Covert use of topical microbicides: implications for acceptability and use
Topical microbicides, substances that are applied in either the vagina or the rectum to reduce the risk of infection, currently hold great promise, in part because they do not require the active participation or even knowledge of the partner. Such innovations invite new decision-making strategies. How a woman decides to use a new product is a complex process -- a balance of her perception of risk, understanding of the product and how it works, anticipation of her partner's reaction to use and consideration of the relationship's balance of power. Furthermore, even though these concerns are likely to be similar for women everywhere, socioeconomic status and social and cultural norms will influence the outcome of such decision-making. Use of microbicides, theoretically under a woman's control, may not be possible if she has no decision-making power in sexual activities. Control may be accomplished through secret or hidden use, which carries its own risk should it be discovered. Most likely there will be variations in how covert use is rationalized and accomplished, yet the implications have not been well considered by researchers and advocates for microbicides. Some strategies may be less secret than others, with women preferring secrecy yet not fearing discovery. For others, potential repercussions of discovery could preclude even consideration of use. The introduction of microbicides is still a few years away, which affords researchers time to study the implications, consequences and advisability of secret use. Covert use and its possible risks and benefits should be considered far in advance of product introduction. Well-informed introduction is paramount. Careful attention to product presentation and cultural context is necessary, as some marketing strategies could either encourage or discourage covert use, discourage use altogether or alienate male partners, which could make the discovery of covert use more perilous for women. This paper discusses findings from research on contraceptive and condom use as well as microbicide studies, to show how women decide to use a new product. The term "covert" is used in this paper, since it is less associated with illicit or illegal activities than "stealth" or "clandestine".