Sino-implant (II)--a levonorgestrel-releasing two-rod implant: systematic review of the randomized controlled trials

The Effect Of Contraception On Genital Cytokines In Women Randomized To Copper Intrauterine Device, Intramuscular Depot Medroxyprogesterone Acetate Or Levonorgestrel Implant

BACKGROUND

The ECHO Trial randomized women to intramuscular depot medroxyprogesterone acetate (DMPA-IM), levonorgestrel implant (LNG-implant), or copper intrauterine device (Cu-IUD). In a sub-study of the ECHO Trial, we tested the hypothesis that contraceptives influence genital inflammation by comparing cervicovaginal cytokine changes following contraception initiation. In addition, we compared cytokine profiles in women who acquired HIV (cases) versus those remaining HIV-negative (controls).

METHODS

Women (n=251) from South Africa and Kenya were included. Twenty-seven cervicovaginal cytokines were measured by Luminex at baseline, 1- and 6-month post-contraceptive initiation. In addition, cytokines were measured pre-seroconversion in HIV cases (n=25) and controls (n=100).

RESULTS

At 6-months post-contraceptive initiation, women using Cu-IUD had increased concentrations of 25/27 cytokines compared to their respective baseline concentrations. In contrast, women initiating DMPA-IM and LNG-implant did not experience changes in cervicovaginal cytokines. Pre-seroconversion concentrations of IL-1β, IL-6, and TNF-α, previously associated with HIV risk, correlated with increased HIV risk in a logistic regression analysis, although not significantly after correcting for multiple comparisons. Adjusting for contraceptive arm did not alter these results.

CONCLUSION

Although Cu-IUD use broadly increased cervicovaginal cytokine concentrations at 6-months post-insertion, these inflammatory changes were found not to be a significant driver of HIV risk.

Long-acting biodegradable implant for sustained delivery of antiretrovirals (ARVs) and hormones

Women worldwide confront two major reproductive health challenges: the need for contraception and protection from sexually transmitted infections, including Human Immunodeficiency Virus (HIV). Multipurpose Prevention Technologies (MPTs) that simultaneously prevent unintended pregnancy and HIV could address these challenges with a single product. Here, we developed a long-acting (LA) subcutaneously administered and biodegradable implant system that provides sustained delivery of contraceptive and antiretroviral (ARV) with zero-order release kinetics. The MPT system involves two implants comprising an extruded tube of a biodegradable polymer, poly(ε-caprolactone) (PCL). Each implant is filled with a formulation of progestin [levonorgestrel (LNG) or etonogestrel (ENG)], or a formulation of a potent ARV [tenofovir alafenamide (TAF), or 4'-Ethynyl-2-fluoro-2'-deoxyadenosine (EFdA)]. We demonstrated sustained in-vitro release of LNG, ENG, and EFdA from the implant system for 13-17 months, while maintaining high stability of the drugs (>99%) within the implant reservoirs. We further elucidated the controlled release mechanism of the implant and leveraged several tunable parameters (e.g., type and quantity of the excipient, PCL properties, and implant wall thickness) to tailor the release kinetics and enhance the mechanical integrity of the MPT implant. The optimized MPT showed sustained in-vitro release of ENG and EFdA over 1 year while maintaining a high level of formulation stability and structural integrity. The MPT implant system was further evaluated in a preclinical study using a rodent model and demonstrated sustained release of EFdA (6 months) and ENG (12 months) with high stability of the drug formulation (>95%). This manuscript supports the continued advancement of LA delivery systems for MPTs.

Safety and Benefits of Contraceptives Implants: A Systematic Review

Progestin-only contraceptive implants provide long-acting, highly effective reversible contraception. We searched the medical publications in PubMed, CENTRAL, and EMBASE for relevant articles on hormonal implants published in English between 1990 and 2021. Levonorgestrel (LNG) 6-capsule subdermal implants represented the first effective system approved for reversible contraception. The etonogestrel (ENG) single rod dispositive has been widely employed in clinical practice, since it is a highly effective and safe contraceptive method. Abnormal menstrual bleeding is a common ENG side effect, representing the main reason for its premature discontinuation. Emerging evidence demonstrated that it is possible to extend the use of the ENG implant beyond the three-year period for which it is approved. The ENG implant could be an effective and discrete alternative to the IUD in young girls, such as post-partum/post-abortion. Implants should be inserted by trained skilled clinicians who previously provide adequate counselling about their contraceptive effect, benefits, and any possible adverse events. More studies are needed to validate the extended use of the ENG implant for up to 5 years.

Uptake of long acting reversible contraception following integrated couples HIV and fertility goal-based family planning counselling in Catholic and non-Catholic, urban and rural government health centers in Kigali, Rwanda

BACKGROUND

When integrated with couples' voluntary HIV counselling and testing (CVCT), family planning including long acting reversible contraceptives (LARC) addresses prongs one and two of prevention of mother-to-child transmission (PMTCT).

METHODS

In this observational study, we enrolled equal numbers of HIV concordant and discordant couples in four rural and four urban clinics, with two Catholic and two non-Catholic clinics in each area. Eligible couples were fertile, not already using a LARC method, and wished to limit or delay fertility for at least 2 years. We provided CVCT and fertility goal-based family planning counselling with the offer of LARC and conducted multivariate analysis of clinic, couple, and individual predictors of LARC uptake.

RESULTS

Of 1290 couples enrolled, 960 (74%) selected LARC: Jadelle 5-year implant (37%), Implanon 3-year implant (26%), or copper intrauterine device (IUD) (11%). Uptake was higher in non-Catholic clinics (85% vs. 63% in Catholic clinics, p < 0.0001), in urban clinics (82% vs. 67% in rural clinics, p < 0.0001), and in HIV concordant couples (79% vs. 70% of discordant couples, p = .0005). Religion of the couple was unrelated to clinic religious affiliation, and uptake was highest among Catholics (80%) and lowest among Protestants (70%) who were predominantly Pentecostal. In multivariable analysis, urban location and non-Catholic clinic affiliation, Catholic religion of woman or couple, younger age of men, lower educational level of both partners, non-use of condoms or injectable contraception at enrollment, prior discussion of LARC by the couple, and women not having concerns about negative side effects of implant were associated with LARC uptake.

CONCLUSIONS

Fertility goal-based LARC recommendations combined with couples' HIV counselling and testing resulted in a high uptake of LARC methods, even among discordant couples using condoms for HIV prevention, in Catholic clinics, and in rural populations. This model successfully integrates prevention of HIV and unplanned pregnancy.

Increasing body mass index or weight does not appear to influence the association between efavirenz-based antiretroviral therapy and implant effectiveness among HIV-positive women in western Kenya

OBJECTIVE

Our objective was to evaluate if increasing body mass index (BMI) or weight influences the association between efavirenz-based antiretroviral therapy (ART) and implant effectiveness.

STUDY DESIGN

We conducted a secondary cohort analysis of HIV-positive women aged 15 to 45 years enrolled in HIV care in western Kenya using an implant from January 2011 to December 2015. Implant use, ART regimen and weight were documented at each clinic visit and height at enrollment. We categorized BMI as underweight, normal weight, overweight or obese, and weight as <70 kg or ≥70 kg. Our primary outcome was incident pregnancy diagnosed clinically. We used crude and adjusted Poisson models with robust standard errors to account for covariates and repeated observations to estimate adjusted incident rate ratios (aIRRs).

RESULTS

In this analysis, 12,960 women contributed a total of 11,285 woman-years of observation time while using an implant, with a median of 6.6 months. The aIRRs comparing efavirenz- to nevirapine-based ART groups did not increase as BMI increased; the aIRRs were 2.0 (1.1-3.6) for underweight, 1.9 (1.5-2.5) for normal, 3.1 (1.6-6.0) for overweight and 2.1 (0.6-6.9) for obese women. The aIRRs comparing efavirenz- to nevirapine-based ART groups did not increase as weight increased; the aIRRs were 2.0 (1.6-2.6) for weight <70 kg and 2.1 (1.0-4.5) for weight ≥70 kg.

CONCLUSION

Higher BMI or weight did not appear to modify the relationship between efavirenz use and implant effectiveness.

IMPLICATIONS

Programs should not recommend differential counseling for women with higher BMI or weight who concomitantly use implants and efavirenz.

Randomized trial to evaluate contraceptive efficacy, safety and acceptability of a two-rod contraceptive implant over 4 years in the Dominican Republic

Objective

Sino-implant (II) is a contraceptive implant that had a commodity price one-third of the competing products a decade ago. To make Sino-implant (II) more widely available, we conducted a trial to collect safety and efficacy data required for World Health Organization (WHO) prequalification, a quality standard allowing global donors to procure a pharmaceutical product.

Study design

This was a randomized controlled trial allocating 650 participants to either Sino-implant (II) or Jadelle®. Participants were seen at 1 and 6 months, and then semiannually. The primary efficacy measure was the pregnancy Pearl Index [number of pregnancies per 100 women-years (WY) of follow-up] in the Sino-implant (II) group during up to 4 years of implant use.

Results

For the primary outcome, Sino-implant (II) had a 4-year Pearl Index of 0.74 (95% confidence interval, 0.36-1.37) compared to 0.00 (95% confidence interval, 0.00-1.04) for Jadelle®. The Sino-implant (II) pregnancy rate was significantly higher in the fourth year (3.54 per 100 WY) than in the first 3 years combined (0.18 per 100 WY; p <.001). Total levonorgestrel concentrations were equivalent between groups at month 12, but were 19%, 22% and 32% lower in the Sino-implant (II) group at months 24, 36 and 48, respectively (p <.001 at each time point). Safety and acceptability of the two products were similar, while providers documented significantly higher breakage rates during removal of Sino-implant (II) (16.3% vs. 3.1%; p <.001).

Conclusion

Based on these results, WHO prequalified Sino-Implant (II) with a 3-year use label in June 2017, 2 years shorter than the 5-year duration of Jadelle®.

Implications

WHO prequalification allows global donors to procure Sino-implant (II), which means women in many low resource countries will have greater access to highly effective and acceptable contraceptive implants. Our study noted important clinical differences, including shorter duration of high effectiveness with Sino-implant (II) when compared to the other available two-rod system, Jadelle®. Introduction strategies should include appropriate training on these differences.

Cohort study to evaluate efficacy, safety and acceptability of a two-rod contraceptive implant during third, fourth and fifth year of product use in China

Objective

Sino-implant (II) is a contraceptive implant approved for 4 years of use in China. We evaluated the contraceptive efficacy during the third, fourth and fifth year, and assessed additional pharmacokinetics (PK), safety, and acceptability endpoints.

Study design

We enrolled a cohort of 255 current Sino-Implant (II) users entering their third year and a second cohort of 243 users entering their fourth year. We followed these two cohorts for 12 and 24 months, respectively. To characterize PK endpoints (i.e. levonorgestrel (LNG), sex hormone binding globulin and free LNG index) over 5 years, we collected blood samples in a subset of 50 participants we followed during the third, fourth and fifth year. We also enrolled small cohorts (n = 20) of Sino-implant (II) users entering their sixth month and second year and followed them each for up to 6 months. Our primary efficacy measures were the pregnancy Pearl Indices during Year 3 and 4. Secondary objectives included assessments of PK, safety, acceptability and efficacy in the fifth year.

Results

We recorded four pregnancies, with a higher pregnancy rate during Year 3 [1.34 (95% CI: 0.28–3.93)] than Year 4 [0.44 (95% CI: 0.01–2.47)] or Year 5 [0.00 (95% CI: 0.00–2.02)]. The overall pregnancy rate for the third, fourth and fifth years of product use was 0.63 per 100 WY; 95% CI: (0.17–1.62). Mean LNG concentrations remained well above 200 pg/mL (Year 3 = 280.9; Year 4 = 233.6; Year 5 = 270.6). Most participants (93.7%) described their bleeding pattern as acceptable.

Conclusion

Sino-implant (II) is a highly effective contraceptive method in this population of Chinese women over 5 years.

Implications

Sino-implant (II) is a highly effective contraceptive method with an estimated Pearl Index of less than 1% over the third, fourth and fifth years of use in a population of Chinese women of reproductive age.

Systematic review of efficacy with extending contraceptive implant duration

BACKGROUND

Extending contraceptive implant duration of use increases accessibility by maximizing the lifetime of devices.

OBJECTIVES

To review the contraceptive efficacy during extended use of progestin implants.

SEARCH STRATEGY

PubMed and EMBASE were searched for articles in any language, 1996-2017, utilizing terms for devices and contraceptive efficacy.

SELECTION CRITERIA

Randomized clinical trials (RCTs), cohort studies, and case-control studies were included; abstracts, posters, and presentations were excluded. Studies evaluating Norplant and implants currently in pre-marketing trials were excluded.

DATA COLLECTION AND ANALYSIS

Titles and abstracts of articles were reviewed; those that met inclusion and exclusion criteria underwent full text review and data abstraction.

MAIN RESULTS

The search identified 2951 articles; six met inclusion and exclusion criteria. Five studies evaluated the etonogestrel implant (Implanon), and one the levonorgestrel implant (Jadelle). One RCT randomized to method, not duration; the remaining studies were prospective cohort studies. Three studies analyzed efficacy among women beyond currently approved duration separately. All studies were of poor to fair quality by United States Preventative Services Task Force (USPTF) grading. Limitations include lack of generalizability and control of important confounders.

CONCLUSION

These studies provide limited data for extended duration of contraceptive implants.

Factors associated with first-year discontinuation of Implanon in Upper Egypt: clients' and providers' perspectives

BACKGROUND

The etonogestrel implant Implanon is a favourable and cost-effective contraceptive method for women in developing countries, and expansion of its use represents a priority for the family planning (FP) programme in Egypt. We studied the factors affecting first-year Implanon discontinuation from clients' and providers' perspectives.

METHODS

We used a mixed quantitative-qualitative methodology. We conducted a household survey of Implanon clients and three focus group discussions with FP physicians and directors.

RESULTS

We found that 13.5% of Implanon users discontinued its use in the first year. Survival analysis found that clients who had previously used Implanon (HR 0.36, 95% CI 0.15 to 0.88) and whose husbands had secondary or a higher level of education (HR 0.36,95% CI 0.19 to 0.69) were less likely to discontinue Implanon use after the first year, while clients who experienced side effects of Implanon use were more likely to discontinue it (HR 3.6,95% CI 1.60 to 8.11). Other causes of discontinuation which emerged in the qualitative analysis were the unjustified advice for Implanon removal by non-gynaecologists, due to unrelated users' complaints, and deficient pre-insertion counselling.

CONCLUSIONS

Implanon has a low first-year discontinuation rate as compared with other contraceptive methods. FP clients should be given sufficient pre-insertion counselling about side effects of Implanon and duration of protection. Physicians should offer Implanon mainly to clients seeking long-term contraception in order to decrease its discontinuation rate and increase its cost effectiveness.

Twelve month follow-up of a contraceptive implant outreach service in rural Papua New Guinea

BACKGROUND

Poor access to contraception contributes to persistently high maternal mortality rates in Papua New Guinea (PNG). Since 2012 contraceptive implants have been provided to women in rural areas of PNG through outreach services but follow-up data in these communities on continuation and acceptability is lacking.

OBJECTIVE

To gain insight into women's experience with contraceptive implants by assessing the acceptability, satisfaction, 12 month continuation rates and efficacy of contraceptive implants among women in rural PNG.

MATERIAL AND METHODS

We undertook a cross-sectional survey of women in two rural provinces who had received a contraceptive implant at least 12 months prior using a structured questionnaire. We sought information on device continuation rates, satisfaction scores, side effects and failure rates.

RESULTS

Of the 860 women surveyed, 97% (n = 836) still had the device in situ after 12 months and 92% (n = 793) were very happy with it. Seventy-six percent of women (n = 654) reported no side effects. Irregular bleeding was the most commonly reported side effect (n = 178, 20.6%) but only 7% (n = 13) said the bleeding was bothersome. Documented failure rates were 0.8% although pregnancy at the time of insertion could not be excluded in any of these cases.

CONCLUSION

Twelve month implant follow-up data in this study showed high continuation rates and high levels of satisfaction among a rural population in PNG. Implants have the potential to lower maternal morbidity and mortality and simultaneously address the unmet need for contraception in these communities.

Concomitant contraceptive implant and efavirenz use in women living with HIV: perspectives on current evidence and policy implications for family planning and HIV treatment guidelines

Introduction: Preventing unintended pregnancies is important among all women, including those living with HIV. Increasing numbers of women, including HIV-positive women, choose progestin-containing subdermal implants, which are one of the most effective forms of contraception. However, drug–drug interactions between contraceptive hormones and efavirenz-based antiretroviral therapy (ART) may reduce implant effectiveness. We present four inter-related perspectives on this issue.

Discussion: First, as a case study, we discuss how limited data prompted country-level guidance against the use of implants among women concomitantly using efavirenz in South Africa and its subsequent negative effects on the use of implants in general. Second, we discuss the existing clinical data on this topic, including the observational study from Kenya showing women using implants plus efavirenz-based ART had three-fold higher rates of pregnancy than women using implants plus nevirapine-based ART. However, the higher rates of pregnancy in the implant plus efavirenz group were still lower than the pregnancy rates among women using common alternative contraceptive methods, such as injectables. Third, we discuss the four pharmacokinetic studies that show 50–70% reductions in plasma progestin concentrations in women concurrently using efavirenz-based ART as compared to women not on any ART. These pharmacokinetic studies provide the biologic basis for the clinical findings. Fourth, we discuss how data on this topic have marked implications for both family planning and HIV programmes and policies globally.

Conclusion: This controversy underlines the importance of integrating family planning services into routine HIV care, counselling women appropriately on increased risk of pregnancy with concomitant implant and efavirenz use, and expanding contraceptive method mix for all women. As global access to ART expands, greater research is needed to explore implant effectiveness when used concomitantly with newer ART regimens. Data on how HIV-positive women and their partners choose contraceptives, as well as information from providers on how they present and counsel patients on contraceptive options are needed to help guide policy and service delivery. Lastly, greater collaboration between HIV and reproductive health experts at all levels are needed to develop successful strategies to ensure the best HIV and reproductive health outcomes for women living with HIV.

Current and future contraceptive options for women living with HIV

INTRODUCTION

Among women living with HIV, half of the pregnancies are unintended. Effective contraception can prevent unintended pregnancies and consequently reduce maternal mortality and perinatal transmission of HIV. While contraceptive options available for all women also apply to women living with HIV, specific considerations exist to the use of contraception by women living with HIV.

AREAS COVERED

First, general principles guiding the use of contraception among women living with HIV are discussed, such as choice, method mix, relative effectiveness, and drug-drug interactions. Second, a detailed discussion of each contraceptive method and issues surrounding the use of that method, such as drug-drug interactions, follows. Third, future contraceptive options in advanced development for use by women or men are briefly discussed.

EXPERT OPINION

Contraceptive methods available to all women should also be accessible to women living with HIV. When the relative effectiveness of a contraceptive method is reduced, for example due to drug-drug interactions with antiretrovirals, the method should still be made available to women living with HIV with the appropriate information sharing and counseling. Greater research on various aspects of contraceptive use by women living with HIV and more comprehensive testing of co-administration of hormonal contraceptives and common medications used by these women are warranted.

Association of Progestin Contraceptive Implant and Weight Gain

OBJECTIVE

To evaluate initiation of a two-rod, 150-mg levonorgestrel contraceptive implant on women's perceived and observed body weight.

METHODS

We conducted a secondary analysis of data from an open, randomized controlled trial of adult, nonpregnant, human immunodeficiency virus-negative women attending a public clinic in Kingston, Jamaica, who were assigned to initiate implant use either immediately or after a 3-month delay. The primary objective of the parent study was to assess the effect of initiation of the implant on the frequency of condom use. We compared study arms during follow-up using one-sided χ tests for differences in perceived weight gain and loss, one-sided Wilcoxon-Mann-Whitney tests for median gain in measured weight, and logistic regression with generalized estimating equations for risk of gaining greater than 2 kg.

RESULTS

From 2012 to 2014, women were assigned to the implant (n=208) or delay arm (n=206). At 3 months, more women in the implant arm (15.3%) reported perceived weight gain than in the control arm (4.3%) (P=.01). Despite differences in perception, the implant and control arms did not differ significantly in median weight gain at 1-month (0.0 kg and 0.0 kg, respectively; P=.44) and 3-month visits (0.5 kg and 0.0 kg, respectively; P=.27). Study arms did not differ in risk of gaining greater than 2 kg (odds ratio 0.9, 95% confidence interval 0.6-1.3).

CONCLUSION

We found no evidence of weight gain from short-term implant use. Through the power of the nocebo effect, the practice of counseling women to expect possible weight gain from initiating implant use could lead them to perceive weight gain even in its absence and contribute to the early discontinuation of this highly effective contraceptive method.

Canadian Contraception Consensus (Part 3 of 4): Chapter 8 - Progestin-Only Contraception

OBJECTIVE

To provide guidelines for health care providers on the use of contraceptive methods to prevent pregnancy and on the promotion of healthy sexuality.

OUTCOMES

Overall efficacy of cited contraceptive methods, assessing reduction in pregnancy rate, safety, ease of use, and side effects; the effect of cited contraceptive methods on sexual health and general well-being; and the relative cost and availability of cited contraceptive methods in Canada.

EVIDENCE

Published literature was retrieved through searches of Medline and The Cochrane Database from January 1994 to January 2015 using appropriate controlled vocabulary (e.g., contraception, sexuality, sexual health) and key words (e.g., contraception, family planning, hormonal contraception, emergency contraception). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies published in English from January 1994 to January 2015. Searches were updated on a regular basis in incorporated in the guideline to June 2015. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

VALUES

The quality of the evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1). CHAPTER 8: PROGESTIN-ONLY CONTRACEPTION: Summary Statements Recommendations.

Pregnancy rates in HIV-positive women using contraceptives and efavirenz-based or nevirapine-based antiretroviral therapy in Kenya: a retrospective cohort study

BACKGROUND

Concerns have been raised about efavirenz reducing the effectiveness of contraceptive implants. We aimed to establish whether pregnancy rates differ between HIV-positive women who use various contraceptive methods and either efavirenz-based or nevirapine-based antiretroviral therapy (ART) regimens.

METHODS

We did this retrospective cohort study of HIV-positive women aged 15-45 years enrolled in 19 HIV care facilities supported by Family AIDS Care and Education Services in western Kenya between Jan 1, 2011, and Dec 31, 2013. Our primary outcome was incident pregnancy diagnosed clinically. The primary exposure was a combination of contraceptive method and efavirenz-based or nevirapine-based ART regimen. We used Poisson models, adjusting for repeated measures, and demographic, behavioural, and clinical factors, to compare pregnancy rates among women receiving different contraceptive and ART combinations.

FINDINGS

24,560 women contributed 37,635 years of follow-up with 3337 incident pregnancies. In women using implants, adjusted pregnancy incidence was 1.1 per 100 person-years (95% CI 0.72-1.5) for nevirapine-based ART users and 3.3 per 100 person-years (1.8-4.8) for efavirenz-based ART users (adjusted incidence rate ratio [IRR] 3.0, 95% CI 1.3-4.6). In women using depot medroxyprogesterone acetate, adjusted pregnancy incidence was 4.5 per 100 person-years (95% CI 3.7-5.2) for nevirapine-based ART users and 5.4 per 100 person-years (4.0-6.8) for efavirenz-based ART users (adjusted IRR 1.2, 95% CI 0.91-1.5). Women using other contraceptive methods, except for intrauterine devices and permanent methods, had 3.1-4.1 higher rates of pregnancy than did those using implants, with 1.6-2.8 higher rates in women using efavirenz-based ART.

INTERPRETATION

Although HIV-positive women using implants and efavirenz-based ART had a three-times higher risk of contraceptive failure than did those using nevirapine-based ART, these women still had lower contraceptive failure rates than did those receiving all other contraceptive methods except for intrauterine devices and permanent methods. Guidelines for contraceptive and ART combinations should balance the failure rates for each contraceptive method and ART regimen combination against the high effectiveness of implants.

FUNDING

None.

In vivo release of levonorgestrel from Sino-implant (II) — an innovative comparison of explant data

OBJECTIVES

Measuring the amount of progestin remaining in contraceptive implants used for different lengths of time provides useful information on in vivo release kinetics including change over time. We compared estimated in vivo levonorgestrel (LNG) release rates derived from Sino-implant (II) explants with similar data from removed Jadelle.

STUDY DESIGN

We measured LNG remaining in 44 sets of Sino-implant (II) used for up to 7 years and removed in four Chinese clinics. Results were compared with published data for Jadelle explants used for up to 36 months. We estimated and compared monthly and daily LNG release rates for the two products using prediction models for drug release. We also estimated the dissolution profile similarity factor, f2, for LNG release.

RESULTS

Both Sino-implant (II) and Jadelle release approximately 30% of total LNG load after 3 years. Results of fitting the data to a biologically plausible modified Higuchi prediction model indicate comparable release through 3 years. An estimated similarity factor of 80.6 (90% confidence interval: 70.8-85.7) indicates similarity in the dissolution profiles of the two implants.

CONCLUSIONS

LNG release in vivo measured through explant analysis suggest that Sino-implant (II) and Jadelle may perform similarly through 3 years of use and could remain highly effective beyond this time point. These results align with published data for Jadelle and Sino-implant (II) showing high effectiveness for 5 years. Ongoing clinical studies comparing the products over 5 years present an opportunity to verify this supportive measure of clinical effectiveness.

IMPLICATIONS

This innovative approach provides evidence that Sino-implant (II) may perform clinically similarly to Jadelle over 3 years and remain a highly effective contraceptive beyond this time point. Data from explant analyses show promise for investigating the equivalence of elusion profiles of contraceptive implants.

Applying emerging science to contraception research: implications for the clinic

Emerging science will make an important contribution towards the development of improved contraceptives. While long-acting reversible contraceptives remain the most effective method, new user-controlled, mid-acting methods will avoid the need for procedures requiring trained providers. Contraceptives combined with other agents may bring additional health benefits, such as dual protection against both pregnancy and sexually transmitted infections. Emerging research areas in proteomics allowed the discovery of new reproductive targets that may lead to non-hormonal contraceptives for both men and women. Current research objectives include the improvement of existing contraceptive methods, as well as discovery of new materials able to deliver new molecules more specifically to their target without systemic actions.

Sino-implant (II)® continuation and effect of concomitant tenofovir disoproxil fumarate-emtricitabine use on plasma levonorgestrel concentrations among women in Bondo, Kenya

OBJECTIVE

The objective was to assess associations between tenofovir disoproxil fumarate-emtricitabine (TDF-FTC) exposure and levonorgestrel (LNG) concentrations among Kenyan HIV prevention trial participants using Sino-implant (II) LNG implants for contraception.

METHODS

Women were offered implants among other contraceptive methods, were randomized to daily TDF-FTC or placebo, and followed monthly up to 56weeks. Associations between TDF-FTC exposure and mean LNG values were analyzed with linear mixed models.

RESULTS

Of 739 women, 29 (3.9%) received implants with no incident pregnancies and one discontinuation. Mean LNG concentrations over 56weeks among 28 women contributing data ranged between 214.0 and 659.8pg/mL with no significant difference between TDF-FTC and placebo arms or between variable levels of TDF-FTC adherence.

CONCLUSION

Concomitant TDF-FTC use was not associated with a significant change in plasma LNG concentrations among women using Sino-implant (II) in the first year of use.

Contraceptive procedures

Although most women desire to control the size and spacing of their family, the rate of unintended pregnancy in the United States remains high, with approximately half of all pregnancies being unintended. Reducing unintended pregnancy is a national public health goal, and the increased use of long-acting reversible contraceptives (LARCs) (intrauterine devices and implants) can help meet this goal. LARCs are among the most effective forms of contraception available. There are few contraindications to their use, and insertion and removal are straightforward procedures that are well tolerated in the outpatient office setting.

Implant removal experience with Sino-implant (II) at four Chinese sites

OBJECTIVES

Complications during contraceptive implant removal are important for users and programs. We describe breakage rates during Sino-implant (II) removals at four Chinese family planning clinics.

STUDY DESIGN

We collected data by observation of consecutive removal cases and subsequent data transcription onto a standardized case report form. Three sites used the "pull out" removal technique, and one site used the "U" technique.

RESULTS

Sino-implant (II) rods were removed from 318 women. There were 16 implant breaks (5.0%), with the breakage rate varying by site from 0% to 7.4%. All 16 breaks occurred at the three sites that used the standard "pull out" technique. Six implants were cut by the scalpel, five were snapped by the clamp, and five were unspecified. Other contributing factors included deeper or wider positioning of the implants (n=6) and implants that were enveloped by thick fibrous tissue (n=3). There was no relationship between breakage rate and duration of implant use. Less than 1% of removals took more than 10 min.

CONCLUSIONS

Both the standard "pull out" technique as well as the "U" technique can be used to remove Sino-implant (II). Breakage during implant removal may not be problematic if all fragments of the rod are readily removable. Breakage occurs with predictable low frequency, and training is needed to assure that providers can deal with breakage events.

IMPLICATIONS

Contraceptive implant removal complications are important for users and programs. These are some of the first data on breakage during removal of Sino-implant (II). More than one removal technique can be used, but training is required to ensure that providers can deal with the infrequent implant breaks.

Progestin-only contraception: injectables and implants

Progestin-only contraceptive injectables and implants are highly effective, longer-acting contraceptive methods that can be used by most women in most circumstances. Globally, 6% of women using modern contraception use injectables and 1% use implants. Injectables are the predominant contraceptive method used in sub-Saharan Africa, and account for 43% of modern contraceptive methods used. A lower-dose, subcutaneous formulation of the most widely used injectable, depot-medroxyprogesterone acetate, has been developed. Implants have the highest effectiveness of any contraceptive method. Commodity cost, which historically limited implant availability in low-resource countries, was markedly lowered between 2012 and 2013. Changes in menstrual bleeding patterns are extremely common with both methods, and a main cause of discontinuation. Advice from normative bodies differs on progestin-only contraceptive use by breastfeeding women 0-6 weeks postpartum. Whether these methods are associated with HIV acquisition is a controversial issue, with important implications for sub-Saharan Africa, which has a disproportionate burden of both human immunodeficiency virus (HIV) and maternal mortality.

Rationale, design, and cohort enrolment of a prospective observational study of the clinical performance of the new contraceptive implant (Femplant) in Pakistan

Introduction

The use of hormonal implants has gained positive traction in family planning programs in recent times. Compared to other popular methods, such as long-term reversible intrauterine devices, the use of hormonal implants as a family planning method has distinct advantages in terms of long-term efficiency and better user compliance and availability. This paper presents a study protocol to document and evaluate the efficacy, safety, and acceptability of Femplant (contraceptive implant) in Pakistan during the first year of its use among married women of reproductive age (18–44 years) at clinics in two provinces of Pakistan (Sindh and Punjab).

Materials and methods

A total of 724 married women were enrolled in a noncomparative prospective observational study. The study involved six government clinics from the Population Welfare Department in Sindh Province and 13 clinics run by the Marie Stopes Society (a local nongovernmental organization) in both provinces. The participation of women was subject to voluntary acceptance and medical eligibility. All respondents were interviewed at baseline and subsequently at each scheduled visit during the study period. Side effects, complications and adverse events, if any, were recorded for every participant at each visit to the facility.

Discussion

Over the next 5-year period (2013–2018), 27 million hormonal implants will be made available in lower- to middle-income countries by international donors and agencies. The evidence generated from this study will identify factors affecting the acceptability and satisfaction of end users with Femplant (Sino-implant II). This will help to guide policies to enhance access to and the use of long-acting contraceptive implants in Pakistan and similar developing countries.

Effectiveness, safety and acceptability of Sino-implant (II) during the first year of use: results from Kenya and Pakistan

BACKGROUND

Sino-implant (II) is a two-rod subcutaneous contraceptive implant used up to 4 years, containing 150 mg of levonorgestrel. We conducted two observational studies of Sino-implant (II) to evaluate its performance in routine service delivery settings.

METHODS

We enrolled 1326 women age 18-44 who had Sino-implant (II) inserted at clinics in Pakistan and Kenya. Women were followed-up using either an active or passive follow-up scheme in each study. Study outcomes were: one-year cumulative pregnancy and discontinuation rates; rates of insertion and removal complications; adverse event and side effect rates; reasons for discontinuation; and implant acceptability and satisfaction with clinic services.

RESULTS

A total of 754 women returned for at least one follow-up visit. The overall Pearl pregnancy rate was 0.4 per 100 woman-years [95% confidence interval (CI) 0.1, 0.9] resulting from 1 confirmed post-insertion pregnancy in Kenya and 4 in Pakistan. Country-specific Pearl rates were 0.2 (95% CI 0.0, 0.9) in Kenya and 0.6 (95% CI 0.2, 1.6) in Pakistan. The total cumulative 12-month probability of removal was 7.6% (95% CI 6.1, 9.1), with country-specific removal probabilities of 3.7% in Kenya (95% CI 2.1, 5.3) and 10.8% in Pakistan (95% CI 8.5, 13.2). Four serious adverse events occurred in Kenya and none occurred in Pakistan; one SAE (an ectopic pregnancy) was possibly related to Sino-implant (II). Most women in both countries said they would recommend the implant to others.

CONCLUSION

The results from these studies reveal high effectiveness and favorable safety and acceptability during the first year of use of Sino-implant.

IMPLICATION

The favorable Sino-implant (II) findings from Kenya and Pakistan provide further evidence from disparate regions that Sino-implant (II) is safe, effective and acceptable during routine service delivery.

Antenatal contraception - simple, feasible, but is it safe and ethical in resource-poor environments?

In developing countries, antenatal care is used by more women than any other reproductive health services available and many women who receive antenatal care will not receive intrapartum care by a trained provider and even fewer will receive postnatal care. At present, antenatal care provides contraceptive counselling but not contraceptive provision. An important reason for this is the perceived absence of a suitable method that could be distributed or started during antenatal care. In this article, we discuss the available options. We conclude that antenatal insertion of subdermal contraceptive implants is very likely to be safe and ethically defensible where access to contraceptive services is poor.