In high HIV prevalence and incidence areas where microbicides are likely to be introduced for HIV Prevention, it is imperative that acceptability of novel technologies is determined in the population at large. Our study suggests the need and acceptability of microbicides among those who are already infected with HIV. The strengths of the study include: a) that Carraguard is in advanced stages of clinical testing and so acceptability data are particularly important; b) it is one of the few studies to assess acceptability in a randomised controlled trial in sexually active and abstinent HIV positive women, and sexually abstinent HIV positive men; and c) it adds value to current knowledge on microbicide acceptability by assessing acceptability and perceptions based on use of product in advanced Phase III trials.
From the responses received by both HIV-positive men and women in the current study regarding the need for microbicides, it is suggested that irrespective of individual HIV status, a product such as a microbicide would be purchased, used and accepted by individuals. This study confirms favorable acceptability findings from previous studies among men and women [6, 7].
One of the disconcerting findings of this study and other studies involving men is that we are likely to see condom migration in the event a microbicide or any other intervention becoming available. Given that many of these products are unlikely to be 100 % effective, accurate messages regarding the use of the product with condoms will need to be emphasized. Behaviour change including promotion of safe sex using condoms will have to be emphasized.
Adherence to product use and its coital dependency is an important issue in ongoing large scale trials. In this short study, adherence to product use was very good among all study participants. The study was too short to ascertain whether this trend would have continued for long-term use. Of note, however, was that application of the product within the time-frame of 1 hour prior to sexual intercourse may not always be achievable and it would be important to develop products which are longer acting. While these findings suggest that coital dependency of the product may not be an issue if the product is easy to use and acceptable, it is important to bear in mind that some women are not able to control the timing or terms of sex and so may have difficulty using a product that requires use just prior to intercourse. From these data, it appears that product use would be enhanced if a woman's partner is aware and accepting of the product as well.
Unlike other studies in sub-Saharan Africa that have reported a common preference for "dry sex" , it appears that our study population did not have a high desire for dry sex and that some lubrication provided by the gel was acceptable. However, it was clear, too, that a significant number of participants felt the gel caused excessive wetness, and so the volume of gel may have been too much. While the applicators were designed to deliver 4 ml of gel, data from earlier studies using the same applicator indicated that 4.5–5.0 ml was the average amount squeezed out, which may have been why women found the gel to be too wet [7, 9] Despite this concern, participants did report favorably on the effect of the gel on sex. This is in line with previous studies that showed that vaginal gel can enhance sexual pleasure [10, 11].
When the need for microbicide products discussions began in the late 1980's  it was strongly believed that a product that a woman could use covertly was required to prevent HIV acquisition among women and that women's empowerment was key to addressing the escalating HIV infection among women. However, over the years, it has become increasingly evident in hypothetical and real-use acceptability studies among both men and women that covert use may not be desirable for all women, particularly those in steady relationships. In this study, less than a third of the women felt that the gel could be used without a male partner's knowledge, and only 26% of them said they themselves would use the gel covertly. Interestingly, somewhat more men (around half) said they thought women should or could use the gel covertly. However, the majority of the men did respond that use of the product should be a joint decision, which is in keeping with other research from South Africa. It is difficult to pinpoint the precise dynamics underlying these mixed responses. It is possible that the low preference for covert use among these individuals reflects the types of relationships (e.g., steady vs. casual, whether egalitarian, etc.) they are in. Alternatively, it could be linked to participants' other opinions about the gel, for example the feeling that the gel was too wet, which would logically reduce confidence in being able to use such a product covertly. Participants' strong desire for an ideal microbicide "not to be noticed" could also be related to their opinions about covert use (Table 4). Despite these findings, however, the possibility to use a microbicide covertly remains an important option for those who would need it.
While it is desirable to assess acceptability of the gel among HIV-positive men and their partners, the present study was limited in that the most comprehensive acceptability assessment among men was based on penile application of the gel. Men's responses may therefore not necessarily reflect acceptability during sexual intercourse. For similar reasons, the sexually abstinent women's acceptability responses may not be optimal. Furthermore, findings of this study cannot be generalized to all HIV-infected populations due to the unique characteristics, for example clinical status and sexual activity, of this population. Thus, while this study provides a snapshot of acceptability among HIV-positive men and women in Durban, a much larger study would be required to generalize acceptability outcomes to all HIV-positive individuals.