Countdown Y2K: Part 6 of a 12-Part Series

Imagine a world without condoms. I’m talking not about the cure, a widespread conversion to barebacking or mandatory castration, but a future in which rubbers are obsolete relics, replaced by an inexpensive, easy-to-use, anti-STD gel applied internally to the vagina or the rectum before sex. These “chemical condoms,” known as microbicides, would ideally inactivate a range of harmful bacteria, viruses and other bugs, revolutionizing safer sex as we know it. Contraceptive microbicides such as spermicidal films, foams and jellies have been available over the counter and by prescription for more than two decades. More recently, scientists have begun struggling to develop a similar technology to prevent infection with HIV and other STDs. By 2000, however, the Clinton administration’s $100 million, four-year initiative to develop such “topical agents” will barely even be slouching toward its goal.

As infection rates climb among women, especially in developing countries, the need for a low-cost, female-controlled form of protection has become urgent. Gender inequity within heterosexual relationships has long been a driving force for technology to balance the scales of sexual decision-making, and two organizations have formed in the United States to carry out this advocacy—Microbicides as an Alternative Solution (MAS), in Berkeley, California, and the Alliance for Microbicide Development, in Takoma Park, Maryland. “Because condoms are controlled by the man, both partners must agree to use them,” says MAS’s Bethany Holt, explaining her group’s quest for products that can be used exclusively by the receptive partner. AIDS service organizations worldwide have reported commonplace episodes of domestic violence triggered by disputes over condom use. Even in the absence of intimidation or force, many women have learned to defer their own pleasure and safety in favor of men’s desires. Yet amidst this growing pro-microbicide chorus, one omission goes unnoticed by all but a handful of angry critics who ask, “What about microbicides for the rectum?”

Scientists and public health experts have long approached anal sex with a mix of anxiety, scorn and denial. Take, for example, the often-unacknowledged fact that the FDA has never approved a single condom or other device for anal sex. As the scientific agenda of safer sex seems to be guided more by morality than epidemiology, people who practice anal sex have been technologically abandoned.

Surprisingly, gay men have failed to rally for latex-free technologies that maximize pleasure in addition to safety. Dr. Clark Taylor, a senior researcher at the Institute for the Advanced Study of Sexuality, says, “The most astonishing and reprehensible thing is, why, when the gay male community has so much to gain with this scientific development and so much to lose without it, we raise no voice to advocate for it.”

With more than 50 microbicides now in the research pipeline, only one has entered FDA Phase I clinical trials for rectal use. A vaginal product will almost certainly be developed first, due to greater allocation of resources and the diversity of substances being tested. The strategies for developing an effective microbicide include: using detergents that disrupt viral membranes without harming healthy human cells; combining nonoxynol-9 with a seaweed extract to enhance its protective properties; using a liquid that clings to the vaginal lining and congeals to form a defensive coating; altering the body’s acidity to create an environment hostile to pathogens; and genetically engineering antibodies that prevent infection.

Resistance to designing a product specifically for anal sex makes the prospect of a rectal microbicide grim, not least because of basic anatomy. Unlike the vagina, the rectum is an open-ended cavity, making it difficult to thoroughly coat. There are also differences between ecologies of the vagina and rectum, raising questions of how microbicides might upset the body’s natural balance of helpful bacteria, pH levels and more.

But the political minefield of FDA approval poses even bigger problems. When the mainstream media caught wind, in 1996, of the only government-funded clinical trial in which gay men used rectal microbicides, a right-wing feeding frenzy ensued. Condemning the study, the Family Research Council said, “We are facilitating, at taxpayer expense, an illegal and immoral activity that’s abhorrent to most Americans.” Sodomy laws often provide a rationale for squelching any government act that might encourage safer anal sex. Such was the case with the Reality Female Condom. Formerly named “Aegis” and pitched as a gender-neutral barrier pouch for rectum and vagina, the device was restricted to vaginal use by the FDA, citing sodomy statutes as a deciding factor. Still, some gay men use Reality for anal sex.

The use of pharmaceutical products for unintended purposes related to sexual health is nothing new. The New York state health department published a 1992 brochure titled “For Women Only,” giving suggestions for noncondom alternatives to reduce the risk of HIV infection, arranged along a spectrum of safety. At the riskiest end, the brochure proposed the use of a spermicide alone as “better than nothing.” But the health department refused to make any recommendation about rectal use of the same nonoxynol-9 based product. Anal sex enthusiasts will be left to fend for themselves when it comes to microbicides, likely crossing the boundaries of gender- and anatomy-specific marketing to adopt yet another vaginal product for rectal use with little prior testing for safety. Taylor offers anecdotal reports of gay men already using over-the-counter contraceptive gels along with or instead of latex.

The profitability of microbicides, above all else, will dictate their likelihood of development and viability. Unlike other large-scale HIV prevention efforts, most funding for microbicides is concentrated in the private sector of the pharmaceutical industry. As with condoms and spermicides, the federal government regulates their marketing but is not responsible for their creation. This commercial enterprise necessitates pumping research dollars into a product that will eventually return a profit. Past lawsuits against drug companies for contraceptive failures make them gun shy about possible liability over HIV infection. And patents on many microbicide ingredients have expired, further narrowing profit margins.

Although AIDS activists have become adept at pressuring drug companies to accelerate access to treatments, a similar approach to prevention technologies has yet to be organized with the same degree of sophistication. The vast majority of prevention work has concentrated on strategies for behavioral change, reinforcing a divide between prevention and treatment camps that mirrors the split between social and medical sciences.

Yet technologies such as nonlatex barriers are now beginning to spark prevention debates that echo past AIDS treatment struggles around industry accountability, corporate greed, the ethics of human experimentation, diversity of clinical trials participants and more. Even the recent trends in research draw a striking parallel with those of protease inhibitors. Scientists have begun to use a cocktail approach to boost the effectiveness of microbicides, struggling to produce a substance hostile to dangerous pathogens while less toxic to the body, as well as time-released versions that work longer with less dosing.

But don’t expect a David Ho of microbicides to emerge anytime soon. Because so few scientists are willing to tackle research on sex, let alone homosexuality or anal sex, the kind of collaboration enjoyed by treatment scientists is rare. Connie Celum, MD, a researcher at the University of Washington and principal investigator of the only study that has tested rectal microbicides in human subjects, says, “Most of the researchers in this field aren’t just homophobic, they are erotophobic.” With rare exceptions, sexuality as a field of scientific inquiry holds little promise for professionals looking for money and prestige.

As with past attempts to democratize science, political pressure for new sexual technologies must be initiated from outside as well as within. Past prevention has been bolstered by organizations specializing in behavioral studies, such as San Francisco’s Center for AIDS Prevention Studies, and advocacy groups like MAS have yet to formulate a comprehensive approach to prevention science. A group based on the model of Treatment Action Group (TAG) or Project Inform could advocate for new prevention, serve as a clearinghouse for the latest research  and distill complex science into accessible information for the layperson to use in making more informed choices about risk, ranging from oral sex to instructions for using the Reality Female Condom for anal sex.

As the science of safer sex evolves, it becomes clear that women and gay men’s health are inextricably linked. Microbicides have presented both populations with the latest version of an all-too-familiar choice: Form a political partnership by finding ways to collaborate toward a mutually beneficial goal, or reinforce divisive competition along lines of gender and sexual orientation.

Unfortunately this choice has emerged in a time of escalating gender conflict within the epidemic. The percentage of male-to-male transmission among new infections is decreasing, while heterosexual transmission rises. Women of color, in particular, comprise the population of fastest-growing rates of infection. Within most AIDS organizations, however, white gay men still hold the purse strings.

Yet even if an effective microbicide is never found, the far-reaching implications for such a quest can already be felt. The needs of women, although still horribly underserved, are beginning to get the attention they deserve. And for the first time we have allowed ourselves to imagine life without latex, prioritizing pleasure along with safety. That alone is cause for celebration.