Researchers in Africa Ask if Diaphragms Block HIV

As international officials mark World AIDS Day, researchers are looking for new measures that will help women protect themselves from the deadly disease. One possibility: the diaphragm.

Nancy Padian

JOHANNESBURG (WOMENSENEWS)-When Cecilia Mtembu's husband died, she went for a blood test at the free clinic in Soweto, the sprawling township of several million on the outskirts of Johannesburg where she lives. Her husband hadn't died of AIDS, but Mtembu knew he had been with other women. And she had been hearing frightening things about this new disease that could be spread through sex.

"They took the blood and in the afternoonthey gave you the result," said Mtembu, who isnow 36. "The doctor called me into his room and told me that I was positive. I was so angry at my husband, because sometimes I tried to get him to use a condom but he always said no."

As the international community marks World AIDS day today, researchers are looking for new measures that will help women like Mtembu protect themselves from AIDS. Women now comprise half of the world's HIV infections, mostly as a result of unprotected sex with HIV-positive men, the United Nations reported last week. And the disease is now the leading cause of death among African women ages 15 to 39, according to a report released in November by the South African government.

Now a new study by researchers at the University of California, San Francisco will investigate whether women in this AIDS-devastated region might protect themselves against HIV by using a diaphragm during sex. If proven effective in reducing HIV transmission rates, the diaphragm could safeguard millions of women around the world who currently lack means to protect themselves from the fatal disease.

Woman-Controlled Prevention Essential in AIDS-Ravaged Africa

Infection rates among women are skyrocketing. In sub-Saharan Africa, 58 percent of HIV-positive people are women and the gender gap between men and women is growing in younger age groups. But many women in the developing world, especially in AIDS-stricken Southern Africa, have a difficult time convincing their partners to use a condom.

But diaphragm use is completely within the woman's control and can be used without a man's knowledge, said Nancy Padian, director of UCSF's Women's Global Health Imperative program. Diaphragms, she notes, are low-tech and already available.

"What's particularly exciting about this is that it's woman-controlled," said Padian, a public health researcher. "Gender power imbalances in Southern Africa, and indeed in much of the world, are severe. Women are not often in a position to demand that their partner use a condom."

The $28 million study is being funded by the Bill and Melinda Gates Foundation and will begin sometime in the next few months. It will involve about 4,500 women at two sites in South Africa and one in Zimbabwe, where Padian has been doing AIDS-prevention research for several years. Both countries have among the highest HIV-infection rates in the world. Some 20 percent of South Africans and nearly 34 percent of Zimbabweans are HIV-positive.

The Gates Foundation is also funding research at the Eastern Virginia Medical School Contraceptive Research and Development Program on microbicides-vaginal creams, gels and capsules that would kill harmful microbes including HIV. Like the diaphragm, microbicide use could be initiated by women themselves, but a viable product probably will not reach the market before 2007, researchers say.

Women Want to Try Diaphragm, Even Without Proof That It Blocks HIV

In previous research counseling Zimbabwean women on condom use, Padian's team found that the majority of women could not convince their partners to use a condom and that the suggestion by women that a condom be used was often used as evidence of infidelity on the part of the woman. She found that women in the capital Harare were anxious to try the diaphragm, even knowing that its efficacy in protecting against HIV had not been proven.

"That so many were interested in using it knowing that its efficacy had not been proven shows how many women out there are desperate," Padian said.

Mtembu doesn't know what a diaphragm is. It's not a widely available contraception method among South African women. But she said she would gladly have used any new protection method that didn't require her husband's consent.

"As long as he didn't know about it, I would have used it," she said. "But it would have to be secret. If he found out he would probably have beaten me."

The researchers at the Women's Global Health Imperative believe diaphragms may help prevent the spread of AIDS and other sexually transmitted diseases because the cervix is more susceptible to transmission of HIV. Cervical tissue is more fragile than that of the vagina, and therefore more easily damaged or inflamed, which can facilitate HIV infection. Also, the cervix has more HIV-receptor cells than the vagina. Padian also believes that diaphragms may help prevent the spread of HIV by reducing the spread of other sexually transmitted diseases that can make a person more susceptible to AIDS.

"Will it be as effective as a male condom if a male condom is used consistently and effectively? I don't know. I think it's possible," she said.

Even If Diaphragm Proven Effective, Scientist Says Condoms Still Necessary

Deanna Kerrigan, a professor at the Johns Hopkins Bloomberg School of Public Health, agrees that women-controlled methods of HIV prevention need to be found, but says trials like Padian's must be done carefully.

"The concern would be that by introducing the diaphragm, people would see a lesser need to use condoms, because we don't have any real information about how effective the diaphragm can be in preventing HIV," she said.

Padian says her study will offer diaphragms only to women who have not been able to convince their partners to use condoms.

If the four-year study shows that diaphragm use can reduce HIV transmission rates, Padian says there is still much work to be done to make the contraceptive method more available in countries like Zimbabwe and South Africa that are battling the AIDS epidemic.

Diaphragms are not commonly used by women in Southern Africa and often require a doctor's prescription, although there is a debate among medical professionals about whether diaphragms need to be individually fitted. Padian says there is evidence that one-size fits all diaphragms may work for most people.

Still, the cost of a diaphragm in the developing world may be prohibitive for many women there, and the Women's Global Health Imperative is negotiating with pharmaceutical companies to try to convince them to reduce the price in less-developed countries if the study is successful.

Nicole Itano is a freelance writer based in Johannesburg.

For more information:

Women's Global Health Imperative-
"Acceptability of Diaphragm Use in Zimbabwe":

Bill and Melinda Gates Foundation-
"New Approaches Promote Shared Responsibility for Women and Men to Prevent HIV and Unplanned Pregnancy":

Global Campaign for Microbicides
"Protecting the cervix may be key":