**International Subcommittee of the Presidential Advisory Council on
HIV/AIDS (PACHA) Town Hall Meeting on the**

**President's Emergency Plan for AIDS Relief**

**Testimony from the**

**Alliance for Microbicide Development**

**Global Campaign for Microbicides**

**International Partnership for Microbicides**

We heartily commend the President and the US Congress for supporting a
strategy to combat global HIV/AIDS through the enlightened and essential
provision of treatment and care to those who bear great burdens of
disease and disability, and prevention strategies to protect those as
yet unburdened. All of us who have been working in many different ways
to address the pandemic can only be heartened by this historic and
comprehensive commitment.

We realize that the particular focus of this Town Hall Meeting is
learning from programs having to do with those crucial sets of
interventions. Still, we respectfully urge the PACHA and those present
today to pause to contemplate the very special needs and pivotal
position of women in this epidemic. At Mr. Tobias's briefing at the
Woodrow Wilson Center last week, he was asked about the issue of
protecting mothers as well as children in programs intended to address
maternal-infant transmission, and we would like to carry that line of
thought a bit further for consideration by the Council.

Only recently have policy-makers recognized the implications of the fact
that the global HIV-1 epidemic is now fueled by heterosexual
transmission, which accounts for 80% of the 42 million people now
infected with the virus. In less than a generation, the face of AIDS, at
home and abroad, has become increasingly female. Not only that but in so
many instances, in so many settings, the women affected have few social,
legal, or material resources. They are, more likely than not and to put
it bluntly, poor and in critical ways defenseless.

Why is this? The reasons are a complex and potent synergy among gender
physiology, culture, and economics. We now know that biologically, women
are more vulnerable to sexually transmitted infections in general than
are men. We also know that they are less likely to exhibit the clear
symptoms that might motivate timely and appropriate care and that even
when they are so motivated, the necessary services are in some way
remote. These basic vulnerabilities are compounded by formidable
variables:

-a lack of economic and social power in the many societies and
situations where they cannot control sexual encounters;

-and where they cannot insist on protective measures such as abstinence,
mutual monogamy, or condom use;

-where attempts to do so may be met with punitive responses;

-and/or where economic pressures make sex work necessary to survival.

Perhaps the most stunning and increasingly well-documented dimension of
this picture is that the typical woman who becomes infected with HIV in
the developing world has only one partner---her husband.

For adolescent females, the picture is still bleaker. Anatomically more
vulnerable to contracting these infections than are older women, girls
have far more difficulty negotiating safer sex practices with partners.
Even early in the AIDS epidemic, we learned that women, on average, were
becoming infected five to ten years earlier than men. In Sub-Saharan
Africa, young girls are five times more likely to be HIV-infected than
are boys: almost 25% of 15- to 19-year-old girls in some parts of
Sub-Saharan Africa now carry the virus. In Botswana, where 45% of women
attending prenatal clinics are HIV-positive, a 15-year-old girl has an
80% chance of dying of AIDS. Newer research finds only exacerbation of
that trend.

As you will see from the heading of this statement, we speak today from
a community concerned with the development of a biomedical
technology---topical microbicides, a class of products designed to be
applied topically in different formulations and delivery systems, to
prevent transmission of HIV and other infections that enhance its
transmission. The idea for microbicides arose in the early days of the
HIV epidemic as we realized that it would inevitably take an
ever-greater toll on women and, thereby, their infants and their
families, and as we realized that so many of those women would have no
way of protecting themselves that they themselves could determine or
initiate.

We are here today not to advocate specifically for microbicides, since
this is not a meeting on biomedical prevention technologies. Instead, we
return to our historical roots and ask that as the dialogue proceeds
today, as the PACHA moves forward with its work, and as Mr. Tobias moves
forward with the Emergency Plan, the particular needs of women are
abundantly and practically addressed. We ask that some realities that
are quite meaningful for women be kept clearly in mind. We know that
abstinence is ideal but not always possible, particularly for those
whose power is not dominant. We know that behavior change in general is
critical but alone is not enough and is fragile and difficult to
sustain, especially when it is not one's own behavior that needs
changing. We know that educating the male population is crucial but will
take time and the kinds of effort that cannot be imported from other
cultures. And we know that condoms work if they are used consistently
and correctly, but that is not always the case; most important in the
present context is that their use, like abstinence, depends on the
acquiescence of another.

We close by observing that while the foregoing may seem to emerge solely
from some kind of gender ideology, that is not the case. There is a
solid public health argument here that is pretty close to unarguable,
and that is that: the most efficient method of reducing the spread of
HIV in the general population is to reduce its transmission among those
groups at highest risk. If we agree that women are at the epicenter of
the epidemic, evidence now strongly suggests that stopping new
infections among women should be a top priority and we commend that
concept to you.

Thank you for the opportunity to be here, to comment, and to learn.

*Polly F. Harrison, PhD*

*Director*

*Alliance for Microbicide Development*

*8484 Georgia Avenue, Suite 940*

*Silver Spring, Maryland 20910*

*T 301-588-8091*

*F 301-588-8390*

*info@microbicide.org*

*www.microbicide.org*