Johns Hopkins Bloomberg School of Public Health: The INFO Project

If microbicides are to fulfill their promise, they must be accessible and affordable as well as safe and effective. A successful introduction strategy will involve manufacturers, suppliers, public health systems, and governments and will include communication, marketing, logistics, and pricing plans as part of the strategy. Strategies for promoting access and affordability—for example, advocacy to ensure that microbicides are included in Essential Drugs Lists—will be a key responsibility for the public sector (94).

How a microbicide is positioned in the marketplace could make the difference between limited acceptance and widespread use (1). Marketing strategies that introduce microbicides as a product for good reproductive health and healthy vaginal conditions, as a contraceptive (that is, if it is also spermicidal), or even as a product to enhance sexual pleasure could promote widespread public acceptance. In contrast, initial promotion efforts aimed at sex workers or other high-risk groups could stigmatize microbicides among the general public and lead most people to reject them (1).

Because the first microbicides are likely to be less effective than male condoms, they should be promoted as an adjunct or back-up to condoms, rather than as a replacement, and for added pleasure (due to lubrication) and protection (49). Additionally, use of a microbicide along with a condom, diaphragm, cervical cap, or another barrier method probably would improve effectiveness against STIs. HIV, gonorrhea, chlamydial infection, and HPV transmission occur frequently in the cervix. Therefore, many researchers believe that contraceptive barrier methods such as diaphragms or cervical caps, which protect the cervix, offer STI protection (82), although epidemiologic evidence has yet to establish this effect (45) (see Population Reports, New Choices in Contraception, forthcoming).

Community outreach and counseling. In areas where phase III clinical trials are planned, health care and civic organizations have begun introducing the concept of microbicides through community preparedness campaigns. For example, the Gender AIDS Forum, a South African nongovernmental organization (NGO), has developed and tested materials that explain microbicides in the English and Zulu languages. The materials are designed to make people aware of microbicides and to encourage their widespread use (115). In India a network of NGOs has begun to reach out to social workers, doctors, health counselors, and journalists about the potential of microbicides to empower women (8). Community preparedness activities where clinical trials are not being conducted, and thus where there is little awareness of microbicides, also could help set the stage for successful introduction of microbicides.

Health care providers will be influential in how clients perceive microbicides (67). Counselors will need training to promote and provide microbicides without bias and in a nonjudgmental way to anyone who wants them. They also need to understand and be able to explain to individual users that microbicides are only partially effective in preventing STIs (22).

For people at risk of HIV and other STIs, counseling messages could advise using a condom every time they have sex. If they cannot use a condom, they should use a microbicide. Providers also could ask women to consider whether their partners will discontinue condom use if they begin to use microbicides (125). Providers should help clients to understand the relatively lower effectiveness against HIV of microbicides compared with consistent and correct use of condoms and encourage consistent and correct condom users to continue using condoms instead of switching to microbicides (22, 28, 106).

How would people obtain microbicides? To help ensure access, microbicides should not require a doctor’s prescription and should be available through a broad range of outlets, including pharmacies, health clinics, family planning clinics, community health workers, shops, taxi stands, markets, convenience stores, bars, and workplace dispensaries (1, 22). Community-based organizations also will have an important role in distributing microbicides to the groups they serve (1, 22, 94).

When health providers offer microbicides, they also can offer education, counseling, and support, which will be especially useful with their introduction. Also, preparing for the addition of microbicides to national supply chain systems will help ensure that they reach rural areas as well as urban areas. Planning for distribution needs to take account of the specific characteristics of each microbicide such as storage requirements, shelf life, and biostability—the ability of a microbicide product to maintain its physical and chemical integrity (1).

Will microbicides be affordable? Where the need for microbicides is greatest, they will require subsidization by international donor agencies and national governments (22, 81). According to one estimate, buying, distributing, and marketing microbicides to 10% of urban women in 66 low- and middle-income countries would cost almost US$2 billion per year (62). This figure is based on the assumption that microbicides would cost US$1 per application, including shipping, storage, and transportation—a cost unaffordable for many people in developing countries. Some microbicide developers consider this unit cost to be an overestimate. CONRAD is aiming for a cost that is substantially lower—ideally, 10 US cents per application or less (30).

Many women, however, say they would be willing to pay a high price for the ideal microbicide. In the 1996–97 Brazil study, for example, almost half of the 635 women surveyed were willing to pay up to US$5 per application (41). Similarly, a 1998 study among 4,000 urban women in 11 countries found that women would be willing to pay several times the price of a condom for a microbicide (52).

The total cost of offering microbicides in specific countries will reflect not only the production costs of the product itself but also the costs of registration, shipping, tariffs, duties, taxes, logistics systems, marketing, and similar expenses. Packaging and applicators are likely to account for a substantial proportion of the total cost (1).

The price of microbicides to consumers can be kept down. Governments could provide production incentives, including low-interest loans for building manufacturing plants. Reproductive health organizations and governments could buy microbicides and applicators in bulk and build on existing distribution systems for delivering microbicide products to users (1). If international donors and governments work together to devise finance strategies, microbicides could be accessible and affordable to all who want them (22).