We present a simple mathematical model for assessing the effects of introducing a microbicide as an HIV infection protective method. As very little is known about the in vivo efficacy of microbicides, we ran sample scenarios for microbicides of various efficacies. We found that, in general, if existing condom usage in a community is low, introducing a microbicide will most likely have a positive impact on HIV incidence as abandonment of condom use in favor of microbicides will not play a significant role. If condom use in a community is high, though, attrition of condom users could play a role large enough to overwhelm any added risk reduction afforded new microbicide users. Our model illustrates the importance of knowing key behavioral parameters, such as the proportion of the population that uses condoms, before microbicides can be safely introduced. These parameters include the proportion of condom users likely to maintain condom use and the proportion of condom nonusers likely to adopt microbicides, as well as the efficacy of the candidate microbicide. The use of vaginal microbicides as HIV transmission barriers has been advocated for some time, but development has been slow. 1 A vaginal preparation inserted before intercourse may be more acceptable to a large number of women who know their sexual partner may be a risk of HIV infection but who cannot negotiate the use of condoms. 2 In the role of reaching out and empowering women for whom condom use is not possible, microbicides could be a significant force in reducing new HIV infections. At the same time, new intervention methods may lead to changes in risk behavior. 3,4 For example, a microbicide may be associated with some condom users switching away from condoms, with the possible consequence of putting those users at higher risk. Given that condoms are highly likely to be a more effective barrier against HIV transmission, 5 even a small reduction in their use can significantly affect the epidemic. Clinical trials that accurately gauge microbicide efficacy in reducing HIV transmission risk are difficult to conduct. 6 Thus the variance associated with estimates of microbicide efficacy is likely to be fairly large. Further, predicting whether the availability of a microbicide will counteract any increased risk resulting from changes in condom use should prove to be difficult. The only completed clinical trials of microbicide efficacy in vivo are for the detergent nonoxynol 9. It was found to have no significant impact on HIV infection rates. 7 Apart from this trial, to the best of our knowledge, only in vivo tests of potential microbial compounds have been undertaken. Here we address the concerns raised above by using a simple disease transmission model to examine how uncertainty in microbicide efficacy and switching away from condom use may affect the future course of an HIV/AIDS epidemic. We ask what level of abandonment of condoms would be needed to overwhelm the potential advantage of increased protection due to microbicides and also how microbicides of different efficacies could be expected to affect the future course of an HIV epidemic.
Published in Journal of Acquired Immune Deficiency Syndromes 2003: 34(1), 71-75
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