Preventing Sexually Transmitted Infections and Unintended Pregnancy, and Safeguarding Fertility: Triple Protection Needs of Young Women

Assessing nurses' knowledge and attitudes towards promoting female condom use in South African primary healthcare clinics

BACKGROUND

Female condoms protect against unplanned pregnancies and sexually transmitted infections (STIs) including HIV; however, their uptake is very low in South Africa. Nurses are frontline healthcare workers and are uniquely positioned to promote their use to their clients. This study assesses nurses' knowledge of, attitudes to, and practices regarding the promotion of female condoms at selected primary healthcare facilities in the King Sabata Dalindyebo sub-district of the Eastern Cape, South Africa.

METHODS

A descriptive cross-sectional study was conducted from April to May 2021 at five community health centres in the King Sabata Dalindyebo sub-district, South Africa. A total of 139 nurses completed a self-administered questionnaire. Data were analysed using simple descriptive statistics.

RESULTS

The majority of the participants (82.7%) were knowledgeable about the female condom. Some participants did not have a good attitude and willingness to promote female condom use to their clients. Junior nurses (enrolled nursing assistants and newly qualified professional nurses) were less knowledgeable about the female condom than more qualified and older nurses. There was no significant association between level of knowledge and attitude or willingness to promote the use of the female condom.

CONCLUSION

This study found good knowledge of the female condom among the nurses; however, the knowledge did not translate into a willingness to promote the device at their health facilities. Capacity building of the junior nurses will fill the knowledge gaps identified. Studies exploring the sociocultural issues around the female condom are needed in the region.

High prevalence and incidence of gonorrhoea and chlamydia in young women eligible for HIV pre-exposure prophylaxis in South Africa and Zimbabwe: results from the HPTN 082 trial

INTRODUCTION

We investigated the prevalence, incidence and factors associated with sexually transmitted infections (STIs) among young African women seeking HIV pre-exposure prophylaxis (PrEP).

METHODS

HPTN 082 was a prospective, open-label PrEP study enrolling HIV-negative sexually active women aged 16-25 years in Cape Town and Johannesburg, South Africa, and Harare, Zimbabwe. Endocervical swabs from enrolment, months 6 and 12 were tested for Neisseria gonorrhoeae (GC) and Chlamydia trachomatis (CT) by nucleic acid amplification, and Trichomonas vaginalis (TV) by a rapid test. Intracellular tenofovir-diphosphate (TFV-DP) concentrations in dried blood spots were measured at months 6 and 12. Associations between risk characteristics and STI outcomes were assessed using Poisson regression.

RESULTS

Of 451 enrolled participants, 55% had an STI detected at least once. CT incidence was 27.8 per 100 person-years (py) (95% CI 23.1, 33.2), GC incidence was 11.4 per 100 py (95% CI 8.5, 15.0) and TV incidence was 6.7 per 100 py (95% CI 4.5, 9.5). 66% of incident infections were diagnosed in women uninfected at baseline. Baseline cervical infection (GC or CT) risk was highest in Cape Town (relative risk (RR) 2.38, 95% CI 1.35, 4.19) and in those not living with family (RR 1.87, 95% 1.13, 3.08); condom use was protective (RR 0.67, 95% CI 0.45, 0.99). Incident CT was associated with baseline CT (RR 2.01; 95% CI 1.28, 3.15) and increasing depression score (RR 1.05; 95% CI 1.01, 1.09). Incident GC was higher in Cape Town (RR 2.40; 95% CI 1.18, 4.90) and in participants with high PrEP adherence (TFV-DP concentrations ≥700 fmol/punch) (RR 2.04 95% CI 1.02, 4.08).

CONCLUSION

Adolescent girls and young women seeking PrEP have a high prevalence and incidence of curable STIs. Alternatives to syndromic management for diagnosis and treatment are needed to reduce the burden of STIs in this population.

TRIAL REGISTRATION NUMBER

NCT02732730.

Co-delivery of an HIV prophylactic and contraceptive using PGSU as a long-acting multipurpose prevention technology

OBJECTIVES

Poly(glycerol sebacate) urethane (PGSU) elastomers formulated with 4'-ethynyl-2-fluoro-2'-deoxyadenosine (EFdA), levonorgestrel (LNG), or a combination thereof can function as multipurpose prevention technology implants for prophylaxis against HIV and unintended pregnancies. For these public health challenges, long-acting drug delivery technologies may improve patient experience and adherence. Traditional polymers encounter challenges delivering multiple drugs with dissimilar physiochemical properties. PGSU offers an alternative option that successfully delivers hydrophilic EFdA alongside hydrophobic LNG.

METHODS

This article presents the formulation, design, and characterization of PGSU implants, highlighting the impact of API loading, dimensions, and individual- versus combination-loading on release rates.

RESULTS

Co-delivery of hydrophilic EFdA alongside hydrophobic LNG acted as a porogen to accelerate LNG release. Increasing the surface area of LNG-only implants increased LNG release. All EFdA-LNG, EFdA-only, and LNG-only formulated implants demonstrated low burst release and linear release kinetics over 245 or 122 days studied to date.

CONCLUSION

PGSU co-delivers two APIs for HIV prevention and contraception at therapeutically relevant concentrations in vitro from a single bioresorbable, elastomeric implant. A new long-acting polymer technology, PGSU demonstrates linear-release kinetics, dual delivery of APIs with disparate physiochemical properties, and biocompatibility through long-term subcutaneous implantation. PGSU can potentially meet the demands of complex MPT or fixed-dose combination products, where better solutions can serve and empower patients.

Unintended Pregnancy and Associated Factors among Women Who Live in Ilu Gelan District, Western Ethiopia, 2021

Background

The World Health Organization Report noted that unintended pregnancy is the most common cause of maternal mortality in developing countries. Most unintended pregnancies occur where access to maternal care is limited, and because of this, many mothers lose their life. Therefore, this study was an attempt to assess the proportion of unintended pregnancy and associated factors among women who live in Ilu Gelan District, Western Ethiopia, 2021.

Method

A community-based cross-sectional study was conducted in the rural and urban kebeles of Ilu Gelan Woreda West Shoa Zone, Ethiopia, from March 1 to 30, 2021. The study population consists of 540 pregnant women who were living in Ilu Gelan Woreda for at least the last six months during the data collection period. Simple random sampling by lottery method was used to recruit the study subject. Data were checked, coded, entered to EpiData version 3, and then exported to SPSS version 25 for analysis. Both descriptive and analytical statistical procedures were utilized. Both bivariable and multivariable logistic regressions was implemented.

Result

In this study, the proportion of unintended pregnancy was found to be 55%, at 95% CI: 50.7-59.3. Multivariable logistic regression results showed that married women (AOR = 0.117, CI: 0.04-0.38), monthly income less than 1000 Ethiopian Birr (AOR = 4.93, CI: 1.72-14.09), gravidity greater than or equal to five (AOR = 6.07, CI: 2.4-15.28), birth interval less than 2 years (AOR = 3.35 (1.44-7.8)), lack of awareness about contraceptive (AOR = 2.06 (1.03-4.15)), and husband decision-making on health care (AOR = 11.1 (2.07-59.51)) were significantly associated with unintended pregnancy. Conclusion and Recommendation. This study indicated that more than half of pregnant women reported that their current pregnancy was found to be unintended pregnancy. Married women, family monthly income less than 1000 Ethiopian Birr, gravidity greater than or equal to five, birth space less than two years, lack of contraceptive awareness, and health care decisions by husband only showed a significant association with unintended pregnancy. To decrease the current level of unintended pregnancy, all concerned stakeholders should emphatically consider those identified factors for intervention; specifically, Ilu Gelan District Health Bureau and health providers should empower women with health education about family planning and decision-making related to their health issues in the study area.

Experiences with simultaneous use of contraception and the vaginal ring for HIV prevention in sub-Saharan Africa

BACKGROUND

Clinical trials have found that a monthly dapivirine vaginal ring was well-tolerated and reduced HIV-1 risk among women in sub-Saharan Africa. However, in order for the ring or other novel prevention methods to have optimal impact, it is necessary to understand and address women's challenges to uptake and adherence. This paper provides insight into a few key challenges noted by women using the ring and contraceptives simultaneously.

METHODS

The qualitative portion of the MTN-020/ASPIRE study consisted of data collection using single in-depth interviews, serial in-depth interviews, and focus group discussions, conducted with 214 participants across 15 sites in Malawi, South Africa, Uganda and Zimbabwe. A coding team used qualitative analysis software to identify themes within the interviews.

RESULTS

The primary qualitative themes among participant data pertained to side effects. Participants reported negative side effects related to menses, in some cases attributing these effects to their contraceptives and in others to the vaginal ring. Participants also expressed concern over the long-term impact of contraception and ring use on fertility, including the reversibility of the contraceptive, especially among nulliparous women.

CONCLUSIONS

Women's attitudes toward contraceptives can impact their willingness to concurrently use and adhere to a novel HIV prevention product. To optimize the potential of both prevention products, researchers should pre-emptively address concerns about contraceptive impact on fertility and counsel women about the expected side effects of contraceptives versus the ring. Clinical trials identifier NCT01617096. Registered on 6-12-2012 at clinicaltrials.gov https://clinicaltrials.gov/ct2/show/NCT01617096.

Fertility awareness and parenting intentions among Mexican undergraduate and graduate university students

An online, cross-sectional survey was carried out between November 2017 and January 2018 to assess fertility awareness among students attending the National Autonomous University of Mexico (UNAM) in Mexico City. A total of 371 students participated in the survey (n = 228 females, 143 males). 75% of females and 74% of males believed a woman's fertility begins to decline markedly after age 40. Over 75% of all participants overestimated the probability of couples having a live birth after undergoing one cycle of IVF. With regard to parenting intentions, only 48% of females wished to have children compared to 59% of males (p = 0.037) and men were more likely to have their first child at age 30 or later (71% men vs 55% women). In the event of infertility, participants had a higher preference not to have children or to pursue adoption rather than use in vitro fertilisation (IVF). In summary, university students in Mexico City demonstrated low levels of fertility awareness and a smaller proportion indicated a wish to have children than has been reported by young people elsewhere in the world.

Demographic and sexual risk predictors of delay discounting of condom-protected sex

Objective: Sexual delay discounting describes the decreased likelihood of condom-protected sex if a condom is not immediately available, which can be quantitatively summarised using the Sexual Delay Discounting Task (SDDT). The present studies determined the extent to which condom use likelihood as assessed by the SDDT is associated with self-reported sexual risk behaviours and demographics in two online samples of adults. Design: Study 1 (n = 767) assessed demographics, sexual risk behaviour, and delay discounting, and examined relations between these variables using correlation and regression. Study 2 (n = 267) examined whether real-world instances of unprotected sex because a condom was not immediately available predicted greater sexual discounting. Main outcome measures: Sexual delay discounting, condom use. Results: Both studies observed significant positive relations between sexual delay discounting and self-reported sexual risk behaviours, and found that males tended to show greater sexual discounting. In Study 2, 46% of the sample self-reported having unprotected sex because a condom was not immediately available, and these individuals showed significantly greater sexual delay discounting. Conclusion: These results extend prior findings by demonstrating that delay is a critical variable underlying real-life sexual risk behaviour among non-clinical samples. The SDDT is an ecologically valid measure of these processes.

RISK FACTORS FOR FEMALE INFERTILITY AT A TERTIARY HEALTH FACILITY IN AKURE, SOUTH-WEST NIGERIA

Background. The inability of couples to achieve pregnancy is a major cause of psycho-social problems in family relationship that could lead to marital disharmony. Objective. The aim of this study was to find out the possible risk factors for female infertility. Methods. A case-control design and a sample size of 400 (200 cases of infertility and 200 controls) were used in the study. Cases and controls were selected at random at the infertility and family planning clinic of the University of Medical Sciences Teaching Hospital Complex, Akure and were subjected to a predesigned interviewer administered questionnaire to collect the data. The cases were classified into primary and secondary infertility; binary and stepwise logistic regressions were used to generate the Odds ratio and 95% confidence interval of the possible risk factors and the level of significance was set at P<0.05. Results. The mean age of the women with infertility was 28.5±5.43 years and the mean age of those in the control group was 29.1±5.62 years. Among the cases, 155 (77.5%) had secondary infertility, while 45 (22.5%) had primary infertility. Significant risk factors for female infertility included presence of fibroids, having had fibroid operation, multiple sexual partners, previous abortion, polycystic ovary syndrome (PCOS), sexually transmitted infection (STI) and post abortion sepsis. Conclusion. The study showed that secondary infertility is still the most prevalent and the risk factors were multi factorial. Efforts should be intensified to reduce infertility due to preventable causes.

pH-responsive delivery of Griffithsin from electrospun fibers

Human immunodeficiency virus (HIV-1) affects over 36 million people globally. Current prevention strategies utilize antiretrovirals that have demonstrated protection, but result in antiviral resistance, adverse toxicity, and require frequent administration. A novel biologic, griffithsin (GRFT), has demonstrated outstanding safety and efficacy against laboratory and primary HIV isolates and against intravaginal murine herpes simplex virus 2 (HSV-2) challenge, making it a promising microbicide candidate. However, transient activity and instability remain concerns surrounding biologic delivery, particularly in the harsh environment of the female reproductive tract (FRT). Recently, electrospun fibers (EFs) have demonstrated promise for intravaginal delivery, with the potential to conserve active agent until release is needed. The goal of this study was to fabricate and characterize pH-responsive fibers comprised of poly(lactic-co-glycolic acid) (PLGA) or methoxypolyethylene glycol-b-PLGA (mPEG-PLGA) with varying ratios of poly(n-butyl acrylate-co-acrylic acid) (PBA-co-PAA), to selectively release GRFT under pH-conditions that mimic semen introduction. Fibers comprised of mPEG-PLGA:PBA-co-PAA (90:10 w/w) demonstrated high GRFT loading that was maintained within simulated vaginal fluid (SVF), and pH-dependent release upon exposure to buffered and SVF:simulated semen solutions. Moreover, GRFT fibers demonstrated potent in vitro efficacy against HIV-1 and safety in vaginal epithelial cells, suggesting their future potential for efficacious biologic delivery to the FRT.

Evaluation of poly(lactic-co-glycolic acid) and poly(dl-lactide-co-ε-caprolactone) electrospun fibers for the treatment of HSV-2 infection

More diverse multipurpose prevention technologies are urgently needed to provide localized, topical pre-exposure prophylaxis against sexually transmitted infections (STIs). In this work, we established the foundation for a multipurpose platform, in the form of polymeric electrospun fibers (EFs), to physicochemically treat herpes simplex virus 2 (HSV-2) infection. To initiate this study, we fabricated different formulations of poly(lactic-co-glycolic acid) (PLGA) and poly(dl-lactide-co-ε-caprolactone) (PLCL) EFs that encapsulate Acyclovir (ACV), to treat HSV-2 infection in vitro. Our goals were to assess the release and efficacy differences provided by these two different biodegradable polymers, and to determine how differing concentrations of ACV affected fiber efficacy against HSV-2 infection and the safety of each platform in vitro. Each formulation of PLGA and PLCL EFs exhibited high encapsulation efficiency of ACV, sustained-delivery of ACV through one month, and in vitro biocompatibility at the highest doses of EFs tested. Additionally, all EF formulations provided complete and efficacious protection against HSV-2 infection in vitro, regardless of the timeframe of collected fiber eluates tested. This work demonstrates the potential for PLGA and PLCL EFs as delivery platforms against HSV-2, and indicates that these delivery vehicles may be expanded upon to provide protection against other sexually transmitted infections.

Griffithsin-Modified Electrospun Fibers as a Delivery Scaffold To Prevent HIV Infection

Despite current prophylactic strategies, sexually transmitted infections (STIs) remain significant contributors to global health challenges, spurring the development of new multipurpose delivery technologies to protect individuals from and treat virus infections. However, there are few methods currently available to prevent and no method to date that cures human immunodeficiency virus (HIV) infection or combinations of STIs. While current oral and topical preexposure prophylaxes have protected against HIV infection, they have primarily relied on antiretrovirals (ARVs) to inhibit infection. Yet continued challenges with ARVs include user adherence to daily treatment regimens and the potential toxicity and antiviral resistance associated with chronic use. The integration of new biological agents may avert some of these adverse effects while also providing new mechanisms to prevent infection. Of the biologic-based antivirals, griffithsin (GRFT) has demonstrated potent inhibition of HIV-1 (and a multitude of other viruses) by adhering to and inactivating HIV-1 immediately upon contact. In parallel with the development of GRFT, electrospun fibers (EFs) have emerged as a promising platform for the delivery of agents active against HIV infection. In the study described here, our goal was to extend the mechanistic diversity of active agents and electrospun fibers by incorporating the biologic GRFT on the EF surface rather than within the EFs to inactivate HIV prior to cellular entry. We fabricated and characterized GRFT-modified EFs (GRFT-EFs) with different surface modification densities of GRFT and demonstrated their safety and efficacy against HIV-1 infection in vitro We believe that EFs are a unique platform that may be enhanced by incorporation of additional antiviral agents to prevent STIs via multiple mechanisms.

Exploring Infertility from the Cultural Context of Latino College Students: Results from a Preliminary Focus Group

Despite a racial/ethnic disparity, little research has examined minority group perceptions of infertility. After developing a 15-question English-language focus group guide, 13 Latino college students (ages 19-22) at a Midwestern university were recruited to participate in a focus group to discuss their perceptions of infertility in the context of their family and culture. The focus group was audio recorded, professionally transcribed, and analyzed according to the constructed Grounded Theory approach. Three major themes were identified: 1) infertility is not considered when looking towards the future; 2) infertility is not discussed due to shame; and 3) infertility does not require a medical resolution. College students have the opportunity to make lifestyle modifications that can optimize fertility, but intention to change behavior is contingent on accurate fertility knowledge, which is often influenced by cultural norms. Our results suggest that these Latino students do not consider infertility a risk in their future lives nor is infertility something they consider should be explicitly discussed. Importantly, they do not perceive the need for medical interventions when addressing infertility, which carries implications for treatment seeking. When creating educational interventions for infertility, it is important to take into account the cultural lens through which infertility is understood.

Aligning product development and user perspectives: social-behavioural dimensions of multipurpose prevention technologies

Multipurpose prevention technologies provide a compelling response to the multiple and reinforcing sexual and reproductive health risks faced by women globally. To ensure that this potential is realised, product-specific characteristics and their social-behavioural correlates must be considered early in the product development process. This paper provides an overview of the key user-related social and behavioural dimensions of three broad categories of multipurpose prevention technologies: 1) sustained release vaginal rings, 2) pericoital vaginal products, and 3) co-formulated or co-administered injectables. The authors build upon the broad parameters of Target Product Profiles for such products, aligning them with user perspective considerations.

Perception of susceptibility to the negative outcomes associated with unprotected sex among University of Venda students

Objectives: The purpose of this study was to determine the perception of University of Venda students on their susceptibility to the negative outcomes associated with unprotected sex.

Methods: This cross sectional study involved 408 (206 females and 202 males) University of Venda students residing within the university campus. Simple and systematic sampling methods were used to select participants. A 4-likert scaled self-administered questionnaire was used for data collection and a cut-off point of 75% of the total scores was used as criteria for assessing perception.

Results: Majority (90.90%) of the participants understood the magnitude and problems posed by HIV and other sexually transmitted infection in the society, 94.60% believe that anyone can be infected with HIV or fall pregnant when exposed to unprotected sex. Majority (87.30%) believed that alcohol consumption while engaging in sexual activities increases the chances of being infected with HIV, other STI or falling pregnant, 92.40% believed that having multiple sexual partnerships increases the risk of being infected with HIV and other sexually transmitted infections. Eighty six percent of participants agreed or strongly agreed that pregnancy could occur with one sexual intercourse in a month and only 68.45% of the participants believed that practising oral sex could expose them to HIV infection (with no significant difference between male and female).

Conclusion: Majority of the students showed high perception regarding their susceptibility to the negative outcomes associated with unprotected sex, especially when they consume alcohol while engaging in sexual activities and when having multiple sexual partnerships. Contrastingly, the students demonstrated low perception regarding susceptibility to HIV transmission through the practice of oral sex. There is a need to create awareness on the dangers posed by the practise of oral sex.

Multipurpose prevention technologies: products in development

Multipurpose prevention technologies (MPTs) are broadly defined as products capable of simultaneously addressing multiple sexual and reproductive health needs including unintended pregnancy, STIs including HIV-1, and other reproductive tract infections. MPTs have been discussed for a few decades but little product development has occurred. With the recent proof-of-concept that a topically applied antiretroviral (ARV) can effectively reduce sexual transmission of HIV-1 (tenofovir 1% gel) the impetus to develop MPTs is gaining momentum. Products currently in development are broadly categorized as either long-acting or on-demand. Long-acting MPTs include intravaginal rings (IVRs) and long-acting injectable products. Several IVR MPTs are under development including one designed to release tenofovir to prevent transmission of HIV-1 and levonorgestrel (LNG) to prevent unintended pregnancy over a 90-day period. Another MPT IVR under development is designed to release the ARV dapivirine and LNG for 2 months. Long-acting injectable pre-exposure prophylaxis (PrEP) formulations of rilpivirine (TMC278) and GSK1265744 have entered clinical evaluation and could form the basis of long-acting injectable products for HIV-1 prevention and prevention of unintended pregnancy. On-demand products include TFV 1% gel (HIV-1/HSV-2 prevention), a zinc/carrageenan zinc gel (HIV-1/HSV-2 prevention), and the SILCS diaphragm administered with TFV 1% gel. Significant technical, funding, and regulatory hurdles must be overcome to develop most MPTs; however, the significant reproductive health benefits to many women around the world should provide motivation to overcome these hurdles. This article is based on a presentation at the "Product Development Workshop 2013: HIV and Multipurpose Prevention Technologies", held in Arlington, Virginia on February 21-22, 2013. It forms part of a special supplement to Antiviral Research.

Barriers to use of modern contraceptives among women in an inner city area of Osogbo metropolis, Osun state, Nigeria

Objectives

To determine the knowledge and attitudes on modern contraceptive use of women living in an inner city area of Osogbo.

Materials and methods

Three hundred and fifty nine women of childbearing age were studied utilizing a community-based, descriptive, cross-sectional study design. A multistage random sampling technique was used in recruiting respondents to the study. A four-part questionnaire was applied dually, by interviewers and by respondents’ self administration, and the data was analyzed using the SPSS software version 17.0.

Results

The mean age of respondents was 28.6 ± 6.65 years. The majority (90.3%) of respondents were aware of modern methods of family planning (FP), 76.0% claimed awareness of where to obtain FP services, and 74.9% knew of at least five methods. However, only 30.6% had ever used contraceptives, while only 13.1% were current users. The most frequently used method was the male condom. The commonly perceived barriers accounting for low use of FP methods were fear of perceived side effects (44.0%), ignorance (32.6%), misinformation (25.1%), superstition (22.0%), and culture (20.3%). Some reasons were proffered for respondents’ nonuse of modern contraception. Predictors of use of modern contraceptives include the awareness of a place of FP service provision, respondents’ approval of the use of contraceptives, higher education status, and being married.

Conclusion

Most of the barriers reported appeared preventable and removable and may be responsible for the reported low point prevalence of use of contraceptives. It is recommended that community-based behavioral-change communication programs be instituted, aimed at improving the perceptions of women with respect to bridging knowledge gaps about contraceptive methods and to changing deep-seated negative beliefs related to contraceptive use in Nigeria.

University students' perceptions of environmental risks to infertility

BACKGROUND

Canadian young adults may be at risk of future infertility due to the high incidence of sexually transmissible infections (STIs) in this population. Young adults' perceptions of environmental risks, including contaminants, STIs and lifestyle habits on infertility, have not been examined. We have therefore designed a qualitative study to explore risk perceptions, awareness and knowledge of common environmental risk factors for infertility in a multiethnic sample of young adults.

METHODS

Semistructured interviews were carried out with 40 university undergraduate students (16 men and 24 women) in Ottawa, Canada, followed by qualitative analysis of interview transcripts to identify major themes.

RESULTS

The following broad themes described participants' risk perceptions about infertility and (1) environmental contaminants: knowledge gaps, media reports and negative perception of chemicals; (2) STIs: superficial understanding of their role in infertility, general awareness, associations with sexual behaviours and knowledge gaps; and (3) lifestyle: protective benefits of healthy lifestyle, dose or exposure effects for smoking and alcohol, and knowledge gaps. Students demonstrated a superficial understanding of environmental risks, at times relying on media reports and anecdotal information to support their beliefs.

CONCLUSIONS

This next generation of potential infertility patients exhibits a general understanding of environmental risks to infertility; however, young adults are overly optimistic that healthy lifestyle behaviours will safeguard future fertility. STIs represent the most significant modifiable risk factors for this age group; a message that can be supported by sexual and reproductive health education and promotion with greater emphasis on the long-term outcomes of STIs, including infertility.

Drug delivery in multiple indication (multipurpose) prevention technologies: systems to prevent HIV-1 transmission and unintended pregnancies or HSV-2 transmission

INTRODUCTION

The development of multiple indication (multipurpose) prevention technologies (MIPTs) is driven by overlapping relationships in the area of female reproductive health.

AREAS COVERED

In this review, the basis for MIPTs is detailed. The current state of the field for the use of drug delivery in novel MIPTs is covered. Of particular interest is the application of intravaginal rings (IVRs) for the delivery of two drugs simultaneously, to prevent one STI and pregnancy, or two STIs. IVRs are currently available commercially for contraception and have been developed for release of microbicides to prevent sexual transmission of HIV-1. Novel IVRs capable of releasing relatively large amounts of drugs such as tenofovir are discussed, along with those that contain independent delivery elements, such as pods, that can be used to release drugs at independent rates. The vaginal administration of macromolecules (antibodies and vaccines) is also reviewed in the context of MIPTs.

EXPERT OPINION

The field of MIPTs remains one of potential. There is yet to be a proven microbicide effective at preventing sexual transmission of HIV-1. Development of MIPTs in the near term will proceed under the assumption that one or more antiretroviral (ARV) drugs will eventually be proven successful. IVRs have already demonstrated success in the area of contraception. Prevention of sexual transmission of HIV-1 and herpes simplex virus-2 (HSV-2) (or suppression of recurrence) remains an attractive MIPT target. In the long term, development of MIPTs will require validation of surrogate end points, particularly for prevention of HIV-1 transmission.

Missed conceptions or misconceptions: perceived infertility among unmarried young adults in the United States

CONTEXT

Perceived infertility is an individual's belief that she or he is unable to conceive or impregnate, regardless of whether this belief is medically accurate. This perception may lead to contraceptive nonuse, which may, in turn, lead to unintended pregnancy. Little research has examined perceived infertility among young adults, including potential associations with contraceptive behaviors.

METHODS

The frequency of perceived infertility among young adults was assessed using 2009 data from a nationally representative telephone survey of 1,800 unmarried men and women aged 18-29. Multinomial regression analyses assessed associations between respondents' perceived infertility and selected background, reproductive knowledge, sexual experience and contraceptive use characteristics.

RESULTS

Overall, 19% of women and 13% of men believed that they were very likely to be infertile. Hispanic women and women who had received public assistance in the past year had elevated odds of perceived infertility (odds ratios, 3.4 and 3.0, respectively), as did Hispanic men and men of other racial or ethnic minorities, except blacks (2.5 and 6.1, respectively). Men who had some college education, had received sex education or were not in a current relationship had decreased odds of thinking they were very likely to be infertile (0.3-0.4). Among men, perceived infertility was associated with the belief that they were likely to have sex without using a contraceptive in the next three months (2.6).

CONCLUSIONS

A substantial proportion of young adults believe they are infertile. Improved provider counseling and sex education may be useful in helping them to better understand their actual probability of infertility, and this knowledge may lead to improved contraceptive use.

Dual use of condoms and contraceptives in the USA

Background Use of condoms in conjunction with other contraceptive methods has multiple benefits: prevention of unintended pregnancy, protection against sexually transmissible infections (STI), and sequentially, defence against the threat of infertility. However, few reviews compare dual method use prevalence or trends or systematically review the facilitators and barriers of dual method use across multiple studies. Methods: The authors review the literature on trends and covariates of dual method use in the USA among both nationally representative and smaller samples. Results: Although dual method use prevalence estimates vary widely across study populations, nationally representative estimates are consistently lower than Western European countries, who in turn report lower rates of unintended pregnancies and STI. The majority of published work on dual method use focuses on adolescents. Prior studies have associated dual method use with a range of individual-level factors: socio-demographic variables, such as younger age; STI risk behaviours and risk perception; relationship variables, such as number of partners, relationship length, and partner support of condoms; and educational factors, such as prior exposure to HIV prevention messages. Conclusions: Although dual method use appears to be on the rise, especially among adolescents and young adults, US rates are comparatively low and leave much room for improvement. This review identifies several populations most in need of intervention. However, we encourage public health practitioners to evolve beyond individual-level studies and interventions to focus on the relational, socio-cultural, and structural influences on dual method use. Dual use promotion programs and policies should also equally target men and women, adolescents and adults.

The risk factor profile of women with secondary infertility: an unmatched case-control study in Kigali, Rwanda

Background

Secondary infertility is a common, preventable but neglected reproductive health problem in resource-poor countries. This study examines the association of past sexually transmitted infections (STIs) including HIV, bacterial vaginosis (BV) and factors in the obstetric history with secondary infertility and their relative contributions to secondary infertility.

Methods

Between November 2007 and May 2009 a research infertility clinic was set up at the Kigali University Teaching Hospital in Rwanda. Cases were defined as sexually-active women aged 21-45 years presenting with secondary infertility (n = 177), and controls as multiparous women in the same age groups who recently delivered (n = 219). Participants were interviewed about socio-demographic characteristics and obstetric history using structured questionnaires, and were tested for HIV and reproductive tract infections (RTIs).

Results

Risk factors in the obstetric history for secondary infertility were lack of prenatal care in the last pregnancy, the first pregnancy before the age of 21 years, a history of unwanted pregnancy, a pregnancy with other than current partner, an adverse pregnancy outcome, stillbirth, postpartum infection and curettage. Presence of HIV, herpes simplex virus type 2 (HSV-2), or Treponema pallidum antibodies, and bacterial vaginosis (BV), were significantly more common in women in secondary infertile relationships than those in fertile relationships. The population attributable fractions (PAF%) for obstetric events, HIV, other (STIs), and BV were 25%, 30%, 27%, and 14% respectively.

Conclusions

The main finding of this study is that obstetric events, HIV and other STIs contribute approximately equally to secondary infertility in Rwanda. Scaling up of HIV/STI prevention, increased access to family planning services, improvement of prenatal and obstetric care and reduction of stillbirth and infant mortality rates are all likely to decrease secondary infertility in sub-Saharan Africa.

Gender differences and factors associated with treatment-seeking behaviour for infertility in Rwanda

BACKGROUND

This study examines perceptions of infertility causes, treatment-seeking behaviour and factors associated with seeking medical care in an urban infertile population in Rwanda, as well as the response of health providers.

METHODS

Between November 2007 and May 2009 a hospital based survey was conducted among 312 women and 254 male partners in an infertile relationship.

RESULTS

Infertility causes based on a medical diagnosis were mentioned by 24% of women and 17% of men. Male infertility awareness was low in both sexes with 28% of men and 10% of women reporting male-related causes. Seventy-four per cent of women and 22% of men had sought care for their infertility in the past. Seeking treatment in the formal medical sector was associated with higher income, being married and infertility duration of more than 5 years in both sexes. In women, higher education and being nulliparous and in men blaming oneself for the infertility was also associated with seeking formal medical care. Participants reported a wide array of treatments they received in the past, often including ineffective or even harmful interventions.

CONCLUSION

Health authorities should invest in improving information, education and counselling on issues pertaining to causes and treatments of infertility, and in drawing up guidelines for the management of infertility at all levels of health care.

Fertility desires and infection with the HIV: results from a survey in rural Uganda

OBJECTIVE

To determine how a positive HIV diagnosis influences fertility desires and reproductive decisions for women and men living in western Uganda.

DESIGN

: Cross-sectional survey comparing two groups of participants: those who tested HIV-positive and those who tested HIV-negative.

METHODS

Semistructured interviews were conducted with 421 individuals living in rural areas. Descriptive, bivariate and multivariate methods were used to analyze the relationship of the HIV status to the desire to stop childbearing, reproductive decision-making and to the use of family planning methods.

RESULTS

The multivariate logistic regression model indicated that the odds ratio (OR) of wanting to stop childbearing was found to be 6.25 times greater (P < 0.01) for HIV-positive than for HIV-negative individuals. Additional predictors included older age (OR 1.13, P < 0.01), female sex (OR 2.42, P = 0.03), Mutooro ethnic group (OR 3.20, P < 0.01) and greater number of living children (OR 1.62, P < 0.01). Use of dual protection against HIV/sexually transmitted infection and unwanted pregnancy was rare in both groups with seven HIV-positive participants (3.5%) using two contraceptives compared with only one (0.4%) in the HIV-negative group. The unmet need for a highly effective family planning method was higher in HIV-positive participants compared with HIV-negative ones (90 vs. 78%).

CONCLUSION

HIV-positive individuals in the Kabarole region have a much greater desire to stop childbearing than their HIV-negative counterparts. The barriers to utilizing family planning services, as evidenced through the very low use of highly effective contraceptive methods, have to be jointly addressed by HIV/AIDS care/prevention and family planning programs.

Limits to modern contraceptive use among young women in developing countries: a systematic review of qualitative research

Background

Improving the reproductive health of young women in developing countries requires access to safe and effective methods of fertility control, but most rely on traditional rather than modern contraceptives such as condoms or oral/injectable hormonal methods. We conducted a systematic review of qualitative research to examine the limits to modern contraceptive use identified by young women in developing countries. Focusing on qualitative research allows the assessment of complex processes often missed in quantitative analyses.

Methods

Literature searches of 23 databases, including Medline, Embase and POPLINE^®, were conducted. Literature from 1970–2006 concerning the 11–24 years age group was included. Studies were critically appraised and meta-ethnography was used to synthesise the data.

Results

Of the 12 studies which met the inclusion criteria, seven met the quality criteria and are included in the synthesis (six from sub-Saharan Africa; one from South-East Asia). Sample sizes ranged from 16 to 149 young women (age range 13–19 years). Four of the studies were urban based, one was rural, one semi-rural, and one mixed (predominantly rural). Use of hormonal methods was limited by lack of knowledge, obstacles to access and concern over side effects, especially fear of infertility. Although often more accessible, and sometimes more attractive than hormonal methods, condom use was limited by association with disease and promiscuity, together with greater male control. As a result young women often relied on traditional methods or abortion. Although the review was limited to five countries and conditions are not homogenous for all young women in all developing countries, the overarching themes were common across different settings and contexts, supporting the potential transferability of interventions to improve reproductive health.

Conclusion

Increasing modern contraceptive method use requires community-wide, multifaceted interventions and the combined provision of information, life skills, support and access to youth-friendly services. Interventions should aim to counter negative perceptions of modern contraceptive methods and the dual role of condoms for contraception and STI prevention should be exploited, despite the challenges involved.

Sexual risk reduction needs of adolescents living with HIV in a clinical care setting

As anti-retroviral therapy becomes increasingly available, young people living with HIV need tailored support to adopt healthy sexual behaviors. There has been a gap in the availability of culturally appropriate techniques for secondary prevention and sexual risk reduction in this target group. This formative study assessed sexual and reproductive health needs and problems, as well as determinants of sexual risk-taking among young people living with HIV aged 11-21 years attending the Paediatric Infectious Disease Clinic in Kampala, Uganda. Theoretical guidance was provided by the Information-Motivation-Behavioral Skills Model. Socio-demographic and selected psychosexual data were assessed using a brief anonymous questionnaire. A total of 75 young people living with HIV participated in eight focus group discussions. In addition, one focus group was conducted with adult key informants (service providers). About a quarter of the young participants reported prior or current sexual experience. The study revealed knowledge gaps relating to reproductive health, HIV transmission, and contraceptive methods. Motivations for protection included hope for the future, good counseling, and fear of the consequences of sexual activity such as unwanted pregnancies. Barriers to adopting preventive behaviors included peer pressure, poverty, HIV-related stigma, ignorance of their partners, alcohol use, and a desire to have children for the older ones. Young sero-positive people in this setting lacked specific behavioral skills, such as disclosure of HIV status to their sexual partners, this being closely linked to fear of rejection and stigma. HIV-positive youths need support in developing the appropriate behavioral skills to adopt healthy sexual behaviors. Interventions in this field need to be developmentally appropriate and tailored to young people's specific needs. Structural interventions should at the same time address and reduce HIV-related stigma and socio-economic needs of young people living with HIV.

Reproductive Choice for Women and Men Living with HIV: Contraception, Abortion and Fertility

From a policy and programmatic point of view, this paper reviews the literature on the fertility-related needs of women and men living with HIV and how the entry points represented by family planning, sexually transmitted infection and HIV-related services can ensure access to contraception, abortion and fertility services for women and men living with HIV. Most contraceptive methods are safe and effective for HIV positive women and men. The existing range of contraceptive options should be available to people living with HIV, along with more information about and access to emergency contraception. Potential drug interaction must be considered between hormonal contraception and treatment for tuberculosis and certain antiretroviral drugs. Couples living with HIV who wish to use a permanent contraceptive method should have access to female sterilisation and vasectomy in an informed manner, free of coercion. How to promote condoms and dual protection and how to make them acceptable in long term-relationships remains a challenge. Both surgical and medical abortion are safe for women living with HIV. To reduce risk of vertical transmission of HIV and in cases of infertility, people with HIV should have access to sperm washing and other assisted conception methods, if these are available. Simple and cost-effective procedures to reduce risk of vertical transmission should be part of counselling for women and men living with HIV who intend to have children. Support for the reproductive rights of people with HIV is a priority. More operations research on best practices is needed.

Contraception today

Modern contraceptive methods represent more than a technical advance: they are the instrument of a true social revolution-the "first reproductive revolution" in the history of humanity, an achievement of the second part of the 20th century, when modern, effective methods became available. Today a great diversity of techniques have been made available and-thanks to them, fertility rates have decreased from 5.1 in 1950 to 3.7 in 1990. As a consequence, the growth of human population that had more than tripled, from 1.8 to more than 6 billion in just one century, is today being brought under control. At the turn of the millennium, all over the world, more than 600 million married women are using contraception, with nearly 500 million in developing countries. Among married women, contraceptive use rose in all but two developing countries surveyed more than once since 1990. Among unmarried, sexually active women, it grew in 21 of 25 countries recently surveyed. Hormonal contraception, the best known method, first made available as a daily pill, can today be administered through seven different routes: intramuscularly, intranasally, intrauterus, intravaginally, orally, subcutaneously, and transdermally. In the field of oral contraception, new strategies include further dose reduction, the synthesis of new active molecules, and new administration schedules. A new minipill (progestin-only preparation) containing desogestrel has been recently marketed in a number of countries and is capable of consistently inhibiting ovulation in most women. New contraceptive rings to be inserted in the vagina offer a novel approach by providing a sustained release of steroids and low failure rates. The transdermal route for delivering contraceptive steroids is now established via a contraceptive patch, a spray, or a gel. The intramuscular route has also seen new products with the marketing of improved monthly injectable preparations containing an estrogen and a progestin. After the first device capable of delivering progesterone directly into the uterus was withdrawn, a new system releasing locally 20 microg evonorgestrel is today marketed in a majority of countries with excellent contraceptive and therapeutic performance. Finally, several subcutaneously implanted systems have been developed: contraceptive "rods," where the polymeric matrix is mixed with the steroid and "capsules" made of a hollow polymer tube filled with free steroid crystals. New advances have also been made in nonhormonal intrauterine contraception with the development of "frameless" devices. The HIV/AIDS pandemic forced policy makers to look for ways to protect young people from sexually transmitted diseases as well as from untimely pregnancies. This led to the development of the so-called dual protection method, involving the use of a physical barrier (condom) as well as that of a second, highly effective contraceptive method. More complex is the situation with antifertility vaccines, still at a preliminary stage of development and unlikely to be in widespread use for years to come. Last, but not least, work is in progress to provide effective emergency contraception after an unprotected intercourse. Very promising in this area is the use of selective progesterone receptor modulators (antiprogestins).

The contribution of sexual and reproductive health services to the fight against HIV/AIDS: a review

Approximately 80% of HIV cases are transmitted sexually and a further 10% perinatally or during breastfeeding. Hence, the health sector has looked to sexual and reproductive health programmes for leadership and guidance in providing information and counselling to prevent these forms of transmission, and more recently to undertake some aspects of treatment. This paper reviews and assesses the contributions made to date by sexual and reproductive health services to HIV/AIDS prevention and treatment, mainly by services for family planning, sexually transmitted infections and antenatal and delivery care. It also describes other sexual and reproductive health problems experienced by HIV-positive women, such as the need for abortion services, infertility services and cervical cancer screening and treatment. This paper shows that sexual and reproductive health programmes can make an important contribution to HIV prevention and treatment, and that STI control is important both for sexual and reproductive health and HIV/AIDS control. It concludes that more integrated programmes of sexual and reproductive health care and STI/HIV/AIDS control should be developed which jointly offer certain services, expand outreach to new population groups, and create well-functioning referral links to optimize the outreach and impact of what are to date essentially vertical programmes.