Johns Hopkins Bloomberg School of Public Health: The INFO Project

Many women and men would have great interest in using microbicides, acceptability studies indicate (7, 14, 15, 23). Acceptability studies ask people what characteristics they would prefer in such a product and whether they would be likely to use a microbicide (67).

Of the 61 microbicide acceptability studies done between 1995 and 2002, 24 focused on developed countries, 25 on countries in sub-Saharan Africa, 6 in Asia, and 1 in Latin America, while 5 covered multiple regions. Most acceptability studies are among people who have not used a microbicide because formulations appropriate for testing have only recently become available.

Nevertheless, more than one-quarter (17 of the 61) are among people using candidate products in clinical trials for up to 14 days. Clinical trials provide the best information on acceptability because study participants can report their detailed experiences with using an actual product (67).

People’s interest in using a microbicide appears likely to depend on the level of severity of the AIDS epidemic in an area. Where HIV/AIDS is widespread, acceptability studies find that women perceive their risk to be high, and interest in microbicides is substantially greater than where HIV/AIDS is less prevalent (6, 83).

What formulations would people prefer? To guide microbicide development, researchers have conducted detailed studies on what people would prefer as to formulation, degree of protection, applicator, packaging, color, and other characteristics (38). For instance, an acceptability study among 635 Brazilian women of various ages and backgrounds suggests that an ideal microbicide would be odorless, colorless, a cream rather than a suppository, placed in the vagina with an applicator rather than with the fingers, applied well before sex rather than just beforehand, and protective against all STIs, not just HIV.

In this study 96% of respondents said they would use a microbicide if they could apply it only with an applicator, while 76% said they would use it even if they had to insert a finger to apply it. Yet in interviews most respondents expressed discomfort with either inserting an applicator or touching their vaginas. Such findings suggest that manufacturers, distributors, and reproductive health programs probably would need to help women feel comfortable touching themselves in order to assure widespread acceptance and long-term, effective use of microbicides (37).

Over 99% of respondents in the Brazilian study said that they would prefer a formulation if it offered dual protection against STIs and pregnancy. Also, a majority would want microbicidal effects to last at least eight hours. The researchers concluded that women’s interest in a formulation that could be used well before intercourse indicates a desire to maintain privacy or intimacy (39, 40).

Many women say that microbicides would be unacceptable if they leaked, were messy, or required application just before sex (38). In a clinical trial of BufferGel in India, Malawi, Thailand, and Zimbabwe, some women reported that the formula was too wet, drippy, or sticky.

Since insufficient vaginal lubrication during sex is a common problem, microbicides could improve sexual intercourse for women and men (1, 125). In the BufferGel study about half of the 100 women using the compound reported that their sexual pleasure was increased, and nearly as many reported that their partners’ pleasure was increased (6).

Researchers in the Dominican Republic and South Africa use illustrated charts to assess people’s preferences for single-use or reusable applicators.

To address people’s diverse preferences, microbicide developers are likely to offer several different formulations, including gels, films, creams, suppositories, foams, and sponges (51). Researchers also are exploring several different types of applicators, including reusable and prefilled applicators, single-use applicators, and vaginal rings (16, 117).

What do men say about microbicides? Most clinical trials and acceptability studies focus on women’s views of microbicides (67). If microbicides are to be widely used, however, they should be acceptable to men as well (125). Based on the surveys that are available, men appear to be interested in microbicides. In a 1999 survey of 243 South African men, over 75% said they would like their partners to use a microbicide, and most said they wanted to be involved in making the decision. Most respondents preferred a microbicide formulation that prevents STIs but does not also prevent pregnancy (98).

In focus-group discussions in Mexico, Zimbabwe, and the US in 1996–97, most of 106 men interviewed thought that microbicides would be preferable to condoms for preventing STIs, although they expressed concern about potential side effects. Some of the men thought that a woman should have permission from her partner before using a microbicide (15).

In South Africa in interviews and focus-group discussions, men said they were concerned that microbicide use would make it difficult to distinguish whether a woman was wet due to the microbicide or because she had sex previously with another man. This study also found that women would be concerned about being accused of infidelity, having an STI, or having poor hygiene (22). For these reasons, women in the South African study, as well as other studies, report that they would want to tell their partners if they were using a microbicide (15, 34).

The few studies that have examined acceptability of microbicides among men who have sex with men suggest that microbicides also are likely to prove acceptable for use in anal sex, particularly since using lubrication is popular among men whether or not they use condoms. In one study of 307 men who have sex with men, 92% said that they would use a lubricant with a microbicide (14).

Anal intercourse is a primary means of HIV transmission among both opposite-sex and same-sex couples (12, 36), and thus acceptability studies of microbicide use during anal sex would be useful (67). Some microbicide advocates, however, call for deferring spending to test the effectiveness of a product for rectal use until it first proves safe and effective for vaginal application. If a product is not safe and effective as a vaginal microbicide, it also would not be appropriate for use rectally, and resources are too limited to spend on rectal safety and effectiveness studies before effectiveness for vaginal use has been demonstrated (108).