify. This works against microbicides when they compete withinlarge pharmaceutical companies for access to research and development funds.

As a result, the task of microbicides research and development (R&D) has fallen to not-for-profitresearch institutes, university-based sciences, and small biotech companies, all of whom aredependent on government and foundation resources to take their product leads forward. This is why public education and advocacy are critical to the task of bringing public health goods—such as microbicides and vaccines—to market. Advocacy creates the political will and momentum necessary to propel the scientific enterprise forward—whether through highlighting the urgency of the task at hand, educating those in a position to make a difference, or fomenting political pressure for change.

In the case of microbicides, advocacy must extend beyond merely ensuring that a product isproduced. It must include research, policy work, and political activism to ensure that the productsdeveloped are widely available and correctly and consistently used by individuals at risk of HIVand STDs, especially women. This requires focusing advocacy on issues of pricing, accessibility, stigma, gender bias, and women's empowerment, in addition to efforts to accelerate product development and approval.

Moreover, because microbicides are a user-controlled technology and a global public health good, any successful microbicides strategy must be informed by user needs and perspectives, andengage users and civil society as active partners.

Conclusions and Recommendations

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