Background:  HIV prevention messages for women highlight abstinence, monogamy, and condom usage. However, many women living in the highest HIV incidence areas are married or have a single sexual partner. Condom usage is difficult to negotiate within these relationships, and, during preparedness studies for a clinical trial of microbicides, use of condoms by male partners during follow-up was 20% and did not increase despite provision of male condoms and extensive counseling. Female-controlled barriers are being evaluated in ongoing HIV prevention trials and self-reported data suggest that these methods are more likely to be used than male-controlled condoms. Female condoms are the only female-controlled physical barrier method that has empirical data supporting their potential to provide HIV prevention comparable to male condoms. A decrease in sexually transmitted infections has been reported with the use of female condoms. Diaphragms and other cervical barriers are worn internally, physically protecting the cervix and access to the upper genital tract, the main sites of entry for HIV and many sexually transmitted infections.

Conclusions:  There is a growing consensus that a highly effective female-controlled method will require a combination of products or methods, and combining cervical barriers and microbicides offers a compelling approach to HIV/ sexually transmitted infections prevention. Additional work is focused on development of microbicides, which are not coitally dependent. Strategies currently under development include daily application of ART-based gels and intravaginal rings that can be inserted monthly and which slowly release molecules with high levels of potency against HIV. Ongoing studies are evaluating daily vs coitally dependent usage of tenofovir gel and non-nucleoside reverse transcriptase inhibitors, such as TMC-120 in vaginally applied rings. Combinations of chemical agents, including ART, and fusion or entry inhibitors are also being developed. Long-term studies will be needed to ensure that microbicide usage does not lead to condom migration and that the microbicide products do not weaken the male or female barrier methods. Development of physical and chemical barrier strategies for women will provide real prevention strategy for women at risk of HIV.