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Mngomezulu K, Mzobe G, Mtshali A, Baxter C, Ngcapu S. The use of PSA as a biomarker of recent semen exposure in female reproductive health studies. J Reprod Immunol 2021; 148:103381. [PMID: 34563757 DOI: 10.1016/j.jri.2021.103381] [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: 02/27/2021] [Revised: 09/07/2021] [Accepted: 09/08/2021] [Indexed: 11/16/2022]
Abstract
Semen contains potent soluble proteins, bacteria, viruses, activated immune cells as well as anti- and pro-inflammatory cytokines that may influence the inflammatory response and alter microbial composition of the female genital tract. The presence of semen in the female genital mucosa may be a significant confounder that most studies have failed to control for in their analysis. Prostate-specific antigen (PSA), a protein secreted by the prostate into the urethra during ejaculation, is a well-established biomarker of semen exposure. Several studies have demonstrated discordance between self-reports of sexual behavior and the presence of PSA. Recent semen exposure has been shown to promote pro-inflammatory responses, stimulate the recruitment of activated immune cells and decrease Lactobacilli abundance in the female genital mucosa. As a result, it is important to understand the concordance between self-reported consistent condom use and the presence of semen biomarkers. Furthermore, to ensure that the interpretation of data in clinical studies of the immunological and microbial environment in the female genital mucosa are accurate, it is essential to establish whether semen is present in the vaginal fluid. This review explores the impact of semen exposure on the mucosal microenvironment and assesses the use of the PSA as an objective biomarker of semen exposure to reduce reliance on self-reported sexual intercourse.
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Affiliation(s)
- Khanyisile Mngomezulu
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Gugulethu Mzobe
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Andile Mtshali
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Cheryl Baxter
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa; Department of Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Sinaye Ngcapu
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa; Department of Medical Microbiology, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa.
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Walsh TL, Snead MC, St Claire BJ, Schwartz JL, Mauck CK, Frezieres RG, Blithe DL, Archer DF, Barnhart KT, Jensen JT, Nelson AL, Thomas MA, Wan LS, Weaver MA. Comparison of self-reported female condom failure and biomarker-confirmed semen exposure. Contraception 2019; 100:406-412. [PMID: 31381878 DOI: 10.1016/j.contraception.2019.07.143] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 07/20/2019] [Accepted: 07/24/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To investigate whether rates of self-reported Woman's Condom (WC) clinical failure and semen exposure from a functionality study are comparable to results from a contraceptive efficacy substudy. STUDY DESIGN We structured our comparative analysis to assess whether functionality studies might credibly supplant contraceptive efficacy studies when evaluating new female condom products. Couples not at risk of pregnancy in the functionality (breakage/slippage/invagination/penile misdirection) study and women in the contraceptive efficacy study completed condom self-reports and collected precoital and postcoital vaginal samples for up to four uses of the WC. Both studies used nearly identical self-report questions and the same self-sampling procedures and laboratory for prostatic specific antigen (PSA), a well-studied semen biomarker. We compared condom failure and semen exposure proportions using generalized estimating equations methods accounting for within-couple correlation. RESULTS Ninety-five (95) efficacy substudy participants used 334 WC and 408 functionality participants used 1572 WC. Based on self-report, 19.2% WC (64 condoms) clinically failed in the efficacy substudy compared to 12.3% WC (194 condoms) in the functionality study (p=.03). Of the 207 WC efficacy uses with evaluable postcoital PSA levels, 14.5% (30 uses) resulted in semen exposure compared to 14.2% (184 uses) of the 1293 evaluable WC functionality study uses. CONCLUSIONS When evaluating the ability of an experimental condom to prevent semen exposure, the rate of clinical condom failure reported by participants risking pregnancy in an efficacy substudy was significantly higher than the rate reported by participants not risking pregnancy in a functionality study. The rate of semen exposure, assessed by an objective biomarker was nearly identical for the two studies. IMPLICATIONS Our results suggest that an objective marker of semen exposure in functionality studies could provide a reasonable alternative to contraceptive efficacy studies in evaluating risk of unintended pregnancy and inferring protection from sexually transmitted infection than condom failure rates based on self-report.
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Affiliation(s)
- Terri L Walsh
- Essential Access Health (formerly California Family Health Council), 3600 Wilshire Blvd., Ste. 600, Los Angeles, CA 90010.
| | - Margaret C Snead
- Division of Reproductive Health, Centers for Disease Control and Prevention, 1600 Clifton Rd., Atlanta, GA 30333
| | - Breione J St Claire
- Essential Access Health (formerly California Family Health Council), 3600 Wilshire Blvd., Ste. 600, Los Angeles, CA 90010
| | - Jill L Schwartz
- CONRAD/EVMS, 1911 N. Fort Myer Drive, Ste. 900, Arlington, VA 22209
| | | | - Ron G Frezieres
- Essential Access Health (formerly California Family Health Council), 3600 Wilshire Blvd., Ste. 600, Los Angeles, CA 90010
| | - Diana L Blithe
- Contraceptive Development Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, 6710B Rockledge Dr, Bethesda, MD 20817
| | - David F Archer
- Obstetrics & Gynecology, Eastern Virginia Medical School, PO Box 1980, Norfolk, VA 23501
| | - Kurt T Barnhart
- University of Pennsylvania Medical Center, 3701 Market St., Ste. 800, Philadelphia, PA 19104
| | - Jeffrey T Jensen
- Department of Obstetrics & Gynecology, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd., Portland, OR 97239
| | - Anita L Nelson
- Essential Access Health (formerly California Family Health Council), 3600 Wilshire Blvd., Ste. 600, Los Angeles, CA 90010
| | - Michael A Thomas
- Department of Obstetrics & Gynecology, University of Cincinnati Medical Center, 234 Goodman St., Cincinnati, OH 45219
| | - Livia S Wan
- Department of Obstetrics & Gynecology, New York University,462 First Ave., New York, NY 10016
| | - Mark A Weaver
- Department of Mathematics and Statistics, Elon University, Elon, NC 27244
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Kulczycki A, Brill I, Snead MC, Macaluso M. Prostate-specific antigen concentration in vaginal fluid after exposure to semen. Contraception 2017; 96:336-343. [PMID: 28711645 DOI: 10.1016/j.contraception.2017.07.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2016] [Revised: 06/24/2017] [Accepted: 07/01/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Prostate-specific antigen (PSA) is the best established biomarker of semen exposure. PSA in vaginal fluid returns to pre-exposure concentrations within 24-48 h, but the speed of decay during the first 10 h is unknown. We sought to determine how fast PSA concentrations decline during the first 10 h after exposure to semen. STUDY DESIGN Women in the 50 enrolled couples were intravaginally inoculated with 10, 20, 100 and 200 μl of their partner's semen and then collected vaginal swabs immediately after, 30 min, 4 h and 10 h after exposure. Forty-seven sets of samples were tested for PSA. Mixed linear models for repeated measures examined the association between log-transformed PSA values and sampling time and semen exposure volume. Sensitivity analyses excluded data from nonabstainers. Fixed-effect estimates from the statistical models were graphed. RESULTS PSA values were highest at 200 μl inoculation volumes and at earlier post-exposure time points, then decline steadily. The lowest inoculation volume (10 μl) corresponded to the smallest concentration of PSA throughout the post-inoculation time points. Average PSA levels return to clinically non-detectable levels within 10 h only at the lowest semen exposures. The PSA decay curve assumes a very similar profile across all time points and semen amounts. CONCLUSIONS The PSA decay curve is similar for varying semen exposure volumes, with average PSA concentrations remaining above clinical thresholds 10 h after exposure at all except the very smallest semen exposure levels. PSA is an objective marker of recent exposure to semen, permitting such detection with high accuracy. IMPLICATIONS This study clarifies how PSA values vary at different semen exposure levels and time points during the first 10 h post-exposure. Future contraceptive studies that use PSA as a semen biomarker will be better informed about PSA concentrations at different sampling times and exposure amounts.
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Affiliation(s)
- Andrzej Kulczycki
- Department of Health Care Organization and Policy, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Ilene Brill
- Department of Epidemiology, UAB, Birmingham, AL, USA
| | - Margaret Christine Snead
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Maurizio Macaluso
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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Wilson KS, Deya R, Yuhas K, Simoni J, Vander Stoep A, Shafi J, Jaoko W, Hughes JP, Richardson BA, McClelland RS. A Prospective Cohort Study of Intimate Partner Violence and Unprotected Sex in HIV-Positive Female Sex Workers in Mombasa, Kenya. AIDS Behav 2016; 20:2054-64. [PMID: 27094785 DOI: 10.1007/s10461-016-1399-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
We conducted a prospective cohort study to test the hypothesis that intimate partner violence (IPV) is associated with unprotected sex in HIV-positive female sex workers in Mombasa, Kenya. Women completed monthly visits and quarterly examinations. Any IPV in the past year was defined as ≥1 act of physical, sexual, or emotional violence by the current or most recent emotional partner ('index partner'). Unprotected sex with any partner was measured by self-report and prostate specific antigen (PSA) test. Recent IPV was associated with significantly higher risk of unprotected sex (adjusted relative risk [aRR] 1.91, 95 % CI 1.32, 2.78, p = 0.001) and PSA (aRR 1.54, 95 % CI 1.17, 2.04, p = 0.002) after adjusting for age, alcohol use, and sexual violence by someone besides the index partner. Addressing IPV in comprehensive HIV programs for HIV-positive women in this key population is important to improve wellbeing and reduce risk of sexual transmission of HIV.
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Thurman A, Jacot T, Melendez J, Kimble T, Snead M, Jamshidi R, Wheeless A, Archer DF, Doncel GF, Mauck C. Assessment of the vaginal residence time of biomarkers of semen exposure. Contraception 2016; 94:512-520. [PMID: 27259675 DOI: 10.1016/j.contraception.2016.05.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Revised: 05/26/2016] [Accepted: 05/27/2016] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The primary objective of this pilot study is to determine and compare the residence time in the vagina of biomarkers of semen exposure for up to 15 days post exposure. The biomarkers are prostate-specific antigen (PSA), Y chromosome DNA, the sex determining region of the Y chromosome (SRY) and testis-specific protein Y-encoded 4 (TSPY4). The secondary objectives are to determine if biomarker concentrations differed between intercourse and inoculation groups, to establish whether the sampling frequency post exposure affected biomarker concentrations and decay profile and to determine if biomarker concentrations in vaginal swabs obtained by the participant at home were similar to swabs obtained by the nurse in the clinic. STUDY DESIGN We randomized healthy women to unprotected intercourse (n=17) versus vaginal inoculation with the male partner's semen in the clinic (n=16). Women were then further randomized to have vaginal swabs obtained at either 7 or 4 time points after semen exposure, up to 15 days post exposure, either obtained at home by the participant or in the clinic by the research nurse. RESULTS PSA and SRY were markers of recent semen exposure. TSPY4 was detectable in approximately 50% of participants at 15 days post exposure. Unprotected intercourse resulted in significantly higher concentrations of select biomarkers. Sampling frequency and home versus clinic sampling had no significant effect on biomarker concentrations. CONCLUSIONS Objective biomarkers of recent or distant semen exposure may have great utility for verifying protocol compliance in a variety of clinical trials.
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Affiliation(s)
- Andrea Thurman
- Eastern Virginia Medical School, 601 Colley Avenue, Room 235, Norfolk, VA 23507, USA.
| | - Terry Jacot
- Eastern Virginia Medical School, 601 Colley Avenue, Room 235, Norfolk, VA 23507, USA
| | - Johan Melendez
- Eastern Virginia Medical School, 601 Colley Avenue, Room 235, Norfolk, VA 23507, USA
| | - Thomas Kimble
- Eastern Virginia Medical School, 601 Colley Avenue, Room 235, Norfolk, VA 23507, USA
| | - Margaret Snead
- Eastern Virginia Medical School, 601 Colley Avenue, Room 235, Norfolk, VA 23507, USA
| | - Roxanne Jamshidi
- Eastern Virginia Medical School, 601 Colley Avenue, Room 235, Norfolk, VA 23507, USA
| | - Angie Wheeless
- Eastern Virginia Medical School, 601 Colley Avenue, Room 235, Norfolk, VA 23507, USA
| | - David F Archer
- Eastern Virginia Medical School, 601 Colley Avenue, Room 235, Norfolk, VA 23507, USA
| | - Gustavo F Doncel
- Eastern Virginia Medical School, 601 Colley Avenue, Room 235, Norfolk, VA 23507, USA
| | - Christine Mauck
- Eastern Virginia Medical School, 601 Colley Avenue, Room 235, Norfolk, VA 23507, USA
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Snead MC, Black CM, Kourtis AP. The use of biomarkers of semen exposure in sexual and reproductive health studies. J Womens Health (Larchmt) 2014; 23:787-91. [PMID: 25268551 DOI: 10.1089/jwh.2014.5018] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Biomarkers of semen exposure have been used in studies investigating the safety and efficacy of barrier methods of contraception. They have been used as objective indicators of semen exposure when studying sexual behaviors and in human immunodeficiency virus/sexually transmitted infection research interventions where participants are advised to avoid unprotected sex. Semen biomarkers have also been used to assess or validate self-reported sexual behaviors or condom use in reproductive health settings. Prostate-specific antigen (PSA) and Y chromosome DNA (Yc-DNA) have each been evaluated in the past as semen biomarkers and are the most widely used in the field. While both are considered reliable for evaluating exposure to semen, each has unique characteristics. In this report, we summarize the literature and provide some considerations for reproductive health researchers who are interested in using PSA or Yc-DNA as semen biomarkers. We also synthesize our previous published work on the optimal conditions of collecting and storing specimens and assay performance in the presence of other vaginal products that may influence various assays. Semen biomarkers are innovative and promising tools to further study and better understand women's reproductive and sexual health and behavior. More research is needed to better understand the strengths, limitations, and optimal performance conditions of specific assays in vivo.
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Affiliation(s)
- Margaret Christine Snead
- 1 Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention , Atlanta, Georgia
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Snead MC, Kourtis AP, Melendez JH, Black CM, Mauck CK, Penman-Aguilar A, Chaney DM, Gallo MF, Jamieson DJ, Macaluso M, Doncel GF. Does tenofovir gel or do other microbicide products affect detection of biomarkers of semen exposure in vitro? Contraception 2014; 90:136-41. [PMID: 24746557 DOI: 10.1016/j.contraception.2014.03.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Revised: 03/10/2014] [Accepted: 03/16/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVES There is currently no information on whether products evaluated in HIV microbicide trials affect the detection of the semen biomarkers prostate-specific antigen (PSA) or Y chromosome DNA. STUDY DESIGN We tested (in vitro) dilutions of tenofovir (TFV), UC781 and the hydroxyethylcellulose (HEC) placebo gels using the Abacus ABAcard and the quantitative (Abbott Architect total PSA) assays for PSA and Y chromosome DNA by real-time polymerase chain reaction. RESULTS TFV gel and the HEC placebo adversely affected PSA detection using the ABAcard but not the Abbott Architect total PSA assay. UC781 adversely affected both the ABAcard and Abbott Architect total PSA assays. While there were some quantitative changes in the magnitude of the signal, none of the products affected positivity of the Y chromosome assay. CONCLUSIONS The presence of TFV or HEC gels did not affect quantitative PSA or Y chromosome detection in vitro. Confirmation of these findings is recommended using specimens obtained following use of these gels in vivo. IMPLICATIONS Researchers should consider the potential for specific microbicides or any products to affect the particular assay used for semen biomarker detection. The ABAcard assay for PSA detection should not be used with TFV UC781, or HEC.
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Affiliation(s)
- Margaret C Snead
- The Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Baltimore, MD, USA.
| | - Athena P Kourtis
- The Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Baltimore, MD, USA
| | | | - Carolyn M Black
- The Division of Scientific Resources, National Center for Emerging and Ζοοnotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Ana Penman-Aguilar
- The Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Baltimore, MD, USA
| | | | - Maria F Gallo
- The Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Baltimore, MD, USA
| | - Denise J Jamieson
- The Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Baltimore, MD, USA
| | - Maurizio Macaluso
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Gustavo F Doncel
- CONRAD, Eastern Virginia Medical School (EVMS), Arlington, VA, USA
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Snead MC, Melendez JH, Kourtis AP, Chaney DM, Brown TM, Black CM, Mauck CK, Schwartz JL, Zenilman JM, Jamieson DJ, Macaluso M, Doncel GF. Effect of lubricants and a vaginal spermicide gel on the detection of prostate specific antigen, a biomarker of semen exposure, using a quantitative (Abbott ARCHITECT) assay. Contraception 2013; 89:134-8. [PMID: 24314911 DOI: 10.1016/j.contraception.2013.09.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Revised: 09/18/2013] [Accepted: 09/23/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVES Little is known about the effects of commonly used lubricants on detection of biomarkers of semen exposure. We investigated the in vitro effect of Gynol®, K-Y Jelly®, Replens®, Astroglide®, Carbopol, and Silicorel on quantitative detection of prostate specific antigen (PSA). STUDY DESIGN A predetermined concentration of each of the gels was added to serially diluted semen samples. Additionally, serial dilutions of each of the gels were added to three different semen dilutions (high, medium, or low). The resulting samples were tested for PSA on the Abbott ARCHITECT System. RESULTS When using the Abbott ARCHITECT system, the only products that inhibited PSA detection were Gynol® and Replens®. The inhibition caused by Gynol® was dose-dependent, but that of Replens was dose-independent. K-Y Jelly®-spiked samples had higher PSA values than controls. CONCLUSIONS Caution is warranted when using the Abbott quantitative assay for PSA detection as a biomarker of semen exposure in settings where Gynol®, Replens® or K-Y Jelly® might also have been used. Neither Astroglide® nor Silicorel inhibited PSA detection. Additional studies evaluating other vaginal products, including microbicides, and their effects on other assays, are needed. In vivo studies will be especially important to optimize PSA detection from clinical samples. IMPLICATIONS Researchers should consider the potential for specific lubricants or any vaginal products to affect the particular assay used for semen biomarker detection. The Abbott ARCHITECT's total PSA assay should not be used with the product Replens. Caution is warranted when using the assay in settings where Gynol or K-Y jelly may have been used.
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Affiliation(s)
- Margaret C Snead
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, and the Division of Scientific Resources, National Center for Emerging and Ζoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA 30341, USA.
| | - Johan H Melendez
- Johns Hopkins University, Department of Infectious Diseases, Baltimore, MD 21224, USA
| | - Athena P Kourtis
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, and the Division of Scientific Resources, National Center for Emerging and Ζoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA 30341, USA
| | - Dorothy M Chaney
- Johns Hopkins University, Department of Infectious Diseases, Baltimore, MD 21224, USA
| | - Teresa M Brown
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, and the Division of Scientific Resources, National Center for Emerging and Ζoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA 30341, USA
| | - Carolyn M Black
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, and the Division of Scientific Resources, National Center for Emerging and Ζoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA 30341, USA
| | - Christine K Mauck
- CONRAD, Eastern Virginia Medical School (EVMS), Arlington, VA 23501, USA
| | - Jill L Schwartz
- CONRAD, Eastern Virginia Medical School (EVMS), Arlington, VA 23501, USA
| | - Jonathan M Zenilman
- Johns Hopkins University, Department of Infectious Diseases, Baltimore, MD 21224, USA
| | - Denise J Jamieson
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, and the Division of Scientific Resources, National Center for Emerging and Ζoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA 30341, USA
| | - Maurizio Macaluso
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Gustavo F Doncel
- CONRAD, Eastern Virginia Medical School (EVMS), Arlington, VA 23501, USA
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van der Straten A, Montgomery ET, Hartmann M, Minnis A. Methodological Lessons from Clinical Trials and the Future of Microbicide Research. Curr HIV/AIDS Rep 2012. [DOI: 10.1007/s11904-012-0141-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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