The human immunodeficiency virus (HIV) has reached a point where it's known as 'an epidemic of women'. In sub-Saharan Africa, women ages 15 to 24 years-old are twice as likely to contract HIV as their male counterparts, and globally it remains the leading cause of death in women of reproductive age.
Gender inequality accounts for a lot of this disruption worldwide, placing women on the lower rungs of the social ladder where they struggle to control their sexual health, but the other factor is inescapably biological. "Women are just more vulnerable, anatomically and biologically, than men," says Leslie Nielsen, a director at the International Aids Vaccine Initiative. Nielsen works in Entebbe, Uganda to develop and deliver appropriate prevention options to communities at risk from HIV.
The vagina's surface area is massive, Nielsen explains, making it more susceptible to infection than a penis. Further, the vagina has thinner membrane, which makes it easier for the virus to penetrate. Semen also carries more of the virus than vaginal mucus. When combined, all these factors make the female reproductive system becomes fertile ground for HIV to seed itself and reap destruction.
The vagina's surface area is massive, making it more susceptible to infection than a penis
Yet the preferred prophylactic against HIV is a male condom, billions of which have been distributed throughout sub-Saharan Africa.
Increasingly, researchers around the world are recognizing the vagina's potential as a locus of protection, taking advantage of its biological response to HIV: a sexually transmitted virus stays localized inside the vagina for a few days before attacking the immune system and spreading elsewhere. Now researchers are capitalizing on that brief window of time by building the vagina an internal armory—a suite of tools designed to plug, line, and infuse it with HIV-fighting drugs—that will transform the female reproductive system into the first line of defense against the deadly disease.
This signals a major shift in the way we think about prevention: emerging from an era where male condoms have long been the default method against HIV, women are finally beginning to see options tailor-made just for them.
A current headliner is The Ring—a flexible, cookie-sized band that gets inserted into the vagina and releases a steady dose of the drug dapivirine, an antiretroviral (ARV) that suppresses the growth of HIV. In February this year, at the close of the two sister studies, the trial researchers announced that The Ring had reduced HIV transmission in participant women by 30 percent.
One of these women was Sandra, a single mother of two young daughters who joined the trial in South Africa. "I decided to take part, to stand for women," she says. "Now HIV is all over the place, so I was hoping that the ring was going to help us, the whole nation, our children also." She adds coyly, "If you put that ring inside you, the men can't steal it."
If you put that ring inside you, the men can't steal it.
The discretion Sandra hints at is a new benefit women might not get from the female condom for example, which is visible, and stands accused of rustling awkwardly during sex. Because The Ring is long acting and entirely hidden from view, "Women can insert it, forget about it, and remove it after a month," explains Dr. Annalene Nel from South Africa, study director on The Ring Study for IPM. Most men reported they couldn't feel it during sex, she adds.
Researchers were holding out hope that The Ring would be even more protective, but it was deemed effective enough that thousands of trial participants have now been given the device to use while it awaits commercial approval. "The difference that you can make protecting a third of women, it's already significant," says Dr. Nel. But her passion for prevention goes beyond The Ring alone. "I strongly believe that our women need more options, and we must persevere in this journey to get them."
There are many other tools in the earlier stages of development—like vaginal gels, which are loaded with antiretrovirals and used to coat the internal tissues before or after sex to limit HIV's spread. The Population Council and the International Partnership for Micobicides (IPM) have both tested these substances in human trials, there have been some hiccups, but IPM hopes to have the gel on the market in a few years.
IPM is also driving the development of paper-thin films that dissolve within minutes into the vagina, creating an immediate internal shield against HIV. And CONRAD, an organization which does reproductive health research and development, is creating vaginal suppositories in tablet form that rapidly deliver ARVs into its tissues where they can be absorbed and used for 12 hours as an arsenal against HIV.
Though still years away from consumers' reality, there are even diaphragms that would deliver a double-whammy of contraceptive and anti-HIV drugs to the user, freeing women of two concerns at once. Even further down the line, others are working on the invention of miniscule nano-fibers that carry tenofovir—another ARV medication—into the vagina, from where they launch an attack on any infected incoming semen.
Not all of these will necessarily make it to market, but there's a drive to keep investing in more tools, and to make as many of them a reality as possible. Focusing protection on the vagina isn't just a practical matter; it also gives women a way to claim the vagina back as private territory when they wouldn't otherwise have a chance.