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Martin CE, Kutywayo A, Mataboge P, Chidumwa G, Mthimkhulu N, Bothma R, Mullick S. Prevention method preferences and factors influencing hypothetical choice among women in South Africa: a survey exploring opportunities for a multipurpose prevention technology implant. FRONTIERS IN REPRODUCTIVE HEALTH 2024; 6:1368889. [PMID: 38983594 PMCID: PMC11231390 DOI: 10.3389/frph.2024.1368889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 05/31/2024] [Indexed: 07/11/2024] Open
Abstract
Introduction South African women bear an intersecting burden of HIV, sexually transmitted infections (STIs) and unintended pregnancy. Multipurpose prevention technologies (MPTs) are a class of products that address multiple needs and have the potential to improve uptake and use of prevention products. Methods Analysing survey data from 703 HIV-negative women 18-40 years in three provinces in South Africa, collected between July and November 2022, this study explores their preferences for prevention methods and factors influencing choice of hypothetical prevention methods, including MPTs. Descriptive statistics and multinomial regression analyses were conducted to determine prevention method preferences and factors associated with choosing a pill, injectable or MPT-implant type prevention method. Results Most women wanted to prevent HIV, STIs and pregnancy. The most important factors when choosing a prevention product were whether it provided dual and long-term protection and if side effects were manageable. If choosing only one method, half of women would choose any MPT-implant and a quarter each would choose a pill or an injectable method, with method choices differing by population group. Discussion Prevention method choices were influenced by sexual-behavioural factors and current and prior contraceptive method use. Providing a choice of prevention methods and a population specific approach to new method development and introduction with access to accurate information could enhance their ability to fill a gap in prevention needs.
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Affiliation(s)
| | - Alison Kutywayo
- Wits RHI, University of the Witwatersrand, Johannesburg, South Africa
| | - Paballo Mataboge
- Wits RHI, University of the Witwatersrand, Johannesburg, South Africa
| | - Glory Chidumwa
- Wits RHI, University of the Witwatersrand, Johannesburg, South Africa
| | - Nqaba Mthimkhulu
- Wits RHI, University of the Witwatersrand, Johannesburg, South Africa
| | - Rutendo Bothma
- Wits RHI, University of the Witwatersrand, Johannesburg, South Africa
| | - Saiqa Mullick
- Wits RHI, University of the Witwatersrand, Johannesburg, South Africa
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Mayanja Y, Kayesu I, Kamacooko O, Lunkuse JF, Muturi-Kioi V, Price M, Kosidou K, Ekström AM. Preference for novel biomedical HIV pre-exposure prophylaxis methods among adolescent girls and young women in Kampala, Uganda: a mixed methods study. Front Public Health 2024; 12:1369256. [PMID: 38846614 PMCID: PMC11153736 DOI: 10.3389/fpubh.2024.1369256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 04/30/2024] [Indexed: 06/09/2024] Open
Abstract
Background Novel HIV pre-exposure prophylaxis (PrEP) methods including a potential future HIV vaccine, will increase prevention options for adolescent girls and young women (AGYW) at high risk of HIV infection in Eastern and Southern Africa, yet data on AGYW's preferences for various PrEP methods is limited. We investigated preferences for five biomedical PrEP methods (oral, injectable, vaginal ring, implant, HIV vaccine) among 14-24-years-old AGYW in Kampala, Uganda. Methods From January to December 2019, we conducted a mixed methods study including 265 high-risk AGYW. After receiving two education sessions on the five PrEP methods, participants were asked about their "most preferred PrEP method." Multinomial logistic regression (oral PrEP as reference category) was used to determine participant characteristics associated with method preference. Results are presented as adjusted relative risk ratios (aRRR) with 95% confidence intervals (CI). In-depth interviews were conducted with 20 selected participants to examine reasons influencing PrEP preferences and suggestions for method improvements. Transcripts were analyzed thematically. Results Participants preferred methods were: HIV vaccine (34.7%), oral PrEP (25.7%), injectable PrEP (24.9%), PrEP implant (13.6%), and vaginal ring (1.1%). Preference for injectable PrEP increased with every year of age (aRRR 1.22; 95% CI 1.04-1.44) and among participants with chlamydia or gonorrhoea (aRRR 2.53; 95% CI 1.08-5.90), while it was lower among participants having sexual partner(s) living with HIV or of unknown HIV status (aRRR 0.30; 95% CI 0.10-0.91). Preference for PrEP implants also increased with age (aRRR 1.42; 95% CI 1.14-1.77) and was strong among participants having ≥10 sexual partners in the past 3 months (aRRR 3.14; 95% CI 1.16-8.55), while it was lower among those with sexual partner(s) living with HIV or of unknown HIV status (aRRR 0.25; 95% CI 0.07-0.92). PrEP method preference was influenced by product attributes and prior experiences with similar product forms commonly used in health care. Conclusion AGYW have varied preferences for biomedical PrEP method and those with higher sexual behavioral risk prefer long-acting methods. As we anticipate more available PrEP options, oral PrEP use should be supported among AGYW, especially for those with sexual partners living with HIV or of unknown HIV status.
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Affiliation(s)
- Yunia Mayanja
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine (MRC/UVRI & LSHTM) Uganda Research Unit, Entebbe, Uganda
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Ivy Kayesu
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine (MRC/UVRI & LSHTM) Uganda Research Unit, Entebbe, Uganda
| | - Onesmus Kamacooko
- Child Health and Development Centre, School of Medicine, Makerere University, Kampala, Uganda
| | - Jane Frances Lunkuse
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine (MRC/UVRI & LSHTM) Uganda Research Unit, Entebbe, Uganda
| | | | - Matt Price
- 4IAVI, New York, NY, United States
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, United States
| | - Kyriaki Kosidou
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Centre for Epidemiology and Community Medicine, Region Stockholm, Stockholm, Sweden
| | - Anna Mia Ekström
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Department of Infectious Diseases/Venhälsan, Södersjukhuset, Stockholm, Sweden
- Department of Clinical Science and Education, Södersjukhuset, Stockholm, Sweden
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3
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Shi D, Ye T. Behavioral carry-over effect and power consideration in crossover trials. Biometrics 2024; 80:ujae023. [PMID: 38563531 PMCID: PMC10985791 DOI: 10.1093/biomtc/ujae023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 02/28/2024] [Accepted: 03/07/2024] [Indexed: 04/04/2024]
Abstract
A crossover trial is an efficient trial design when there is no carry-over effect. To reduce the impact of the biological carry-over effect, a washout period is often designed. However, the carry-over effect remains an outstanding concern when a washout period is unethical or cannot sufficiently diminish the impact of the carry-over effect. The latter can occur in comparative effectiveness research, where the carry-over effect is often non-biological but behavioral. In this paper, we investigate the crossover design under a potential outcomes framework with and without the carry-over effect. We find that when the carry-over effect exists and satisfies a sign condition, the basic estimator underestimates the treatment effect, which does not inflate the type I error of one-sided tests but negatively impacts the power. This leads to a power trade-off between the crossover design and the parallel-group design, and we derive the condition under which the crossover design does not lead to type I error inflation and is still more powerful than the parallel-group design. We also develop covariate adjustment methods for crossover trials. We evaluate the performance of cross-over design and covariate adjustment using data from the MTN-034/REACH study.
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Affiliation(s)
- Danni Shi
- Department of Biostatistics, University of Washington, Seattle, WA 98195, United States
| | - Ting Ye
- Department of Biostatistics, University of Washington, Seattle, WA 98195, United States
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Zhao X, Boyd P, Bashi YD, Murphy DJ, McCoy CF, Coulter S, Laverty G, Malcolm RK. Two into one does go: Formulation development of a multipurpose combination vaginal ring releasing dapivirine and metronidazole for prevention of HIV infection and treatment of bacterial vaginosis. Int J Pharm 2023; 648:123572. [PMID: 37926178 DOI: 10.1016/j.ijpharm.2023.123572] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 10/20/2023] [Accepted: 10/31/2023] [Indexed: 11/07/2023]
Abstract
Bacterial vaginosis (BV) is a common but often asymptomatic dysbiosis of the human vagina characterized by an imbalance in the normal vaginal microbiota due to loss of lactobacilli and an overgrowth of certain anaerobic bacteria. While BV itself is not a sexually transmitted infection, it is associated with an increased risk in women of various sexually acquired infections, including human immunodeficiency virus (HIV) infection. There is, therefore, a strong rationale for pursuing new multipurpose products that seek to treat or prevent BV alongside preventing HIV infection. With the dapivirine-releasing vaginal ring for HIV prevention now approved in several African countries, here we report formulation development of a next-generation ring product that releases both dapivirine (DPV) and the antibiotic drug metronidazole (MET). Following thermal analysis studies to characterize the phase behaviour of DPV-MET mixtures and rheological analysis to assess the cure characteristics of the active silicone elastomer mixes, matrix-type rings were manufactured containing 25 or 200 mg DPV in combination with 100, 250, 500, 1000 or 2000 mg MET. The results for drug content, in vitro release, mechanical testing, and Gardnerella vaginalis time-kill experiments demonstrate the feasibility of incorporating both DPV and MET in a matrix-type ring formulation and indicate that clinically effective release rates may be possible.
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Affiliation(s)
- Xinyu Zhao
- School of Pharmacy, Medical Biology Centre, Queen's University Belfast, Belfast BT9 7BL, UK
| | - Peter Boyd
- School of Pharmacy, Medical Biology Centre, Queen's University Belfast, Belfast BT9 7BL, UK
| | - Yahya Dallal Bashi
- School of Pharmacy, Medical Biology Centre, Queen's University Belfast, Belfast BT9 7BL, UK
| | - Diarmaid J Murphy
- School of Pharmacy, Medical Biology Centre, Queen's University Belfast, Belfast BT9 7BL, UK
| | - Clare F McCoy
- School of Pharmacy, Medical Biology Centre, Queen's University Belfast, Belfast BT9 7BL, UK
| | - Sophie Coulter
- School of Pharmacy, Medical Biology Centre, Queen's University Belfast, Belfast BT9 7BL, UK
| | - Garry Laverty
- School of Pharmacy, Medical Biology Centre, Queen's University Belfast, Belfast BT9 7BL, UK
| | - R Karl Malcolm
- School of Pharmacy, Medical Biology Centre, Queen's University Belfast, Belfast BT9 7BL, UK.
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Fynn L, Gill K, Wallace M, Atujuna M, Duyver M, Ngcobo P, Spiegel H, Rinehart A, Hosek S, Bekker LG. "It's already in your body and it's preventing": a qualitative study of African female adolescent's acceptability and preferences for proxy HIV prevention methods in Cape Town, South Africa. BMC Public Health 2023; 23:2143. [PMID: 37919697 PMCID: PMC10621226 DOI: 10.1186/s12889-023-16955-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 10/06/2023] [Indexed: 11/04/2023] Open
Abstract
BACKGROUND Advances in biomedical HIV prevention will soon offer young women a choice of HIV prevention methods, including various pre-exposure prophylaxis (PrEP) modalities such as daily oral pills, dapivirine vaginal ring, and long-acting injectable agents. By understanding preferences for contraceptive methods, we may draw analogies for the HIV prevention needs of young women. The UChoose Study was an open-label randomised cross-over study designed to evaluate the acceptability and preference for several contraceptive options as a proxy for HIV prevention methods that use similar types of administration. The study enrolled healthy HIV uninfected young women aged 15 to 19 years. At enrolment, participants were randomly assigned to a contraceptive method for a period of 16 weeks in the form of monthly Nuvaring® (vaginal ring), daily combined oral contraceptive (daily pills), or bi-monthly injectable contraceptive (injectable). After 16 weeks, participants crossed over to another contraceptive method, and those who had received the injectable and the daily pills received the vaginal ring for another 16 weeks, whereas those who had received the vaginal ring were able to choose between the injectable and daily pills, to ensure that all participants tried the vaginal ring-the least familiar option to the study population. RESULTS Thirty-three participants were purposively recruited to participate in seven focus group discussions (FGD) and completed a pre-survey for their assigned group. Our sample comprised 14 participants randomised to use of the vaginal ring and daily pills and 19 participants randomised to use of the vaginal ring and injectable. For most participants, their preferences for a prevention method were based primarily on their desire to avoid negative aspects of one method rather than their positive user experience with another method. Most participants expressed initial hesitancy for trying new contraception method products; however, a lack of familiarity was moderated by a strong interest in diverse user-controlled prevention methods. Participants valued methods that had infrequent dosing and simplified use requirements. The injection and vaginal ring were preferred over daily pills as a potential HIV prevention method. CONCLUSION Expanding the availability of diverse products could provide adolescents with multiple choices in HIV prevention for the uninitiated. TRIAL REGISTRATION ClinicalTrials.gov ( NCT02404038 ). Registered March 31, 2015-Registered.
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Affiliation(s)
- Lauren Fynn
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa.
| | - Katherine Gill
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Melissa Wallace
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Millicent Atujuna
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Menna Duyver
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Penelope Ngcobo
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Hans Spiegel
- Department of Health and Human Services, Kelly Government Solutions, Contractor to National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD, USA
| | | | - Sybil Hosek
- Stroger Hospital of Cook County, Chicago, IL, USA
| | - Linda-Gail Bekker
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
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Young IC, Pallerla A, Cottrell ML, Maturavongsadit P, Prasher A, Shrivastava R, De la Cruz G, Montgomery SA, Schauer A, Sykes C, Kashuba ADM, Benhabbour SR. Long-acting injectable multipurpose prevention technology for prevention of HIV and unplanned pregnancy. J Control Release 2023; 363:606-620. [PMID: 37797892 PMCID: PMC10841820 DOI: 10.1016/j.jconrel.2023.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 09/30/2023] [Accepted: 10/02/2023] [Indexed: 10/07/2023]
Abstract
Only condoms are proven to protect against both HIV and unplanned pregnancy, however, poor user acceptability and lack of partner cooperation impede effectiveness. We developed an injectable ultra-long-acting, biodegradable, and removable in-situ forming implant (ISFI) as multipurpose prevention technology (MPT). MPT ISFIs co-formulated an antiretroviral (dolutegravir (DTG)) or cabotegravir (CAB)), and a hormonal contraceptive (etonogestrel (ENG) or medroxyprogesterone acetate (MPA)). All formulations were well-tolerated in mice with no signs of chronic local or systemic inflammation. Plasma CAB and DTG concentrations were above 4× PA-IC90 for 90 days with zero-order and diffusion-controlled absorption, respectively, and no differences when co-formulated with either hormone. Plasma ENG and MPA concentrations were quantifiable for 90 days. Complete removal of CAB/MPA ISFIs resulted in MPA concentrations falling below the limit of quantification after 24 h post-removal, but incomplete CAB elimination from plasma. Collectively, we demonstrated the ability to co-formulate antiretrovirals with contraceptives in an ISFI that is well-tolerated with sustained plasma concentrations up to 90 days.
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Affiliation(s)
- Isabella C Young
- Division of Pharmacoengineering and Molecular Pharmaceutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Aryani Pallerla
- Department of Psychology and Neuroscience, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Mackenzie L Cottrell
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Panita Maturavongsadit
- Joint Department of Biomedical Engineering, North Carolina State University and The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Alka Prasher
- Joint Department of Biomedical Engineering, North Carolina State University and The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Roopali Shrivastava
- Joint Department of Biomedical Engineering, North Carolina State University and The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | | | - Amanda Schauer
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Craig Sykes
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Angela D M Kashuba
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - S Rahima Benhabbour
- Division of Pharmacoengineering and Molecular Pharmaceutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Joint Department of Biomedical Engineering, North Carolina State University and The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
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7
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Mataboge P, Mthimkhulu N, Kutywayo A, Martin CE, Mazibuko M, Kwatsha K, Makalela N, Briedenhann E, Butler V, Bothma R, Mullick S. Preferences, educational messaging, and demand creation channels for multipurpose-prevention technologies (MPTs) among women in South Africa. BMC Public Health 2023; 23:2090. [PMID: 37880628 PMCID: PMC10598950 DOI: 10.1186/s12889-023-16904-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 10/05/2023] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND South African women, including female sex workers (FSWs), are disproportionately affected by HIV, experience a high unmet need for contraception and high rates of sexually transmitted infections (STIs). Products that address the interlinked risk between HIV, unplanned pregnancy, and other STIs are needed. There are several multipurpose-prevention technologies (MPTs) in development, aimed at preventing both HIV and pregnancy. This study aimed to explore educational messaging and demand creation channels to improve the potential uptake of a hypothetical MPT implant, using participatory action research. It also aimed to look at product and service provision attributes preferred by potential end users. METHODS Between July and August 2022, 303 PrEP-eligible adolescent girls and young women (AGYW) (18-24 years), women > 24 years, and FSW's (≥ 18 years) participated in 4-hour workshops, where they were asked about their ideal messaging and demand creation channels and their preferences for different attributes of an MPT implant. Quantitative descriptive analysis was conducted to determine the frequency and ranking for each demand creation message, channel, and each product and service provision attribute, by population group. A chi-square test was used to assess MPT implant characteristics associated with age. Qualitative data were analysed using deductive and thematic analysis. RESULTS A total of 104 AGYW, 157 women > 24 years, and 42 FSWs participated in the PAR workshops. Participants preferred demand creation messages that were empowering, motivational and encouraged body autonomy. The use of slang was popular. Community radio stations and newspapers, social media, and information at hospitals and clinics were participants' preferred MPT demand creation channels because they were easily accessible. Providing long-term and dual HIV and pregnancy protection, receiving implant services at the local clinic, manageable side effects, discreet and private implant, and numbing the area before insertion and removal, were the most preferred product and service provision attributes. CONCLUSION Early considerations for women's product preferences are key to product development. Educational messaging around the MPT implant should be empowering and in local languages, this may motivate women to learn more about it and use it. Multiple demand creation channels should be used to engage both young and older populations, which may ensure better reach.
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Affiliation(s)
- Paballo Mataboge
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
| | - Nqaba Mthimkhulu
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Alison Kutywayo
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Catherine E Martin
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mbali Mazibuko
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Khanyiswa Kwatsha
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Nthabiseng Makalela
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Elmari Briedenhann
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Vusile Butler
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Rutendo Bothma
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Saiqa Mullick
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Cummins JE, Allen CL, Lee S, Senn TE. Biomedical, socio-behavioral, and implementation science gaps in multipurpose prevention technology research. FRONTIERS IN REPRODUCTIVE HEALTH 2023; 5:1244659. [PMID: 37744288 PMCID: PMC10513059 DOI: 10.3389/frph.2023.1244659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 08/15/2023] [Indexed: 09/26/2023] Open
Abstract
There is strong global need for the development of Multipurpose Prevention Technologies (MPTs) that prevent HIV, pregnancy, and/or other sexually transmitted infections (STIs). However, despite decades of research focused on the development of MPTs, numerous research gaps remain, contributing to reproductive health disparities. This commentary will highlight biomedical, socio-behavioral, and implementation science gaps in MPT research. Biomedical gaps and barriers include limited dosage forms, challenges around drug selection and stable coformulation of multiple drugs, and an unclear regulatory pathway. Behavioral, social, and structural gaps include lack of research around MPT preferences for some subgroups of potential end users, lack of knowledge around whether MPTs improve uptake, adherence, and persistence vs. separate products, and a need to further understand how social and cultural factors might impact MPT interest and use. Gaps in implementation science research will need to be addressed to better understand how to implement MPTs to maximize effectiveness and benefit. This commentary will also identify opportunities for integrating biomedical and behavioral science around MPTs.
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Affiliation(s)
- James E. Cummins
- Preclinical Microbicide and Prevention Research Branch (PMPRB), National Institute of Allergy and Infectious Diseases (NIAID), Rockville, MD, United States
| | - C. Leigh Allen
- Contraception Research Branch (CRB), Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), Bethesda, MD, United States
| | - Sonia Lee
- Maternal and Pediatric Infectious Disease Branch (MPIDB), Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), Bethesda, MD, United States
| | - Theresa E. Senn
- HIV Prevention and Care Continuum, Co-Morbidities, and Translational Research Branch, National Institute of Mental Health (NIMH), Rockville, MD, United States
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Shapley-Quinn MK, Song M, Chen BA, Devlin B, Luecke E, Brown J, Blithe DL, Achilles SL, van der Straten A. Participant experiences with a multipurpose vaginal ring for HIV and pregnancy prevention during a phase 1 clinical trial: learning from users to improve acceptability. FRONTIERS IN REPRODUCTIVE HEALTH 2023; 5:1147628. [PMID: 37484873 PMCID: PMC10359149 DOI: 10.3389/frph.2023.1147628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 06/01/2023] [Indexed: 07/25/2023] Open
Abstract
Introduction With high concurrent global rates of HIV incidence and unintended pregnancy, there is a need to provide options beyond condoms to enable users to simultaneously prevent HIV acquisition and pregnancy. Multiple vaginal rings are in development as "MPTs" (multipurpose prevention technologies) as they are shown to provide several co-occurring benefits such as discretion, convenience, reversibility and user control. Methods In this Phase 1 trial of a 3-month MPT ring in the U.S., 25 participants (low-risk for HIV and pregnancy) were randomized to use the study ring for 90 days continuously or in 28-day cycles with 2-day removal periods in between. All participants completed in-depth interviews at the end of their study participation. Results Overall, the ring was well tolerated. Participants resoundingly endorsed the concept of an extended-use, dual-purpose vaginal ring, but reported too many functional challenges and side effects to endorse this particular ring. Participants assigned to the continuous regimen reported more positive experiences with ring use than those in the cyclic group. A minority of participants who experienced minimal side effects and did not experience challenges with vaginal retention of the ring found it appealing. However, the majority of participants experienced challenges (ring slippage, expulsions, side effects, vaginal bleeding changes) with product use that outweighed the potential benefits and led them to report that - in the future - they would not be interested in using this specific version of the ring in its current form. A subset expressed interest in using the current MPT ring under certain conditions (e.g., if fewer expulsions, less bleeding, higher risk for HIV/pregnancy). Discussion User feedback regarding participant experiences and challenges with the study ring was continuously shared with the product developer, underscoring the value of early-stage end-user feedback in product development.
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Affiliation(s)
| | - Mei Song
- Magee-Womens Research Institute, Pittsburgh, PA, United States
| | - Beatrice A. Chen
- Magee-Womens Research Institute, Pittsburgh, PA, United States
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh, School of Medicine, Pittsburgh, PA, United States
| | - Brid Devlin
- Center for Biomedical Research, Population Council, New York, NY, United States
| | - Ellen Luecke
- Women’s Global Health Imperative, RTI International, Berkeley, CA, United States
| | - Jill Brown
- Contraceptive Development Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, United States
| | - Diana L. Blithe
- Contraceptive Development Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, United States
| | - Sharon L. Achilles
- Magee-Womens Research Institute, Pittsburgh, PA, United States
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh, School of Medicine, Pittsburgh, PA, United States
| | - Ariane van der Straten
- Center for AIDS Prevention Studies, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
- ASTRA Consulting, Kensington, CA, United States
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Lorenzetti L, Dinh N, van der Straten A, Fonner V, Ridgeway K, Rodolph M, Schaefer R, Schmidt HA, Baggaley R. Systematic review of the values and preferences regarding the use of injectable pre-exposure prophylaxis to prevent HIV acquisition. J Int AIDS Soc 2023; 26 Suppl 2:e26107. [PMID: 37439057 PMCID: PMC10805120 DOI: 10.1002/jia2.26107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 05/04/2023] [Indexed: 07/14/2023] Open
Abstract
INTRODUCTION Pre-exposure prophylaxis (PrEP) is an important HIV prevention option. Two randomized trials have provided efficacy evidence for long-acting injectable cabotegravir (CAB-LA) as PrEP. In considering CAB-LA as an additional PrEP modality for people at substantial risk of HIV, it is important to understand community response to injectable PrEP. We conducted a systematic review of values, preferences and perceptions of acceptability for injectable PrEP to inform global guidance. METHODS We searched nine databases and conference websites for peer-reviewed and grey literature (January 2010-September 2021). There were no restrictions on location. A two-stage review process assessed references against eligibility criteria. Data from included studies were organized by constructs from the Theoretical Framework of Acceptability. RESULTS We included 62 unique references. Most studies were observational, cross-sectional and qualitative. Over half of the studies were conducted in North America. Men who have sex with men were the most researched group. Most studies (57/62) examined injectable PrEP, including hypothetical injectables (55/57) or placebo products (2/57). Six studies examined CAB-LA specifically. There was overall interest in and often a preference for injectable PrEP, though there was variation within and across groups and regions. Many stakeholders indicated that injectable PrEP could help address adherence challenges associated with daily or on-demand dosing for oral PrEP and may be a better lifestyle fit for individuals seeking privacy, discretion and infrequent dosing. End-users reported concerns, including fear of needles, injection site pain and body location, logistical challenges and waning or incomplete protection. DISCUSSION Despite an overall preference for injectable PrEP, heterogeneity across groups and regions highlights the importance of enabling end-users to choose a PrEP modality that supports effective use. Like other products, preference for injectable PrEP may change over time and end-users may switch between prevention options. There will be a greater understanding of enacted preference as more end-users are offered anti-retroviral (ARV)-containing injectables. Future research should focus on equitable implementation, including real-time decision-making and how trained healthcare providers can support choice. CONCLUSIONS Given overall acceptability, injectable PrEP should be included as part of a menu of prevention options, allowing end-users to select the modality that suits their preferences, needs and lifestyle.
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Affiliation(s)
- Lara Lorenzetti
- Global Health and Population ResearchFHI 360DurhamNorth CarolinaUSA
| | - Nhi Dinh
- Global Health and Population ResearchFHI 360DurhamNorth CarolinaUSA
| | - Ariane van der Straten
- ASTRA ConsultingKensingtonCaliforniaUSA
- Center for AIDS Prevention StudiesDepartment of MedicineUniversity of CaliforniaSan FranciscoCaliforniaUSA
| | - Virginia Fonner
- Global Health and Population ResearchFHI 360DurhamNorth CarolinaUSA
| | | | - Michelle Rodolph
- World Health OrganizationGlobal HIVHepatitis and STI ProgrammesGenevaSwitzerland
| | - Robin Schaefer
- World Health OrganizationGlobal HIVHepatitis and STI ProgrammesGenevaSwitzerland
| | - Heather‐Marie A. Schmidt
- World Health OrganizationGlobal HIVHepatitis and STI ProgrammesGenevaSwitzerland
- UNAIDS Regional Office for Asia and the PacificBangkokThailand
| | - Rachel Baggaley
- World Health OrganizationGlobal HIVHepatitis and STI ProgrammesGenevaSwitzerland
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11
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Coulter SM, Pentlavalli S, Vora LK, An Y, Cross ER, Peng K, McAulay K, Schweins R, Donnelly RF, McCarthy HO, Laverty G. Enzyme-Triggered l-α/d-Peptide Hydrogels as a Long-Acting Injectable Platform for Systemic Delivery of HIV/AIDS Drugs. Adv Healthc Mater 2023; 12:e2203198. [PMID: 36880399 DOI: 10.1002/adhm.202203198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 02/24/2023] [Indexed: 03/08/2023]
Abstract
Eradicating HIV/AIDS by 2030 is a central goal of the World Health Organization. Patient adherence to complicated dosage regimens remains a key barrier. There is a need for convenient long-acting formulations that deliver drugs over sustained periods. This paper presents an alternative platform, an injectable in situ forming hydrogel implant to deliver a model antiretroviral drug (zidovudine [AZT]) over 28 days. The formulation is a self-assembling ultrashort d or l-α peptide hydrogelator, namely phosphorylated (naphthalene-2-ly)-acetyl-diphenylalanine-lysine-tyrosine-OH (NapFFKY[p]-OH), covalently conjugated to zidovudine via an ester linkage. Rheological analysis demonstrates phosphatase enzyme instructed self-assembly, with hydrogels forming within minutes. Small angle neutron scattering data suggest hydrogels form narrow radius (≈2 nm), large length fibers closely fitting the flexible cylinder elliptical model. d-Peptides are particularly promising for long-acting delivery, displaying protease resistance for 28 days. Drug release, via hydrolysis of the ester linkage, progress under physiological conditions (37 °C, pH 7.4, H2 O). Subcutaneous administration of Napffk(AZT)Y[p]G-OH in Sprague Dawley rats demonstrate zidovudine blood plasma concentrations within the half maximal inhibitory concentration (IC50 ) range (30-130 ng mL-1 ) for 35 days. This work is a proof-of-concept for the development of a long-acting combined injectable in situ forming peptide hydrogel implant. These products are imperative given their potential impact on society.
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Affiliation(s)
- Sophie M Coulter
- School of Pharmacy, Queen's University Belfast, Medical Biology Centre, 97 Lisburn Road, Belfast, Co. Antrim, Northern Ireland, BT9 7BL, UK
| | - Sreekanth Pentlavalli
- School of Pharmacy, Queen's University Belfast, Medical Biology Centre, 97 Lisburn Road, Belfast, Co. Antrim, Northern Ireland, BT9 7BL, UK
| | - Lalitkumar K Vora
- School of Pharmacy, Queen's University Belfast, Medical Biology Centre, 97 Lisburn Road, Belfast, Co. Antrim, Northern Ireland, BT9 7BL, UK
| | - Yuming An
- School of Pharmacy, Queen's University Belfast, Medical Biology Centre, 97 Lisburn Road, Belfast, Co. Antrim, Northern Ireland, BT9 7BL, UK
| | - Emily R Cross
- School of Pharmacy, Queen's University Belfast, Medical Biology Centre, 97 Lisburn Road, Belfast, Co. Antrim, Northern Ireland, BT9 7BL, UK
| | - Ke Peng
- School of Pharmacy, Queen's University Belfast, Medical Biology Centre, 97 Lisburn Road, Belfast, Co. Antrim, Northern Ireland, BT9 7BL, UK
| | - Kate McAulay
- School of Chemistry, University of Glasgow, Joseph Black Building, Glasgow, Scotland, G12 8QQ, UK
- School of Computing, Engineering and Built Environment, Glasgow Caledonian University, Glasgow, Scotland, G4 0BA, UK
| | - Ralf Schweins
- Large Scale Structures Group, Institut Laue - Langevin, 71 Avenue des Martyrs, CS 20156, Grenoble Cedex 9, 38042, France
| | - Ryan F Donnelly
- School of Pharmacy, Queen's University Belfast, Medical Biology Centre, 97 Lisburn Road, Belfast, Co. Antrim, Northern Ireland, BT9 7BL, UK
| | - Helen O McCarthy
- School of Pharmacy, Queen's University Belfast, Medical Biology Centre, 97 Lisburn Road, Belfast, Co. Antrim, Northern Ireland, BT9 7BL, UK
| | - Garry Laverty
- School of Pharmacy, Queen's University Belfast, Medical Biology Centre, 97 Lisburn Road, Belfast, Co. Antrim, Northern Ireland, BT9 7BL, UK
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12
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Bhushan NL, Ridgeway K, Luecke EH, Palanee-Phillips T, Montgomery ET, Minnis AM. Synthesis of end-user research to inform future multipurpose prevention technologies in sub-Saharan Africa: a scoping review. FRONTIERS IN REPRODUCTIVE HEALTH 2023; 5:1156864. [PMID: 37325244 PMCID: PMC10264572 DOI: 10.3389/frph.2023.1156864] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 05/04/2023] [Indexed: 06/17/2023] Open
Abstract
Introduction Women in sub-Saharan Africa (SSA) experience disproportionately high rates of HIV infection and unintended pregnancy compared to their age-matched counterparts in other regions of the world. Multipurpose prevention technologies (MPTs) that offer protection against HIV and unintended pregnancy in a single product stand to address these dual sexual and reproductive health needs simultaneously. The aim of this scoping review is to identify factors that are important for optimizing the likelihood of MPT adoption by end users in SSA. Methods Study inclusion criteria included MPT research (HIV and pregnancy prevention dual indication) published or presented in English from 2000 to 2022 and conducted in SSA amongst end-users (women aged 15-44), male partners, health care providers, and community stakeholders. References were identified by searching peer reviewed literature, grey literature, conference presentations (2015-2022), grant databases, and outreach to MPT subject matter experts. Of 115 references identified, 37 references met inclusion criteria and were extracted for analysis. A narrative synthesis approach was used to summarize findings within and across MPT products. Results Studies were identified from six countries in SSA and a substantial proportion included a South African (n = 27) and/or Kenyan (n = 16) study site. Most studies utilized a qualitative study design (n = 22) and evaluated MPT acceptability and preferences by presenting hypothetical products through images or a list of product attributes (n = 21). The vaginal ring (n = 20), oral tablet (n = 20), and injection (n = 15) were examined most frequently. Across studies, there was high acceptability and demand for an HIV and pregnancy prevention MPT. End users valued choice in prevention product type as well as discreetness and long-acting options. Provider counseling and community sensitization were reported as essential for future introduction of novel MPT delivery forms. Conclusion Recognizing the heterogeneity of women's preferences and changing reproductive and sexual health needs over the life course, choice is important in the delivery of pregnancy and HIV prevention products as well as amongst MPT products with distinct product profiles. End user research with active MPTs, vs. hypothetical or placebo MPTs, is necessary to advance understanding of end-user preferences and acceptability of future products.
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Affiliation(s)
| | - Kathleen Ridgeway
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Ellen H. Luecke
- RTI International, Research Triangle Park, NC, United States
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13
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Young IC, Massud I, Cottrell ML, Shrivastava R, Maturavongsadit P, Prasher A, Wong-Sam A, Dinh C, Edwards T, Mrotz V, Mitchell J, Seixas JN, Pallerla A, Thorson A, Schauer A, Sykes C, De la Cruz G, Montgomery SA, Kashuba ADM, Heneine W, Dobard CW, Kovarova M, Garcia JV, García-Lerma JG, Benhabbour SR. Ultra-long-acting in-situ forming implants with cabotegravir protect female macaques against rectal SHIV infection. Nat Commun 2023; 14:708. [PMID: 36759645 PMCID: PMC9911691 DOI: 10.1038/s41467-023-36330-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 01/24/2023] [Indexed: 02/11/2023] Open
Abstract
Ultra-long-acting delivery platforms for HIV pre-exposure prophylaxis (PrEP) may increase adherence and maximize public health benefit. We report on an injectable, biodegradable, and removable in-situ forming implant (ISFI) that is administered subcutaneously and can release the integrase inhibitor cabotegravir (CAB) above protective benchmarks for more than 6 months. CAB ISFIs are well-tolerated in female mice and female macaques showing no signs of toxicity or chronic inflammation. In macaques, median plasma CAB concentrations exceed established PrEP protection benchmarks within 3 weeks and confer complete protection against repeated rectal SHIV challenges. Implant removal via a small incision in 2 macaques at week 12 results in a 7- to 48-fold decrease in plasma CAB levels within 72 hours. Modeling to translate CAB ISFI dosing suggests that a 3 mL injection would exceed protective benchmarks in humans for over 5 months post administration. Our results support the clinical advancement of CAB ISFIs for ultra-long-acting PrEP in humans.
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Affiliation(s)
- Isabella C Young
- Division of Pharmacoengineering and Molecular Pharmaceutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Ivana Massud
- Laboratory Branch, Division of HIV Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Mackenzie L Cottrell
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Roopali Shrivastava
- Joint Department of Biomedical Engineering, North Carolina State University and The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Panita Maturavongsadit
- Joint Department of Biomedical Engineering, North Carolina State University and The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Alka Prasher
- Joint Department of Biomedical Engineering, North Carolina State University and The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Andres Wong-Sam
- Laboratory Branch, Division of HIV Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Chuong Dinh
- Laboratory Branch, Division of HIV Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Tiancheng Edwards
- Laboratory Branch, Division of HIV Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Victoria Mrotz
- Comparative Medicine Branch, Division of Scientific Resources, National Center for Emerging and Zoonotic Infection Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - James Mitchell
- Laboratory Branch, Division of HIV Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Josilene Nascimento Seixas
- Infectious Diseases Pathology Branch, Division of High-Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infection Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Aryani Pallerla
- Department of Psychology and Neuroscience, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Allison Thorson
- Joint Department of Biomedical Engineering, North Carolina State University and The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Amanda Schauer
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Craig Sykes
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Gabriela De la Cruz
- Pathology Services Core, Lineberger Comprehensive Cancer Center, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Stephanie A Montgomery
- Pathology Services Core, Lineberger Comprehensive Cancer Center, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Angela D M Kashuba
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Walid Heneine
- Laboratory Branch, Division of HIV Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Charles W Dobard
- Laboratory Branch, Division of HIV Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Martina Kovarova
- International Center for the Advancement of Translational Science, Division of Infectious Diseases, Center for AIDS Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - J Victor Garcia
- International Center for the Advancement of Translational Science, Division of Infectious Diseases, Center for AIDS Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - J Gerardo García-Lerma
- Laboratory Branch, Division of HIV Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | - S Rahima Benhabbour
- Division of Pharmacoengineering and Molecular Pharmaceutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
- Joint Department of Biomedical Engineering, North Carolina State University and The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
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14
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Mataboge P, Nzenze S, Mthimkhulu N, Mazibuko M, Kutywayo A, Butler V, Naidoo N, Mullick S. Planning for decentralized, simplified prEP: Learnings from potential end users in Ga-Rankuwa, gauteng, South Africa. FRONTIERS IN REPRODUCTIVE HEALTH 2023; 4:1081049. [PMID: 36699142 PMCID: PMC9868940 DOI: 10.3389/frph.2022.1081049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 12/16/2022] [Indexed: 01/12/2023] Open
Abstract
Background In South Africa, youth experience challenges with oral Pre-Exposure Prophylaxis (PrEP) access and uptake. Taking services out of healthcare settings has the potential to increase reach and overcome these challenges. This paper presents young and older people's preferences for decentralized, simplified PrEP service delivery and new long-acting HIV prevention methods, in Ga-Rankuwa, South Africa. Methods Between May and August 2021, both PrEP user and non-user adolescent girls and young women (AGYW), pregnant AGYW, female sex workers, adolescent boys and young men (ABYM), and men who have sex with men (MSM) were recruited to participate in focus group discussions (FDGs) in Ga-Rankuwa, Gauteng. Twenty-two FGDs were conducted. Participants were asked about PrEP uptake, potential acceptability of long-acting HIV prevention products, provision of integrated, simplified, and decentralized services, and digital tools to facilitate access to PrEP and other SRH services. A qualitative approach using inductive thematic analysis was carried out to explore emerging themes on decentralized, simplified delivery and the acceptability of long-acting methods. Results Of the 109 participants included in the study approximately 45% (n = 50) were female, the median age was 23 years ± 5.3. A third (n = 37) were current or previous PrEP users, of which, 59.5% (n = 22) collected PrEP refills from the clinic. Decentralized, simplified service delivery was appealing; health facilities, pharmacies and institutions of learning were preferred as service points for PrEP and SRH services, and recreational spaces preferred for dissemination of health information and engagement. ABYM were more open to having recreational spaces as service points. Long-acting Cabotegravir was preferred over the Dapivirine Vaginal Ring due to concerns around perceived side-effects, efficacy, and comfort. Conclusion Providing long-acting PrEP methods through decentralized, simplified service delivery was appealing to this population. They provided practical locations for decentralized service provision to potentially increase their engagement with and uptake of HIV prevention and SRH services.
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15
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Nkomo S, Makoni W, Shapley-Quinn MK, Luecke E, Mbatsane E, Manenzhe K, Ahmed K, Johnson LM, Mahaka I, van der Straten A. Prospective acceptability of a multipurpose technology (MPT) implant in preclinical development to prevent HIV and unplanned pregnancy: Qualitative insights from women end users and health care providers in South Africa and Zimbabwe. PLoS One 2023; 18:e0285711. [PMID: 37195918 DOI: 10.1371/journal.pone.0285711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 05/01/2023] [Indexed: 05/19/2023] Open
Abstract
BACKGROUND Given the high rates of both HIV and unintended pregnancies in sub-Saharan Africa, the SCHIELD program aims to develop a multipurpose technology implant for HIV and pregnancy prevention. An end-user evaluation was undertaken with young women and health care providers to assess preferences for modifiable implant attributes to improve future adoption and rollout. METHODS Focus group discussions were conducted with potential women end users, and health care providers experienced in implant insertion or removal participated in in-depth interviews. All participants were recruited from Harare, Zimbabwe, or Soshanguve, South Africa. The purposively stratified sampled women were either implant experienced or implant naïve and were categorized into three groups: nulliparous, postpartum, or engaged in transactional sex. Topics covered included duration (six months to three years), biodegradability, removability, and independent rod retrievability (per indication). Data were analyzed using Dedoose software and summarized into emerging themes. RESULTS Participants identified three key areas that could facilitate rollout, uptake, and adherence of an implant for HIV and pregnancy prevention. First, discreetness was the most salient topic and was associated with implant characteristics such as anatomical location, flexibility, and biodegradability. Second, the ability to independently retrieve the HIV or pregnancy prevention component was preferred, as life circumstances may change and was favored by all participants, except for young women in Soshanguve. Third, there is a need for proper counseling, sensitization, provider training, and health campaigns to facilitate rollout of a 2-in-1 implant. CONCLUSIONS A 2-in-1 implant was seen as highly desirable by most young women and health care providers. Participants discussed potential concerns and barriers to uptake of a biodegradable implant with dual HIV prevention and contraceptive properties, identifying key implant attributes that product developers can modify while still in preclinical stages.
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Affiliation(s)
| | | | - Mary Kate Shapley-Quinn
- Women's Global Health Imperative, RTI International, San Jose, California, United States of America
| | - Ellen Luecke
- Women's Global Health Imperative, RTI International, San Jose, California, United States of America
| | | | | | - Khatija Ahmed
- Setshaba Research Centre, Soshanguve, South Africa
- Faculty of Health Sciences, Department of Medical Microbiology, University of Pretoria, Pretoria, South Africa
| | - Leah M Johnson
- RTI International, Research Triangle Park, North Carolina, United States of America
| | | | - Ariane van der Straten
- ASTRA Consulting, Kensington, California, United States of America
- Center for AIDS Prevention Studies, University of California, San Francisco, San Francisco, California, United States of America
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16
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Bhushan NL, Musara P, Hartmann M, Stoner MCD, Shah SR, Nabukeera J, Rukundo I, Mutero P, Lewis MA, Piper J, Shapley‐Quinn MK, Etima J, Minnis AM. Making the Case for Joint Decision-Making in Future Multipurpose Prevention Technology (MPT) Choice: Qualitative Findings on MPT Attribute Preferences from the CUPID Study (MTN-045). J Int AIDS Soc 2022; 25:e26024. [PMID: 36254362 PMCID: PMC9577116 DOI: 10.1002/jia2.26024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 09/21/2022] [Indexed: 11/06/2022] Open
Abstract
Introduction Young women in sub‐Saharan Africa account for two‐thirds of all new HIV infections and face high rates of unintended pregnancy. Multipurpose prevention technologies (MPTs) are promising products under development that are designed to simultaneously prevent HIV and unintended pregnancy. Since MPTs will be used in the context of sexual relationships, ensuring acceptability and use requires understanding the role of male partners in MPT use decision‐making. Methods This paper draws on qualitative data from 39 couples enrolled in the Microbicide Trials Network (MTN) 045 study, conducted in 2019–2020. Partners completed a discrete choice experiment (DCE), first separately and then jointly, to measure preferences for future MPT attributes and then completed a qualitative interview. We also draw on quantitative data from interviewer observation about who dominated the decision‐making process during the joint DCE. Content analysis was used to examine (1) how couples made decisions on existing non‐MPT HIV and pregnancy prevention products; (2) how couples made decisions on future ideal‐MPT product during the DCE; and (3) how these decision‐making processes varied by decision‐making dominance (10 male, 10 female and 19 equal) and interview type (19 joint and 20 separate). Results Existing non‐MPT product decisions focused on trust between partners and product attributes, while future ideal‐MPT product decisions exclusively focused on product attributes. Across existing and future products, preferences for product attributes varied by gender. Male partners were most concerned with limiting side effects impacting sexual pleasure, female partners were most concerned with limiting side effects causing physical symptoms and both were concerned with the return to fertility. Across all dominance and interview types, couples reported making decisions together and female partners were often able to negotiate with male partners for their preferred product or set of product attributes. Conclusions Research activities in this study provided an opportunity for couples to openly present their product attribute preferences to their partner, learn about their partner's attribute preferences, negotiate for their ideal set of attributes and ultimately choose attributes that benefited the couple without disempowering the female partner. Future research should focus on the utility of couple‐based decision‐making aids or similar tools for facilitating joint MPT decision‐making.
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Affiliation(s)
| | - Petina Musara
- Clinical Trials Research CentreUniversity of ZimbabweHarareZimbabwe
| | | | | | - Shweta R. Shah
- RTI InternationalResearch Triangle ParkNorth CarolinaUSA
| | - Josephine Nabukeera
- Makerere University ‐ Johns Hopkins University Research Collaboration (MU‐JHU)KampalaUganda
| | - Ivan Rukundo
- Makerere University ‐ Johns Hopkins University Research Collaboration (MU‐JHU)KampalaUganda
| | - Prisca Mutero
- Clinical Trials Research CentreUniversity of ZimbabweHarareZimbabwe
| | - Megan A. Lewis
- RTI InternationalResearch Triangle ParkNorth CarolinaUSA
| | - Jeanna Piper
- National Institute of Allergy and Infectious DiseasesNational Institutes of HealthBethesdaMarylandUSA
| | | | - Juliane Etima
- Makerere University ‐ Johns Hopkins University Research Collaboration (MU‐JHU)KampalaUganda
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17
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Zhao X, Milford C, Smit J, Zulu B, Boyd P, Malcolm RK, Beksinska M. Color, Scent and Size: Exploring Women's Preferences Around Design Characteristics of Drug-Releasing Vaginal Rings. AIDS Behav 2022; 26:2954-2968. [PMID: 35294694 PMCID: PMC8924943 DOI: 10.1007/s10461-022-03596-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2022] [Indexed: 11/30/2022]
Abstract
Steroid-releasing vaginal rings are available for contraception and estrogen replacement therapy, and a new antiretroviral-releasing ring was recently approved for HIV prevention. Marketed rings are white or transparent in appearance, non-scented, and supplied as one-size-fits-all devices with diameters ranging from 54 to 56 mm. In this study, drug-free silicone elastomer rings were manufactured in different sizes, colors and scents, and the opinions/preferences of 16 women (eThekwini District, South Africa; 20-34 years) assessed through focus group discussions and thematic analysis. Opinions varied on ring color and scent, with some women preferring specific colors or scent intensities, while for others these attributes were unimportant. Concerns about color and scent were linked to perceptions around vaginal health and safety related to chemical composition. There was greater agreement on preferred ring size; flexibility and width were considered important factors for insertion and comfort. Greater choice with ring products could facilitate acceptability and overall uptake.
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Affiliation(s)
- Xinyu Zhao
- School of Pharmacy, Queen’s University Belfast, Belfast, BT9 7BL UK
| | - Cecilia Milford
- MRU (MatCH Research Unit), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | - Jenni Smit
- MRU (MatCH Research Unit), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | - Bongiwe Zulu
- MRU (MatCH Research Unit), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | - Peter Boyd
- School of Pharmacy, Queen’s University Belfast, Belfast, BT9 7BL UK
| | - R. Karl Malcolm
- School of Pharmacy, Queen’s University Belfast, Belfast, BT9 7BL UK
| | - Mags Beksinska
- MRU (MatCH Research Unit), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
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Rosen JG, Park JN, Schneider KE, White RH, Beckham SW, Glick JL, Footer KHA, Sherman SG. Mapping Interests in Event-Driven and Long-Acting Pre-exposure Prophylaxis Formulations onto the HIV Risk Environment of Street-Based Female Sex Workers: A Latent Class Analysis. AIDS Behav 2022; 26:1992-2002. [PMID: 35362908 DOI: 10.1007/s10461-022-03613-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2021] [Indexed: 11/01/2022]
Abstract
Despite growing availability, HIV pre-exposure prophylaxis (PrEP) uptake and adherence remains suboptimal among female sex workers (FSW) in the United States. Using cross-sectional data from a survey of 236 street-based cisgender FSW in Baltimore, Maryland, we examined interest in event-driven and long-acting PrEP formulations. Latent class analysis identified discrete patterns of interest in five novel PrEP agents. Multinomial latent class regression then examined factors associated with probabilistic class membership. A three-class solution emerged as the best-fit latent class model: Injectable Acceptors (~ 24% of sample), Universal Acceptors (~ 18%), and Non-Acceptors (~ 58%). Compared to Non-Acceptors, Universal Acceptors had significantly (p < 0.05) higher odds of reporting condomless vaginal sex with clients, client condom coercion, and client-perpetrated physical violence. Relative to Non-Acceptors, Injectable Acceptors were distinguished by significantly higher rates of condomless vaginal sex with clients and injection drug use. Expanding PrEP options for FSW could help overcome barriers to PrEP initiation and persistence.
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Rogers Z, Pintye J, Kinuthia J, O’Malley G, Abuna F, Escudero J, Mugambi M, Awuor M, Dollah A, Dettinger JC, Kohler P, John-Stewart G, Beima-Sofie K. Key influences on the decision to initiate PrEP among adolescent girls and young women within routine maternal child health and family planning clinics in Western Kenya. AIDS Care 2022; 34:363-370. [PMID: 34543077 PMCID: PMC8934309 DOI: 10.1080/09540121.2021.1981217] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
We sought to understand influences on PrEP uptake among Kenyan adolescent girls and young women (AGYW) whose decision on PrEP use was misaligned with their risk for HIV acquisition. In-depth interviews were conducted with 47 Kenyan HIV-negative AGYW aged 15-24 years who were offered PrEP during routine maternal and child health and family planning services. AGYW were sampled from two groups (1) declined PrEP and had ≥1 sexual partner(s) of unknown HIV status and (2) initiated PrEP and reported having one HIV-negative partner. AGYW with HIV-negative partners initiated PrEP due to known or suspected infidelity. AGYW with partners of unknown HIV status recognized PrEP as a helpful HIV prevention tool, yet worried about partner reactions and prioritized avoiding uncomfortable or unsafe situations over PrEP. Among pregnant AGYW, the responsibility of motherhood and providing a future for one's family, through staying healthy and remaining HIV-free, was a strong PrEP use motivator. Among AGYW who desired future motherhood, fears that PrEP could negatively impact fertility or reduce contraceptive effectiveness led to declining PrEP. Peers positively influenced PrEP decision-making, especially personally knowing a PrEP user. Strategies are needed to enhance messaging and delivery approaches that are tailored to AGYW, including peer-led strategies.
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Affiliation(s)
- Zoe Rogers
- University of Washington Department of Global Health, Seattle, WA, USA
| | - Jillian Pintye
- University of Washington, Department of Biobehavioral Nursing and Health Informatics, Seattle, WA, USA
| | - John Kinuthia
- University of Washington Department of Global Health, Seattle, WA, USA,Kenyatta National Hospital, Nairobi, Kenya
| | | | | | - Jaclyn Escudero
- University of Washington Department of Global Health, Seattle, WA, USA
| | - Melissa Mugambi
- University of Washington Department of Global Health, Seattle, WA, USA
| | | | | | - Julia C Dettinger
- University of Washington Department of Global Health, Seattle, WA, USA
| | - Pamela Kohler
- University of Washington Department of Global Health, Seattle, WA, USA,University of Washington Child, Family, and Population Health, Seattle, WA, USA
| | - Grace John-Stewart
- University of Washington Department of Global Health, Seattle, WA, USA,University of Washington, Department of Epidemiology, Seattle, WA, USA,University of Washington, Department of Medicine, Seattle, WA, USA,University of Washington, Department of Pediatrics, Seattle, WA, USA
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20
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Brah AT, Barthold D, Hauber B, Collier AC, Ho RJY, Marconi VC, Simoni JM, Graham SM. The systematic development of attributes and levels for a discrete choice experiment of HIV patient preferences for long-acting antiretroviral therapies in the United States. AIDS Res Ther 2022; 19:13. [PMID: 35216610 PMCID: PMC8881811 DOI: 10.1186/s12981-022-00435-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 02/04/2022] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Patient preferences for long-acting antiretroviral therapies (LA-ART) should inform development of regimens with optimal adherence and acceptability. We describe a systematic process used to identify attributes and levels for a discrete choice experiment (DCE) designed to elicit preferences for potential LA-ART options in the US. METHODS Our approach was conducted in four stages: data collection, data reduction, removing inappropriate attributes, and optimizing wording. We started with 8 attributes defining potential LA-ART products based on existing literature and knowledge of products in development. We conducted 12 key informant interviews with experts in HIV treatment. The list of attributes, the set of plausible levels for each attribute, and restrictions on combinations of attribute levels were updated iteratively. RESULTS Despite uncertainty about which products will become available, key informant discussions converged on 4 delivery modes (infusions and patches were not considered immediately feasible) and 6 additional attributes. Treatment effectiveness and frequency of clinical monitoring were dropped. Oral lead-in therapy was split into two attributes: pre-treatment time undetectable and pre-treatment negative reaction testing. We omitted product-specific systemic and local side effects. In addition to mode, the final set of attributes included: frequency of dosing; location of treatment; pain; pre-treatment time undetectable; pre-treatment negative reaction testing; and late-dose leeway. CONCLUSIONS A systematic process successfully captured elements that are both feasible and relevant to evaluating the acceptability of potential LA-ART alternatives to patients.
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Affiliation(s)
- Aaron T. Brah
- grid.34477.330000000122986657Division of Allergy & Infectious Diseases, Department of Medicine, University of Washington, Seattle, WA USA
| | - Douglas Barthold
- grid.34477.330000000122986657The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, University of Washington, Seattle, WA USA
| | - Brett Hauber
- grid.34477.330000000122986657The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, University of Washington, Seattle, WA USA ,grid.410513.20000 0000 8800 7493Pfizer, Inc, New York, NY USA
| | - Ann C. Collier
- grid.34477.330000000122986657Division of Allergy & Infectious Diseases, Department of Medicine, University of Washington, Seattle, WA USA
| | - Rodney J. Y. Ho
- grid.34477.330000000122986657Department of Pharmaceutics and Bioengineering, University of Washington, Seattle, WA USA
| | - Vincent C. Marconi
- grid.189967.80000 0001 0941 6502Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA USA ,grid.189967.80000 0001 0941 6502Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA USA
| | - Jane M. Simoni
- grid.34477.330000000122986657Department of Psychology, University of Washington, Seattle, WA USA ,grid.34477.330000000122986657Department of Global Health, University of Washington, Seattle, WA USA
| | - Susan M. Graham
- grid.34477.330000000122986657Division of Allergy & Infectious Diseases, Department of Medicine, University of Washington, Seattle, WA USA ,grid.34477.330000000122986657Department of Global Health, University of Washington, Seattle, WA USA ,grid.34477.330000000122986657Department of Epidemiology, University of Washington, Seattle, WA USA
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21
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Ridgeway K, Montgomery ET, Smith K, Torjesen K, van der Straten A, Achilles SL, Griffin JB. Vaginal ring acceptability: A systematic review and meta-analysis of vaginal ring experiences from around the world. Contraception 2022; 106:16-33. [PMID: 34644609 PMCID: PMC9128798 DOI: 10.1016/j.contraception.2021.10.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 09/28/2021] [Accepted: 10/03/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The vaginal ring (ring) is a female-initiated, long-acting drug delivery system for different indications, including HIV prevention. Our aim was to provide evidence for acceptability of the vaginal ring across indications to support dapivirine and multipurpose prevention technology ring introduction and roll out. STUDY DESIGN This systematic review and meta-analysis followed PRISMA guidelines. We searched PubMed, Web of Science, Embase, and grey literature for publications reporting favorable ring acceptability and secondary outcomes involving actual ring use (comfort, ease of ring use, ring comfort during sex, expulsions, and vaginal symptoms) or hypothetical acceptability for any indication published January 1, 1970-June 15, 2021. We estimated random-effects pooled prevalence, assessing between-study variation using meta-regression. RESULTS Of 2,234 records, we included 123 studies with 40,434 actual and hypothetical ring users. The primary outcome assessment included 50 studies with 60 ring subgroups totaling 19,271 ring users. The favorable acceptability pooled prevalence was 85.6% (95%CI 81.3, 89.0), while hypothetical acceptability among non-ring users was 27.6% (95%CI 17.5, 40.5). In meta-regression, acceptability was higher in menopause (95.4%; 95%CI 88.4, 98.2) compared to contraceptive rings (83.7%; 95%CI 75.6, 89.5). Acceptability was lower in pharmacokinetic studies (50%; 95%CI 22.1, 77.9) compared to RCTs (89.5%; 95%CI 85.8.92.4) and in studies assessing acceptability at ≥12 months (78.5%; 95%CI 66.5, 87.1) versus studies assessing acceptability at <3 months (91.9%; 95%CI 83.7, 96.1). European (90.6%; 95%CI 83.9, 94.7), Asian (97.1%; 95%CI 92.0, 99.0), and multi-region studies (93.5%; 95%CI 84.6, 97.4) reported more favorable acceptability compared to African studies (59.4%; 95%CI 38.3, 77.5). Secondary outcomes were similarly favorable, including ring comfort (92.9%; 95%CI 89.2, 95.4), ease of use (90.9%; 95%CI 86.5, 94.0), and comfort during sex (82.7%; 95%CI 76.4, 87.6). Limitations include inconsistent outcome definitions and unmeasured factors affecting acceptability. CONCLUSIONS Women who used vaginal rings reported they were acceptable across indications geographic regions and indications. Policy makers should consider the ring as an important option for pregnancy and HIV prevention drug development. IMPLICATIONS This review found favorable acceptability among vaginal ring users across indications and geographic areas, in contrast to low hypothetical acceptability among non-users. Vaginal rings are an important drug delivery system for pregnancy and HIV preventions, and scale-up should plan to address initial hesitancy among new users.
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Affiliation(s)
- Kathleen Ridgeway
- FHI 360, Global Health Population Nutrition, Durham, NC, United States
| | - Elizabeth T. Montgomery
- RTI International, Women’s Global Health Imperative, Berkeley, CA, United States,Center for AIDS Pervention Studies, Department of Medicine, University of California San Francisco, San Francisco, CA, United States
| | - Kevin Smith
- Centre for Global Health, RTI International, Durham, NC, United States
| | - Kristine Torjesen
- FHI 360, Global Health Population Nutrition, Durham, NC, United States
| | - Ariane van der Straten
- RTI International, Women’s Global Health Imperative, Berkeley, CA, United States,Center for AIDS Pervention Studies, Department of Medicine, University of California San Francisco, San Francisco, CA, United States
| | - Sharon L. Achilles
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States,Magee-Womens Research Institute, Pittsburgh, PA, USA
| | - Jennifer B. Griffin
- Centre for Global Health, RTI International, Durham, NC, United States,Corresponding author. J. B. Griffin, (J.B. Griffin)
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22
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Crowley K, Dugas M, Gao GG, Burn L, Igumbor K, Njapha D, Piper J, Veronese F, Agarwal R. Market segmentation of South African adolescent girls and young women to inform HIV prevention product marketing strategy: A mixed methods study. Health Mark Q 2021; 39:159-172. [PMID: 34895110 DOI: 10.1080/07359683.2021.2007587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The uptake of and adherence to HIV prevention products in South Africa has not achieved widespread success. This study aimed to develop a holistic understanding of the psychographics of adolescent girls and young women in South Africa, a primary audience for HIV prevention products, in order to inform market segmentation and marketing strategies. Extensive ethnographic analyses were complemented with a survey (n = 1,500) centered on personal care product journeys. Clustering and qualitative methods yielded six segments with measurable differences, and revealed common themes surrounding empowerment and self-determination, patriarchy, and misinformation risk. The findings enable targeted approaches for HIV prevention product campaigns.
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Affiliation(s)
- Kenyon Crowley
- Center for Health Information & Decision Systems (CHIDS), Robert H. Smith School of Business, University of Maryland, College Park, MD, USA.,College of Information Studies, University of Maryland, College Park, MD, USA
| | - Michelle Dugas
- Center for Health Information & Decision Systems (CHIDS), Robert H. Smith School of Business, University of Maryland, College Park, MD, USA
| | - Guodong Gordon Gao
- Center for Health Information & Decision Systems (CHIDS), Robert H. Smith School of Business, University of Maryland, College Park, MD, USA
| | | | | | | | - Jeanna Piper
- Division of AIDS, National Institute of Allergy and Infectious Diseases, Rockville, MD, USA
| | - Fulvia Veronese
- Division of AIDS, National Institute of Allergy and Infectious Diseases, Rockville, MD, USA
| | - Ritu Agarwal
- Center for Health Information & Decision Systems (CHIDS), Robert H. Smith School of Business, University of Maryland, College Park, MD, USA
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23
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Sekhon M, van der Straten A. Pregnant and breastfeeding women's prospective acceptability of two biomedical HIV prevention approaches in Sub Saharan Africa: A multisite qualitative analysis using the Theoretical Framework of Acceptability. PLoS One 2021; 16:e0259779. [PMID: 34784355 PMCID: PMC8594804 DOI: 10.1371/journal.pone.0259779] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 10/26/2021] [Indexed: 11/19/2022] Open
Abstract
HIV infection during pregnancy and breastfeeding has implications for maternal health. Between May- November 2018, we explored prospective acceptability of two novel HIV Pre-exposure Prophylaxis (PrEP) products, oral pills and vaginal rings, through focus group discussions with 65 pregnant and breastfeeding women in Malawi, South Africa, Uganda, Zimbabwe. Qualitative analysis was completed, guided by the Theoretical Framework of Acceptability (TFA). First, a deductive thematic analysis was applied to relevant coded data, into the seven TFA constructs (Affective Attitude; Burden; Ethicality, Intervention Coherence; Opportunity Costs; Perceived Effectiveness; Self-efficacy). Next, an iterative analysis was completed to generate themes within each of the TFA constructs. Women’s positive attitudes towards daily oral PrEP highlighted the familiarity of taking pills, understanding the purpose of taking pills, and the perception that it is an effective method to protect mothers and babies from HIV during pregnancy and breastfeeding. Women emphasized the ease of using the ring given its monthly duration that lowers burden on the user, its discreetness and invisibility once in place. The TFA analysis highlighted how acceptability of both methods could be enhanced by focusing on perceptions of the end users (i.e. the women) and not just the products themselves. This approach provided insights into how to refine the intervention materials and plans for implementation.
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Affiliation(s)
- Mandeep Sekhon
- Department of Population Health Sciences, School of Population Health and Environmental Sciences, Faculty of Life Sciences & Medicine, King’s College London, London, United Kingdom
- * E-mail:
| | - Ariane van der Straten
- Center for AIDS prevention studies, University of California San Francisco, CA, United States of America
- Women’s Global Health imperative, RTI International, Berkeley, CA, United States of America
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24
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Krovi SA, Johnson LM, Luecke E, Achilles SL, van der Straten A. Advances in long-acting injectables, implants, and vaginal rings for contraception and HIV prevention. Adv Drug Deliv Rev 2021; 176:113849. [PMID: 34186143 DOI: 10.1016/j.addr.2021.113849] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 06/15/2021] [Accepted: 06/22/2021] [Indexed: 12/22/2022]
Abstract
Worldwide, women face compounding reproductive health risks, including human immunodeficiency virus (HIV), sexually-transmitted infections (STIs), and unintended pregnancy. Multipurpose prevention technologies (MPTs) offer combined protection against these overlapping risks in singular prevention products that offer potential for simplified use, lower burden, higher acceptability, and increased public health benefits. Over the past decade, substantial progress has been made in development of extended-release MPTs, which have further potential to grant sexual and reproductive health autonomy to women globally and to offer choice for women to accommodate varying needs during their reproductive lives. Here, we highlight the advances made in injectable, implant, and ring delivery forms, and the importance of incorporating end-user preferences early in the research and development of these products.
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Affiliation(s)
| | | | - Ellen Luecke
- Women's Global Health Imperative, RTI International, Berkeley, CA, USA
| | - Sharon L Achilles
- University of Pittsburgh, School of Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, Pittsburgh, PA, USA; Magee-Womens Research Institute, Pittsburgh, PA, USA
| | - Ariane van der Straten
- Center for AIDS Prevention Studies, Dept of Medicine, University of California San Francisco, San Francisco, CA, USA; ASTRA Consulting, Kensington, CA, USA
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25
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Acceptability of the Dapivirine Vaginal Ring for HIV-1 Prevention and Association with Adherence in a Phase III Trial. AIDS Behav 2021; 25:2430-2440. [PMID: 33713213 PMCID: PMC8222015 DOI: 10.1007/s10461-021-03205-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2021] [Indexed: 12/16/2022]
Abstract
We evaluated the acceptability of the 25 mg dapivirine vaginal ring (DVR) as an HIV prevention intervention and its influence on DVR adherence in the MTN-020/ASPIRE phase III trial. Acceptability measures were captured using ACASI at month 3 and end of product use (median 24 months, IQR 15–30). Monthly returned rings were classified as nonadherent if dapivirine release rate was ≤ 0.9 mg/month. Associations between acceptability measures and nonadherence were estimated using Poisson regression models with robust standard errors. At month 3 (N = 2334), 88% reported DVR was comfortable, 80% were unaware of it during daily activities, and 74% never felt it during sex. At exit, 66% were ‘very likely’ to use DVR in the future. Acceptability was found to differ significantly by country across several measures including wearing the ring during sex, during menses, partner acceptability, impact on sexual pleasure and willingness to use the ring in the future. Risk of nonadherence at month 12 was elevated if DVR was felt during sex at month 3 (aRR 1.67, 95% CI 1.26, 2.23). Risk of nonadherence in the last year of study participation was elevated if, at exit, participants minded wearing during sex (aRR 2.08, 95% CI 1.52, 2.85), during menses (aRR 1.57, 95% CI 1.06, 2.32), reported a problematic change to the vaginal environment (aRR 1.57, 95% CI 1.12, 2.21), and were not “very likely” to use DVR in the future (aRR 1.31, 95% CI 1.02, 1.68). DVR acceptability was overall high yet varied by country. Addressing perceived ring interference with sex, menses, or problematic changes to the vaginal environment in future interventions could help improve adherence, as could embracing sex-positive messaging related to ring use and increased pleasure. Trial Registration ClinicalTrials.gov Identifier: NCT01617096.
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26
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Young IC, Benhabbour SR. Multipurpose Prevention Technologies: Oral, Parenteral, and Vaginal Dosage Forms for Prevention of HIV/STIs and Unplanned Pregnancy. Polymers (Basel) 2021; 13:2450. [PMID: 34372059 PMCID: PMC8347890 DOI: 10.3390/polym13152450] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 07/19/2021] [Accepted: 07/20/2021] [Indexed: 11/17/2022] Open
Abstract
There is a high global prevalence of HIV, sexually transmitted infections (STIs), and unplanned pregnancies. Current preventative daily oral dosing regimens can be ineffective due to low patient adherence. Sustained release delivery systems in conjunction with multipurpose prevention technologies (MPTs) can reduce high rates of HIV/STIs and unplanned pregnancies in an all-in-one efficacious, acceptable, and easily accessible technology to allow for prolonged release of antivirals and contraceptives. The concept and development of MPTs have greatly progressed over the past decade and demonstrate efficacious technologies that are user-accepted with potentially high adherence. This review gives a comprehensive overview of the latest oral, parenteral, and vaginally delivered MPTs in development as well as drug delivery formulations with the potential to advance as an MPT, and implementation studies regarding MPT user acceptability and adherence. Furthermore, there is a focus on MPT intravaginal rings emphasizing injection molding and hot-melt extrusion manufacturing limitations and emerging fabrication advancements. Lastly, formulation development considerations and limitations are discussed, such as nonhormonal contraceptive considerations, challenges with achieving a stable coformulation of multiple drugs, achieving sustained and controlled drug release, limiting drug-drug interactions, and advancing past preclinical development stages. Despite the challenges in the MPT landscape, these technologies demonstrate the potential to bridge gaps in preventative sexual and reproductive health care.
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Affiliation(s)
- Isabella C. Young
- Division of Pharmacoengineering and Molecular Pharmaceutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA;
| | - Soumya Rahima Benhabbour
- Division of Pharmacoengineering and Molecular Pharmaceutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA;
- Joint Department of Biomedical Engineering, North Carolina State University and The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
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27
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Minnis AM, Krogstad E, Shapley-Quinn MK, Agot K, Ahmed K, Danielle Wagner L, van der Straten A. Giving voice to the end-user: input on multipurpose prevention technologies from the perspectives of young women in Kenya and South Africa. Sex Reprod Health Matters 2021; 29:1927477. [PMID: 34224341 PMCID: PMC8259853 DOI: 10.1080/26410397.2021.1927477] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Unintended pregnancy and unmet need for modern contraception contribute substantially to reproductive health disparities globally. In sub-Saharan Africa they occur in contexts of disproportionately high rates of HIV infection. Multipurpose prevention technologies (MPTs) can address HIV and pregnancy prevention needs in a single “2-in-1” product; however, few studies have solicited end-user views to inform design of new MPTs. We conducted the Tablets, Ring, Injections as Options (TRIO) study with young women aged 18−30 in Kenya and South Africa (N = 277) to examine preferences and acceptability of future MPTs. In a randomised clinical cross-over study in which women used three placebo delivery forms, we complemented quantitative acceptability assessments with in-depth interviews and focus group discussions (N = 88 participants). We examined anticipated enablers and barriers to adoption and use of future MPTs and synthesised novel product design recommendations. Participants expressed high interest in MPTs. Anticipated side effects constituted a primary concern; however, many expected barriers were not dosage form-specific, but addressed contextual factors instead, such as fears regarding use of new biomedical technologies, misunderstandings and stigma regarding use, and navigating partner disclosure and engagement. Women preferred MPTs that offered discreetness and long-duration protection to minimise user-burden, did not interfere with their relationships, and conferred protection for unanticipated situations. End-user research to identify and pre-emptively address potential barriers while underscoring benefits to a new MPT product is vital. Attention to cultural contexts in implementation of new MPTs is important to communicating perceived benefits, achieving acceptability and maximising public health benefits.
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Affiliation(s)
- Alexandra M Minnis
- Senior Research Epidemiologist and Director, Women's Global Health Imperative, RTI International, Berkeley, CA, USA; Associate Adjunct Professor, School of Public Health, University of California, Berkeley, CA, USA. Correspondence:
| | - Emily Krogstad
- Scholar, Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | | | - Kawango Agot
- Executive Director, Impact Research and Development Organization, Kisumu, Kenya
| | - Khatija Ahmed
- Chief Executive Officer, Setshaba Research Centre, Soshanguve, South Africa
| | - L Danielle Wagner
- Project Coordinator, Women's Global Health Imperative, RTI International, Berkeley, CA, USA
| | - Ariane van der Straten
- Senior Fellow, Women's Global Health Imperative, RTI International, Berkeley, CA, USA; Adjunct Professor, Center for AIDS Prevention Studies, Department of Medicine, University of California, San Francisco, CA, USA; Consultant, ASTRA Consulting, Kensington, CA, USA
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28
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van der Straten A, Ryan JH, Reddy K, Etima J, Taulo F, Mutero P, Taylor J, Piper J, Musara P. Influences on willingness to use vaginal or oral HIV PrEP during pregnancy and breastfeeding in Africa: the multisite MAMMA study. J Int AIDS Soc 2021; 23:e25536. [PMID: 32524700 PMCID: PMC7287313 DOI: 10.1002/jia2.25536] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 03/25/2020] [Accepted: 04/15/2020] [Indexed: 12/15/2022] Open
Abstract
Introduction Women in sub‐Saharan Africa spend a substantial portion of their reproductive lives pregnant and/or breastfeeding (P/BF), yet they have limited options to prevent HIV during these maternal stages. In preparation for phase 3b prevention trials in P/BF women, we explored attitudes about using a vaginal ring or oral pills for pre‐exposure prophylaxis (PrEP), perceptions of HIV risk during P/BF and key influences on future PrEP use. Methods In 2018, we conducted 16 single‐sex focus group discussions (FGDs) with community‐ and clinic‐recruited HIV‐uninfected women, currently or recently P/BF, aged 18 to 40, and men with (currently or recently) P/BF partners, aged 18+. Participants completed a behavioural questionnaire, viewed an educational video and handled prototype placebo products. FGDs were conducted in local languages and transcribed, coded and analysed, using a socio‐ecological framework, for key influences on willingness to use products, HIV risk perceptions and opinions on product attributes. Results Of the 128 participants (65 women, 63 men) 75% lived with their partner and 84% had a child. Women reported the most important influencers when P/BF were partners, and all stated that health decisions when P/BF are typically made jointly (e.g. medication use; ante/postnatal and baby care). There was consensus that P/BF women are at high risk for HIV, primarily because of their partner’s infidelities, and new prevention options were welcomed. Participants valued multiple options and stated that woman’s personal preference would be key to product choice. Anticipated concerns about products included risk of miscarriage, impact on infant development, complications during delivery and adequate production or taste of breastmilk. Specific perceived disadvantages emerged for the ring (e.g. vaginal discomfort, difficulty inserting/removing) and for pills (e.g. nausea/vomiting) that may be exacerbated during pregnancy. Health care providers’ (HCPs) knowledge and approval of product use during P/BF was needed to mitigate anticipated fears. Conclusions Participants perceived pregnancy and breastfeeding as high HIV risk periods and valued new prevention options. HIV protection of the mother‐child dyad, safety of the baby, and ultimately, health of the family were paramount. Endorsement by HCPs and support from partners were key to future product acceptance. Participants recommended involving partners and HCPs in sensitization efforts for future trials.
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Affiliation(s)
- Ariane van der Straten
- Women's Global Health Imperative (WGHI), RTI International, Berkeley, CA, USA.,Center for AIDS Prevention Studies (CAPS), University of California San Francisco, San Francisco, CA, USA
| | - Julia H Ryan
- Women's Global Health Imperative (WGHI), RTI International, Berkeley, CA, USA
| | - Krishnaveni Reddy
- Wits Reproductive Health and HIV Institute (Wits RHI), University of the Witwatersrand, Johannesburg, South Africa
| | - Juliane Etima
- Makerere University - Johns Hopkins University Research Collaboration, Kampala, Uganda
| | - Frank Taulo
- Johns Hopkins Project-College of Medicine, University of Malawi, Blantyre, Malawi
| | - Prisca Mutero
- University of Zimbabwe College of Health Sciences Clinical Trials Research Centre, Harare, Zimbabwe
| | | | | | - Petina Musara
- University of Zimbabwe College of Health Sciences Clinical Trials Research Centre, Harare, Zimbabwe
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29
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Politch JA, Cu-Uvin S, Moench TR, Tashima KT, Marathe JG, Guthrie KM, Cabral H, Nyhuis T, Brennan M, Zeitlin L, Spiegel HML, Mayer KH, Whaley KJ, Anderson DJ. Safety, acceptability, and pharmacokinetics of a monoclonal antibody-based vaginal multipurpose prevention film (MB66): A Phase I randomized trial. PLoS Med 2021; 18:e1003495. [PMID: 33534791 PMCID: PMC7857576 DOI: 10.1371/journal.pmed.1003495] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 01/12/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND MB66 film is a multipurpose prevention technology (MPT) product with monoclonal antibodies (mAbs) against HIV-1 (VRC01-N) and HSV-1 and 2 (HSV8-N). The mAbs were produced by transient expression in Nicotiana benthamiana (N). We conducted a Phase I clinical trial to assess the safety, pharmacokinetics (PK), and ex vivo efficacy of single and repeated doses of MB66 when used intravaginally. METHODS AND FINDINGS The clinical trial enrolled healthy reproductive-aged, sexually abstinent women. In Segment A, 9 women received a single MB66 film which was inserted into the vaginal posterior fornix by a clinician. In Segment B, 29 women were randomly assigned to MB66 (Active) or Placebo film groups and were instructed to insert 1 film vaginally for 7 consecutive days. Visits and clinical sampling occurred predose and at various time points after single and repeated film doses. The primary endpoint was number of adverse events (AEs) Grade 2 or higher related to product use. Secondary endpoints included film dissolution rate, Nugent score (a Gram stain scoring system to diagnose bacterial vaginosis), vaginal pH, post-use survey results, cytokine concentrations in cervicovaginal lavage (CVL) specimens (assessed by Luminex assay), mAb concentrations in vaginal fluid collected from 4 sites (assessed by ELISA), and HIV and HSV neutralization activity of CVL samples ex vivo (assessed by TZM-bl and plaque reduction assay, respectively). The product was generally safe and well tolerated, with no serious AEs recorded in either segment. The AEs in this study were primarily genitourinary in nature with the most commonly reported AE being asymptomatic microscopic hematuria. There were no differences in vaginal pH or Nugent scores or significant increases in levels of proinflammatory cytokines for up to 7 days after film insertion in either segment or between Active and Placebo groups. Acceptability and willingness to use the product were judged to be high by post-use surveys. Concentrations of VRC01-N and HSV8-N in vaginal secretions were assessed over time to generate pharmacokinetic curves. Antibody levels peaked 1 hour postdosing with Active film (median: 35 μg/mL) and remained significantly elevated at 24 hours post first and seventh film (median: 1.8 μg/mL). Correcting for sample dilution (1:20), VRC01-N concentrations ranged from 36 to 700 μg/mL at the 24-hour time point, greater than 100-fold the IC50 for VRC01 (0.32 μg/mL); HSV8-N concentrations ranged from 80 to 601 μg/mL, well above the IC50 of 0.1 μg/m. CVL samples collected 24 hours after MB66 insertion significantly neutralized both HIV-1 and HSV-2 ex vivo. Study limitations include the small size of the study cohort, and the fact that no samples were collected between 24 hours and 7 days for pharmacokinetic evaluation. CONCLUSIONS Single and repeated intravaginal applications of MB66 film were safe, well tolerated, and acceptable. Concentrations and ex vivo bioactivity of both mAbs in vaginal secretions were significantly elevated and thus could provide protection for at least 24 hours postdose. However, further research is needed to evaluate the efficacy of MB66 film in women at risk for HIV and HSV infection. Additional antibodies could be added to this platform to provide protection against other sexually transmitted infections (STIs) and contraception. TRIAL REGISTRATION ClinicalTrials.gov NCT02579083.
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Affiliation(s)
- Joseph A. Politch
- Boston University School of Medicine, Department of Medicine, Boston, Massachusetts, United States of America
| | - Susan Cu-Uvin
- Alpert Medical School of Brown University, Department of Obstetrics and Gynecology and Medicine, Providence, Rhode Island, United States of America
| | - Thomas R. Moench
- Mapp Biopharmaceutical Inc., San Diego, California, United States of America
| | - Karen T. Tashima
- Division of Infectious Diseases, Alpert Medical School of Brown University, Providence, Rhode Island, United States of America
| | - Jai G. Marathe
- Boston University School of Medicine, Department of Medicine, Boston, Massachusetts, United States of America
| | - Kate M. Guthrie
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, Rhode Island, United States of America
| | - Howard Cabral
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Tara Nyhuis
- Mapp Biopharmaceutical Inc., San Diego, California, United States of America
| | - Miles Brennan
- Mapp Biopharmaceutical Inc., San Diego, California, United States of America
| | - Larry Zeitlin
- Mapp Biopharmaceutical Inc., San Diego, California, United States of America
| | - Hans M. L. Spiegel
- Kelly Government Solutions, Contractor to National Institute of Allergy and Infectious Diseases, National Institutes of Health, Department of Health and Human Services, Rockville, Maryland, United States of America
| | - Kenneth H. Mayer
- Harvard Medical School, Department of Medicine, Boston, Massachusetts, United States of America
| | - Kevin J. Whaley
- Mapp Biopharmaceutical Inc., San Diego, California, United States of America
| | - Deborah J. Anderson
- Boston University School of Medicine, Department of Medicine, Boston, Massachusetts, United States of America
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Agot K, Lutnick A, Shapley-Quinn MK, Ahmed K, Okello T, van der Straten A. "I felt like a TRIO champion": end-user perspectives on their role as co-designers of multi-purpose technologies. Gates Open Res 2020; 4:163. [PMID: 33870103 PMCID: PMC8028846 DOI: 10.12688/gatesopenres.13182.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/08/2020] [Indexed: 11/24/2022] Open
Abstract
Background: The likelihood that research will be relevant to and accepted by end-users and their communities is enhanced when the perspectives of both the "researchers" and the "researched" are considered. The Tablets, Ring, Injections as Options (TRIO) Study, conducted with young women in Kenya and South Africa, assessed the acceptability and preferences of three placebo-only multi-purpose technology (MPT) forms for prevention of HIV and unintended pregnancy. The objective of this analysis was to assess whether, and if so how, the women participating in the TRIO Study perceived themselves as co-designers of the three MPT products. Methods: We conducted 55 in-depth interviews, 6 focus group discussions, and 5 dissemination workshops with TRIO Study participants. Woven throughout these activities were questions and opportunities for participants to reflect on their role in the study, and to what extent they identified with their role as a co-designer. Qualitative data from these activities were analyzed thematically. Results: The analysis revealed four key themes about what resulted in the women's views as co-designers: altruism, respectful treatment, agency, and reciprocity. The women were aware of their role in determining what end-users would and would not prefer and were motivated by a desire to help themselves and others. They recognized their role as co-designers and cited being treated well by study staff, being given a chance to make choices during the study period, and being recognized as equal partners of the researchers as the main reasons. Conclusions: If prevention products are going to be successfully developed, end-users and researchers must work hand in hand. Engaging participants meaningfully as co-designers in product development research can be a powerful tool in the effort to ensure new prevention products brought to market are acceptable to the population of interest.
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Affiliation(s)
- Kawango Agot
- Impact Research and Development Organization, Kisumu, Kenya
| | - Alexandra Lutnick
- Behavioral and Urban Health Program, RTI International, San Francisco, California, USA
| | | | - Khatija Ahmed
- Setshaba Research Centre, Soshanguve, Gauteng, South Africa
| | - Timothy Okello
- Impact Research and Development Organization, Kisumu, Kenya
| | - Ariane van der Straten
- Women's Global Health Imperative, RTI International, Berkeley, California, USA
- Department of Medicine, Center for AIDS Prevention Studies, UCSF, San Francisco, California, USA
| | - The TRIO Study Team
- Impact Research and Development Organization, Kisumu, Kenya
- Behavioral and Urban Health Program, RTI International, San Francisco, California, USA
- Women's Global Health Imperative, RTI International, Berkeley, California, USA
- Setshaba Research Centre, Soshanguve, Gauteng, South Africa
- Department of Medicine, Center for AIDS Prevention Studies, UCSF, San Francisco, California, USA
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Vickerman P, Quaife M, Kilbourne-Brook M, Mvundura M, Eakle R, Terris-Prestholt F. HIV prevention is not all about HIV - using a discrete choice experiment among women to model how the uptake and effectiveness of HIV prevention products may also rely on pregnancy and STI protection. BMC Infect Dis 2020; 20:704. [PMID: 32977745 PMCID: PMC7517801 DOI: 10.1186/s12879-020-05399-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 09/06/2020] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION In sub-Saharan Africa, considerable HIV-burden exists among women. Anti-retroviral (ARV) based prevention products could decrease this burden, and their uptake could be increased if they also protect against pregnancy and sexually transmitted infections (STI). METHODS A discrete choice experiment (DCE) was undertaken in South Africa (2015) through a household survey of adult females (n = 158) and adolescent girls (n = 204) who self-reported HIV-negative status. The DCE was used to project the uptake (percentage using product) of oral pre-exposure prophylaxis (PrEP), vaginal rings, and injectable long-lasting ARV agents among these women, and how uptake could depend on whether these products protect against pregnancy or STI acquisition. Uptake estimates were used to model how each product could decrease a women's HIV acquisition risk. RESULTS In adolescent women, there will be limited uptake (< 6% for any product) and impact (< 4% decrease in HIV acquisition risk) of new products unless they provide pregnancy protection, which could quadruple use and impact. Adult women have weaker preference for pregnancy protection, with moderate use (< 17% for each) and impact (< 14 percentage point decrease) if they only provide HIV protection. All women had highest preference for injectable ARVs, with oral PrEP having high preference if injectable ARVs are not available. Adult women will use the ring, but adolescent women will not. Importantly, even with three additional prevention products, all providing pregnancy and STI protection, > 14% of women will remain unprotected and > 31% of the baseline acquisition risk will remain. CONCLUSIONS Incorporating multiple prevention components into new ARV-based prevention products may increase their uptake and impact among women.
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Affiliation(s)
- Peter Vickerman
- Population Health Sciences, University of Bristol, Bristol, BS8 2BN, UK.
| | - Matthew Quaife
- London School of Hygiene and Tropical Medicine, London, UK
| | | | | | - Robyn Eakle
- London School of Hygiene and Tropical Medicine, London, UK
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Anderson DJ, Politch JA, Cone RA, Zeitlin L, Lai SK, Santangelo PJ, Moench TR, Whaley KJ. Engineering monoclonal antibody-based contraception and multipurpose prevention technologies†. Biol Reprod 2020; 103:275-285. [PMID: 32607584 PMCID: PMC7401387 DOI: 10.1093/biolre/ioaa096] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 05/20/2020] [Accepted: 06/02/2020] [Indexed: 12/16/2022] Open
Abstract
Sexually transmitted infections are highly prevalent, and over 40% of pregnancies are unplanned. We are producing new antibody-based multipurpose prevention technology products to address these problems and fill an unmet need in female reproductive health. We used a Nicotiana platform to manufacture monoclonal antibodies against two prevalent sexually transmitted pathogens, HIV-1 and HSV-2, and incorporated them into a vaginal film (MB66) for preclinical and Phase 1 clinical testing. These tests are now complete and indicate that MB66 is effective and safe in women. We are now developing an antisperm monoclonal antibody to add contraceptive efficacy to this product. The antisperm antibody, H6-3C4, originally isolated by Shinzo Isojima from the blood of an infertile woman, recognizes a carbohydrate epitope on CD52g, a glycosylphosphatidylinositol-anchored glycoprotein found in abundance on the surface of human sperm. We engineered the antibody for production in Nicotiana; the new antibody which we call "human contraception antibody," effectively agglutinates sperm at concentrations >10 μg/ml and maintains activity under a variety of physiological conditions. We are currently seeking regulatory approval for a Phase 1 clinical trial, which will include safety and "proof of principle" efficacy endpoints. Concurrently, we are working with new antibody production platforms to bring the costs down, innovative antibody designs that may produce more effective second-generation antibodies, and delivery systems to provide extended protection.
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Affiliation(s)
- Deborah J Anderson
- Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Joseph A Politch
- Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Richard A Cone
- Biophysics Department, Johns Hopkins University, Baltimore, MD, USA
- Mucommune, LLC, Durham, NC, USA
| | | | - Samuel K Lai
- Division of Pharmacoengineering and Molecular Pharmaceutics, Department of Microbiomology & Immunology, University of North Carolina, Chapel Hill, NC, USA
| | - Philip J Santangelo
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University Atlanta, GA, USA
| | - Thomas R Moench
- Mucommune, LLC, Durham, NC, USA
- ZabBio, Inc., San Diego, CA, USA
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Insights for Implementation Science From 2 Multiphased Studies With End-Users of Potential Multipurpose Prevention Technology and HIV Prevention Products. J Acquir Immune Defic Syndr 2020; 82 Suppl 3:S222-S229. [PMID: 31764258 DOI: 10.1097/qai.0000000000002215] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Lower adherence to biomedical HIV prevention and challenges with persistence among young women underscore the need for methods to identify factors that will achieve higher adoption and use of effective prevention options and inform new approaches. SETTING South Africa, Kenya, and Zimbabwe. METHODS We synthesized findings from 2 multiphased studies (TRIO and Quatro) conducted with young women aged 18-30 years that included a crossover clinical study with placebo products, a discrete-choice experiment, and qualitative interviews with women, male partners, and health providers. TRIO evaluated 3 products (tablets, ring, and injections), and Quatro compared 4 vaginal products (ring, insert, film, and gel) for HIV prevention. Both were designed to assess product preferences, choice, and use. RESULTS Increased experience with placebo products in the crossover study informed young women's product ratings and preferences. Over half changed their mind regarding their most preferred product after trying each one. The integrated qualitative component was vital to understanding what prompted these preference shifts. The discrete choice experiment provided insights on how features not available in placebos, like efficacy and contraception, influence choice and the tradeoffs women may be willing to make to gain a desired product feature. CONCLUSION The use of multiple research methods allowed for evaluation of varied dimensions of acceptability, preference, and choice in the context of diverse biomedical HIV prevention delivery forms. Findings elucidated the value of product choice with differences in preference within and across settings. Collectively, the 3 methodologies offered important insights about these products informative to enhanced product design development and future implementation.
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Gitome SW, Kwena ZA, Harper CC, Cohen CR, Bukusi EA. Educating men about vaginal microbicides: considerations from Kenya. CULTURE, HEALTH & SEXUALITY 2020; 22:660-674. [PMID: 31241426 DOI: 10.1080/13691058.2019.1627583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 06/01/2019] [Indexed: 06/09/2023]
Abstract
Men desire to be involved in their partner's decision-making about vaginal microbicide use. This coincides with women's desire to inform male partners about their microbicide use. Educating men about microbicides may enhance acceptability and generate critical support for the female participants of microbicide trials. In this multiphase mixed-methods study, we adapted an educational intervention on vaginal microbicides and tested it among men (n = 45) to determine its effect on men's knowledge regarding HIV/STI, vaginal microbicides and microbicide trials. We also conducted focus group discussions (FGDs) with the female partners (K = 3, n = 43) of the study participants and community representatives (K = 2, n = 24) to obtain their views on male partner microbicide education. We analysed FGD data for key themes using content analysis. HIV and vaginal microbicide knowledge scores increased significantly among men after the educational intervention. Both women and men highly supported male partner microbicide education, in the context of existing gender relations, to increase men's understanding about microbicides, promote adherence and help women gain their partners' trust. Complex gender dynamics should be considered when designing male partner educational interventions to improve acceptability and the use of microbicides and other female-initiated HIV prevention methods.
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Affiliation(s)
- Serah W Gitome
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Zachary A Kwena
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Cynthia C Harper
- Department of Obstetrics, Gynecology & Reproductive Sciences, Bixby Center for Global Reproductive Health, San Francisco, CA, USA
| | - Craig R Cohen
- Department of Obstetrics, Gynecology & Reproductive Sciences, Bixby Center for Global Reproductive Health, San Francisco, CA, USA
| | - Elizabeth A Bukusi
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
- Department of Obstetrics, Gynecology & Reproductive Sciences, Bixby Center for Global Reproductive Health, San Francisco, CA, USA
- Departments of Global Health and Obstetrics and Gynecology, University of Washington, Seattle, WA, USA
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Kidman R, Nachman S, Kohler HP. Interest in HIV pre-exposure prophylaxis (PrEP) among adolescents and their caregivers in Malawi. AIDS Care 2020; 32:23-31. [PMID: 32178529 PMCID: PMC8073398 DOI: 10.1080/09540121.2020.1742861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 03/09/2020] [Indexed: 10/24/2022]
Abstract
Over a third of new HIV infections occur in adolescents aged 10-19 globally. Pre-exposure prophylaxis (PrEP) could be a powerful tool for prevention. Understanding more about the drivers of PrEP interest could inform implementation strategies among this age group. Moreover, family dynamics may play a uniquely critical role for this younger age group, thus it is important to gauge whether caregivers would support their children's use of PrEP. We surveyed 2,089 adolescents (aged 10-16) and their caregivers in Malawi during 2017-2018. Data were collected on PrEP interest, factors that may facilitate PrEP use, and preferences for PrEP modality. We used multivariate logistic regression to estimate the association between the above characteristics and PrEP interest. We find that young adolescents are engaging in behaviors that would put them at substantial risk of acquiring HIV, would likely benefit from PrEP, are largely (82%) interested in using such, would prefer to get an injection over taking a daily pill, and are considerably discouraged by the prospect of side effects. Endorsement by caregivers was even greater (87%). Our findings demonstrate initial support for adolescent PrEP, and suggest parents may be a surprising advocate.
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Affiliation(s)
- Rachel Kidman
- Program in Public Health and Department of Family, Population and Preventive Medicine, Stony Brook University (State University of New York), Stony Brook, USA
| | - Sharon Nachman
- Department of Pediatrics, Stony Brook University (State University of New York), Stony Brook, USA
| | - Hans-Peter Kohler
- Department of Sociology and Population Studies Center, University of Pennsylvania, Philadelphia, USA
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Calabrese SK, Galvao RW, Dovidio JF, Willie TC, Safon CB, Kaplan C, Caldwell A, Blackstock O, Phillips NJ, Kershaw TS. Contraception as a Potential Gateway to Pre-Exposure Prophylaxis: US Women's Pre-Exposure Prophylaxis Modality Preferences Align with Their Birth Control Practices. AIDS Patient Care STDS 2020; 34:132-146. [PMID: 32202930 PMCID: PMC7087409 DOI: 10.1089/apc.2019.0242] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Addressing women's low uptake of HIV pre-exposure prophylaxis (PrEP) requires improved understanding of their product preferences. Such preferences should be contextualized according to other aspects of their reproductive health, including their contraception practices. We investigated women's preferences across 10 PrEP modalities currently available or under study and examined associations between PrEP modality preferences and contraception practices. Heterosexually active women recently engaged in care at Connecticut Planned Parenthood centers (n = 563) completed an online survey. Participants were presented with images and descriptions of 10 PrEP modalities and asked to indicate their preference and specify their reasoning in an open-response format. Participants also reported prior and current use of 16 contraception modalities along with relationship, sexual health, and sociodemographic characteristics. The sample included women ages 18-45 (45.3% 25 or younger) who were predominantly non-Hispanic black (35.7%) or white (33.7%). All PrEP modalities presented were preferred by at least some women, with daily pills (24.9%), injections (24.3%), and invisible implants (14.9%) preferred most commonly. Across all modalities, associated reasoning often centered around ease of use and comfort. Coincidence with contraception modality was the third-most common reason underlying women's preferences. Women currently using the analogous contraception modality versus never having used it had higher odds of preferring PrEP daily pills [adjusted odds ratio (AOR) = 2.03], injections (AOR = 8.45), invisible implants (AOR = 11.63), and vaginal rings (AOR = 8.66). Diversification of available PrEP modalities and prioritization of those coinciding with popular contraception practices-especially daily pills, injections, and implants-could optimize PrEP acceptability, encourage PrEP uptake, and ultimately reduce HIV incidence among women.
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Affiliation(s)
- Sarah K. Calabrese
- Department of Psychological and Brain Sciences and George Washington University, Washington, District of Columbia
- Department of Prevention and Community Health, George Washington University, Washington, District of Columbia
- Center for Interdisciplinary Research on AIDS, Yale University, New Haven, Connecticut
| | - Rachel W. Galvao
- Department of Psychological and Brain Sciences and George Washington University, Washington, District of Columbia
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - John F. Dovidio
- Center for Interdisciplinary Research on AIDS, Yale University, New Haven, Connecticut
- Department of Psychology, Yale University, New Haven, Connecticut
- Social and Behavioral Sciences Department, Yale University, New Haven, Connecticut
| | - Tiara C. Willie
- Center for Interdisciplinary Research on AIDS, Yale University, New Haven, Connecticut
- Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Cara B. Safon
- Social and Behavioral Sciences Department, Yale University, New Haven, Connecticut
- Department of Health Law, Policy, and Management, Boston University, Boston, Massachusetts
| | - Clair Kaplan
- Planned Parenthood of Southern New England, New Haven, Connecticut
| | - Abigail Caldwell
- Planned Parenthood of Southern New England, New Haven, Connecticut
| | - Oni Blackstock
- Center for Interdisciplinary Research on AIDS, Yale University, New Haven, Connecticut
- Division of General Internal Medicine, Montefiore Medical Center, Bronx, New York
| | | | - Trace S. Kershaw
- Center for Interdisciplinary Research on AIDS, Yale University, New Haven, Connecticut
- Social and Behavioral Sciences Department, Yale University, New Haven, Connecticut
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First Impressions Matter: How Initial Worries Influence Adherence to the Dapivirine Vaginal Ring. J Acquir Immune Defic Syndr 2020; 81:304-310. [PMID: 30844995 DOI: 10.1097/qai.0000000000002028] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND In MTN-020/ASPIRE, a dapivirine vaginal ring effectiveness trial in sub-Saharan Africa, we assessed whether worries about ring use changed over time and were associated with adherence. METHODS Participants (N = 2585) were surveyed at baseline and follow-up about worries regarding daily ring use. First, they answered a question about general worries and then responded to 15 items covering specific worries. From a nested qualitative component (N = 214), we extracted themes related to ring worries and adherence. Seven months into the trial, aggregate adherence data were shared with study sites as part of an intervention that included counseling and social support. Nonadherence was defined as dapivirine plasma levels of ≤95 pg/mL. Mixed-effect logistic regression models were used to assess changes in ring worries and nonadherence from baseline to month 3 and later. RESULTS Worry about wearing the ring decreased from 29% at baseline to 4% at month 3 (P < 0.001), while having a specific worry decreased from 47% to 16% (P < 0.001). Among those enrolled before intervention, 29% with baseline worries were nonadherent at month 3 (95% confidence interval: 19% to 39%) compared to 14% without worries (95% confidence interval: 9% to 19%; P = 0.005); the difference persisted through month 6. There was no difference in nonadherence by baseline worry for those enrolled after intervention (P = 0.40). In the qualitative subset, initial ring anxieties reportedly subsided with self-experimentation and practice and the beneficial influence of the intervention. CONCLUSIONS Although worries may be an initial deterrent to correct ring use, intervening early by leveraging social influences from peers and clinicians should facilitate successful adoption and correct ring use.
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Weinrib R, Browne EN, Shapley-Quinn MK, van der Straten A, Beksinska M, Mgodi N, Musara P, Mphili N, Schwartz JL, Ju S, Hanif H, Montgomery ET. Perspectives from Young South African and Zimbabwean Women on Attributes of Four (Placebo) Vaginal Microbicide Delivery Forms. AIDS Behav 2020; 24:637-647. [PMID: 31254190 PMCID: PMC6988116 DOI: 10.1007/s10461-019-02576-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Introduction Incorporating end-user input into the design of new vaginal microbicides for women is key to optimizing their uptake, consistent use, and, ultimately, success in combatting the heterosexual HIV epidemic. Methods The Quatro Study assessed four placebo forms of vaginally inserted HIV-microbicides among young microbicide-naïve African women: on-demand film, insert and gel, and monthly ring. Participants randomly used each product for 1 month and provided product satisfaction ratings (1–5 scale), and opinions on product attributes and potential alternative designs. Qualitative data were collected through focus group discussions at study exit. Multivariable associations between attribute opinions and overall product rating were examined using Poisson regression models with robust standard errors to assess the attributes most influential to satisfaction. Results Overall opinions of products and their individual attributes were generally positive; all products were rated either 4 or a 5 by ≥ 50% of participants. Attributes related to ease of use and interference with normal activities were the most salient predictors of satisfaction. Preferences for duration of use tended toward relatively shorter use periods for the ring (i.e., 1–3 months vs. 12 months) and for coitally independent dosing for the on-demand products. Conclusions How well a product fit in with participants’ lifestyles was important to their overall satisfaction. For on-demand products, greater flexibility around timing of use was desired, to avoid coital dependency of the dosing. Electronic supplementary material The online version of this article (10.1007/s10461-019-02576-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- R Weinrib
- Women's Global Health Imperative, RTI International, San Francisco, CA, USA.
- RTI Health Solutions, RTI International, Barcelona, Spain.
| | - E N Browne
- Women's Global Health Imperative, RTI International, San Francisco, CA, USA
| | - M K Shapley-Quinn
- Women's Global Health Imperative, RTI International, San Francisco, CA, USA
| | - A van der Straten
- Women's Global Health Imperative, RTI International, San Francisco, CA, USA
- Department of Medicine, Center for AIDS Prevention Studies, University of San Francisco, San Francisco, CA, USA
| | - M Beksinska
- MatCH Research Unit, Department of Obstetrics and Gynaecology, School of Clinical Sciences, University of the Witwatersrand, Durban, South Africa
| | - N Mgodi
- University of Zimbabwe College of Health Sciences-Clinical Trials Research Centre, Harare, Zimbabwe
| | - P Musara
- University of Zimbabwe College of Health Sciences-Clinical Trials Research Centre, Harare, Zimbabwe
| | - N Mphili
- MatCH Research Unit, Department of Obstetrics and Gynaecology, School of Clinical Sciences, University of the Witwatersrand, Durban, South Africa
| | - J L Schwartz
- Eastern Virginia Medical School, CONRAD, Arlington, VA, USA
| | - S Ju
- Eastern Virginia Medical School, CONRAD, Arlington, VA, USA
| | - H Hanif
- Eastern Virginia Medical School, CONRAD, Arlington, VA, USA
| | - E T Montgomery
- Women's Global Health Imperative, RTI International, San Francisco, CA, USA
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Young Women's Stated Preferences for Biomedical HIV Prevention: Results of a Discrete Choice Experiment in Kenya and South Africa. J Acquir Immune Defic Syndr 2019; 80:394-403. [PMID: 30633040 PMCID: PMC6410963 DOI: 10.1097/qai.0000000000001945] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Supplemental Digital Content is Available in the Text. Background: Integrating end-user perspectives into the design of new biomedical HIV prevention products is recognized as vital to informing the product development pipeline. Setting: Kisumu, Kenya; and Soshanguve, South Africa. Methods: We conducted a discrete choice experiment survey with 536 women aged 18–30 years to assess preferences for hypothetical HIV prevention products characterized by the attributes of efficacy, pregnancy prevention, delivery form, dosing frequency, and side effects. Participants included product-experienced women from Tablet, Ring, Injection as Options TRIO, a cross-over clinical study evaluating 3 placebo delivery forms (oral tablets, vaginal rings, and injections), and a product-naive sample recruited from the same communities. Analyses used random parameters logit and latent class models. Results: HIV prevention efficacy was a strong determinant of stated choice overall; however, in South Africa, delivery form was just as important, with an injection every 2–3 months most preferred and a daily oral tablet least preferred. In Kenya, product-experienced women preferred monthly injections and least preferred a monthly ring. Respondents indicated a preference for multipurpose prevention technologies that combine HIV and pregnancy protection. Latent class analyses confirmed these findings and delineated heterogeneity in preferences across subgroups defined by age, past experience with the delivery forms, and education. Conclusions: Despite an overall preference for products with high efficacy, we identified attributes salient to future uptake and use of HIV prevention products. Preferences for injectable products underscored interest in this pre-exposure prophylaxis delivery form. Likewise, the multipurpose prevention technology feature was valued in both Kenya and South Africa and most influenced interest in vaginal rings.
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Griffin JB, Ridgeway K, Montgomery E, Torjesen K, Clark R, Peterson J, Baggaley R, van der Straten A. Vaginal ring acceptability and related preferences among women in low- and middle-income countries: A systematic review and narrative synthesis. PLoS One 2019; 14:e0224898. [PMID: 31703094 PMCID: PMC6839883 DOI: 10.1371/journal.pone.0224898] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 10/23/2019] [Indexed: 11/30/2022] Open
Abstract
The vaginal ring (VR) is a female-initiated drug-delivery platform used for different indications, including HIV pre-exposure prophylaxis (PrEP). We conducted a systematic review of VR acceptability, values and preferences among women in low- and middle-income countries (LMIC) to inform further investment and/or guidance on VR use for HIV prevention. Following PRISMA guidelines, we used structured methods to search, screen, and extract data from randomized controlled trials (RCTs) and observational studies reporting quantitative outcomes of acceptability of the VR for any indication published 1/1970-2/2019 (PROSPERO: CRD42019122220). Of 1,110 records identified, 68 met inclusion criteria. Studies included women 15-50+ years from 25 LMIC for indications including HIV prevention, contraception, abnormal bleeding, and menopause. Overall VR acceptability was high (71-98% across RCTs; 62-100% across observational studies), with 80-100% continuation rates in RCTs and favorable ease of insertion (greater than 85%) and removal 89-99%). Users reported concerns about the VR getting lost in the body (8-43%), although actual expulsions and adverse events were generally infrequent. Most women disclosed use to partners, with some worrying about partner anger/violence. The VR was not felt during intercourse by 70-92% of users and 48-97% of partners. Acceptability improved over time both within studies (as women gained VR experience and worries diminished), and over chronological time (as the device was popularized). Women expressed preferences for accessible, long-acting, partner-approved methods that prevent both HIV and pregnancy, can be used without partner knowledge, and have no impact on sex and few side effects. This review was limited by a lack of standardization of acceptability measures and study heterogeneity. This systematic review suggests that most LMIC women users have a positive view of the VR that increases with familiarity of use; and, that many would consider the VR an acceptable future delivery device for HIV prevention or other indications.
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Affiliation(s)
- Jennifer B. Griffin
- RTI International, Center for Global Health, Durham, NC, United States of America
| | - Kathleen Ridgeway
- FHI 360, Global Health Population and Nutrition, Durham, NC, United States of America
| | - Elizabeth Montgomery
- RTI International, Center for Global Health, Durham, NC, United States of America
| | - Kristine Torjesen
- FHI 360, Global Health Population and Nutrition, Durham, NC, United States of America
| | - Rachel Clark
- RTI International, Public Health Research Division, Durham, NC, United States of America
| | - Jill Peterson
- FHI 360, Global Health Population and Nutrition, Durham, NC, United States of America
| | | | - Ariane van der Straten
- RTI International, Center for Global Health, Durham, NC, United States of America
- University of California, San Francisco, Department of Medicine, San Francisco, CA, United States of America
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Agot K, Minnis AM, Manenzhe K, Browne EN, Ahmed K, Okello T, van der Straten A. Engaging study participants in interpreting results: lessons from the TRIO study in Kenya and South Africa. Int J Womens Health 2019; 11:395-403. [PMID: 31372060 PMCID: PMC6636186 DOI: 10.2147/ijwh.s193905] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 02/25/2019] [Indexed: 01/09/2023] Open
Abstract
Background: Women account for 56% of new HIV infections in sub-Saharan Africa. Multipurpose Prevention Technologies (MPTs) are promising interventions because they combine HIV prevention with a less stigmatizing indication, such as pregnancy. We conducted a study with three placebo-only MPT products in Kisumu, Kenya and Soshanguve, South Africa, to assess preferences for attributes of tablets, vaginal rings and injectable products for dual prevention of HIV and pregnancy (TRIO Study). Here, we present former TRIO participants' views on the study results. Methods: After study completion in 2017, we held five dissemination sessions (two in Kisumu and three in Soshanguve) and five one-on-one sharing sessions in Soshanguve. Key results were discussed, with a focus on why some study products were more popular than others, which findings were surprising and why some women changed products over time. A thematic approach was used for analysis. Results: All 277 TRIO participants were telephoned, 168 (60.6%) were reached and 117 (42.2%) attended the dissemination sessions: 71 in Kisumu and 46 in Soshanguve. Participants were engaged and interested in the TRIO findings and willingly shared their perspectives and views candidly. Ease of use, discretion and familiarity were highlighted as drivers of product choice whereas novelty presented a challenge. In explaining the discrepancy between preference ratings and choices, participants cited features such as tablets being easy to explain to a partner or to discontinue. In explaining why 20% of participants switched products after practical experience, issues related to relationships with partners and product attributes perceived as unfavorable were paramount. Conclusion: The dissemination sessions provided an important forum for study participants to interrogate and explain the results to minimize possible misinterpretation. This exercise helped give context to the results, ensured correct lessons were derived from those results and increased credibility of the findings reported by the investigators.
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Affiliation(s)
- Kawango Agot
- Impact Research and Development Organization , Kisumu, Kenya
| | - Alexandra M Minnis
- Women's Global Health Imperative, RTI International, San Francisco, CA, USA
| | | | - Erica N Browne
- Women's Global Health Imperative, RTI International, San Francisco, CA, USA
| | | | - Timothy Okello
- Impact Research and Development Organization , Kisumu, Kenya
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Celum CL, Delany‐Moretlwe S, Baeten JM, van der Straten A, Hosek S, Bukusi EA, McConnell M, Barnabas RV, Bekker L. HIV pre-exposure prophylaxis for adolescent girls and young women in Africa: from efficacy trials to delivery. J Int AIDS Soc 2019; 22 Suppl 4:e25298. [PMID: 31328444 PMCID: PMC6643076 DOI: 10.1002/jia2.25298] [Citation(s) in RCA: 117] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 05/10/2019] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION Adolescent girls and young women (AGYW) in Africa have high HIV incidence despite scale-up of HIV testing and HIV treatment. Placebo-controlled trials of tenofovir-based pre-exposure prophylaxi (PrEP) in diverse populations demonstrated that PrEP works with close to 100% effectiveness if taken with high, but not perfect, adherence. Divergent efficacy estimates among African AGYW led to demonstration and implementation projects to better understand motivations for HIV prevention, uptake, adherence and persistence to PrEP. To inform PrEP programmes, the design and initial findings from PrEP demonstration projects for AGYW are reviewed. DISCUSSION Early lessons from PrEP implementation projects among young African women include: (1) awareness and demand creation with positive messaging about the benefits of PrEP are critical to motivate AGYW to consider this novel prevention technology and to foster awareness among peers, partners, parents and guardians to support AGYW's effective PrEP use; (2) PrEP initiation is high in projects that are integrating PrEP into youth-friendly clinics, family planning clinics and mobile clinics; (3) young African women at risk are initiating PrEP, based on behavioural characteristics, history of intimate partner violence, depression and 30% prevalence of chlamydia and/or gonorrhoea; (4) provision of youth-friendly PrEP delivery programmes that integrate reproductive health services, including contraception and the diagnosis and treatment of sexually transmitted infections, increase health impact; (5) messages that emphasize the necessity for high adherence while at potential risk of HIV exposure and support strategies that addresses AGYW's adherence challenges are essential; and, (6) a substantial proportion of AGYW do not persist with PrEP, and strategies are needed to help AGYW assess their ongoing need, motivation and challenges with persisting with PrEP. CONCLUSIONS PrEP is feasible to implement in integrated reproductive health service delivery models to reach African AGYW. While PrEP demonstration projects indicate that women with behavioural risks and high rates of sexually transmitted diseases are initiating PrEP; effective strategies to support AGYW's adherence and persistence with PrEP are needed. Lessons learned from oral PrEP delivery, a novel first generation HIV prevention product, are relevant to longer-acting and less adherence-dependent strategies which are currently in clinical trials.
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Affiliation(s)
- Connie L Celum
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
- Department of MedicineUniversity of WashingtonSeattleWAUSA
- Department of EpidemiologyUniversity of WashingtonSeattleWAUSA
| | - Sinead Delany‐Moretlwe
- Wits Reproductive Health and HIV InstituteUniversity of WitswatersrandJohannesburgSouth Africa
| | - Jared M Baeten
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
- Department of MedicineUniversity of WashingtonSeattleWAUSA
- Department of EpidemiologyUniversity of WashingtonSeattleWAUSA
| | | | - Sybil Hosek
- Department of PsychiatryStroger HospitalChicagoILUSA
| | - Elizabeth A Bukusi
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
- Kenya Medical Research InstituteNairobiKenya
- Departments of Obstetrics‐GynecologyUniversity of WashingtonSeattleWAUSA
| | - Margaret McConnell
- Department of Global Health and PopulationHarvard T.H. Chan School of Public HealthBostonMAUSA
| | - Ruanne V Barnabas
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
- Department of MedicineUniversity of WashingtonSeattleWAUSA
- Department of EpidemiologyUniversity of WashingtonSeattleWAUSA
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Montgomery ET, Beksinska M, Mgodi N, Schwartz J, Weinrib R, Browne EN, Mphili N, Musara P, Jaggernath M, Ju S, Smit J, Chirenje ZM, Doncel GF, van der Straten A. End-user preference for and choice of four vaginally delivered HIV prevention methods among young women in South Africa and Zimbabwe: the Quatro Clinical Crossover Study. J Int AIDS Soc 2019; 22:e25283. [PMID: 31069957 PMCID: PMC6506690 DOI: 10.1002/jia2.25283] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 04/05/2019] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Adherence to HIV prevention methods is a challenge, particularly for young women in Sub-Saharan Africa. End-user research during product development can inform modifiable factors to increase future uptake and adherence. METHODS Preferences for four vaginally inserted placebo HIV prevention methods were assessed among Zimbabwean and South African young women using a crossover clinical design. For each of months 1 to 4, participants were asked to use a pre-coitally inserted film, insert (vaginal tablet) and gel once/week for a month, and a monthly ring in a randomly assigned sequence. Participants subsequently chose one preferred product to use as directed for the final study month. Women ranked the four products from most preferred to least preferred at enrolment and after trying all products. RESULTS A total of 200 women aged 18 to 30 (mean 23) were enrolled; 178 (89%) completed follow-up. At baseline, 41% of participants selected the gel as their most preferred product and 61% selected the ring as least preferred. During the crossover period, most (82% to 85%) self-reported using each product at least once a week, although only half the time with sex. Objective biomarker data confirmed adequate use of all products. After trying each product, rankings changed with the film, ring, insert and gel being selected by 29%, 28%, 26% and 16% respectively. Choice varied significantly by country (p < 0.001): More Zimbabweans chose the film (45%), and more South Africans chose the insert (34%). Among women choosing the ring, 88% reported using it every time with sex. By contrast, self-reported adherence was lower for "on-demand" (coitally associated) products, with 40% to 55% using them every time during sex (p < 0.001). CONCLUSIONS Preferences for these four dosage forms varied before and after use, and both within and across countries - there was no clear favourite - indicating the need for a range of options for end-users The ring's popularity increased the most with use, was the second most preferred delivery system, and per self-report, provided more coverage during sex. These end-user perspectives provide important information to product developers and funding agencies.
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Affiliation(s)
| | - Mags Beksinska
- MRU (MatCH Research Unit)Faculty of Health SciencesUniversity of the WitwatersrandDurbanSouth Africa
| | - Nyaradzo Mgodi
- University of Zimbabwe College of Health Sciences Clinical Trials Research CentreHarareZimbabwe
| | | | - Rachel Weinrib
- Women's Global Health ImperativeRTI InternationalSan FranciscoCAUSA
| | - Erica N Browne
- Women's Global Health ImperativeRTI InternationalSan FranciscoCAUSA
| | - Nonhlanhla Mphili
- MRU (MatCH Research Unit)Faculty of Health SciencesUniversity of the WitwatersrandDurbanSouth Africa
| | - Petina Musara
- University of Zimbabwe College of Health Sciences Clinical Trials Research CentreHarareZimbabwe
| | - Manjeetha Jaggernath
- MRU (MatCH Research Unit)Faculty of Health SciencesUniversity of the WitwatersrandDurbanSouth Africa
| | - Susan Ju
- CONRADEastern Virginia Medical SchoolArlingtonVAUSA
| | - Jenni Smit
- MRU (MatCH Research Unit)Faculty of Health SciencesUniversity of the WitwatersrandDurbanSouth Africa
| | - Z Mike Chirenje
- University of Zimbabwe College of Health Sciences Clinical Trials Research CentreHarareZimbabwe
| | | | - Ariane van der Straten
- Women's Global Health ImperativeRTI InternationalSan FranciscoCAUSA
- Center for AIDS Prevention StudiesDepartment of MedicineUniversity of CaliforniaSan FranciscoCAUSA
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Shapley-Quinn MK, Manenzhe KN, Agot K, Minnis AM, van der Straten A. "We are not the same": African women's view of multipurpose prevention products in the TRIO clinical study. Int J Womens Health 2019; 11:97-107. [PMID: 30799959 PMCID: PMC6369839 DOI: 10.2147/ijwh.s185712] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Purpose Unintended pregnancy and HIV infection present dual risks for young women in sub-Saharan Africa. New multipurpose prevention technologies (MPTs) are in development to simultaneously prevent unintended pregnancy and HIV, but there is a need for end-user research to ensure these products suit women’s needs. The Tablet, Rings and Injectables as Options (TRIO) for women study took place in Kisumu, Kenya, and Soshanguve, South Africa, with the goal of eliciting young women’s feedback on three potential MPTs. Methods Women in TRIO used three placebo products that represented potential MPTs: daily oral tablets, monthly vaginal rings, and monthly dual injections in a randomized crossover design followed by a period in which they chose a product to use. Eighty-eight TRIO participants completed in-depth interviews and focus group discussions to understand their experiences using each product. Qualitative analyses were conducted after stratifying by product preference at the end of the crossover period. Results The majority (65%) of participants preferred injections, with the remainder evenly split between tablets and rings. Discussions of preference for one product were closely linked with expressed dislike of another product’s attributes. Participants recognized heterogeneity in preferences and choices across users and stressed the need for multiple MPT options that confer a low burden on women’s daily lives. Conclusion Rather than choosing a product to use based on the product’s perceived advantages, women’s choices were based on the unfavorable attributes of other TRIO products. Moreover, the importance that women placed on a given disadvantage varied. Disadvantages that women deemed as most important emerged as a greater driver of product preference than selecting products based on their advantages and favorable characteristics.
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Affiliation(s)
| | | | - Kawango Agot
- Impact Research and Development Organization, Kisumu, Kenya
| | - Alexandra M Minnis
- Women's Global Health Imperative (WGHI) RTI International, San Francisco, CA, USA, .,School of Public Health, UC Berkeley, Berkeley, CA, USA
| | - Ariane van der Straten
- Women's Global Health Imperative (WGHI) RTI International, San Francisco, CA, USA, .,Department of Medicine, Center for AIDS Prevention Studies, UCSF, San Francisco, CA, USA
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Abstract
PURPOSE OF REVIEW The goal of this paper is to review recent data on biomedical, behavioral, and structural HIV prevention interventions for adolescents and young adults. RECENT FINDINGS While it is accepted that HIV prevention interventions must take an integrated approach to achieve maximum effectiveness, to date, there have been limited, rigorously evaluated combination prevention interventions for adolescents. There are currently a range of effective biomedical, behavioral, and structural approaches that can be integrated into prevention packages to address the prevention needs of adolescents, including oral PrEP, male circumcision, rapid HIV testing, numerous behavioral interventions, and structural interventions such as cash transfers and community mobilization to address gender-based violence. There is still a need for rigorously evaluated, innovative combination prevention packages for adolescents. Prevention approaches must take into account the context of young people's lives and address the multiple levels of influence on their lives including parents, partners, and communities.
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Affiliation(s)
- Sybil Hosek
- Department of Psychiatry, John Stroger Hospital of Cook County, 1900 W. Polk Street, Ste. 854, Chicago, IL, 60612, USA.
| | - Audrey Pettifor
- Department of Epidemiology, Gillings School of Public Health, University of North Carolina, Chapel Hill, Chapel Hill, NC, USA
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Lutnick A, Shapley-Quinn MK, Manenzhe KN, Onyango J, Agot K, Ahmed K, van der Straten A. Two Birds with One Stone: Health Care Providers' Perspectives about Prevention Technologies in Kenya and South Africa. J Int Assoc Provid AIDS Care 2019; 18:2325958219841366. [PMID: 31018754 PMCID: PMC6748465 DOI: 10.1177/2325958219841366] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Revised: 02/25/2018] [Accepted: 03/06/2019] [Indexed: 11/19/2022] Open
Abstract
To meet the reproductive health needs of women, especially those in sub-Saharan Africa, multipurpose prevention technologies (MPTs) that combine pregnancy and HIV prevention into a single product could be highly beneficial. This qualitative study with health care providers in Kenya and South Africa examined health system factors that may facilitate or inhibit the delivery of these MPTs. Twelve qualitative interviews were conducted with health care providers at each site (24 interviews total). Providers were presented with pictures and actual placebo prototypes of 4 MPTs: a vaginal ring, an oral pill, an injectable, and an implant. Four themes emerged related to health care providers' reported interest in offering the proposed MPTs: (1) perceptions of young women's interest in the MPTs, (2) considerations about product administration, (3) feedback about product attributes, and (4) providers' training needs. Overwhelmingly, health care providers are eager to offer a product that prevents both HIV and unintended pregnancy in young women.
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Affiliation(s)
- Alexandra Lutnick
- RTI International, Behavioral and Urban Health Program, San Francisco, CA,
USA
| | | | | | - Jacob Onyango
- Impact Research And Development Organisation, Kisumu, Kenya
| | - Kawango Agot
- Impact Research And Development Organisation, Kisumu, Kenya
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Laborde ND, Leslie J, Krogstad E, Morar N, Mutero P, Etima J, Woodrow K, van der Straten A. Perceptions of the "Fabric" - An exploratory study of a novel multi-purpose technology among women in Sub Saharan Africa. PLoS One 2018; 13:e0204821. [PMID: 30379839 PMCID: PMC6209182 DOI: 10.1371/journal.pone.0204821] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 09/15/2018] [Indexed: 11/18/2022] Open
Abstract
Background HIV and pregnancy prevention are dual health priorities for women, and particularly in sub-Saharan Africa. Drug-eluting fibers offer a dosage form that combines HIV prevention and contraception, but early understanding of end-user perspectives is critical to avoid misalignment between products being developed and preferred product attributes. Methods Focus group discussions (FGDs) were conducted in South Africa, Uganda and Zimbabwe, among 55 women who had used vaginal products in previous trials. Participants were given the opportunity to feel a sample of electrospun nanofiber (the fabric), see how it dissolves, and give feedback on shape, size and other attributes. Women were also asked to compare the fabric to vaginal gel and film. Results Three key themes regarding the acceptability of the fabric emerged: 1) look and feel of the product undissolved vs. undissolved, 2) expected effect on sex, and 3) convenience and ease of use. Upon being presented with the fabric, women were initially distrustful, seeing it as undesirable for vaginal insertion. Women generally approved of the product once they saw it dissolve. However, they stressed the importance of the product not interfering with sex by altering the vaginal environment. Women also reacted favorably to the perceived convenience of the fabric, particularly with regards to storage and transport, perceived ease of insertion and use, and dosing regimen. Conclusion Multipurpose prevention technologies, and nanofibers in particular, should be developed with an eye to minimizing impact on sex while maximizing convenience, and presented in such a way as to emphasize non-abrasiveness and ease of dissolution.
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Affiliation(s)
- Nicole D. Laborde
- Women’s Global Health Imperative, RTI International, San Francisco, CA, United States of America
| | - Jonah Leslie
- Women’s Global Health Imperative, RTI International, San Francisco, CA, United States of America
| | - Emily Krogstad
- Women’s Global Health Imperative, RTI International, San Francisco, CA, United States of America
- Department of Bioengineering, University of Washington, Seattle, WA, United States of America
| | - Neetha Morar
- South Africa Medical Research Council, Durban, South Africa
| | - Prisca Mutero
- UZ-UCSF Collaborative Research Programme, Harare, Zimbabwe
| | - Juliane Etima
- Makerere University-Johns Hopkins University Research Unit, Kampala, Uganda
| | - Kim Woodrow
- Department of Bioengineering, University of Washington, Seattle, WA, United States of America
| | - Ariane van der Straten
- Women’s Global Health Imperative, RTI International, San Francisco, CA, United States of America
- Center for AIDS Prevention Studies, Department of Medicine, University of California San Francisco, San Francisco, CA, United States of America
- * E-mail:
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