Need – In spite of social taboos against premarital sex, young people in the country are increasingly sexually active, a report of the National Institute of Health and Family Welfare shows.¹ However, they lack knowledge of or access to prevention methods. Girls, especially out-of-school girls, have less knowledge of HIV risk and prevention than boys.² The National Family Health Survey estimates that 65% of Indian girls marry before age 18, and in some states the average age at marriage for girls is 16. Often young women have little voice in choosing their spouse. Many studies have reported that women who do perceive themselves at risk for HIV have little success in asking their husbands to use condoms. While condom promotion has encouraged men to use condoms with sex workers and casual partners, most men still refuse to use condoms with their wife or regular partner. Predictably, HIV rates in India for young women (0.96%) exceed those for both young men (0.46%) and adults (0.80%) in 2002, according to UNICEF, UNAIDS and WHO, and cases are increasing rapidly among married, monogamous women in the country.

Opportunity – India is already involved in microbicide research and has a strong regulatory and manufacturing sector that could speed access to safe and effective products. In addition, a long tradition of social movements and a vibrant NGO sector encourage active inclusion of civil society and communities in product research as well as policy development.

Overcoming cultural barriers

There are also some barriers to widespread support for microbicides. Morally conservative and patriarchal social norms make it difficult to confront the reality of a sexually transmitted epidemic. A culture of silence around women's sexuality enhances the stigma associated with seeking information or interventions about self-protection. In India as elsewhere, no one wants to acknowledge that girls are sexually active – whether it is voluntary or not – despite evidence to the contrary.

The Global Campaign seeks to build a platform for community-based advocates to engage with scientists, policy-makers, donors, and other actors in overcoming these barriers and addressing the urgent need for prevention methods appropriate for young women at risk. Active community participation in the Global Campaign began in India in 2001 with the Indian Network of NGOs working on HIV and AIDS (IN-N). These NGOs worked hard to address HIV and AIDS issues in their communities, but were at a loss for how to respond to the needs of married women, who have very little power in their relationships to negotiate safer sex. The possibility of prevention methods that women could use themselves was exciting, and the network began building their own capacity in issues related to microbicides and female condoms, giving workshops locally and at major international conferences.

As the global microbicides movement grew, science accelerated, and interest expanded beyond the women's health and HIV/AIDS communities where it had begun, the role of advocates shifted. A more targeted, strategic plan was required to engage policy-makers and researchers with the communities most affected by HIV/AIDS.

Starting with the community

In 2002, IN-N and the Global Campaign co-convened the Community Stakeholders' Meeting on Microbicides and Female Condoms. The meeting drew together representatives from Indian NGOs along with experts in women-controlled prevention methods. The meeting resulted in a set of recommended strategies for taking the advocacy agenda forward, involving media and communications as well as engaging policy-makers and researchers. New allies were identified, such as the Indian Medical Research Council (ICMR), the National AIDS Control Organization (NACO) and the Indian Parliamentarians' Forum on HIV and AIDS.

A National Policy Meeting on Microbicides followed the Community Meeting in 2003. In addition, the Global Campaign constituency in India began outreach with sister networks working in women's rights, who have a long vibrant history of effective grassroots advocacy in India, and whose demands for women's empowerment, government accountability, and appropriate technology resonate closely with the goals of the microbicides movement. Organizations serving men who have sex with men actively participate in the Campaign, endorsing the need for additional methods of prevention for both women and men.

The Global Campaign's role in India remains to advocate for women's needs and priorities in protecting themselves from HIV, and carrying that message to researchers, policy-makers and donors. This process of starting with the community has ensured a place at the table for organizations and community representatives as decisions are made that affect research, development, access and use of microbicides and other HIV prevention methods for women. In addition, participants in the original Community Stakeholders Meeting developed a set of principles that defined priority areas for the NGO community. These included:

• Maintaining a gender analysis and rights framework throughout
• Locating microbicides within a broader range of prevention tools and strategies, including behaviour change, barrier methods, and vaccines, and not promoting one intervention at the expense of others
• Building on the existing strengths of coalition members by taking on activities that complement ongoing work.

Next steps for the Global Campaign in India include participation in a national working group on microbicides, continued coalition development and capacity-building with partners and allies, developing communication strategies that address common questions and concerns, and connecting advocacy to clinical trial sites in India to assist in building partnerships for community involvement. There are four candidate microbicides in clinical trials in India, and Global Campaign partners work with research institutions, local NGOs and policy makers to strengthen civil society participation in the research, development and introduction of these essential prevention tools. As microbicides advance in India, advocates must keep pace, to ensure that progress addresses the rights and needs of Indian women – including young women and girls.