The Beauty of Choice

This summer marked an important milestone for preventing HIV in women and a beautiful moment for me. On July 24, the dapivirine vaginal ring, the first long acting HIV prevention product for women and a major subject of my research at the Women’s Global Health Imperative, moved one step closer to real-world access. After years of uncertainty and delays, the European Medicines Agency provided a positive scientific opinion about the ring. This decision places the ring on the path toward regulatory approval, so that globally, women who need protection from HIV have more options. But mostly, this decision is impactful because it represents the next step towards providing real choice to women. And choice is not just needed, it is also beautiful.

Why is choice beautiful in HIV prevention? First, it empowers the user, thereby fully recognizing individual agency. In one study where we provide product choice to young women who decided to join, they reported feeling respected, loved and “important people”, because the choice of the method they used was theirs. Second, choice is compassionate. It is also inclusive because it explicitly assumes differences in opinions, preferences, behaviors and circumstances. Finally, choice is respectful because it acknowledges that people are not monochromatic. Offering a rainbow of options is an important way to meet their needs.

The Dapivirine Ring is an Important Tool in HIV Prevention

Made out of flexible silicone, the dapivirine ring is inserted into a woman’s vagina for monthly protection against HIV, similarly to the contraceptive NuvaRing. Through decades of research, the prevention field and investigators like myself have realized that women’s lives are complicated, and they need discreet, user-friendly and self-initiated methods that do not require action on a daily basis or at the time of sex. This is a case in point in Sub-Saharan Africa, where the epidemic still rages and the majority of new HIV infections are among young women. Researchers like me, as well as advocates, and program implementers, must seize this moment and build momentum for continued support of the preventative ring by funders and policy makers, so more options become available to end the HIV epidemic globally with all the tools we have.

Is the ring perfect? Absolutely not. Is it 100% efficacious? Probably not. Is it still essential to add the ring to the HIV prevention toolbox? Absolutely! Whereas the ring is a match for some, it will not be every woman’s choice. But the ring coalesces several characteristics that daily oral PrEP (currently approved) or other long-acting options in the pipeline, like injectables, may not have: full user-control, instant reversibility, “set it and forget it” for peace of mind, limited and localized drug exposure to the body and thus a great safety profile. All these offer the promise of simplified roll-out in low resource settings.

Consumers Like Options, Including for HIV

We know from the business world that consumers like options. We have also learned from decades of successful contraception programs that women change their minds or their preference depending on lifestyle and reproductive stages. More options lead to more coverage, and thus fewer unplanned pregnancies. Logic has it that the same should be true for HIV prevention: more options should lead to more HIV infections averted, because a diverse mix of HIV prevention methods takes into account end-users’ changing needs, desires, and preferences.

I have strived throughout my career to stay unbiased: don’t fall in love with your innovation!… Rather, stay in love with providing choice. What we need to end the HIV epidemic are multiple options, as we have understood long ago that the proverbial silver bullet does not exist. Scientists are not immune to trends, and like in the fashion industry, their preferences flicker. Let’s not have the trend of today obscure the benefits of tomorrow. Let’s persist and walk the remaining mile so that women who need and want it, can get the preventative ring. Whereas fashion changes, choice endures. This is the beauty of choice.