Since heterosexual sex has become the main conduit of HIV transmission worldwide, women have come to bear the greatest burden of this disease while possessing the least amount of control over their risk factors. According to the United States Department of Health, in 1990 only 11% of new AIDS cases where diagnosed in women. By the end of 2004, that number had leaped to 27%, with 78% of those cases originating in heterosexual relations. Globally, the numbers are even more disparate. UNAIDS estimates that close to 50% of those currently living with HIV are women, and of those women the majority contracted the virus through heterosexual sex. Gender dynamics, limited autonomy, fertility pressures, religion, poverty, and a woman’s socio-economic status all contribute to the state of this frightening trend. Women in regular partnerships, above all, are experiencing the greatest explosion in infection rates. This is mainly because they are powerless to enforce mutual monogamy. Additionally, these women may have trouble negotiating male condom use within the context of their regular partnership, since this request is often associated with infidelity or a lack of trust. Further compounding this is the fact that women are biologically two to five times more likely to acquire the HIV virus from an infected male partner than for the reverse to occur. As such, according to the CDC, in the United States AIDS is the fifth leading cause of death in women between the ages of 35 to 44, and the sixth leading cause of death in women between the ages of 25 to 34. Globally, UNAIDS believes that of the estimated 34 million current HIV infections, 17.3 million are in women. So, the question arises, what happens to monogamous women, who are currently at the risk of contracting HIV because their partners are unfaithful, abusive, or careless? And, more importantly, should women bear the brunt of this pandemic simply because they lack control over their risks? Women are the new face of AIDS, and unfortunately, many politicians, including some members of the United States Congress, still view HIV transmission as a moral difference issue, and therefore the disease and its subsequent death as a just inequality. This viewpoint, however, is specious at best, and its falsity is preventing the funding of new prevention mechanisms and medicines.
Given the statistical factors on HIV and women, it is imperative that a female controlled sexual barrier becomes available for widespread use. One such possible barrier is microbicides. Microbicides are products- either a gel, cream, or suppository- that can reduce the transmission of the HIV virus and be used by women without the consent or cooperation of their partner. Additionally, microbicides can be created that do not contain a spermicidal agent, so therefore can allow a woman to protect herself against HIV without preventing pregnancy. As such, the development of an effective microbicide would be a powerful tool in the fight against AIDS, and should therefore not be ignored. The creation and funding of microbicides will result in the prevention of millions of deaths, and should therefore be a public policy imperative. Furthermore, if welfare is the satisfaction of rational preferences, shouldn’t we give women the opportunity to satisfy their preferences, rather then have them dictated by unfair circumstances? Not only is the development and distribution of microbicides Pareto Efficient, it satisfies the concept of minimal benevolence. If we can make these women better off, without harming anyone else, we morally ought to do so. If by making these women better off, we can also improve the lives of others and society at large, we economically ought to do so.
Immanuel Kant explicated, through his deontic moral theory, that our ethical obligations are derived via rationality. In other words, what we know and understand of our ethical obligations must be conceived of a priori, or without regard to the observation of dismal human behavior. From this viewpoint, the morals of rational agents stem from equal respect, and therefore, rational agents who wish to promote their self-interest choose to adhere to ethical principals. For this reason, economic tenets can be intertwined with the fulfillment of principled duty. So, within this context it becomes apparent that when addressing the issue of women and the prevention of HIV, we should look beyond the possible value of perceived end markets. If the large pharmaceutical firms cannot, or will not, financially invest in the further development of microbicides, it is the duty of government and charity to do so. Since policy that focuses on need is more viable than policy that focuses on informed preference satisfaction, it is possible to develop a defensible judgment on the funding of microbicides based on the value of health and the prevention of disease in society. So, if the argument of principled duty does not seem compelling enough, the argument that there is much to be gained economically by averting the growth of HIV infections should be.
The future cost savings of utilizing microbicides as a means of HIV prevention is both immense and measurable. We can conservatively calculate the cost benefits of averting the transmission of the HIV virus by measuring both the savings of lifetime treatment, as well as the productivity losses to the economy associated with its illness and death. Moreover, since most female AIDS victims have children, we can also analyze the costs averted by having fewer young children as orphans or wards of the state. UNAIDS currently estimates that over 9 million children under the age of 15 have lost their mothers to AIDS, and that one in three children orphaned by AIDS is younger than 5 years old. Consequently, in the Global South, the aversion of 2.5 million HIV infections would yield an approximate three-year savings of US$2.69 billion in medical costs, and US$1.04 billion in productivity gains. These savings in productivity gains include the loss of staff due to absenteeism, the loss of staff due to premature death, and the increased expenses due to the retraining and replacement of workers. The savings in healthcare include palliative care, and the treatment of symptoms and opportunistic illnesses. Importantly, these numbers do not include the cost savings of utilizing HIV antiretroviral medications since they are not widely available in the Global South and are, in general, largely unavailable for widespread use in low-income countries. As such, the cost savings generated by microbicides in the developed world would be even greater.
Although the ultimate economic savings gained by the development of microbicides is significant, the initial cost barrier of testing, manufacturing, and distributing them is perceived as too high and as technically to difficult to manage by the large pharmaceutical companies. The perceived end market being only low-income women in the Global South further exacerbates this viewpoint, as well as the unique challenge of talking explicitly about gender and power as determinants of sexual risk – a touchy topic that vaccine and treatment advocates do not routinely confront. The Pharmaco-Economic Working Group in Europe estimates that US$775 million is needed to bring a first generation microbicide to market, and the United States NIH currently utilizes only 2% of its annual AIDS budget for microbicides research. Due to this and the general lack of interest amongst the pharmaceutical companies, many potential microbicidal candidates have not been put into phase 3 trials, and those ready to be tested purport a mere 60% efficacy rate. Even so, according to a 2002 study conducted by the Rockefeller Foundation, at a 60% efficacy rate, the number of averted infections in the Global South after the first three years of introduction would top 2,537,700 people total. Specifically, in East Asia the avoided infections would top 793,577, in Sub-Saharan Africa 682,790, in South Asia 882,642, in Eastern Europe 128,246, and in Latin America 50,444. This is because a 95% efficacious method, such as the male condom, used in 20% of sexual encounters provides less protection than a 60% efficacious method used in 40% of sexual encounters. Although this Bayesian fact may seem counter-intuitive on the surface, the clarity of its truth and strength begs to support the argument for putting risk control into the hands of women.
In rationing the scarce funding of medical resources, it is a moral imperative that we take into consideration the concept of medical utility, which embodies the maximization of the welfare of persons who are in the highest percentage of unsought risk. In the case of AIDS this population is women. Medical utility additionally requires that attention be paid to the effective and efficient use of our scant medical resources, and that we therefore gain the most bang out of our prevention buck. This can be achieved through the successful development of microbicides, and the resulting empowerment of women. If we assess the costs of research, the probabilities of success, and the urgency of need, we can conclude that medical research into the further development of microbicides is both economically and ethically sound. This is due not only to the savings incurred through averted infections in women in regular partnerships, but also by the eventual averted transmissions of the virus from sex workers to their clients. By helping women who may contract this disease through no choice of their own, we will be inadvertently aiding those with perhaps less moral behavior, which will thereby benefit both groups of women, as well as men, children, and the common good.
We can no longer afford to observe HIV transmission from a consequentalist viewpoint, where we evaluate behavior in terms of outcomes, since this mindset does not allow us to move forward ethically or economically. The men that seek sex outside of their regular partnerships, either with a sex worker or with another man, may be viewed as receiving their just desert if they contract HIV- but clearly their regular partners and children should not be perceived in this way, for they are merely victims of moral luck. In the case of AIDS and women, it is clear that initial conditions matter too much. The economic assumption that only outcomes matter, and not motivation, does not allow us to address the injustice of how these women and children contracted the virus in the first place. Therefore, since a moral motivation beyond outcomes does exist, we should utilize public policy to shift these initial conditions. By supporting the development of microbicides, we are giving women control over their state of affairs, health, and futures, thereby shifting the underlying or undeserved conditions.
In order to overcome undeserved conditions, either natural or social, ethicist John Rawls argues that we should compensate those with disadvantages. Rawls insists that the evening out of handicaps, especially those that are undeserved and thus beyond ones control, should be a fundamental part of our shared conception of justice. Justice, in these terms, should not only be Pareto Efficient, but should also do something to benefit the least well off. As such, Rawls has analyzed the relations that exist between standards and procedures, and believes that we should be more secure in our judgments about just procedures than in our judgments about just outcomes. Perfect procedural justice would entail both an independent standard for a right outcome as well as an independent procedure to guarantee a right outcome, which is highly improbable. Being that this is the case, shouldn’t our public policy on the funding of microbicides reflect a commitment to their creation and success? In the case of women in regular partnerships and AIDS we may not be able to control a just outcome, we can however, implement a just procedure for the prevention of HIV transmission through the development of microbicides.
In Conclusion, a well-informed policy on the funding and development of microbicides is something that should be supported. It is not only a just moral imperative; it is an economically feasible and sound investment. Women are the new face of AIDS, and it is time we not only recognize this fact, but also make a commitment to pursue a rational solution. If we do not make an effort to place risk control into the hands of women, both families and society at large will suffer. We are currently at the crossroads where the consequences of not funding microbicides research are both dire and reversible. As such, we must boldly face our future and take the decisive action to wager against the odds that our moral luck has run out.
All data provided by The Global Campaign for Microbicides