But why is it that, despite more than 20 years' research into and development of prevention strategies against HIV/AIDS, the number of new infections among women -- and deaths, as well -- continues to rise? An article in the December 2006 issue of International Family Planning Perspectives argues that part of the reason may be that strategies have not been attuned enough to the realities of women's lives and situation, and that, ironically enough, too much emphasis has been placed on the use of the male condom as the "most effective" means of protecting oneself from HIV/AIDS infection.

Erica Gollub, a professor of epidemiology, asserts that "successful HIV prevention work among women means the adoption of a woman-centered paradigm, one that is grounded in women's realities and acknowledges gender roles and gender-based power differentials as critical factors in women's ability to make and effect decisions regarding their health and welfare."

Years of research have also shown that "most women around the world cannot control male condom use," says Gollub, "and we have begun to understand that women's attitudes toward and use of protective methods are based on personal, relational, sociocultural and structural factors, with a different mix for each woman."

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INDEED, because condoms need to be put on by men -- and it would be difficult to get a man to use a condom without his knowledge or consent -- Gollub notes that "we have now recognized the limits of a sole dependence on the male condom." She says: "Male control over the male condom undermines its real-world impact."

Despite decades of work touting the advantages of the condom -- and it is a very effective means of preventing sexually transmitted infections -- "large-scale male condom campaigns . have been inadequate as a public health strategy." Gollub notes that "recent studies of US women at high HIV risk show that the proportion of protected sex acts rarely exceeds 15 percent, a statistic that has not changed over the past decade. Women in developing countries are often not protected at all."

She adds: "Our stubborn insistence on presenting the male condom as a '100 percent method' has played right into the hands of those who argue that advocating male condom use to prevent HIV infection under-serves women because it exposes them to (occasional) failures and does not make the most of women's 'power' in saying no to sex."

"We have seen the credibility of the male condom damaged over the past several years by disinformation campaigns, and the language of reproductive rights twisted to disempower women," recounts Gollub. "Precious resources that could have been used for prevention are now being wasted in countering these attacks. Future HIV prevention efforts should focus on the potential for a given method program or policy to increase a woman's ability to control her reproductive health, rather than on product efficacy values that apply to a narrow set of users under highly manipulated conditions."

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THERE are other, women-controlled "technologies" that offer protection against HIV, including the female condom which is considered to be as effective as the male condom. And while spermicides, which had been looked upon as a promising alternative but have proven to be useless against HIV transmission, Gollub says cervical barriers "hold great promise as risk-reduction tools," mainly because the cervix is more susceptible to HIV infection than the vagina. There is an ongoing large trial to test the effectiveness of a "one-size-fits-many diaphragm." Clinical trials of microbicides are likewise underway.

"Widening our approach to include more than the exclusive promotion of the male condom," says Gollub, "means grasping the essential notion that no prevention method will ever be ideal for all women or in all situations." She asserts: "We are still wrestling with the outdated question of 'which is better?' rather than the considerably more constructive and expedient framework of 'more is better.'"

Gollub says a more efficient next step would be to adopt a "sexual risk reduction" philosophy, "similar to that of the harm-reduction approach to needle-related HIV risk among injection drug users."

Such an approach, she suggests, involves giving women choices when it comes to prevention methodsbehavioral (such as reducing the number of partners), product-based (such as alternatives to the male condom) or bothto maximize prevention potential.

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"SOMETHING is better than nothing," Gollub declares.

While other methods and approaches may not be as effective as the condom against HIV, they "could nevertheless have great individual or public health value if they were used consistently."

In New York, for instance, the State AIDS Institute has "advocated a hierarchical counseling approach that presents available methods that have the potential to reduce STIs and HIV infection, ordered by their efficacy." Such a hierarchy, suggests Gollub, "might place female and male condoms at the top rung, diaphragms and cervical caps on the second rung, and coitus interruptus on the third rung."

Will giving women choices and acknowledging their power to make those choices finally give them the protection they need against HIV infection? What will it take to put HIV prevention in the hands of women -- and not just on the penises of their partners?

More on these questions in tomorrow's column.