In the ongoing battle to curb the spread of HIV around the world, microbicides are being heralded as a way to empower women to protect themselves against the virus. Because microbicides – in the form of gels, creams, films or suppositories – can be used discreetly, say health experts, they give women autonomy over their own sexual health.

But a recent study conducted by researchers from the University of Zambia, Leeds Beckett University and the London School of Hygiene and Tropical Medicine looking at the results of a microbicide clinical trial in Zambia reveals that it may not be so simple. In many cases, the use of microbicides is being dictated by men.

According to the Zambia National Aids Council, the HIV epidemic in the country is driven by unprotected heterosexual sex, with 90 percent of new infections recorded as a result of not using a condom. Their latest estimates show that HIV prevalence is much higher among young women than young men. It stands at 11.2 percent for women and 7.3 percent for men aged 20–24.

The World Health Organization (WHO) defines microbicides as “compounds that can be applied inside the vagina or rectum to protect against sexually transmitted infections (STIs) including HIV,” and says they present a good option for preventing women from contracting the virus because they “do not require the cooperation, consent or even knowledge of the partner.”

“Microbicide research has really been motivated by the agenda for women-controlled HIV prevention methods, which seeks to find ways to give women autonomy as most of the products available at the moment really favor men,” says Ntando Yola, community liaison and education officer with the Desmond Tutu HIV Foundation.

But the Zambian study, which investigates the acceptability and uptake of vaginal microbicide gels, found that men still yield influence over the use of microbicides for various reasons.

First researchers found that the role of men as heads of household gave them power as the ultimate decision-makers, which affected whether and when their wives were able to use the gel.

Various focus groups and interviews with key informants such as community leaders and health workers revealed that both women and men believed a woman should ask for permission from her partner to use the gel and that he has the right to authorize and, in some cases, control and monitor its use.

Researchers also found that there is a general disapproval of letting women decide for themselves how and when to use the gel. Women who use the gel without their partner’s knowledge usually either hide the gel or keep it with relatives or friends because they fear violence from their partners if they are discovered.

And the study found that “belief in the notion that men have strong sexual desires affected not only the general use of the gel but also its consistent use,” as some gel users reported there were times when they didn’t get the chance to apply the gel because their partners demanded sex immediately.

There was some good news: The study also showed that some men preferred the gel over condoms because it allows direct sexual contact, and doesn’t interfere with conception – which is seen as an important measure of masculinity – while at the same time offering protection against HIV.

The fact that in many Zambian communities it’s considered socially acceptable for men to engage in multiple sexual relationships is motivating more women to start using the gel because they perceive themselves to be at risk of HIV from their partners.

Dr. Oliver Mweemba, who teaches public health at the University of Zambia and was a lead researcher on the study, says the results challenged the assumptions that microbicides work as a “woman-driven” method for preventing the spread of HIV.

Instead, the study “suggests that women’s decisions to use microbicides gel are located within the parameters set by their social relationships with their partners and other members of society,” he said via email.

Mweemba says to create an environment in which women have the autonomy to use microbicide gels, as well as other HIV-prevention methods, health programs need to address gender roles.

“These responses were echoed by both men and women,” he said. “So we need to build a participatory approach to transformative gender programs that can sensitize men and women about masculinity and the dangers that it can present to women, families and men themselves.”

But that doesn’t mean cutting men out of the process entirely, says Yola.

“Looking at the African context and other parts of the world where there is still a great level of patriarchy, it is essential that part of the messaging should be open and positive about the inclusion of men and not suggest that men have no role to play in the sexual and reproductive health of women.”