The vaginal ring and politics of global health

14 Mar 2016

Contemporary analyses of public health make much of its globalization and the national and international impact of this. Commentators argue that globalization creates challenges for the governance of global health, including the need to construct international regimes capable of responding to global threats to public health. In public policy literature, there is explicit recognition of the role played by actors outside the government in the formulation and development plans. These extra-governmental policy actors can include international or multi-lateral agencies. For many, the proliferation of new global health actors and shifts in the relative importance and roles of existing actors is to be welcomed. .  

The proliferation of the new global health actors means there are many different bodies involved in quite similar activities both at global and national levels and many a times this being used as a platform to siphon resources from funders especially in less developed countries. Global Health Governance is to re-establish within the policy environment the linkage between specific disease-oriented healthcare interventions and the underlying socio-economic context. It has been observed that this can result in duplication and even conflict in terms of the approaches they advocate or the activities that they are willing to fund or support. One such highly contested domain is on the health intervention treatment and prevention campaigns developed towards fighting HIV/AIDS such as the Safe Male Circumcision Project and now the "Vaginal Ring" whose study findings have just been released.  

As HIV/AIDS continues to spread throughout the world and as the number of people living with HIV and AIDS continues to grow with different social structures and legal system an evaluation of global health governance may help advance conceptual as well as political debates on global health interventions prevention strategies developed to help stop the stubborn epidemic. This opinion piece examines the potential for using polymeric vaginal ring systems to provide controlled delivery of HIV microbicides, in order to prevent heterosexual transmission of the virus.  This is informed by the recent clinical trial studies that have been undertaken in South Africa, Rwanda and. Malawi initiated in 2012 commonly known as "The Ring Study". It is more formally known as IPM 027. The " Ring Study was primarily focused on testing long-term safety and preventive efficacy of an antiretroviral drug, dapivirine, when this is contained in a vaginal ring that releases the drug into the vagina in a sustained manner. The Ring Study explores whether a vaginal ring containing dapivirine, which is changed four -weekly, is safe to use and whether it can protect women from contracting HIV-1. Compared to men, women are at much greater risk of acquiring HIV. The Ring Study presents an important technological advancement. The ring might provide protection not only because of the active drug but also because women only need to put the ring in once a month, so it stays in the body and could offer protection throughout this time.

It was planned that approximately 1 650 women will participate in the Ring Study. Of these, 1 110 will be in the group that uses the dapivirine ring, and 550 women will be in the placebo (any dummy medication or treatment. For example, in a controlled clinical trial, one group may be given a real medication while another group is given a placebo that looks just like it in order to learn if the differences observed are due to the medication or to the power of suggestion. Placebos are widely used in drug trial ) group which will use a similar vaginal ring but without the active drug. Women will be randomly assigned to the two groups and neither the women nor the researchers will know which product is being used by individual participants. At the end of the study, the two groups of women will be compared to see if there were fewer HIV-1 infections among women using the dapivirine ring than among those using the placebo, and if the ring was safe when used for an extended period. The results of the two major studies in Africa recently released show that a new device could help protect women against H.I.V. It is a flexible ring a woman inserts into her vagina, where it slowly releases an antiretroviral drug. In earlier studies in Africa, pills and gels that can prevent H.I.V. infection had high failure rates because women tended not to use them consistently.

But the new ring is inexpensive, easy to insert, effective for one month and, once in place, undetectable by the woman or her male partner. It also has a shelf life of five years and requires no refrigeration - important advantages in the developing world. These devices are female-initiated, robust and capable of long-term delivery of the active agent Vaginal rings may offer an effective system for the controlled delivery of microbicides to prevent heterosexual transmission of HIV. While the last few years have seen growing impatience on the part of national progress, international agencies and public health experts to make headway against the Global HIV epidemic, it must be noted that the desperation that Africa is finding itself devastated by the HIV/AIDS pandemic and being extremely poor has turned it into serving as a Global Health Science laboratory. Thus AIDS Africa has been not only a source of tragic misfortune and death but also a fodder for profound institutional; and intellectual opportunities. It is worth noting that these studies are not first of the kind conducted in Africa.

There have previously been other studies such as the vaginal gel. There has also been the save Male circumcision project undertaken in Africa, Kenya (Kisumu), Uganda (Rakai) and South Africa (Kwa Zulu Natal) focused on cutting of the male sexual organs (genitals) to help curb the spread of HIV/AIDS. In the USA for instance when such studies are undertaken the first people to be thought about as research subject are the African American minorities and Latinos (Hispanics) and not the affluent whites..   Effective HIV prevention thus requires locally contextualized approaches that address individuals, cultural and social norms as well as structures that are grounded in human rights. Condoms remain the most effective way to protect partners from HIV during sex. Yet there are challenges associated with condom use, which in many instances depends on the male partner's willingness to wear a condom during intercourse.    

*Thabo Lucas Seleke is a researcher of Health Policy & Health Systems Strengthening.