Anthropology in/of a clinical trial:
What it revealed, and what
can/can’t/should/shouldn’t you do with
the results?
ROBERT POOL
Centre for Social Science & Global Health
University of Amsterdam
Vaginal
microbicides
Why Microbicides?
Empowering Women to
Protect Their Health
Microbicides Development Programme
MDP 301 Trial
Uganda
To determine the
effectiveness and safety
of “PRO 2000 Gel”
compared to placebo in
preventing vaginally
acquired HIV infection
Tanzania
Zambia
South Africa
OVERVIEW
1. How trial participants appropriated the aim of
the study relating to women’s empowerment
2. And redefined the efficacy of the gel
3. And how the clinical trialists and microbicide
community received these ‘alternative readings’
1. Appropriating Empowerment
Most women did tell their partners
• It was the ‘right’ thing to do
• They would find out anyway
• ‘Informing’ was often a gradual and indirect
process
• Women with ‘difficult’ partners were patient
and creative in getting partners to accept
the gel
Women negotiated use within
existing gender relations
• The need for ‘approval’ didn’t necessarily mean that
men were calling the shots.
• Men only needed to appear to be in control
• Most women got their way without openly challenging
male authority, and couples quickly developed a
modus vivendi
2. Redefining efficacy
Better sex
Pajero: Sexual feelings that have been dormant are shaken up and you start
feeling again.
Noeleen: It’s rebuilt my relationship, because we were always arguing about
sex. I’d say I was tired, any excuse to avoid sex. But now all the tiredness has
gone.
Pajero: My partner wondered why I had no interest in sex. When I heard about
the gel, I asked a woman to give me some but she said I should wait. She told
me that her partner always wanted more sex and it didn’t bore her anymore.
Then I received mine and we tried it, and we can never have sex again without
it, it is so enjoyable.
BMW: You know how difficult it is pretending to enjoy sex when you are not
enjoying at all? But since I started gel things are totally different; I’m now
active and eager to have sex and I believe that the gel has done something to
him because he is no longer too tired when he comes back from a long trip.
Changed relationships
It is working for me, because he now even gives
me the [credit] cards to buy groceries; something
that was not happening. And we’ve gone back to
our teenage stage, doing things we were no longer
doing (during sex). As you grow older you get used
to each other, but now he is enthusiastic and
makes an effort.
Safer sex
I told him that I was participating in a study that
involved using gel. I told him I had to use the gel
and he had to use a condom. And that when the
study finished, it didn’t mean that he could stop
using condoms, oh no!
Before she started using gel, I was not used to
using condoms, but since she started using
the gel I also started using condoms, and I
started enjoying sex; it was all right.
Etic agenda
Tell partners
Empower
women through
secrecy
Prevent HIV
Engage men
Prevent HIV
through engaging
couples
MICROBICIDE
Improve sex &
relationships within
existing structures
& prevent HIV
Prevent HIV
Trial benefits
Negotiate/manipulat
e partner ‘approval’
Emic agenda
Discontinu
e
Better
sex
Better
relationships
Whose relevance?
• Gel is developed as female-controlled HIV prevention
• Social science reveals how women develop their own ways of
integrating gel into their relationships  co-opted as new
strategy: ‘male involvement’
• Social science shows how women redefine the purpose of the
gel  it doesn’t prevent HIV so it is taken away from them
• This re-appropriation disrupts the empowerment and
preventive potential that were the aim in the first place
• Taking these local re-interpretations of relevance into account
requires going beyond the immediate social science-medical
collaboration on the ground
Acknowledgements
The MDP team
DFID (funding)