Until recently the appropriateness of research on microbicide acceptability was questioned on the basis of the absence of an approved product [21, 27, 28]. However the need for such research among a wider population of potential end-users has now become urgent because of the significant progress that has been made in the development of an efficacious product. Such research is essential for generating useful information about potential user preferences including product characteristics such as formulation, colour, odour, feel, ease of use and impact on sexual pleasure. These attributes need to form an important part of microbicide development and the strategies for its promotion [21, 23, 29].
In the absence of a marketed product and away from a microbicide trial setting, the form of microbicide acceptability evaluated in our study could be described as perceived acceptability, i.e. satisfaction with the product and willingness to use it in the future or recommend it to others . In this regard, the perception of respondents is based on their understanding of the product as explained by the investigators and on the basis of experience with microbicide-like products. It is conceivable that perceptions could change after experience with real products when they become available.
Our finding of a possible association between religious persuasion and microbicide acceptability coincides with the findings of Hoel N et al. 2011, who conducted a qualitative study to assess the reflections of Muslim women on the acceptability of vaginal microbicidal products in South Africa . Although we failed to explore this further in the FGDs, we believe that it should prompt attention to the possibility that religious sensitivities could impact on the acceptability of microbicide among some sections of the society.
One of the important justifications that continue to drive interest in microbicides development is the consideration that it is a female-initiated product which can be used covertly. In many settings in sub-Saharan Africa, women are vulnerable to the possibility of partner violence, relationship termination, with attendant loss of financial support and social status . As the findings of our study suggest covert use is likely to fester mistrust particularly when the male partner gets to find out. Limited education, limited employment opportunities and low income even if employed, force many women in sub-Saharan Africa to have men in their lives to ensure their survival . Thus most women in this part of the world are not socially well-placed to take such “risk” . Our finding that microbicide acceptability was strongly associated with perceived male partner acceptability is therefore not entirely unexpected. While many women may wish that it were possible to use a microbicide covertly, it does not appear that they consider it to be feasible. Among women who were reported to find microbicide acceptable in three sites in Africa and India, concerns about covert use were tied to issues of partner acceptability and preference, wetting effect, faithfulness and questionable health status . Again, several studies have documented fear of abuse and other serious consequences especially in patriarchal societies where women generally have low assertive skills to negotiate safe sex [33–35]. The message of discreet use is therefore unlikely to be socially acceptable to women in formal and relatively stable relationships. It is unlikely to be a convincing enough message to rely upon in the promotion of microbicides. There is evidence to suggest that women would actually wish to be able to tell their partners and have their support [36–38]. In a study in Uganda that was linked to a microbicide trial, it was reported that whereas women during the pre-trial period believed that surreptitious microbicide use was advantageous, after the first week of product use, only 40% had actually been able to use the product secretly, 27% after 5 weeks, 22% after 10 weeks, and 13% after 5 months . In other similar studies, even though women found microbicide gel highly acceptable, consistent use was tied to partner related factors which emphasises the need to adequately address partners acceptance in microbicide promotion [33, 39].
In the promotion of microbicides, messages that promote its advantages for male partners need to be highlighted. An example is the reduced infectivity of HIV-infected women during heterosexual contact. For uninfected male partners, the use of microbicides should be promoted as being mutually beneficial in reducing, the risk of HIV infection for both male and female partners. Consistent microbicides should be promoted as the best available alternative for male partners who are reluctant to use condoms.
Sexual pleasure has emerged as an important consideration related to microbicide acceptability [40, 41]. The values that societies place on sex vary across different cultural settings. In many cultures in sub-Saharan Africa, a norm has been established that females have the greater responsibility to satisfy the sexual pleasures of their partners [32, 39]. This burden is considered greater when the woman finds herself in a polygamous marriage or when she has cause to believe that the male partner has other partners. It would appear unreasonable to ask a woman to use a product that could undermine her ability to satisfy her male partner sexually. In a study in Africa and India, acceptability of microbicide gel among women was linked to its lubricating effect and its consequent effect on sexual pleasure . Several microbicide studies have reported how gender power affects the balance between the desire for sexual pleasure and acceptability of microbicide [34, 39, 42]. Our finding that nearly half of the women were concerned about the effect of microbicides on sexual pleasure is therefore not entirely unexpected. It corroborates similar reports from other studies, including those conducted outside sub-Saharan Africa . In one of the failed microbicides trials, women were reluctant to return unused gel which had been given to them, even in the context of possible harm; because they reported that it made sex more pleasurable . Any microbicide that adversely affects sexual pleasure is unlikely to be found acceptable, regardless of its efficacy. On the other hand, an efficacious product that has the added property of enhancing sexual pleasure is likely to be considered acceptable and more likely to be used consistently. Achieving a formulation that has the right biophysical and rheological properties to guarantee efficacy and sustain sexual pleasure should therefore remain a twin goal in microbicides development.
A hypothetical microbicide was described to respondents in the study, most of whom were unfamiliar with the use of microbicides. In addition, some respondents may have considered some of the questions posed to be culturally sensitive. In spite of training to ensure uniformity, it is conceivable that respondents may have been influenced by the way the interviewers described the action of microbicides, and or how they posed the questions.
All the respondents in the study were women living in rural areas in Ghana. It is possible that women living in urban areas could have different perceptions of microbicides. The study was carried out in the wake of the release of the results of the CAPRISA 004 trial. The field of microbicide development is however evolving rapidly and as yet no microbicide has been approved by the World Health Organisation. Contradictory results have also emerged in other trials.