Safer-sex messaging on condoms is universal but the generally poor availability of lubricants, and awareness of them, is hindering HIV prevention, health activists warn.
Some personal lubricant - or “lube”- has been shown to lower the risk of HIV transmission by decreasing the risk of condoms breaking.
Despite preliminary proof of lube’s efficacy, far less of the product is procured and distributed than condoms, leading people to use alternative, sometimes harmful, substances during intercourse such as butter or petroleum jelly; oil-based lubricants weaken latex, making the condom more likely to break.
Activists say, however, that a blind spot in research on lubricants as a part of HIV prevention programmes means not enough is known about their impact on HIV risk.
A 2012 survey by The Global Forum on MSM & HIV (MSMGF), a US-based coalition focused on men who have sex with men (MSM), found that barely a quarter of the 5,000 people from 165 countries surveyed reported easy access to free lubricant. A full 25 percent said free lubricant was completely unavailable. Less than 10 percent of people living in low-income countries reported easy access.
While condoms have been part of family planning and HIV prevention work for decades, safe personal lubricant has only recently emerged as a donor priority. For example, the US government began distributing condoms in the 1970s through its aid and diplomatic missions, but its aid arm, the US Agency for International Development, only began distributing lubricant in 2008.
“Where health systems are less developed, it is critical to help establish and maintain supply chains and distribution systems, as well as support efforts to build and accurately forecast demand [for lube],” explained a representative from the US President’s Emergency Plan for AIDS Relief (PEPFAR):
Acknowledging the importance of using personal lubricants with condoms, especially during anal sex, the UN Population Fund (UNFPA) decided in 2012 to include water-based lubricants in the procurement list of commodities available to governmental and non-governmental clients in low and middle-income countries.
However, outside of community-care settings, the real demand for lubricant remains largely misunderstood.
Research in Burundi found that health care providers sometimes do not provide lube to patients because they consider it to be “promoting homosexual behaviour”, highly-stigmatized there. With lube requests stymied in formal health care settings, NGOs can become the sole method of access.
“Key populations - such as MSM and sex workers - who need the lubricant the most, often get their health-related services from local NGOs, which are not often included in [HIV/AIDS] policies or broader [health] programmes,” explained Bidia Deperthes, a senior HIV adviser with UNFPA’s Comprehensive Condom Programming division in New York.
With these NGOs frequently absent from meetings with donors, lube demand can appear falsely low.
UNFPA, a global leader in the purchase and distribution of contraceptives, spent more than 18 percent of its 2011 budget on male condoms, but less than 0.5 percent on personal lubricants, citing donors’ and decision-makers’ lack of understanding of the true demand for the latter as one reason.
“Before there was lube from the outreach workers, I would use butter,” said Lucky, a transgender sex worker in Kathmandu, Nepal, who said she still uses non-lube products as lubricants when NGOs run out of money to fund free lubricant.
“The condoms would break sometimes, but at least it didn’t hurt as much,” she said.
Silicon and water-based lubricants are “condom compatible” and do not corrode latex. Other types of lubricant, including commercially-produced petroleum-based products like Vaseline, can destroy condoms and put users at risk of HIV and other sexually transmitted diseases.
The World Health Organization (WHO) has published a list of substances commonly used as alternatives to condom-compatible lubricant that may boost the risk of condom failure.
According to an International Rectal Microbicide Advocates (IRMA) 2009 study, most MSM throughout Africa are not using condom-compatible lubricant, a trend also seen in other regions facing a high burden of HIV.
A microbicide is a cream, gel, douche or an enema that may help reduce a person’s risk of HIV infection vaginally or rectally. Medical studies have shown rectal microbicides can offer protection in the absence of condoms and back-up protection if a condom breaks or slips off during anal intercourse.
Distribution and access
The American Foundation for AIDS Research and the US-based Johns Hopkins School of Public Health have identified availability of water-based lubricant and its cost as significant barriers to lubricant access in several countries including Guyana, Ukraine and China.
Lubricant is commercially categorized differently across countries - ranging from a medical device to a cosmetic product - meaning its manufacture, import and export can encounter legal and bureaucratic cross-border delays before reaching users.
Studies have found that even assuming high costs for lubricant production and distribution, “condom-compatible” lube prevention packages that include a condom plus a safe lubricant would only amount to about 1 percent of the global HIV/AIDS budget for 2011 (US$134 million).
Call for more research
Scientists have noted that even in places where lubricant is readily available and widely used,little comprehensive research has been conducted on its safety.
A 2007 global survey revealed more than 100 different types of lubricants are used worldwide during intercourse. WHO has outlined how vaginal and anal intercourse may require different types of lubricant.
“Most importantly, we need to determine the safety of sexual lubricants that are on the market already,” said Jim Pickett, chair of IRMA.
Experts see the lack of research as a disappointment 30 years into the AIDS epidemic, and as a mandate for more studies on lubricant.