Why can’t they just use c-ndoms? That’s often the first question when people find out that in many parts of the world, HIV transmission is continuing unabated, and that there is an ongoing, multi-billion dollar search for new prevention technologies. A group of researchers, advocates and health care workers are meeting in Sydney this week to discuss whether Australia can make a greater contribution to this search.

It’s true that in Australia c-ndom promotion was a key factor in controlling the HIV epidemic among gay men, the most affected group in this country, and nearly two decades of needle and syringe distribution has ensured that we never had the massive outbreaks of HIV that hit drug users in so many other parts of the world.

But for many people, particularly women who face the threat of HIV in developing countries, c-ndom use is not a viable option. The problem is either limited access, or the entrenched social dynamics of gender inequality. In many parts of the world, a woman who has no other s-xual partner than her husband is at risk of HIV through his other contacts, but cannot propose c-ndom use within the marriage.

For people in this situation, an alternative prevention strategy that does not rely on their partners’ cooperation would be a major breakthrough. The analogy is often made with the Pill and other contraceptive methods like implants and injectables, that have successfully decoupled the s-xual act from the strategies for preventing pregnancy. In the same way, a so-called “biomedical” prevention strategy would enable people to take measures to prevent HIV without even requiring that their partners be aware of what they are doing, let alone interrupting s-x.

So far the road to a successful biomedical prevention strategy has been a rocky one, and none of the candidates has yet been shown to work in clinical trials. A vaccine would be ideal, but the failure of products in recent trials suggests that this goal remains on the far distant horizon at present. In the absence of a vaccine, other avenues have been vigorously pursued.

One possible option is a microbicide, a topical preparation for use in the v-gina (and r-ctum). Although the first generation of these products has so far been disappointing in clinical trials, there are a number of new ones in development. Another approach has been the use of oral drugs that are normally used for HIV treatment, but taken preventatively prior to HIV exposure. This strategy, known as “pre-exposure prophylaxis”, or PrEP for short is being investigated in a number of large scale trials.

The search for a biomedical prevention strategy involves many disciplines, including basic science to devise the technology, clinical researchers to test how they work, and social scientists to understand their wider impact, especially their potential to undermine the more traditional forms of HIV prevention, as they are likely to be only partially effective in their first incarnations.

Africa remains the focus of the global HIV epidemic, and so has been the location for much of the research into biomedical prevention, but there is also a great need for new prevention options in parts of the Asia Pacific Region, where Australia has substantial responsibilities as well as a leadership role in biomedical research. The question being asked by both scientists and community advocates is, what should our role be in developing and testing the new HIV prevention technologies?

The current forum will have the twin objectives of charting the direction for our future role in advancing biomedical prevention strategies in the Asia Pacific Region, and preparing Australian communities at risk of HIV infection for the potential impact of these strategies, should they prove to be effective.

It may be some decades before there are effective biomedical prevention strategies, but there will almost certainly a range of partially effective options on the scene before then. It is essential that communities at risk of HIV start talking about the potential role of such strategies, and the impact that they might have on the hard won gains achieved through “traditional” preventions. Such discussions should not be allowed to wait until the results of clinical trials start to emerge,

Australia has been recognised internationally for its contribution to the fight against HIV. Although the potential for biomedical agents to reduce the spread of infection is as yet unproven, it would be prudent to take a strategic a view of these technologies, just as we have done with other aspects of our response to the global pandemic.

Bridget Haire is from the Australian Federation of AIDS Organisations and John Kaldor is deputy director of the National Centre in HIV Epidemiology and Clinical Research.

Peter Fray

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