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Husnik MJ, Heffron R, Hughes JP, Richardson B, van der Straten A, Palanee-Phillips T, Soto-Torres L, Singh D, Mirembe BG, Livant E, Gaffoor Z, Mansoor LE, Siva SS, Dadabhai S, Kiweewa FM, Baeten JM. Efficacy of the Dapivirine Vaginal Ring Accounting for Imperfect Adherence. AIDS Behav 2024:10.1007/s10461-024-04463-3. [PMID: 39158801 DOI: 10.1007/s10461-024-04463-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/02/2024] [Indexed: 08/20/2024]
Abstract
Product adherence is critical to obtaining objective estimates of efficacy of pre-exposure prophylactic interventions against HIV-1 infection. With imperfect adherence, intention-to-treat analyses assess the collective effects of complete, sub-optimal and non-adherence, providing a biased and attenuated estimate of the average causal effect of an intervention. Using data from the MTN-020/ASPIRE phase III trial evaluating HIV-1 efficacy of the dapivirine vaginal ring, we conducted per-protocol, and adherence-adjusted causal inference analyses using principal stratification and marginal structural models. We constructed two adherence cut offs of ≥ 0.9 mg (low cutoff) and > 4.0 mg (high cutoff) that represent drug released from the ring over a 28-day period. The HIV-1 efficacy estimate (95% CI) was 30.8% (3.6%, 50.3%) (P = 0.03) from the per-protocol analysis, and 53.6% (16.5%, 74.3%) (P = 0.01) among the highest predicted adherers from principal stratification analyses using the low cutoff. Marginal structural models produced efficacy estimates (95% CIs) ranging from 48.8 (21.8, 66.4) (P = 0.0019) to 56.5% (32.8%, 71.9%) (P = 0.0002). Application of adherence-adjusted causal inference methods are useful in interpreting HIV-1 efficacy in secondary analyses of PrEP clinical trials.
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Affiliation(s)
- Marla J Husnik
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Statistical Center for HIV/AIDS Research and Prevention, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Renee Heffron
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - James P Hughes
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Barbra Richardson
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Ariane van der Straten
- Department of Medicine, The Center for AIDS Prevention Studies, University of California San Francisco, San Francisco, CA, USA
- ASTRA Consulting, Kensington, CA, USA
| | - Thesla Palanee-Phillips
- Faculty of Health Sciences, Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Lydia Soto-Torres
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Devika Singh
- University of Pittsburgh, Pittsburgh, PA, USA
- Magee-Womens Research Institute, Pittsburgh, PA, USA
| | - Brenda Gati Mirembe
- Makerere University John Hopkins University Research Collaboration (MU-JHU), Kampala, Uganda
| | - Edward Livant
- Magee-Womens Research Institute, Pittsburgh, PA, USA
| | - Zakir Gaffoor
- HIV Prevention Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Leila E Mansoor
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
| | - Samantha S Siva
- HIV Prevention Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Sufia Dadabhai
- Johns Hopkins Bloomberg School of Public Health, Blantyre, Malawi
| | - Flavia Matovu Kiweewa
- Makerere University John Hopkins University Research Collaboration (MU-JHU), Kampala, Uganda
| | - Jared M Baeten
- Department of Epidemiology, University of Washington, Seattle, WA, USA.
- Department of Global Health, University of Washington, Seattle, WA, USA.
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2
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Lorenzetti L, Dinh N, Whitcomb C, Martinez A, Chatani M, Lievense B, Nhamo D, Slack C, Eley N, MacQueen K. Meta-analysis of Pregnancy Events in Biomedical HIV Prevention Trials in Sub-Saharan Africa: Implications for Gender Transformative Trials. AIDS Behav 2024:10.1007/s10461-024-04459-z. [PMID: 39153025 DOI: 10.1007/s10461-024-04459-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/26/2024] [Indexed: 08/19/2024]
Abstract
Historically, pregnant and lactating populations (PLP) have been excluded or disenrolled from biomedical HIV prevention trials, despite being more likely to acquire HIV during pregnancy and the post-partum period. We conducted a meta-analysis of pregnancy events in biomedical HIV prevention trials in sub-Saharan Africa to support trialists moving toward more inclusive clinical and implementation studies. We searched peer-reviewed literature reporting pregnancy events and contraceptive requirements in HIV prevention trials between 2001 and 2022. We hypothesized four variables to explain variation: contraceptive requirements, study start year, study product, and sub-region. We fit a meta-analytic model to estimate individual effect sizes and sampling variances, then conducted sub-group analyses to assess moderating effects. We identified 38 references for inclusion, across which the proportion of pregnancy events was 8% (95% confidence interval [CI]: 6-10%) with high heterogeneity (I2 = 99%). Studies not requiring contraceptives (21%, 95%CI: 7-48%) reported a significantly higher proportion of pregnancy events than studies requiring two methods (5%, 95%CI: 2-10%). Studies launched between 2001 and 2007 (11%, 95%CI: 8-16%), microbicide gel trials (12%, 95%CI: 8-18%), and studies conducted in Western Africa (28%, 95%CI: 13-51%) reported higher proportions of pregnancy events than reference groups. Together, these variables have a moderating effect on pregnancy events (p < 0.0001), explaining 63% of heterogeneity in trials. Results describe how, over time, more stringent contraceptive requirements reduced pregnancy events, which ensured necessary statistical power but limited reproductive choice by participants. With the move toward continuing PLP on experimental products, trialists can utilize estimated pregnancy events reported here to inform strategies that accommodate participants' changing fertility preferences.
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Affiliation(s)
- Lara Lorenzetti
- Behavioral, Epidemiological and Clinical Sciences Division, Durham, NC, FHI 360, USA.
| | - Nhi Dinh
- Behavioral, Epidemiological and Clinical Sciences Division, Durham, NC, FHI 360, USA
| | - Cason Whitcomb
- Behavioral, Epidemiological and Clinical Sciences Division, Durham, NC, FHI 360, USA
| | - Andres Martinez
- Behavioral, Epidemiological and Clinical Sciences Division, Durham, NC, FHI 360, USA
| | | | | | | | - Catherine Slack
- School of Law, University of KwaZulu-Natal, Pietermaritzburg, South Africa
| | - Natalie Eley
- Behavioral, Epidemiological and Clinical Sciences Division, Durham, NC, FHI 360, USA
| | - Kathleen MacQueen
- Behavioral, Epidemiological and Clinical Sciences Division, Durham, NC, FHI 360, USA
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3
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von Maltitz P, Wettstein L, Weil T, Schommers P, Klein F, Münch J. Semen enhances transmitted/founder HIV-1 infection and only marginally reduces antiviral activity of broadly neutralizing antibodies. J Virol 2024; 98:e0119023. [PMID: 38501840 PMCID: PMC11019787 DOI: 10.1128/jvi.01190-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 02/26/2024] [Indexed: 03/20/2024] Open
Abstract
Topically applied microbicides may play a critical role in preventing sexual transmission of human immunodeficiency virus type 1 (HIV-1); however, their efficacy can be compromised by amyloid fibrils present in semen, which significantly increase HIV-1 infectivity. This phenomenon may have contributed to the failure of most microbicide candidates in clinical settings. Understanding the impact of semen on microbicide effectiveness is thus crucial. In our study, we evaluated the influence of semen on the neutralizing activity of broadly neutralizing antibodies (bNAbs), including PG16, PGT121, 10-1074, 3BNC117, and VRC01, which are potential microbicide candidates. We found that semen enhances infection of HIV-1 transmitted/founder viruses but only marginally affects the neutralizing activity of tested antibodies, suggesting their potential for microbicide application. Our findings underscore the need to consider semen-mediated enhancement when evaluating and developing microbicides and highlight the potential of incorporating HIV-1 bNAbs in formulations to enhance efficacy and mitigate HIV-1 transmission during sexual encounters.IMPORTANCEThis study examined the impact of semen on the development of microbicides, substances used to prevent the transmission of HIV-1 during sexual activity. Semen contains certain components that can render the virus more infectious, posing a challenge to microbicide effectiveness. Researchers specifically investigated the effect of semen on a group of powerful antibodies called broadly neutralizing antibodies, which can neutralize a large spectrum of different HIV-1 variants. The results revealed that semen only had a minimal effect on the antibodies' ability to neutralize the virus. This is promising because it suggests that these antibodies could still be effective in microbicides, even in the presence of semen. Understanding this interaction is crucial for developing better strategies to prevent HIV-1 transmission. By incorporating the knowledge gained from this study, scientists can now focus on creating microbicides that consider the impact of semen, bringing us closer to more effective prevention methods.
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Affiliation(s)
- Pascal von Maltitz
- Institute of Molecular Virology, University Ulm Medical Center, Ulm, Germany
| | - Lukas Wettstein
- Institute of Molecular Virology, University Ulm Medical Center, Ulm, Germany
| | - Tatjana Weil
- Institute of Molecular Virology, University Ulm Medical Center, Ulm, Germany
| | - Philipp Schommers
- Laboratory of Experimental Immunology, Institute of Virology, University of Cologne, Faculty of Medicine and University Hospital of Cologne, Cologne, Germany
- German Center for Infection Research, Partner site Bonn-Cologne, Cologne, Germany
- Center for Molecular Medicine Cologne (CMMC), Cologne, Germany
- Department I of Internal Medicine, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Florian Klein
- Laboratory of Experimental Immunology, Institute of Virology, University of Cologne, Faculty of Medicine and University Hospital of Cologne, Cologne, Germany
- German Center for Infection Research, Partner site Bonn-Cologne, Cologne, Germany
- Center for Molecular Medicine Cologne (CMMC), Cologne, Germany
| | - Jan Münch
- Institute of Molecular Virology, University Ulm Medical Center, Ulm, Germany
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Abstract
PURPOSE OF REVIEW Ending the HIV epidemic will require the development of additional effective immune-mediated and nonimmune-mediated means of HIV prevention. Evaluating novel interventions requires large, controlled trials demonstrating efficacy. Recent advances in the field of HIV prevention necessitate new approaches to efficacy trial design. RECENT FINDINGS Three classes of efficacy trial designs are possible: standard of prevention-controlled trials, active-controlled trials, and active-controlled trials augmented with external control data. Recent experience with these approaches provides lessons on considerations around and success of the designs. Additional experience and development is needed for the augmented active-controlled trial design. SUMMARY Efficacy trials of new HIV prevention interventions are feasible but require careful consideration, given the complexity and dynamic state of the prevention field. While standard of prevention-controlled efficacy trials are reasonable approaches for HIV vaccine and monoclonal antibody efficacy trials, trials of new antiretroviral agents may require active-controlled designs.
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Affiliation(s)
- Holly Janes
- Fred Hutchinson Cancer Center
- University of Washington
| | - Susan Buchbinder
- San Francisco Department of Public Health
- University of California, San Francisco
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Guan W, Zhang N, Bains A, Martinez A, LiWang PJ. Sustained Delivery of the Antiviral Protein Griffithsin and Its Adhesion to a Biological Surface by a Silk Fibroin Scaffold. MATERIALS (BASEL, SWITZERLAND) 2023; 16:5547. [PMID: 37629837 PMCID: PMC10456748 DOI: 10.3390/ma16165547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Revised: 08/02/2023] [Accepted: 08/06/2023] [Indexed: 08/27/2023]
Abstract
The protein Griffithsin (Grft) is a lectin that tightly binds to high-mannose glycosylation sites on viral surfaces. This property allows Grft to potently inhibit many viruses, including HIV-1. The major route of HIV infection is through sexual activity, so an important tool for reducing the risk of infection would be a film that could be inserted vaginally or rectally to inhibit transmission of the virus. We have previously shown that silk fibroin can encapsulate, stabilize, and release various antiviral proteins, including Grft. However, for broad utility as a prevention method, it would be useful for an insertable film to adhere to the mucosal surface so that it remains for several days or weeks to provide longer-term protection from infection. We show here that silk fibroin can be formulated with adhesive properties using the nontoxic polymer hydroxypropyl methylcellulose (HPMC) and glycerol, and that the resulting silk scaffold can both adhere to biological surfaces and release Grft over the course of at least one week. This work advances the possible use of silk fibroin as an anti-viral insertable device to prevent infection by sexually transmitted viruses, including HIV-1.
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Affiliation(s)
- Wenyan Guan
- Materials and Biomaterials Science and Engineering, University of California Merced, 5200 North Lake Rd., Merced, CA 95343, USA;
| | - Ning Zhang
- Qingdao Institute of Bioenergy and Bioprocess Technology, Chinese Academy of Sciences, Qingdao 266101, China;
| | - Arjan Bains
- Chemistry and Biochemistry, University of California Merced, 5200 North Lake Rd., Merced, CA 95343, USA;
| | - Airam Martinez
- Department of Bioengineering, University of California Merced, 5200 North Lake Rd., Merced, CA 95343, USA;
| | - Patricia J. LiWang
- Molecular Cell Biology, Health Sciences Research Institute, University of California Merced, 5200 North Lake Rd., Merced, CA 95343, USA
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Zondo NM, Sobia P, Sivro A, Ngcapu S, Mansoor LE, Mahomed S, Lewis L, Ramsuran V, Archary D. Single-nucleotide polymorphisms in ABC drug transporters alter expression and circulating tenofovir in healthy South African women exposed to pre-exposure prophylaxis. Pharmacogenomics 2023; 24:599-613. [PMID: 37503696 DOI: 10.2217/pgs-2023-0058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/29/2023] Open
Abstract
Aim: We investigated if single-nucleotide polymorphisms (SNPs) in ATP-binding cassette (ABC) drug transporters alter gene expression and tenofovir disposition in South African women taking Truvada® for HIV prevention. Materials & methods: In 393 women, real-time PCR was used to determine the associations between six SNPs in ABC transporter genes, mRNA expression and circulating-tenofovir. Results: Univariable and multivariable analyses showed that CT and TT relative to CC genotypes for the ABCC4(3463C/T) SNP had significantly higher tenofovir levels. In contrast, the AA genotype for the ABCC4(4976A/G) SNP showed significantly less tenofovir, while mRNA expression was increased. Conclusion: SNPs in the ABCC4 gene may differentially affect gene expression and circulating tenofovir. Their impact may inform on low pre-exposure prophylaxis efficacy and discern effective drugs in clinical trials of African women enriched for certain genotypes.
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Affiliation(s)
- Nomusa M Zondo
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Mucosal Immunology Department, Durban, Kwa-Zulu Natal, 4075, South Africa
- University of KwaZulu-Natal, Department of Medical Microbiology, School of Laboratory Medicine & Medical Sciences, Durban, Kwa-Zulu Natal, 4075, South Africa
| | - Parveen Sobia
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Mucosal Immunology Department, Durban, Kwa-Zulu Natal, 4075, South Africa
- University of KwaZulu-Natal, Department of Medical Microbiology, School of Laboratory Medicine & Medical Sciences, Durban, Kwa-Zulu Natal, 4075, South Africa
| | - Aida Sivro
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Mucosal Immunology Department, Durban, Kwa-Zulu Natal, 4075, South Africa
- University of KwaZulu-Natal, Department of Medical Microbiology, School of Laboratory Medicine & Medical Sciences, Durban, Kwa-Zulu Natal, 4075, South Africa
- JC Wilt Infectious Disease Research Centre, National Microbiology laboratory, Public Health Agency of Canada, Winnipeg, MB, R3E 3L5, Canada
- University of Manitoba, Department of Medical Microbiology and Infectious Diseases, Winnipeg, R3E 3L5, Canada
| | - Sinaye Ngcapu
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Mucosal Immunology Department, Durban, Kwa-Zulu Natal, 4075, South Africa
- University of KwaZulu-Natal, Department of Medical Microbiology, School of Laboratory Medicine & Medical Sciences, Durban, Kwa-Zulu Natal, 4075, South Africa
| | - Leila E Mansoor
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Mucosal Immunology Department, Durban, Kwa-Zulu Natal, 4075, South Africa
| | - Sharana Mahomed
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Mucosal Immunology Department, Durban, Kwa-Zulu Natal, 4075, South Africa
| | - Lara Lewis
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Mucosal Immunology Department, Durban, Kwa-Zulu Natal, 4075, South Africa
| | - Veron Ramsuran
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Mucosal Immunology Department, Durban, Kwa-Zulu Natal, 4075, South Africa
- University of KwaZulu-Natal, Department of Medical Microbiology, School of Laboratory Medicine & Medical Sciences, Durban, Kwa-Zulu Natal, 4075, South Africa
| | - Derseree Archary
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Mucosal Immunology Department, Durban, Kwa-Zulu Natal, 4075, South Africa
- University of KwaZulu-Natal, Department of Medical Microbiology, School of Laboratory Medicine & Medical Sciences, Durban, Kwa-Zulu Natal, 4075, South Africa
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Thurman AR, Ouattara LA, Yousefieh N, Anderson PL, Bushman LR, Fang X, Hanif H, Clark M, Singh O, Doncel GF. A phase I study to assess safety, pharmacokinetics, and pharmacodynamics of a vaginal insert containing tenofovir alafenamide and elvitegravir. Front Cell Infect Microbiol 2023; 13:1130101. [PMID: 37153145 PMCID: PMC10154607 DOI: 10.3389/fcimb.2023.1130101] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 03/31/2023] [Indexed: 05/09/2023] Open
Abstract
Background New multi-purpose prevention technology (MPT) products are needed to prevent human immunodeficiency virus (HIV) and herpes simplex virus type 2 (HSV2). In this study, we evaluated a fast-dissolve insert that may be used vaginally or rectally for prevention of infection. Objective To describe the safety, acceptability, multi-compartment pharmacokinetics (PK), and in vitro modeled pharmacodynamics (PD) after a single vaginal dose of an insert containing tenofovir alafenamide (TAF) and elvitegravir (EVG) in healthy women. Methods This was a Phase I, open-label, study. Women (n=16) applied one TAF (20mg)/EVG (16mg) vaginal insert and were randomized (1:1) to sample collection time groups for up to 7 days post dosing. Safety was assessed by treatment-emergent adverse events (TEAEs). EVG, TAF and tenofovir (TFV) concentrations were measured in plasma, vaginal fluid and tissue, and TFV-diphosphate (TFV-DP) concentration in vaginal tissue. PD was modeled in vitro by quantifying the change in inhibitory activity of vaginal fluid and vaginal tissue against HIV and HSV2 from baseline to after treatment. Acceptability data was collected by a quantitative survey at baseline and post treatment. Results The TAF/EVG insert was safe, with all TEAEs graded as mild, and acceptable to participants. Systemic plasma exposure was low, consistent with topical delivery, while high mucosal levels were detected, with median TFV vaginal fluid concentrations exceeding 200,000 ng/mL and 1,000 ng/mL for up to 24 hours and 7 days post dosing, respectively. All participants had vaginal tissue EVG concentrations of > 1 ng/mg at 4 and 24 hours post dosing. The majority had tissue TFV-DP concentrations exceeding 1000 fmol/mg by 24 - 72 hours post dosing. Vaginal fluid inhibition of HIV-1 and HSV-2 in vitro significantly increased from baseline and was similarly high at 4 and 24 hours post dosing. Consistent with high tissue TFV-DP concentrations, p24 HIV antigen production from ectocervical tissues infected ex vivo with HIV-1 significantly decreased from baseline at 4 hours post dosing. HSV-2 production from tissue also decreased post treatment. Conclusions A single dose of TAF/EVG inserts met PK benchmarks, with PK data supporting an extended window of high mucosal protection. PD modeling supports mucosal protection against both HIV-1 and HSV-2. The inserts were safe and highly acceptable. Clinical trial registration ClinicalTrials.gov, identifier NCT03762772.
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Affiliation(s)
- Andrea R. Thurman
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA, United States
- *Correspondence: Andrea R. Thurman,
| | - Louise A. Ouattara
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA, United States
| | - Nazita Yousefieh
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA, United States
| | - Peter L. Anderson
- University of Colorado, Colorado Antiviral Pharmacology Lab, School of Pharmacy, Anschutz Medical Campus, Aurora, CO, United States
| | - Lane R. Bushman
- University of Colorado, Colorado Antiviral Pharmacology Lab, School of Pharmacy, Anschutz Medical Campus, Aurora, CO, United States
| | - Xi Fang
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA, United States
| | - Homaira Hanif
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA, United States
| | - Meredith Clark
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA, United States
| | - Onkar Singh
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA, United States
| | - Gustavo F. Doncel
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA, United States
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Karim QA, Archary D, Barré-Sinoussi F, Broliden K, Cabrera C, Chiodi F, Fidler SJ, Gengiah TN, Herrera C, Kharsany ABM, Liebenberg LJP, Mahomed S, Menu E, Moog C, Scarlatti G, Seddiki N, Sivro A, Cavarelli M. Women for science and science for women: Gaps, challenges and opportunities towards optimizing pre-exposure prophylaxis for HIV-1 prevention. Front Immunol 2022; 13:1055042. [PMID: 36561760 PMCID: PMC9763292 DOI: 10.3389/fimmu.2022.1055042] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 11/11/2022] [Indexed: 12/12/2022] Open
Abstract
Preventing new HIV infections remains a global challenge. Young women continue to bear a disproportionate burden of infection. Oral pre-exposure prophylaxis (PrEP), offers a novel women-initiated prevention technology and PrEP trials completed to date underscore the importance of their inclusion early in trials evaluating new HIV PrEP technologies. Data from completed topical and systemic PrEP trials highlight the role of gender specific physiological and social factors that impact PrEP uptake, adherence and efficacy. Here we review the past and current developments of HIV-1 prevention options for women with special focus on PrEP considering the diverse factors that can impact PrEP efficacy. Furthermore, we highlight the importance of inclusion of female scientists, clinicians, and community advocates in scientific efforts to further improve HIV prevention strategies.
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Affiliation(s)
- Quarraisha Abdool Karim
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Doris Duke Medical Research Institute (2Floor), Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, United States
| | - Derseree Archary
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Doris Duke Medical Research Institute (2Floor), Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa,Department of Medical Microbiology, School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban, South Africa
| | | | - Kristina Broliden
- Department of Medicine Solna, Division of Infectious Diseases, Karolinska Institutet, Department of Infectious Diseases, Karolinska University Hospital, Center for Molecular Medicine, Stockholm, Sweden
| | - Cecilia Cabrera
- AIDS Research Institute IrsiCaixa, Institut de Recerca en Ciències de la Salut Germans Trias i Pujol (IGTP), Hospital Germans Trias i Pujol, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Francesca Chiodi
- Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, Stockholm, Sweden
| | - Sarah J. Fidler
- Department of Infectious Disease, Faculty of Medicine, Imperial College London UK and Imperial College NIHR BRC, London, United Kingdom
| | - Tanuja N. Gengiah
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Doris Duke Medical Research Institute (2Floor), Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Carolina Herrera
- Department of Infectious Disease, Section of Virology, Faculty of Medicine, Imperial College London, London, United Kingdom,*Correspondence: Carolina Herrera,
| | - Ayesha B. M. Kharsany
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Doris Duke Medical Research Institute (2Floor), Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa,Department of Medical Microbiology, School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Lenine J. P. Liebenberg
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Doris Duke Medical Research Institute (2Floor), Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa,Department of Medical Microbiology, School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Sharana Mahomed
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Doris Duke Medical Research Institute (2Floor), Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Elisabeth Menu
- Université Paris-Saclay, Inserm, CEA, Center for Immunology of Viral, Auto-immune, Hematological and Bacterial diseases (IMVA-HB/IDMIT), Fontenay-aux-Roses & Le Kremlin-Bicêtre, France,MISTIC Group, Department of Virology, Institut Pasteur, Paris, France
| | - Christiane Moog
- Laboratoire d’ImmunoRhumatologie Moléculaire, Institut national de la santé et de la recherche médicale (INSERM) UMR_S 1109, Institut thématique interdisciplinaire (ITI) de Médecine de Précision de Strasbourg, Transplantex NG, Faculté de Médecine, Fédération Hospitalo-Universitaire OMICARE, Fédération de Médecine Translationnelle de Strasbourg (FMTS), Université de Strasbourg, Strasbourg, France
| | - Gabriella Scarlatti
- Viral Evolution and Transmission Unit, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Nabila Seddiki
- Université Paris-Saclay, Inserm, CEA, Center for Immunology of Viral, Auto-immune, Hematological and Bacterial diseases (IMVA-HB/IDMIT), Fontenay-aux-Roses & Le Kremlin-Bicêtre, France
| | - Aida Sivro
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Doris Duke Medical Research Institute (2Floor), Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa,Department of Medical Microbiology, School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban, South Africa,JC Wilt Infectious Disease Research Centre, National Microbiology Laboratory, Public Health Agency of Canada, Winnipeg, MB, Canada
| | - Mariangela Cavarelli
- Université Paris-Saclay, Inserm, CEA, Center for Immunology of Viral, Auto-immune, Hematological and Bacterial diseases (IMVA-HB/IDMIT), Fontenay-aux-Roses & Le Kremlin-Bicêtre, France
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9
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Ailincai D, Bercea M, Mititelu Tartau L, Marin L. Biocompatible drug delivery systems able to co-deliver antifungal and antiviral agents. Carbohydr Polym 2022; 298:120071. [DOI: 10.1016/j.carbpol.2022.120071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 08/19/2022] [Accepted: 09/01/2022] [Indexed: 11/02/2022]
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10
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Agot K, Hartmann M, Otticha S, Minnis A, Onyango J, Ochillo M, Roberts ST. " I didn't support PrEP because I didn't know what it was": Inadequate information undermines male partner support for young women's pre-exposure prophylaxis use in western Kenya. AFRICAN JOURNAL OF AIDS RESEARCH : AJAR 2022; 21:221-230. [PMID: 36102052 PMCID: PMC10102710 DOI: 10.2989/16085906.2022.2049831] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 02/25/2022] [Accepted: 03/02/2022] [Indexed: 11/22/2022]
Abstract
The HIV infection rate is higher among adolescent girls and young women (AGYW) in Africa than men in the same age range. Pre-exposure prophylaxis (PrEP) can be used by women discreetly; however, for most AGYW, male partner approval is desired. We explored PrEP use in the context of relationship violence and power dynamics through focus group discussions and support club sessions with AGYW, in-depth interviews and male sensitisation sessions with male partners of AGYW, and joint sessions with AGYW and their male partners. Many male partners reported hesitancy in supporting partner's PrEP use without sufficient information; most of these became supportive following their engagement in study activities; and most preferred participation in decisions around PrEP use. For AGYW, male involvement minimised partner violence around their PrEP use. The findings support the need for correct PrEP information to be provided to male partners of AGYW and to involve them early on, in decision-making about PrEP use. This is likely to improve uptake of and adherence to PrEP.
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Affiliation(s)
- Kawango Agot
- Impact Research and Development Organization, PO BOX 9171-40141, Kisumu Kenya
| | - Miriam Hartmann
- Women’s Global Health Imperative, RTI International, Berkeley, CA, USA
| | - Sophie Otticha
- Impact Research and Development Organization, PO BOX 9171-40141, Kisumu Kenya
| | - Alexandra Minnis
- Women’s Global Health Imperative, RTI International, Berkeley, CA, USA
| | - Jacob Onyango
- Impact Research and Development Organization, PO BOX 9171-40141, Kisumu Kenya
| | - Marylyn Ochillo
- Impact Research and Development Organization, PO BOX 9171-40141, Kisumu Kenya
| | - Sarah T. Roberts
- Women’s Global Health Imperative, RTI International, Berkeley, CA, USA
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11
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Zondo NM, Sobia P, Sivro A, Ngcapu S, Ramsuran V, Archary D. Pharmacogenomics of drug transporters for antiretroviral long-acting pre-exposure prophylaxis for HIV. Front Genet 2022; 13:940661. [PMID: 36246609 PMCID: PMC9557974 DOI: 10.3389/fgene.2022.940661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 09/15/2022] [Indexed: 11/13/2022] Open
Abstract
The use of antiretrovirals (ARVs) as oral, topical, or long-acting pre-exposure prophylaxis (PrEP) has emerged as a promising strategy for HIV prevention. Clinical trials testing Truvada® [tenofovir disoproxil fumarate (TDF)/tenofovir (TFV) and emtricitabine (FTC)] as oral or topical PrEP in African women showed mixed results in preventing HIV infections. Since oral and topical PrEP effectiveness is dependent on adequate drug delivery and availability to sites of HIV infection such as the blood and female genital tract (FGT); host biological factors such as drug transporters have been implicated as key regulators of PrEP. Drug transporter expression levels and function have been identified as critical determinants of PrEP efficacy by regulating PrEP pharmacokinetics across various cells and tissues of the blood, renal tissues, FGT mucosal tissues and other immune cells targeted by HIV. In addition, biological factors such as genetic polymorphisms and genital inflammation also influence drug transporter expression levels and functionality. In this review, drug transporters and biological factors modulating drug transporter disposition are used to explain discrepancies observed in PrEP clinical trials. This review also provides insight at a pharmacological level of how these factors further increase the susceptibility of the FGT to HIV infections, subsequently contributing to ineffective PrEP interventions in African women.
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Affiliation(s)
- Nomusa M. Zondo
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Mucosal Immunology Department, Durban, South Africa
- Department of Medical Microbiology, School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Parveen Sobia
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Mucosal Immunology Department, Durban, South Africa
- Department of Medical Microbiology, School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Aida Sivro
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Mucosal Immunology Department, Durban, South Africa
- Department of Medical Microbiology, School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Sinaye Ngcapu
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Mucosal Immunology Department, Durban, South Africa
- Department of Medical Microbiology, School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Veron Ramsuran
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Mucosal Immunology Department, Durban, South Africa
- Department of Medical Microbiology, School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Derseree Archary
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Mucosal Immunology Department, Durban, South Africa
- Department of Medical Microbiology, School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban, South Africa
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Tapsoba JDD, Cover J, Obong’o C, Brady M, Cressey TR, Mori K, Okomo G, Kariithi E, Obanda R, Oluoch-Madiang D, Chen YQ, Drain P, Duerr A. Continued attendance in a PrEP program despite low adherence and non-protective drug levels among adolescent girls and young women in Kenya: Results from a prospective cohort study. PLoS Med 2022; 19:e1004097. [PMID: 36095005 PMCID: PMC9521917 DOI: 10.1371/journal.pmed.1004097] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 09/29/2022] [Accepted: 08/19/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND In sub-Saharan Africa (SSA), adolescent girls and young women (AGYW) ages 15 to 24 years represent <10% of the population yet account for 1 in 5 new HIV infections. Although oral pre-exposure prophylaxis (PrEP) with tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) can be highly effective, low persistence in PrEP programs and poor adherence have limited its ability to reduce HIV incidence among women. METHODS AND FINDINGS A total of 336 AGYW participating in the PEPFAR-funded DREAMS PrEP program in western Kenya were enrolled into a study of PrEP use conducted between 6/2019 to 1/2020. AGYW, who used daily oral TDF/FTC, completed interviews and provided dried blood spots (DBS) for measurement of tenofovir-diphosphate (TFV-DP) concentrations at enrollment and 3 months later, and 176/302 (58.3%, 95% confidence interval [95% CI 52.3 to 63.8]) met our definition of PrEP persistence: having expressed intention to use PrEP and attended both the second interview and an interim refill visit. Among AGYW with DBS taken at the second interview, only 9/197 (4.6%, [95% CI 1.6 to 7.5]) had protective TFV-DP levels (≥700 fmol/punch) and 163/197 (82.7%, [95% CI 77.5 to 88]) had levels consistent with no recent PrEP use (<10 fmol/punch). Perception of being at moderate-to-high risk for HIV if not taking PrEP was associated with persistence (adjusted odds ratio, 10.17 [95% CI 5.14 to 20.13], p < 0.001) in a model accounting for county of residence and variables that had p-value <0.1 in unadjusted analysis (age, being in school, initiated PrEP 2 to 3 months before the first interview, still active in DREAMS, having children, having multiple sex partners, partner aware of PrEP use, partner very supportive of PrEP use, partner has other partners, AGYW believes that a partner puts her at risk, male condom use, injectable contraceptive use, and implant contraceptive use). Among AGYW who reported continuing PrEP, >90% indicated they were using PrEP to prevent HIV, although almost all had non-protective TFV-DP levels. Limitations included short study duration and inclusion of only DREAMS participants. CONCLUSIONS Many AGYW persisted in the PrEP program without taking PrEP frequently enough to receive benefit. Notably, AGYW who persisted had a higher self-perceived risk of HIV infection. These AGYW may be optimal candidates for long-acting PrEP.
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Affiliation(s)
- Jean de Dieu Tapsoba
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
| | - Jane Cover
- PATH, Seattle, Washington, United States of America
| | | | - Martha Brady
- PATH, Seattle, Washington, United States of America
| | | | - Kira Mori
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
| | | | | | | | | | - Ying Qing Chen
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
| | - Paul Drain
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Ann Duerr
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
- * E-mail:
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Tyssen D, Hearps AC, Guntur K, Masson L, Cook S, Moulton SE, Ravel J, Bradshaw CS, Ayehunie S, Tachedjian G. The Impact of Over-The-Counter Lactic Acid Containing Vaginal Gels on the Integrity and Inflammatory State of the Vaginal Epithelium in vitro. FRONTIERS IN REPRODUCTIVE HEALTH 2022; 4:915948. [DOI: 10.3389/frph.2022.915948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 05/24/2022] [Indexed: 11/13/2022] Open
Abstract
The vaginal microbiome influences a wide range of health outcomes in women, where a microbiome dominated by Lactobacillus spp. is considered optimal and associated with reduced risk of pre-term birth and acquisition of sexually transmitted infections including HIV. Conversely, replacement of lactobacilli by non-optimal bacteria leads to the development of bacterial vaginosis, which is associated with increased risk of these outcomes. Lactobacilli produce the metabolite lactic acid (LA) which is a potent antibacterial and antiviral agent. The potential therapeutic benefits of LA have prompted the development of numerous over-the-counter LA-containing gels for use in the vagina, although a comprehensive analysis of the impact of these formulations on the cervicovaginal epithelium and pro-inflammatory cytokine/chemokine responses, has not been assessed. Here, we evaluated the properties of 11 over-the-counter gels, including 9 containing LA, marketed for use in the vagina. Ten of the 11 gels had an osmolality greater than vaginal fluid from women with Lactobacillus-dominated microbiota (370 ± 40 mOsmol/kg in women with Nugent score 0–3), with six gels that were hyperosmolal >2,000 mOsmol/kg. Using a reconstructed primary cell model of the vaginal epithelium, we found hyperosmolal gels had a detrimental impact on epithelial barrier integrity, resulting in substantial cellular toxicity (<10% viability as compared to untreated cells) and reduced epithelial barrier integrity [≈30% of untreated cells, assessed by transepithelial electrical resistance (TEER)]. Treatment of vaginal tissues with most of the gels elicited the production of pro-inflammatory factors including IL-1α (8 of 11) and IL-1β (10 of 11) which are associated with heightened risk of HIV acquisition in vivo. The majority of the OTC gels elicited moderate tissue damage as determined by histology. The detrimental effects of these gels on the human vaginal epithelium in vitro may predict compromised epithelial barrier integrity and genital inflammation in vivo, which has implications for sexual and reproductive health. This study highlights the importance of evaluating the impact of intravaginal products on the integrity and inflammatory status of the mucosal epithelium to avoid unfavorable off target effects.
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14
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Ring-ing in the Future: Participant and Male Partner Perspectives Regarding Future Use of the Dapivirine Vaginal Ring for HIV Prevention. AIDS Behav 2022; 26:1923-1932. [PMID: 35064389 DOI: 10.1007/s10461-021-03542-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2021] [Indexed: 11/01/2022]
Abstract
Women account for a disproportionate percentage of new HIV infections in sub-Saharan Africa indicating a need for female-initiated HIV prevention options congruent with their lifestyles. The dapivirine vaginal ring for HIV prevention is one such option. We explored the interest of women, who used this ring during the Microbicide Trials Network's ASPIRE and HOPE studies, in using the ring post-licensure and what they perceived as important considerations for future use. We also explored perspectives of HOPE participants' male partners on their involvement in their partners' future ring use. Women appeared keen to use the ring in the future and expressed desires for easy access, support for both ongoing and new users and intense community engagement. In parallel, male partners indicated high levels of interest in supporting their partners' ring use and being involved in ring use decision making. These data offer important insights for ring rollout planning and engagement activities.
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Rodríguez‐Izquierdo I, Sepúlveda‐Crespo D, Lasso JM, Resino S, Muñoz‐Fernández MÁ. Baseline and time-updated factors in preclinical development of anionic dendrimers as successful anti-HIV-1 vaginal microbicides. WILEY INTERDISCIPLINARY REVIEWS. NANOMEDICINE AND NANOBIOTECHNOLOGY 2022; 14:e1774. [PMID: 35018739 PMCID: PMC9285063 DOI: 10.1002/wnan.1774] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 12/05/2021] [Accepted: 12/09/2021] [Indexed: 12/12/2022]
Abstract
Although a wide variety of topical microbicides provide promising in vitro and in vivo efficacy, most of them failed to prevent sexual transmission of human immunodeficiency virus type 1 (HIV-1) in human clinical trials. In vitro, ex vivo, and in vivo models must be optimized, considering the knowledge acquired from unsuccessful and successful clinical trials to improve the current gaps and the preclinical development protocols. To date, dendrimers are the only nanotool that has advanced to human clinical trials as topical microbicides to prevent HIV-1 transmission. This fact demonstrates the importance and the potential of these molecules as microbicides. Polyanionic dendrimers are highly branched nanocompounds with potent activity against HIV-1 that disturb HIV-1 entry. Herein, the most significant advancements in topical microbicide development, trying to mimic the real-life conditions as closely as possible, are discussed. This review also provides the preclinical assays that anionic dendrimers have passed as microbicides because they can improve current antiviral treatments' efficacy. This article is categorized under: Nanotechnology Approaches to Biology > Nanoscale Systems in Biology Therapeutic Approaches and Drug Discovery > Nanomedicine for Infectious Disease Toxicology and Regulatory Issues in Nanomedicine > Regulatory and Policy Issues in Nanomedicine.
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Affiliation(s)
| | - Daniel Sepúlveda‐Crespo
- Unidad de Infección Viral e Inmunidad, Centro Nacional de MicrobiologíaInstituto de Salud Carlos IIIMadridSpain
| | | | - Salvador Resino
- Unidad de Infección Viral e Inmunidad, Centro Nacional de MicrobiologíaInstituto de Salud Carlos IIIMadridSpain
| | - Ma Ángeles Muñoz‐Fernández
- Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM)MadridSpain
- Spanish HIV HGM BioBankMadridSpain
- Section of Immunology, Laboratorio InmunoBiología MolecularHospital General Universitario Gregorio Marañón (HGUGM)MadridSpain
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16
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The CHARISMA randomized controlled trial: a relationship-focused counseling intervention integrated within oral PrEP delivery for HIV prevention among women in Johannesburg, South Africa. J Acquir Immune Defic Syndr 2022; 90:425-433. [PMID: 35416797 DOI: 10.1097/qai.0000000000002991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 03/16/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Consistent use of oral pre-exposure prophylaxis (PrEP) has been a challenge among women, particularly when in relationships with lack of partner support or intimate partner violence (IPV). Methods. We conducted a randomized controlled trial (RCT) of an empowerment counseling intervention called "CHARISMA" delivered to women within a PrEP demonstration project in Johannesburg, South Africa. The trial tested the effectiveness of CHARISMA to increase PrEP adherence; decrease social harms (SHs) and IPV; and improve partnership dynamics (e.g. communication, disclosure and support) as compared to those who received the standard of care (SOC) counselling support and referrals. 407 HIV-seronegative, non-pregnant women aged 18-45 years were enrolled for 6 months of PrEP use, with 203 randomized (1:1) to the intervention. All participants reporting IPV received counseling and referrals that followed the WHO five-step Listen, Inquire, Validate, Enhance Safety, and Support approach. Results. This RCT did not identify statistically significant differences between study arms for PrEP adherence or relationship dynamics, with the exception of an increase in PrEP disclosure among intervention arm women. In our study, we cannot determine whether the lack of detectable findings may have been due to lack of intervention effect, strength of SOC services, low risk in the study population or other factors. Conclusions: Addressing IPV and relationship dynamics remain important factors influencing HIV risk, and addressing these within the context of PrEP delivery is an important synergistic opportunity. CHARISMA was highly acceptable to participants, and further adaptation and testing of the intervention to other populations and settings will augment the evidence base.
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Abdool Karim SS, Baxter C, Abdool Karim Q. Advancing HIV prevention using tenofovir-based pre-exposure prophylaxis. Antivir Ther 2022; 27:13596535211067589. [DOI: 10.1177/13596535211067589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Tenofovir-based pre-exposure prophylaxis (PrEP) revolutionized the global HIV prevention landscape. Prior to the proof-of concept trial in 2010, which demonstrated that tenofovir (TFV) could prevent sexual transmission of HIV, prevention options were largely limited to behavior change, condoms, and circumcision. Several subsequent studies evaluating oral tenofovir disoproxil fumarate (TDF) or the TDF/emtricitabine (FTC) combination as PrEP for HIV prevention provided evidence for regulatory approval and inclusion in national and international guidelines. By 2021, 1.5 million people had initiated oral tenofovir-based PrEP, contributing to declines in HIV incidence in some regions. Here we reflect on how oral tenofovir-based PrEP became an important component of combination HIV prevention programs across the globe.
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Affiliation(s)
- Salim S Abdool Karim
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Cheryl Baxter
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
| | - Quarraisha Abdool Karim
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
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Ouattara LA, Thurman AR, Jacot TA, Cottrell M, Sykes C, Blake K, Fang X, Ju S, Vann NC, Schwartz J, Doncel GF. Genital Mucosal Drug Concentrations and anti-HIV Activity in Tenofovir-Based PrEP Products: Intravaginal Ring vs. Oral Administration. J Acquir Immune Defic Syndr 2022; 89:87-97. [PMID: 34878438 PMCID: PMC8647693 DOI: 10.1097/qai.0000000000002820] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 09/20/2021] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To describe and compare systemic and local pharmacokinetics (PK) and cervicovaginal (CV) pharmacodynamics (PD) of oral tenofovir disoproxil fumarate (TDF) in combination with emtricitabine (FTC) with tenofovir (TFV) intravaginal ring (IVR). DESIGN Phase I, randomized, parallel-group study. Women (n = 22) used TDF/FTC oral tablets daily or TFV IVR continuously and were assessed at baseline and 14 days. METHODS TFV and FTC concentrations were measured in plasma, CV fluid (CVF), and CV tissue. TFV-diphosphate and FTC-triphosphate were assessed in CV tissue. In vitro PD antiviral activities of TFV and FTC (using in vivo concentration ranges) were modeled in the CVF and by infecting CV tissue explants ex vivo with HIV-1BaL. RESULTS Adverse events (AEs) were more common with oral TDF/FTC use (P < 0.01). The median CVF TFV concentrations were 106 ng/mL after use of TFV IVR vs. 102 ng/mL for TDF/FTC. The median TFV and TFV-diphosphate concentrations in CV tissue were >100-fold higher among IVR users. The median CVF FTC concentrations were 103 ng/mL. FTC and FTC-triphosphate were detected in all CV tissues from TDF/FTC users. HIV inhibitory activity of CVF increased significantly with treatment in both cohorts (P < 0.01) but was higher in TFV IVR users (P < 0.01). In vitro inhibition of tissue infection with ex vivo administration of TFV and FTC was dose dependent, with maximal efficacy achieved with 10 µg/mL TFV, 1 µg/mL FTC, and 0.1 µg/mL of TFV and FTC combined. CONCLUSIONS Both products were safe and increased mucosal HIV inhibitory activity. In addition to systemic protection, oral TDF/FTC displays a PK/PD profile compatible with CV mucosal antiviral activity. TFV IVR resulted in fewer AEs, lower TFV plasma concentrations, higher CVF and tissue TFV and TFV-DP concentrations, and greater anti-HIV activity in CVF.
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Affiliation(s)
| | - Andrea R. Thurman
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA; and
| | - Terry A. Jacot
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA; and
| | | | - Craig Sykes
- University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Kimberly Blake
- University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Xi Fang
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA; and
| | - Susan Ju
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA; and
| | - Nikolas C. Vann
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA; and
| | - Jill Schwartz
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA; and
| | - Gustavo F. Doncel
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA; and
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Paredes AJ, Volpe-Zanutto F, Vora LK, Tekko IA, Permana AD, Picco CJ, McCarthy HO, Donnelly RF. Systemic delivery of tenofovir alafenamide using dissolving and implantable microneedle patches. Mater Today Bio 2022; 13:100217. [PMID: 35243292 PMCID: PMC8858997 DOI: 10.1016/j.mtbio.2022.100217] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 02/09/2022] [Accepted: 02/10/2022] [Indexed: 12/30/2022] Open
Abstract
The human immunodeficiency virus (HIV) remains a global health concern, with 37.7 million people currently living with the infection and 1.5 million new cases every year. Current antiretroviral (ARV) therapies are administered through the oral route daily, often in lifelong treatments, leading to pill fatigue and poor treatment adherence. Therefore, the development of novel formulations for the administration ARV drugs using alternative routes is actively sought out. In this sense, microneedle array patches (MAPs) offer a unique user-centric platform that can be painlessly self-applied to the skin and deliver drugs to the systemic circulation. In this work, dissolving and implantable MAPs loaded with the tenofovir alafenamide (TAF) were developed with the aim of releasing the drug systemically. Both MAPs were sufficiently strong to pierce excised neonatal full-thickness porcine skin and form drug depots. In vitro release experiments performed in dialysis membrane models, demonstrated a relatively fast delivery of the drug in all cases. Franz cells experiments revealed that dissolving and implantable MAPs deposited 47.87 ± 16.33 μg and 1208.04 ± 417.9 μg of TAF in the skin after 24 h. Pharmacokinetic experiments in rats demonstrated a fast metabolization of TAF into tenofovir, with a rapid elimination of the metabolite from the plasma. The MAPs described in this work could be used as an alternative to current oral treatments for HIV management.
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Affiliation(s)
- Alejandro J. Paredes
- School of Pharmacy, Queen's University Belfast, Medical Biology Centre, 97 Lisburn Road, Belfast, BT9 7BL, Northern Ireland, UK
| | - Fabiana Volpe-Zanutto
- School of Pharmacy, Queen's University Belfast, Medical Biology Centre, 97 Lisburn Road, Belfast, BT9 7BL, Northern Ireland, UK
| | - Lalitkumar K. Vora
- School of Pharmacy, Queen's University Belfast, Medical Biology Centre, 97 Lisburn Road, Belfast, BT9 7BL, Northern Ireland, UK
| | - Ismaiel A. Tekko
- School of Pharmacy, Queen's University Belfast, Medical Biology Centre, 97 Lisburn Road, Belfast, BT9 7BL, Northern Ireland, UK
| | - Andi Dian Permana
- School of Pharmacy, Queen's University Belfast, Medical Biology Centre, 97 Lisburn Road, Belfast, BT9 7BL, Northern Ireland, UK
- Department of Pharmaceutics, Faculty of Pharmacy, Hasanuddin University, Makassar, Indonesia
| | - Camila J. Picco
- School of Pharmacy, Queen's University Belfast, Medical Biology Centre, 97 Lisburn Road, Belfast, BT9 7BL, Northern Ireland, UK
| | - Helen O. McCarthy
- School of Pharmacy, Queen's University Belfast, Medical Biology Centre, 97 Lisburn Road, Belfast, BT9 7BL, Northern Ireland, UK
| | - Ryan F. Donnelly
- School of Pharmacy, Queen's University Belfast, Medical Biology Centre, 97 Lisburn Road, Belfast, BT9 7BL, Northern Ireland, UK
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Evidence for use of a healthy relationships assessment tool in the CHARISMA pilot study. PLoS One 2022; 16:e0261526. [PMID: 34972141 PMCID: PMC8719706 DOI: 10.1371/journal.pone.0261526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 12/03/2021] [Indexed: 12/01/2022] Open
Abstract
Introduction The CHARISMA intervention, nested within the MTN-025/HOPE vaginal ring trial in Johannesburg, South Africa, seeks to facilitate women’s use of HIV prevention products by promoting partner dialogue and mitigating intimate partner violence (IPV). We developed “HEART”, a lay counselor-administered relationship assessment tool, for the CHARISMA pilot. The five-scale tool assesses participants’ endorsement of Traditional Values (TV), her HIV Prevention Readiness (HPR) and levels of partner support (PS), abuse and control (PAC), and resistance to HIV prevention (PR), guiding decisions about which of three counselling modules to offer (partner communication/A; ring disclosure/B; and IPV prevention/C). Methods We correlated baseline scores on HEART subscales with a) independent measures of relationship stability, disclosure and IPV to assess construct validity, and b) with specific modules offered to determine how HEART was used in the pilot. We examined changes in HEART scores at three and six months. Finally, we ran separate growth models for each subscale to examine changes in scores, accounting for partnership changes and counseling module(s) received. Results Baseline HEART scores correlated as predicted among subscales and with other measures. Reliabilities for four subscales were 0.75 or higher. Women who disclosed study participation and ring use scored higher on PS and lower on PR. Women experiencing IPV scored lower on PS, and higher on PAC and PR. During the pilot, 82% of women received one and 17% received two or more modules; over half received the IPV module. Women with higher PAC and PR scores were more likely to receive the IPV than the communication or disclosure modules. Over time, the TV, PAC and PR scores decreased, and PS score increased. Receiving the IPV module was associated with a decreased PAC score. Conclusions These data offer preliminary evidence for HEART construct and predictive validity and support its further evaluation to guide implementation and monitor the impact of the CHARISMA intervention in a randomized controlled evaluation.
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Palanee-Phillips T, Baum MM, Moss JA, Clark MR, Nuttall J, Romano JW. Drug-releasing vaginal rings for HIV/STI and pregnancy prevention: A review of recent advances and clinical applications. Expert Opin Drug Deliv 2021; 19:47-58. [PMID: 34958283 DOI: 10.1080/17425247.2022.2020242] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Adolescent girls and young women (AGYW), as well as pre- and post-menopausal women globally would benefit from expanded choice to address their sexual and reproductive health (SRH) needs related to Human Immunodeficiency Virus (HIV), sexually transmitted infections (STIs) and pregnancy prevention. Lack of adequate preventative vaccines for HIV/STIs reinforces public health prioritization for options women may use independently to mitigate risk for infectious disease and unplanned pregnancy. Drug releasing intravaginal rings (IVR) represent one such technology that has garnered attention based on the modality's success recently as a pre-exposure prophylaxis (PrEP) delivery option and its impact on reduction in HIV risk. AREAS COVERED : This article provides a synopsis of three IVR technologies in active clinical development for prevention of HIV, STI, and unintended pregnancy demonstrating advancements in terms of compatibility with a wide range of drug types with a focus on dapivirine-based silicone rings (International Partnership for Microbicides (IPM), tenofovir-based polyurethane rings (CONRAD), and pod-based rings (Oak Crest Institute of Science). EXPERT OPINION The goals of IVR research are to reduce burdens of HIV/STIs and unplanned pregnancies. Through the evolution of IVR technologies, the potential exists to trigger integration of healthcare services through formulation of products with multiple indications.
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Affiliation(s)
- Thesla Palanee-Phillips
- Faculty of Health Sciences, Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Marc M Baum
- Oak Crest Institute of Science, Monrovia, CA, USA
| | - John A Moss
- Oak Crest Institute of Science, Monrovia, CA, USA
| | | | - Jeremy Nuttall
- International Partnership for Microbicides, Silver Spring, MD, USA
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Rees H, Chersich MF, Munthali RJ, Brumskine W, Palanee-Phillips T, Nkala B, Ahmed K, Sebe M, Mabude Z, Nchabeleng M, Bekker LG, Kotze P, Mogodiri T, Naidoo I, Panchia R, Myer L, Lombard C, Doncel GF, Gray G, Delany-Moretlwe S. HIV Incidence Among Pregnant and Nonpregnant Women in the FACTS-001 Trial: Implications for HIV Prevention, Especially PrEP Use. J Acquir Immune Defic Syndr 2021; 88:376-383. [PMID: 34710071 DOI: 10.1097/qai.0000000000002785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 07/13/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND During pregnancy and postpartum period, the sexual behaviors of women and their partners change in ways that may either increase or reduce HIV risks. Pregnant women are a priority population for reducing both horizontal and vertical HIV transmission. SETTING Nine sites in 4 South African provinces. METHODS Women aged 18-30 years were randomized to receive pericoital tenofovir 1% gel or placebo gel and required to use reliable modern contraception. We compared HIV incidence in women before, during, and after pregnancy and used multivariate Cox Proportional hazards models to compare HIV incidence by pregnancy status. RESULTS Rates of pregnancy were 7.1 per 100 woman-years (95% confidence interval [CI]: 6.3 to 8.1) and highest in those who reported oral contraceptive use (25.1 per 100 woman-years; adjusted hazard ratio 22.97 higher than other women; 95% CI: 5.0 to 105.4) or had 2 children. Birth outcomes were similar between trial arms, with 59.8% having full-term live births. No difference was detected in incident HIV during pregnancy compared with nonpregnant women (2.1 versus 4.3%; hazard ratio = 0.56, 95% CI: 0.14 to 2.26). Sexual activity was low in pregnancy and the early postpartum period, as was consistent condom use. CONCLUSIONS Pregnancy incidence was high despite trial participation being contingent on contraceptive use. We found no evidence that rates of HIV acquisition were elevated in pregnancy when compared with those in nonpregnant women. Risks from reductions in condom use may be offset by reduced sexual activity. Nevertheless, high HIV incidence in both pregnant and nonpregnant women supports consideration of introducing antiretroviral-containing pre-exposure prophylaxis for pregnant and nonpregnant women in high HIV prevalence settings.
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Affiliation(s)
- Helen Rees
- Wits Reproductive Health and HIV Institute (Wits RHI), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Matthew Francis Chersich
- Wits Reproductive Health and HIV Institute (Wits RHI), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Richard J Munthali
- Wits Reproductive Health and HIV Institute (Wits RHI), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Thesla Palanee-Phillips
- Wits Reproductive Health and HIV Institute (Wits RHI), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Busi Nkala
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | | | | | - Zonke Mabude
- MATCH, University of the Witwatersrand, Johannesburg, South Africa
| | - Maphoshane Nchabeleng
- Mecru Clinical Research Unit, Sefako Makgatho Health Sciences University, Ga-Rankuwa, South Africa
| | - Linda-Gail Bekker
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Philip Kotze
- Qhakaza Mbokodo Research Centre, Ladysmith, South Africa
| | - Thembisile Mogodiri
- Wits Reproductive Health and HIV Institute (Wits RHI), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Ishana Naidoo
- Wits Reproductive Health and HIV Institute (Wits RHI), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Ravindre Panchia
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Landon Myer
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Carl Lombard
- Biostatistics Unit, South African Medical Research Council, Cape Town, South Africa ; and
- Division of Epidemiology and Biostatistics, Department of Global Health, University of Stellenbosch, Stellenbosch, South Africa
| | | | - Glenda Gray
- Setshaba Research Centre, Soshanguve, South Africa
- South African Medical Research Council, Cape Town, South Africa
| | - Sinead Delany-Moretlwe
- Wits Reproductive Health and HIV Institute (Wits RHI), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Nishiura K, Sharma S, Sterling M, Makarova N, Martin A, Dinh C, Mitchell J, García-Lerma JG, Heneine W, Dobard C. Pharmacokinetics of vaginally applied integrase inhibitors in macaques. J Antimicrob Chemother 2021; 76:2894-2901. [PMID: 34423357 DOI: 10.1093/jac/dkab293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 07/20/2021] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES We conducted a detailed pharmacokinetic assessment in macaques treated with vaginal gels formulated with HIV integrase strand transfer inhibitors (INSTIs) to better understand drug distribution and identify INSTI concentrations associated with previously demonstrated in vivo protection against vaginal simian HIV challenge. METHODS Six macaques received vaginal gel containing 1% raltegravir (30 mg) once-weekly over 6 weeks. Following a washout period, five macaques received once-weekly gel containing 0.23% L-870,812 (7 mg). Drug concentrations were measured in plasma, mucosal fluids and vaginal tissues at baseline and 2, 5 and 24 h post-dosing. RESULTS The median maximum concentration (Cmax) for raltegravir and L-870,812 in plasma was below the limit of quantification and 41.1 ng/mL, respectively. The Cmax in vaginal fluids (1441 and 1250 μg/mL) and tissues (266.7 and 368.4 μg/g) was achieved 2-5 h after dosing, respectively. A similar half-life was observed for raltegravir and L-870,812 in vaginal fluids (8-10 h) and remained 3-4 orders of magnitude above the protein-adjusted IC95 (0.016 and 0.106 μg/mL, respectively) at 24 h. Drug concentrations in vaginal fluids correlated well with those in vaginal tissues (Pearson r ≥ 0.788). Both drugs were consistently detected in rectal fluids 2 h after vaginal dosing, albeit at much lower levels (31-92-fold) than those in vaginal fluids. CONCLUSIONS To the best of our knowledge, this study provides the first data on INSTI levels in vaginal tissues associated with in vivo protection and demonstrates rectal drug distribution of INSTIs after vaginal dosing. These findings may inform dose selection for topical products with INSTIs for HIV prevention.
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Affiliation(s)
- Kenji Nishiura
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Sunita Sharma
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Mara Sterling
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Natalia Makarova
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Amy Martin
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Chuong Dinh
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - James Mitchell
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - J Gerardo García-Lerma
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Walid Heneine
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Charles Dobard
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
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Safety and pharmacokinetics of islatravir subdermal implant for HIV-1 pre-exposure prophylaxis: a randomized, placebo-controlled phase 1 trial. Nat Med 2021; 27:1712-1717. [PMID: 34608329 DOI: 10.1038/s41591-021-01479-3] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 07/22/2021] [Indexed: 11/09/2022]
Abstract
Islatravir (MK-8591) is a highly potent type 1 human immunodeficiency virus (HIV-1) nucleoside reverse transcriptase translocation inhibitor with a long intracellular half-life that is in development for the prevention and treatment of HIV-1. We conducted a randomized, double-blind, placebo-controlled, phase 1 trial in adults without HIV-1 infection. Participants received islatravir or placebo subdermal implants for 12 weeks and were monitored throughout this period and after implant removal. The co-primary end points were safety and tolerability of the islatravir implant and pharmacokinetics, including concentration at day 85, of islatravir triphosphate in peripheral blood mononuclear cells (PBMCs). Secondary end points included additional pharmacokinetic parameters for islatravir triphosphate in PBMCs and the plasma pharmacokinetic profile of islatravir. Based on preclinical data, two doses were assessed: 54 mg (n = 8, two placebo) and 62 mg (n = 8, two placebo). The most frequently reported adverse events were mild-to-moderate implant-site reactions (induration, hematoma, pain). Throughout the 12-week trial, geometric mean islatravir triphosphate concentrations were above a pharmacokinetic threshold of 0.05 pmol per 106 PBMCs, which was estimated to provide therapeutic reverse transcriptase inhibition (concentration at day 85 (percentage of geometric coefficient of variation): 54 mg, 0.135 pmol per 106 cells (27.3); 62 mg, 0.272 pmol per 106 cells (45.2)). Islatravir implants at both doses were safe and resulted in mean concentrations above the pharmacokinetic threshold through 12 weeks, warranting further investigation of islatravir implants as a potential HIV prevention strategy.
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Zane D, Roller S, Shelton J, Singh R, Jain R, Wang Y, Yang B, Felx M, Alessi T, Feldman PL. A 28-Day Toxicity Study of Tenofovir Alafenamide Hemifumarate by Subcutaneous Infusion in Rats and Dogs. Microbiol Spectr 2021; 9:e0033921. [PMID: 34190595 PMCID: PMC8552772 DOI: 10.1128/spectrum.00339-21] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 05/25/2021] [Indexed: 11/20/2022] Open
Abstract
The toxicity of tenofovir alafenamide (TAF) hemifumarate (HF) was evaluated when administered by continuous subcutaneous (s.c.) infusion via an external infusion pump for 28 days to rats and dogs. The toxicokinetics of TAF and two metabolites, tenofovir (TFV) and tenofovir diphosphate (TFV-DP) were also evaluated. After administration of TAF HF in rats and dogs, primary systemic findings supported an inflammatory response that was considered minimal to mild. Gross pathology and histopathologic evaluation of tissue surrounding the s.c. infusion site revealed signs of inflammation, including edema, mass formation, fibrosis, and mononuclear cell inflammation in groups receiving ≥300 μg/kg/day in rats and ≥25 μg/day in dogs. Although these changes were observed in animals receiving vehicle, the severity was greater in animals receiving TAF HF. Changes in the local tissue were considered a TAF HF-mediated exacerbation of an inflammatory response to the presence of the catheter. In rats, systemic and local findings were considered not adverse due to their low severity and reversibility; therefore, the "no observed adverse effect level" (NOAEL) was set at 1,000 μg/kg/day. Because none of the systemic findings were related to systemic exposure to TAF, the systemic NOAEL was set at 250 μg/kg/day in dogs. Due to the severity of the observations noted, a NOAEL for local toxicity could not be established. Although these results might allow for exploration of tolerability and pharmacokinetics of s.c. administered TAF HF in humans, data suggest a local reaction may develop in humans at doses below a clinically relevant dose. IMPORTANCE Human immunodeficiency virus (HIV) infection continues to be a serious global human health issue, with ∼38 million people living with HIV worldwide at the end of 2019. HIV preexposure prophylaxis (PrEP) has introduced the use of antiretroviral therapies as another helpful tool for slowing the spread of HIV worldwide. One possible solution to the problem of inconsistent access and poor adherence to HIV PrEP therapies is the development of subcutaneous (s.c.) depots or s.c. implantable devices that continuously administer protective levels of an HIV PrEP therapy for weeks, months, or even years at a time. We evaluate here the toxicity of tenofovir alafenamide, a potent inhibitor or HIV replication, after continuous s.c. infusion in rats and dogs for HIV PrEP.
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Affiliation(s)
- Doris Zane
- Intarcia Therapeutics, Inc., Hayward, California, USA
| | - Shane Roller
- Intarcia Therapeutics, Inc., Research Triangle Park, California, USA
| | | | - Roshni Singh
- Intarcia Therapeutics, Inc., Hayward, California, USA
| | - Rachna Jain
- Intarcia Therapeutics, Inc., Hayward, California, USA
| | - Yan Wang
- Intarcia Therapeutics, Inc., Hayward, California, USA
| | - Bing Yang
- Intarcia Therapeutics, Inc., Hayward, California, USA
| | - Melanie Felx
- Charles River Laboratories, Senneville, Quebec, Canada
| | - Thomas Alessi
- Intarcia Therapeutics, Inc., Hayward, California, USA
| | - Paul L. Feldman
- Intarcia Therapeutics, Inc., Research Triangle Park, California, USA
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das Neves J, Notario-Pérez F, Sarmento B. Women-specific routes of administration for drugs: A critical overview. Adv Drug Deliv Rev 2021; 176:113865. [PMID: 34280514 DOI: 10.1016/j.addr.2021.113865] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 07/07/2021] [Accepted: 07/09/2021] [Indexed: 12/19/2022]
Abstract
The woman's body presents a number of unique anatomical features that can constitute valuable routes for the administration of drugs, either for local or systemic action. These are associated with genitalia (vaginal, endocervical, intrauterine, intrafallopian and intraovarian routes), changes occurring during pregnancy (extra-amniotic, intra-amniotic and intraplacental routes) and the female breast (breast intraductal route). While the vaginal administration of drug products is common, other routes have limited clinical application and are fairly unknown even for scientists involved in drug delivery science. Understanding the possibilities and limitations of women-specific routes is of key importance for the development of new preventative, diagnostic and therapeutic strategies that will ultimately contribute to the advancement of women's health. This article provides an overview on women-specific routes for the administration of drugs, focusing on aspects such as biological features pertaining to drug delivery, relevance in current clinical practice, available drug dosage forms/delivery systems and administration techniques, as well as recent trends in the field.
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27
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Krovi SA, Johnson LM, Luecke E, Achilles SL, van der Straten A. Advances in long-acting injectables, implants, and vaginal rings for contraception and HIV prevention. Adv Drug Deliv Rev 2021; 176:113849. [PMID: 34186143 DOI: 10.1016/j.addr.2021.113849] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 06/15/2021] [Accepted: 06/22/2021] [Indexed: 12/22/2022]
Abstract
Worldwide, women face compounding reproductive health risks, including human immunodeficiency virus (HIV), sexually-transmitted infections (STIs), and unintended pregnancy. Multipurpose prevention technologies (MPTs) offer combined protection against these overlapping risks in singular prevention products that offer potential for simplified use, lower burden, higher acceptability, and increased public health benefits. Over the past decade, substantial progress has been made in development of extended-release MPTs, which have further potential to grant sexual and reproductive health autonomy to women globally and to offer choice for women to accommodate varying needs during their reproductive lives. Here, we highlight the advances made in injectable, implant, and ring delivery forms, and the importance of incorporating end-user preferences early in the research and development of these products.
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Affiliation(s)
| | | | - Ellen Luecke
- Women's Global Health Imperative, RTI International, Berkeley, CA, USA
| | - Sharon L Achilles
- University of Pittsburgh, School of Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, Pittsburgh, PA, USA; Magee-Womens Research Institute, Pittsburgh, PA, USA
| | - Ariane van der Straten
- Center for AIDS Prevention Studies, Dept of Medicine, University of California San Francisco, San Francisco, CA, USA; ASTRA Consulting, Kensington, CA, USA
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28
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Gao Z, Fu R, Li X, Wang J, He Y. Safety Assessment of Microbicide 2P23 on the Rectal and Vaginal Microbiota and Its Antiviral Activity on HIV Infection. Front Immunol 2021; 12:702172. [PMID: 34447373 PMCID: PMC8382973 DOI: 10.3389/fimmu.2021.702172] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 07/21/2021] [Indexed: 02/01/2023] Open
Abstract
Containment of the AIDS pandemic requires reducing HIV transmission. HIV infection is initiated by the fusion of the membrane between the virus and the cell membrane of the host. 2P23 is an effective HIV membrane fusion inhibitor that may be a good entry inhibitor microbicide candidate. This study evaluated the potential of using gel-formulated 2P23 as a topical microbicide to prevent sexual transmission of HIV in the rectum and vagina. Our data revealed that 2P23 formulated in gel is effective against HIV. There was no change in antiviral activity at 25°C for 4 months or 60°C for 1 week. In addition, we demonstrated that the 2P23 gel was stable and fully functional at pH 4.0-8.0 and under different concentrations of H2O2. Finally, the 2P23 gel exhibited no cytotoxicity or antimicrobial activity and did not induce inflammatory changes in the rectal or vaginal mucosal epithelium in New Zealand rabbits after 20 mg/day daily rectovaginal application for 14 consecutive days. Despite repeated tissue sampling and 2P23 gel treatment, the inflammatory cytokines and microbiota of the rectum and vagina remained stable. These results add to general knowledge on the in vivo evaluation of anti-HIV microbicide application concerning inflammatory cytokines and microbiota changes in the rectum and vagina. These findings suggest that the 2P23 gel is an excellent candidate for further development as a safe and effective pre-exposure prophylactic microbicide for the prevention of HIV transmission.
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Affiliation(s)
- Zhengqin Gao
- NHC Key Laboratory of Systems Biology of Pathogens, Institute of Pathogen Biology and Center for AIDS Research, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Institute for Laboratory Animal Resources, National Institutes for Food and Drug Control, Beijing, China
| | - Rui Fu
- Institute for Laboratory Animal Resources, National Institutes for Food and Drug Control, Beijing, China
| | - Xiaobo Li
- Institute for Laboratory Animal Resources, National Institutes for Food and Drug Control, Beijing, China
| | - Ji Wang
- Institute for Laboratory Animal Resources, National Institutes for Food and Drug Control, Beijing, China
| | - Yuxian He
- NHC Key Laboratory of Systems Biology of Pathogens, Institute of Pathogen Biology and Center for AIDS Research, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Workowski KA, Bachmann LH, Chan PA, Johnston CM, Muzny CA, Park I, Reno H, Zenilman JM, Bolan GA. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep 2021; 70:1-187. [PMID: 34292926 PMCID: PMC8344968 DOI: 10.15585/mmwr.rr7004a1] [Citation(s) in RCA: 825] [Impact Index Per Article: 275.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
These guidelines for the treatment of persons who have or are at risk for
sexually transmitted infections (STIs) were updated by CDC after consultation
with professionals knowledgeable in the field of STIs who met in Atlanta,
Georgia, June 11–14, 2019. The information in this report updates the
2015 guidelines. These guidelines discuss 1) updated recommendations for
treatment of Neisseria gonorrhoeae, Chlamydia trachomatis,
and Trichomonas vaginalis; 2) addition of
metronidazole to the recommended treatment regimen for pelvic inflammatory
disease; 3) alternative treatment options for bacterial vaginosis; 4) management
of Mycoplasma genitalium; 5) human papillomavirus vaccine
recommendations and counseling messages; 6) expanded risk factors for syphilis
testing among pregnant women; 7) one-time testing for hepatitis C infection; 8)
evaluation of men who have sex with men after sexual assault; and 9) two-step
testing for serologic diagnosis of genital herpes simplex virus. Physicians and
other health care providers can use these guidelines to assist in prevention and
treatment of STIs.
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Abstract
HIV incidence has recently been in decline across some of the most intense epidemics in sub-Saharan Africa due to the scale-up of prevention and transmission-blocking treatments. Understanding whether declines in incidence are being felt equally across age and gender can help prioritize demographic groups where more effort is needed to lower transmission. We found that HIV incidence has declined disproportionately in the youngest men and women in a population with the highest HIV prevalence in the world. Shifts in the age distribution of risk may be the consequence of aging prevalence, prioritized prevention to younger individuals, and delays in age at infection from reduced overall force of infection. Our results highlight the need to expand age targets for HIV prevention. Recent declines in adult HIV-1 incidence have followed the large-scale expansion of antiretroviral therapy and primary HIV prevention across high-burden communities of sub-Saharan Africa. Mathematical modeling suggests that HIV risk will decline disproportionately in younger adult age-groups as interventions scale, concentrating new HIV infections in those >age 25 over time. Yet, no empirical data exist to support these projections. We conducted a population-based cohort study over a 16-y period (2004 to 2019), spanning the early scale-up of antiretroviral therapy and voluntary medical male circumcision, to estimate changes in the age distribution of HIV incidence in a hyperepidemic region of KwaZulu-Natal, South Africa, where adult HIV incidence has recently declined. Median age of HIV seroconversion increased by 5.5 y in men and 3.0 y in women, and the age of peak HIV incidence increased by 5.0 y in men and 2.0 y in women. Incidence declined disproportionately among young men (64% in men 15 to 19, 68% in men 20 to 24, and 46% in men 25 to 29) and young women (44% in women 15 to 19, 24% in women 20 to 24) comparing periods pre- versus post-universal test and treat. Incidence was stable (<20% change) in women aged 30 to 39 and men aged 30 to 34. Age shifts in incidence occurred after 2012 and were observed earlier in men than in women. These results provide direct epidemiological evidence of the changing demographics of HIV risk in sub-Saharan Africa in the era of large-scale treatment and prevention. More attention is needed to address lagging incidence decline among older individuals.
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Abstract
PURPOSE OF REVIEW Although tremendous successes in HIV treatment and prevention have occurred in the past decade, existing HIV prevention options are inadequate, unacceptable or inaccessible to many. Topical antiretroviral-based preexposure prophylaxis (PrEP) options may offer effective, long-acting prevention to those who do not desire systemic exposure to anti-HIV drugs or who want greater control over their own prevention. RECENT FINDINGS Among long-acting topical PrEP agents, the dapivirine vaginal ring has advanced the furthest in product development; recent studies have shown high adherence and persistence and evidence of HIV protection in open-label studies as well as a well tolerated safety profile, across the life cycle in women. A range of other long-acting topical PrEP products for vaginal or rectal drug delivery are under development. Rigorous end-user research has explored how to develop products that are behaviorally congruent for the population at risk and has shown that no single product option will be desired by all, but rather different options will achieve the greatest prevention coverage. SUMMARY Topically delivered, long-acting antiretroviral PrEP options are being designed to align with user preferences and lifestyles, providing the potential to more effectively expand the HIV prevention method mix and use and achieve an important impact on HIV globally.
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Gustin A, Cromarty R, Schifanella L, Klatt NR. Microbial mismanagement: how inadequate treatments for vaginal dysbiosis drive the HIV epidemic in women. Semin Immunol 2021; 51:101482. [PMID: 34120819 DOI: 10.1016/j.smim.2021.101482] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 05/24/2021] [Indexed: 12/18/2022]
Abstract
Women and girls represent a key population driving new HIV infections and persistence of the HIV pandemic. A key determinant of HIV susceptibility is the composition of the vaginal microbiome, which can influence the local immune cell population, inflammation status, and HIV prevention drug levels. While a low-diversity composition dominated by Lactobacillus crispatus is associated with a decreased risk of HIV acquisition, high diversity environments associated with bacterial vaginosis increase risk of HIV. Given the important role of the vaginal microbiome in determining HIV susceptibility, altering the microbiome towards a Lactobacillus-dominated state is an attractive complementary strategy to reduce HIV incidence rates. Here, we provide an overview of the mechanisms by which the vaginal microbiome may contribute to HIV acquisition risk. Furthermore, we address the advantages and limitations of historical treatments and emerging technologies under investigation to modify the vaginal microbiome, including: antibiotics, bacteriophages, probiotics, topicals, and engineered bacteria. By addressing the current state of vaginal microbiome knowledge and strategies for manipulation, we hope to amplify the growing calls for increased resources and research into vaginal microbial health, which will be essential to accelerating preventative efforts amongst the world's most vulnerable populations.
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Affiliation(s)
- Andrew Gustin
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Ross Cromarty
- Department of Surgery, Division of Surgical Outcomes and Precision Medicine Research, University of Minnesota, Minneapolis, MN, USA; Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Luca Schifanella
- Department of Surgery, Division of Surgical Outcomes and Precision Medicine Research, University of Minnesota, Minneapolis, MN, USA
| | - Nichole R Klatt
- Department of Surgery, Division of Surgical Outcomes and Precision Medicine Research, University of Minnesota, Minneapolis, MN, USA.
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Al-Khouja A, Shieh E, Fuchs EJ, Marzinke MA, Bakshi RP, Hummert P, Ham AS, Buckheit KW, Breakey J, Weld ED, Chen H, Caffo BS, Buckheit RW, Hendrix CW. Examining the Safety, Pharmacokinetics, and Pharmacodynamics of a Rectally Administered IQP-0528 Gel for HIV Pre-Exposure Prophylaxis: A First-In-Human Study. AIDS Res Hum Retroviruses 2021; 37:444-452. [PMID: 33371779 DOI: 10.1089/aid.2020.0188] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
A lubricating microbicide gel designed for rectal and vaginal use would provide a behaviorally congruent strategy to enhance pre-exposure prophylaxis adherence and reduce HIV infection risk. In this study, we report the first-in-human evaluation of such a gel containing 1% IQP-0528, an investigational antiretroviral. Seven HIV-1-negative participants received one 10 mL rectal dose of radiolabeled 1% IQP-0528 gel. We assessed safety; IQP-0528 pharmacokinetics in plasma, and rectal and vaginal tissue; ex vivo local pharmacodynamics (PD); and colorectal distribution. The 1% gel was determined to be safe with one mild event attributed to study product and no effects on rectal tissue histology. All concentrations measured in plasma and vaginal tissue were below the limit of quantitation. Median IQP-0528 concentrations in rectal tissue exceeded the in vitro EC95 against HIV-1 (0.07 ng/mg) by 3-5 h of dosing and remained above this concentration for at least 24 h, despite a 3-log reduction in concentration over this duration of time. Rectal tissue PD-assessed by ex vivo HIV challenge-demonstrated significant p24 antigen reduction 3-5 h postdose compared with baseline (p = .05), but not 24-26 h postdose (p = .75). Single-photon emission computed tomography/computed tomography imaging revealed that product distribution was localized to the rectosigmoid. The IQP-0528 gel possesses desirable features for a topical microbicide including: local safety with no systemic absorption, delivery of locally high IQP-0528 concentrations, and significant reductions in ex vivo HIV infectivity. However, the gel is limited by its rapid clearance and inability to penetrate vaginal tissues following rectal dosing. Clinical Trial Registration number: NCT03082690.
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Affiliation(s)
- Amer Al-Khouja
- Division of Clinical Pharmacology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Eugenie Shieh
- Division of Clinical Pharmacology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Edward J. Fuchs
- Division of Clinical Pharmacology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Mark A. Marzinke
- Division of Clinical Pharmacology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Rahul P. Bakshi
- Division of Clinical Pharmacology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Pamela Hummert
- Division of Clinical Pharmacology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | | | - Jennifer Breakey
- Division of Clinical Pharmacology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ethel D. Weld
- Division of Clinical Pharmacology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Huan Chen
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Brian S. Caffo
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | - Craig W. Hendrix
- Division of Clinical Pharmacology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Liu AY, Dominguez Islas C, Gundacker H, Neradilek B, Hoesley C, van der Straten A, Hendrix CW, Beamer M, Jacobson CE, McClure T, Harrell T, Bunge K, Devlin B, Nuttall J, Spence P, Steytler J, Piper JM, Marzinke MA. Phase 1 pharmacokinetics and safety study of extended duration dapivirine vaginal rings in the United States. J Int AIDS Soc 2021; 24:e25747. [PMID: 34118115 PMCID: PMC8196716 DOI: 10.1002/jia2.25747] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 04/27/2021] [Accepted: 04/30/2021] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION Vaginal rings are a promising approach to provide a woman-centred, long-acting HIV prevention strategy. Prior trials of a 25 mg dapivirine (DPV) ring have shown a favourable safety profile and approximately 30% risk reduction of HIV-1 infection. Extended duration rings replaced every three months may encourage user adherence, improve health service efficiency and reduce cost overall. We evaluated safety, pharmacokinetics, adherence and acceptability of two three-month rings with different DPV dosages, compared with the monthly DPV ring. METHODS From December 2017 to October 2018, MTN-036/IPM-047 enrolled 49 HIV-negative participant in Birmingham, Alabama and San Francisco, California into a phase 1, randomized trial comparing two extended duration (three-month) rings (100 or 200 mg DPV) to a monthly 25 mg DPV ring, each used over 13 weeks, with follow-up completed in January 2019. Safety was assessed by recording adverse events (AEs). DPV concentrations were quantified in plasma, cervicovaginal fluid (CVF) and cervical tissue, at nominal timepoints. Geometric mean ratios (GMRs) relative to the comparator ring were estimated from a regression model. RESULTS There were no differences in the proportion of participants with grade ≥2 genitourinary AEs or grade ≥3 AEs in the extended duration versus monthly ring arms (p = 1.0). Plasma and CVF DPV concentrations were higher in the extended duration rings compared to the monthly ring. Plasma GMRs were 1.31 to 1.85 and 1.41 to 1.86 and CVF GMRs were 1.45 to 2.87 and 1.74 to 2.60 for the 100 and 200 mg ring respectively. Cervical tissue concentrations were consistently higher in the 200 mg ring (GMRs 2.36 to 3.97). The majority of participants (82%) were fully adherent (ring inserted at all times, with no product discontinuations/outages) with no differences between the monthly versus three-month rings. Most participants found the ring acceptable (median = 8 on 10-point Likert scale), with a greater proportion of participants reporting high acceptability (9 or 10) in the 25 mg arm (73%) compared with the 100 mg (25%) and 200 mg (44%) arms (p = 0.01 and p = 0.15 respectively). CONCLUSIONS The extended duration DPV rings were well-tolerated and achieved higher DPV concentrations compared with the monthly DPV ring. These findings support further evaluation of three-month DPV rings for HIV prevention.
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Affiliation(s)
- Albert Y Liu
- Bridge HIVSan Francisco Department of Public HealthSan FranciscoCAUSA
- Department of MedicineUniversity of CaliforniaSan FranciscoCAUSA
| | - Clara Dominguez Islas
- Vaccine and Infectious Disease DivisionFred Hutchinson Cancer Research CenterSeattleWAUSA
| | - Holly Gundacker
- Statistical Center for HIV/AIDS Research & PreventionFred Hutchinson Cancer Research CenterSeattleWAUSA
| | - Blazej Neradilek
- Statistical Center for HIV/AIDS Research & PreventionFred Hutchinson Cancer Research CenterSeattleWAUSA
| | | | - Ariane van der Straten
- Department of MedicineUniversity of CaliforniaSan FranciscoCAUSA
- Women’s Global Health Imperative (WGHI)RTI InternationalBerkeleyCAUSA
- ASTRA ConsultingKensingtonCAUSA
| | - Craig W Hendrix
- Division of Clinical PharmacologyDepartment of MedicineJohns Hopkins University School of MedicineBaltimoreMDUSA
| | - May Beamer
- Magee‐Womens Research InstitutePittsburghPAUSA
| | | | | | - Tanya Harrell
- Statistical Center for HIV/AIDS Research & PreventionFred Hutchinson Cancer Research CenterSeattleWAUSA
| | - Katherine Bunge
- Magee‐Womens Research InstitutePittsburghPAUSA
- Department of Obstetrics, Gynecology, and Reproductive SciencesUniversity of PittsburghPittsburghPAUSA
| | - Brid Devlin
- International Partnership for MicrobicidesSilver SpringMDUSA
| | - Jeremy Nuttall
- International Partnership for MicrobicidesSilver SpringMDUSA
| | - Patrick Spence
- International Partnership for MicrobicidesSilver SpringMDUSA
| | - John Steytler
- International Partnership for MicrobicidesSilver SpringMDUSA
| | - Jeanna M Piper
- Division of AIDSNational Institutes of HealthBethesdaMDUSA
| | - Mark A Marzinke
- Division of Clinical PharmacologyDepartment of MedicineJohns Hopkins University School of MedicineBaltimoreMDUSA
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Romano JW, Baum MM, Demkovich ZR, Diana F, Dobard C, Feldman PL, Garcia-Lerma JG, Grattoni A, Gunawardana M, Ho DK, Hope TJ, Massud I, Milad M, Moss JA, Pons-Faudoa FP, Roller S, van der Straten A, Srinivasan S, Veazey RS, Zane D. Tenofovir Alafenamide for HIV Prevention: Review of the Proceedings from the Gates Foundation Long-Acting TAF Product Development Meeting. AIDS Res Hum Retroviruses 2021; 37:409-420. [PMID: 33913760 PMCID: PMC8213003 DOI: 10.1089/aid.2021.0028] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
The ability to successfully develop a safe and effective vaccine for the prevention of HIV infection has proven challenging. Consequently, alternative approaches to HIV infection prevention have been pursued, and there have been a number of successes with differing levels of efficacy. At present, only two oral preexposure prophylaxis (PrEP) products are available, Truvada and Descovy. Descovy is a newer product not yet indicated in individuals at risk of HIV-1 infection from receptive vaginal sex, because it still needs to be evaluated in this population. A topical dapivirine vaginal ring is currently under regulatory review, and a long-acting (LA) injectable cabotegravir product shows strong promise. Although demonstrably effective, daily oral PrEP presents adherence challenges for many users, particularly adolescent girls and young women, key target populations. This limitation has triggered development efforts in LA HIV prevention options. This article reviews efforts supported by the Bill & Melinda Gates Foundation, as well as similar work by other groups, to identify and develop optimal LA HIV prevention products. Specifically, this article is a summary review of a meeting convened by the foundation in early 2020 that focused on the development of LA products designed for extended delivery of tenofovir alafenamide (TAF) for HIV prevention. The review broadly serves as technical guidance for preclinical development of LA HIV prevention products. The meeting examined the technical feasibility of multiple delivery technologies, in vivo pharmacokinetics, and safety of subcutaneous (SC) delivery of TAF in animal models. Ultimately, the foundation concluded that there are technologies available for long-term delivery of TAF. However, because of potentially limited efficacy and possible toxicity issues with SC delivery, the foundation will not continue investing in the development of LA, SC delivery of TAF products for HIV prevention.
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Affiliation(s)
| | - Marc M. Baum
- Department of Chemistry, Oak Crest Institute of Science, Monrovia, California, USA
| | | | - Frank Diana
- FJD-CMC Consulting, LLC., Ocean City, New Jersey, USA
| | - Charles Dobard
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Paul L. Feldman
- Intarcia Therapeutics, Inc., Research Triangle Park, North Carolina, USA
| | - J. Gerardo Garcia-Lerma
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Alessandro Grattoni
- Department of Nanomedicine, Houston Methodist Research Institute, Houston, Texas, USA
| | - Manjula Gunawardana
- Department of Chemistry, Oak Crest Institute of Science, Monrovia, California, USA
| | - Duy-Khiet Ho
- Department of Bioengineering, University of Washington, Seattle, Washington, USA
| | - Thomas J. Hope
- Department of Cell and Developmental Biology, Northwestern University, Chicago, Illinois, USA
| | - Ivana Massud
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Mark Milad
- Milad Pharmaceutical Consulting, Plymouth, Michigan, USA
| | - John A. Moss
- Department of Chemistry, Oak Crest Institute of Science, Monrovia, California, USA
| | | | - Shane Roller
- Intarcia Therapeutics, Inc., Research Triangle Park, North Carolina, USA
| | - Ariane van der Straten
- Women's Global Health Imperative, RTI International, Berkeley, California, USA
- Department of Medicine, Center for AIDS Prevention Study (CAPS), UCSF, San Francisco, California, USA
| | - Selvi Srinivasan
- Department of Bioengineering, University of Washington, Seattle, Washington, USA
| | - Ronald S. Veazey
- Department of Pathology and Laboratory Medicine, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Doris Zane
- Intarcia Therapeutics, Inc., Heyward, California, USA
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Xie M, Li J, Zhang S, Zhu D, Mei X, Wang Z, Cheng X, Li Z, Wang S, Cheng K. A trifunctional contraceptive gel enhances the safety and quality of sexual intercourse. Bioact Mater 2021; 6:1777-1788. [PMID: 33336110 PMCID: PMC7724154 DOI: 10.1016/j.bioactmat.2020.11.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 11/26/2020] [Accepted: 11/27/2020] [Indexed: 12/15/2022] Open
Abstract
Current contraceptive methods come with a number of drawbacks, including low efficacy, in the case of commercial contraceptive gels, and a reduction in the quality of sexual intercourse, in the case of condoms. Adding pharmacologically-active agents to contraceptive gels holds the potential to improve sexual experience, and hardbor safety and hygiene. In this study, we fabricated a Carbomer-based contraceptive gel consisting of three agents: tenofovir, gossypol acetate, and nitroglycerin (TGN), with pH adjusted to 4.5 (to be compatible with the vagina). In vitro, the gossypol component of the contraceptive gel proved to be a significantly effective spermicide. When the concentration of gossypol acetate was 10 mg/ml, the spermicidal ability reached 100% after 30s. In addition, tenofovir in the gel significantly inhibited lentiviral transfection efficiency in cell-containing media. In 6 pairs of rats, the gel successfully prevented all females from conceiving after successful mating. Moreover, increased sexual frequency and enhanced erection, which were promoted by the nitroglycerin in the components, were observed in male rats that had the gel applied to their penises. This novel TGN contraceptive gel yielded a higher contraceptive success rate than that of the commercial contraceptive gel (Contragel®). In addition, it has the added benefits to prevent sexually transmitted diseases and improve male libido and erection function during sexual intercourse. Combining three FDA-approved and marketed agents together, our trifunctional TGN gel has a great potential for further translation and commercialization.
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Affiliation(s)
- Mengjie Xie
- The Key Laboratory of Geriatrics, Beijing Institute of Geriatrics, Beijing Hospital, National Center of Gerontology, National Health Commission, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, PR China
- Department of Molecular Biomedical Sciences, North Carolina State University, Raleigh, NC, 27607, USA
- Joint Department of Biomedical Engineering, North Carolina State University & University of North Carolina at Chapel Hill, Raleigh, NC, 27607, USA
| | - Junlang Li
- Department of Molecular Biomedical Sciences, North Carolina State University, Raleigh, NC, 27607, USA
- Joint Department of Biomedical Engineering, North Carolina State University & University of North Carolina at Chapel Hill, Raleigh, NC, 27607, USA
| | - Sichen Zhang
- Department of Molecular Biomedical Sciences, North Carolina State University, Raleigh, NC, 27607, USA
- Joint Department of Biomedical Engineering, North Carolina State University & University of North Carolina at Chapel Hill, Raleigh, NC, 27607, USA
- Department of Gynecology and Obstetrics, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, PR China
| | - Dashuai Zhu
- Department of Molecular Biomedical Sciences, North Carolina State University, Raleigh, NC, 27607, USA
- Joint Department of Biomedical Engineering, North Carolina State University & University of North Carolina at Chapel Hill, Raleigh, NC, 27607, USA
| | - Xuan Mei
- Department of Molecular Biomedical Sciences, North Carolina State University, Raleigh, NC, 27607, USA
- Joint Department of Biomedical Engineering, North Carolina State University & University of North Carolina at Chapel Hill, Raleigh, NC, 27607, USA
| | - Zhenzhen Wang
- Department of Molecular Biomedical Sciences, North Carolina State University, Raleigh, NC, 27607, USA
- Joint Department of Biomedical Engineering, North Carolina State University & University of North Carolina at Chapel Hill, Raleigh, NC, 27607, USA
| | - Xiao Cheng
- Department of Molecular Biomedical Sciences, North Carolina State University, Raleigh, NC, 27607, USA
- Joint Department of Biomedical Engineering, North Carolina State University & University of North Carolina at Chapel Hill, Raleigh, NC, 27607, USA
| | - Zhenhua Li
- Department of Molecular Biomedical Sciences, North Carolina State University, Raleigh, NC, 27607, USA
- Joint Department of Biomedical Engineering, North Carolina State University & University of North Carolina at Chapel Hill, Raleigh, NC, 27607, USA
| | - Shaowei Wang
- The Key Laboratory of Geriatrics, Beijing Institute of Geriatrics, Beijing Hospital, National Center of Gerontology, National Health Commission, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, PR China
- Department of Gynecology and Obstetrics, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, PR China
| | - Ke Cheng
- Department of Molecular Biomedical Sciences, North Carolina State University, Raleigh, NC, 27607, USA
- Joint Department of Biomedical Engineering, North Carolina State University & University of North Carolina at Chapel Hill, Raleigh, NC, 27607, USA
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Crakes KR, Herrera C, Morgan JL, Olstad K, Hessell AJ, Ziprin P, LiWang PJ, Dandekar S. Efficacy of silk fibroin biomaterial vehicle for in vivo mucosal delivery of Griffithsin and protection against HIV and SHIV infection ex vivo. J Int AIDS Soc 2021; 23:e25628. [PMID: 33073530 PMCID: PMC7569169 DOI: 10.1002/jia2.25628] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 09/14/2020] [Accepted: 09/21/2020] [Indexed: 12/22/2022] Open
Abstract
Introduction The majority of new HIV infections occur through mucosal transmission. The availability of readily applicable and accessible platforms for anti‐retroviral (ARV) delivery is critical for the prevention of HIV acquisition through sexual transmission in both women and men. There is a compelling need for developing new topical delivery systems that have advantages over the pills, gels and rings, which currently fail to guarantee protection against mucosal viral transmission in vulnerable populations due to lack of user compliance. The silk fibroin (SF) platform offers another option that may be better suited to individual circumstances and preferences to increase efficacy through user compliance. The objective of this study was to test safety and efficacy of SF for anti‐HIV drug delivery to mucosal sites and for viral prevention. Methods We formulated a potent HIV inhibitor Griffithsin (Grft) in a mucoadhesive silk fibroin (SF) drug delivery platform and tested the application in a non‐human primate model in vivo and a pre‐clinical human cervical and colorectal tissue explant model. Both vaginal and rectal compartments were assessed in rhesus macaques (Mucaca mulatta) that received SF (n = 4), no SF (n = 7) and SF‐Grft (n = 11). In this study, we evaluated the composition of local microbiota, inflammatory cytokine production, histopathological changes in the vaginal and rectal compartments and mucosal protection after ex vivo SHIV challenge. Results Effective Grft release and retention in mucosal tissues from the SF‐Grft platform resulted in protection against HIV in human cervical and colorectal tissue as well as against SHIV challenge in both rhesus macaque vaginal and rectal tissues. Mucoadhesion of SF‐Grft inserts did not cause any inflammatory responses or changes in local microbiota. Conclusions We demonstrated that in vivo delivery of SF‐Grft in rhesus macaques fully protects against SHIV challenge ex vivo after two hours of application and is safe to use in both the vaginal and rectal compartments. Our study provides support for the development of silk fibroin as a highly promising, user‐friendly HIV prevention modality to address the global disparity in HIV infection.
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Affiliation(s)
- Katti R Crakes
- Department of Medical Microbiology & Immunology, School of Medicine, University of California Davis, Davis, CA, USA
| | - Carolina Herrera
- Department of Medicine, St. Mary's Campus Imperial College, London, United Kingdom
| | - Jessica L Morgan
- Department of Molecular Cell Biology, University of California Merced, Merced, CA, USA
| | - Katie Olstad
- California National Primate Research Center, University of California Davis, Davis, CA, USA
| | - Ann J Hessell
- Division of Pathobiology and Immunology, Oregon National Primate Research Center, Oregon Health and Sciences University, Beaverton, OR, USA
| | - Paul Ziprin
- Department of Surgery and Cancer, St. Mary's Campus Imperial College, London, United Kingdom
| | - Patricia J LiWang
- Department of Molecular Cell Biology, University of California Merced, Merced, CA, USA
| | - Satya Dandekar
- Department of Medical Microbiology & Immunology, School of Medicine, University of California Davis, Davis, CA, USA
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Rodriguez-Garcia M, Connors K, Ghosh M. HIV Pathogenesis in the Human Female Reproductive Tract. Curr HIV/AIDS Rep 2021; 18:139-156. [PMID: 33721260 PMCID: PMC9273024 DOI: 10.1007/s11904-021-00546-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/25/2021] [Indexed: 01/05/2023]
Abstract
PURPOSE OF REVIEW Women remain disproportionately affected by the HIV/AIDS pandemic. The primary mechanism for HIV acquisition in women is sexual transmission, yet the immunobiological factors that contribute to HIV susceptibility remain poorly characterized. Here, we review current knowledge on HIV pathogenesis in women, focusing on infection and immune responses in the female reproductive tract (FRT). RECENT FINDINGS We describe recent findings on innate immune protection and HIV target cell distribution in the FRT. We also review multiple factors that modify susceptibility to infection, including sex hormones, microbiome, trauma, and how HIV risk changes during women's life cycle. Finally, we review current strategies for HIV prevention and identify barriers for research in HIV infection and pathogenesis in women. A complex network of interrelated biological and sociocultural factors contributes to HIV risk in women and impairs prevention and cure strategies. Understanding how HIV establishes infection in the FRT can provide clues to develop novel interventions to prevent HIV acquisition in women.
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Affiliation(s)
- Marta Rodriguez-Garcia
- Department of Immunology, Tufts University School of Medicine, 150 Harrison Ave, Boston, MA, 02111, USA
| | - Kaleigh Connors
- Department of Infectious Diseases and Microbiology, Graduate School of Public Health, University of Pittsburgh, 130 De Soto Street, Pittsburgh, PA, 15261, USA
| | - Mimi Ghosh
- Department of Epidemiology, Milken Institute School of Public Health and Health Services, The George Washington University, 800 22nd St NW, Washington, DC, 20052, USA.
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Obiero J, Ogongo P, Mwethera PG, Wiysonge CS. Topical microbicides for preventing sexually transmitted infections. Cochrane Database Syst Rev 2021; 3:CD007961. [PMID: 33719075 PMCID: PMC8092571 DOI: 10.1002/14651858.cd007961.pub3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND This is a updated version of our Cochrane Review published in Issue 6, 2012. Sexually-transmitted infections (STIs) continue to rise worldwide, imposing an enormous morbidity and mortality burden. Effective prevention strategies, including microbicides, are needed to achieve the goals of the World Heath Organization (WHO) global strategy for the prevention and control of these infections. OBJECTIVES To determine the effectiveness and safety of topical microbicides for preventing acquisition of STIs, including HIV. SEARCH METHODS We undertook a comprehensive search of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, LILACS, CLIB, Web of Science, ClinicalTrials.gov, WHO International Clinical Trials Registry Platform, and reference lists of relevant articles up to August 2020. In addition, we contacted relevant organisations and experts. SELECTION CRITERIA We included randomised controlled trials of vaginal microbicides compared to placebo (except for nonoxynol-9 because it is covered in related Cochrane Reviews). Eligible participants were sexually-active non-pregnant, WSM and MSM, who had no laboratory confirmed STIs. DATA COLLECTION AND ANALYSIS Two review authors independently screened and selected studies, extracted data, and assessed risks of bias in duplicate, resolving differences by consensus. We conducted a fixed-effect meta-analysis, stratified by type of microbicide, and assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS We included eight trials from the earlier version of the review and four new trials, i.e. a total of 12 trials with 32,464 participants (all WSM). We did not find any eligible study that enrolled MSM or reported fungal STI as an outcome. We have no study awaiting assessment. All 12 trials were conducted in sub-Saharan Africa, with one having a study site in the USA, and another having a site in India. Vaginal microbicides tested were BufferGel and PRO 2000 (1 trial, 3101 women), Carraguard (1 trial, 6202 women), cellulose sulphate (2 trials, 3069 women), dapivirine (2 trials, 4588 women), PRO 2000 (1 trial, 9385 women), C31G (SAVVY) (2 trials, 4295 women), and tenofovir (3 trials, 4958 women). All microbicides were compared to placebo and all trials had low risk of bias. Dapivirine probably reduces the risk of acquiring HIV infection: risk ratio (RR) 0.71, (95% confidence interval (CI) 0.57 to 0.89, I2 = 0%, 2 trials, 4588 women; moderate-certainty evidence). The other microbicides may result in little to no difference in the risk of acquiring HIV (low-certainty evidence); including tenofovir (RR 0.83, 95% CI 0.68 to 1.02, cellulose sulphate (RR 1.20, 95% CI 0.74 to 1.95, BufferGel (RR 1.05, 95% CI 0.73 to 1.52), Carraguard (RR 0.89, 95% CI 0.71 to 1.11), PRO 2000 (RR 0.93, 95% CI 0.77 to 1.14), and SAVVY (RR 1.38, 95% CI 0.79 to 2.41). Existing evidence suggests that cellulose sulphate (RR 0.99, 95% CI 0.37 to 2.62, 1 trial, 1425 women), and PRO 2000 (RR 0.95, 95% CI 0.73 to 1.23) may result in little to no difference in the risk of getting herpes simplex virus type 2 infection (low-certainty evidence). Two studies reported data on tenofovir's effect on this virus. One suggested that tenofovir may reduce the risk (RR 0.55, 95% CI 0.36 to 0.82; 224 participants) while the other did not find evidence of an effect (RR 0.94, 95% CI 0.85 to 1.03; 1003 participants). We have not reported the pooled result because of substantial heterogeneity of effect between the two studies (l2 = 85%). The evidence also suggests that dapivirine (RR 1.70, 95% CI 0.63 to 4.59), tenofovir (RR 1.27, 95% CI 0.58 to 2.78), cellulose sulphate (RR 0.69, 95% CI 0.26 to 1.81), and (Carraguard (RR 1.07, 95% CI 0.75 to 1.52) may have little or no effect on the risk of acquiring syphilis (low-certainty evidence). In addition, dapivirine (RR 0.97, 95% CI 0.89 to 1.07), tenofovir (RR 0.90, 95% CI 0.71 to 1.13), cellulose sulphate (RR 0.70, 95% CI 0.49 to 0.99), BufferGel (RR 0.97, 95% CI 0.65 to 1.45), Carraguard (RR 0.96, 95% CI 0.83 to 1.12), and PRO 2000 (RR 1.01, 95% CI 0.84 to 1.22) may result in little to no difference in the risk of acquiring chlamydia infection (low-certainty evidence). The evidence also suggests that current topical microbicides may not have an effect on the risk of acquiring gonorrhoea, condyloma acuminatum, trichomoniasis, or human papillomavirus infection (low-certainty evidence). Microbicide use in the 12 trials, compared to placebo, did not lead to any difference in adverse event rates. No study reported on acceptability of the intervention. AUTHORS' CONCLUSIONS: Current evidence shows that vaginal dapivirine microbicide probably reduces HIV acquisition in women who have sex with men. Other types of vaginal microbicides have not shown evidence of an effect on acquisition of STIs, including HIV. Further research should continue on the development and testing of new microbicides.
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Affiliation(s)
- Jael Obiero
- Department of Reproductive Health and Biology, Institute of Primate Research, Nairobi, Kenya
| | - Paul Ogongo
- Tropical and Infectious Diseases, Institute of Primate Research, Nairobi, Kenya
| | - Peter G Mwethera
- Head, Reproductive Health & Biology, Institute of Primate Research, Nairobi, Kenya
| | - Charles S Wiysonge
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
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Farr Zuend C, Noël-Romas L, Hoger S, McCorriser S, Westmacott G, Marrazzo J, Hillier SL, Dezzutti C, Squires K, Bunge KE, Burgener A. Influence of dapivirine vaginal ring use on cervicovaginal immunity and functional microbiome in adolescent girls. AIDS 2021; 35:369-380. [PMID: 33181534 PMCID: PMC7924934 DOI: 10.1097/qad.0000000000002751] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 04/15/2020] [Accepted: 04/21/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The antiretroviral-based dapivirine vaginal ring reduced HIV risk among women in phase III clinical trials. However, limited data exists on the impact of dapivirine on the vaginal microenvironment in adolescents. DESIGN A comprehensive metaproteomics approach was used to assess host proteome and microbiome changes in cervicovaginal mucus with dapivirine ring use in adolescents enrolled in the MTN-023/IPM 030 (MTN-023) trial. METHODS Participants were randomized 3 : 1 to use dapivirine or placebo vaginal rings monthly for 6 months. Cervicovaginal samples from a subset of 35 participants (8 placebo, 27 dapivirine) were analyzed. RESULTS Mass spectrometry analysis identified 405 human and 2467 bacterial proteins belonging to 15 unique genera. The host proteome belonged to many functional pathways primarily related to inflammation. When stratified by study treatment arm, 18 (4.4%) and 28 (6.9%) human proteins were differentially abundant (adjusted P < 0.05) between baseline and follow-up in the placebo and dapivirine arms, respectively. The vaginal microbiome was predominantly composed of Lactobacillus, Gardnerella, and Prevotella. Although bacterial taxa did not differ by arm or change significantly, Lactobacillus crispatus increased (P < 0.001) and Lactobacillus iners decreased (P < 0.001) during the 6-month follow-up. There were no significant differences in bacterial functions by arm or time in the trial. Protected vaginal sex significantly associated with decreased neutrophil inflammatory biomarkers and may be associated with changes in bacterial taxa and metabolism. CONCLUSION Condom use may associate with differences to inflammation and bacterial function but dapivirine ring use does not, thereby supporting the mucosal safety profile of this vaginal ring for adolescents.
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Affiliation(s)
- Christina Farr Zuend
- Center for Global health and Diseases, Case Western Reserve University, Cleveland, Ohio, USA
| | - Laura Noël-Romas
- Center for Global health and Diseases, Case Western Reserve University, Cleveland, Ohio, USA
- Departments of Obstetrics and Gynecology and Medical Microbiology, University of Manitoba
| | - Sarah Hoger
- Departments of Obstetrics and Gynecology and Medical Microbiology, University of Manitoba
| | - Stuart McCorriser
- Mass Spectrometry and Proteomics Core Facility, National Microbiology Laboratory, Public Health Agency of Canada, Winnipeg, Manitoba, Canada
| | - Garrett Westmacott
- Mass Spectrometry and Proteomics Core Facility, National Microbiology Laboratory, Public Health Agency of Canada, Winnipeg, Manitoba, Canada
| | - Jeanne Marrazzo
- University of Alabama at Birmingham School of Medicine, Birmingham, Alabama
| | - Sharon L. Hillier
- University of Pittsburgh School of Medicine
- Magee-Women's Research Institute, Pittsburgh
| | - Charlene Dezzutti
- University of Pittsburgh School of Medicine
- Magee-Women's Research Institute, Pittsburgh
| | - Kathleen Squires
- Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Katherine E. Bunge
- University of Pittsburgh School of Medicine
- Magee-Women's Research Institute, Pittsburgh
| | - Adam Burgener
- Center for Global health and Diseases, Case Western Reserve University, Cleveland, Ohio, USA
- Departments of Obstetrics and Gynecology and Medical Microbiology, University of Manitoba
- Department of Medicine Solna, Center for Molecular Medicine, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
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Notario-Pérez F, Galante J, Martín-Illana A, Cazorla-Luna R, Sarmento B, Ruiz-Caro R, das Neves J, Veiga MD. Development of pH-sensitive vaginal films based on methacrylate copolymers for topical HIV-1 pre-exposure prophylaxis. Acta Biomater 2021; 121:316-327. [PMID: 33333257 DOI: 10.1016/j.actbio.2020.12.019] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 12/05/2020] [Accepted: 12/08/2020] [Indexed: 01/09/2023]
Abstract
Interest is growing in "smart" vaginal microbicides as a strategy to protect women from sexual transmission of human immunodeficiency virus (HIV). The concept is based on the development of products featuring low drug release in acidic media such as vaginal fluid but switch to a fast release profile when the medium becomes neutral or slightly alkaline. This mimics the surge in pH occurring in the vagina after sexual intercourse due to the seminal fluid. Semen is the main vehicle for HIV-1, and increasing antiretroviral drug levels in the vagina upon ejaculation may contribute to enhanced protection against viral sexual transmission. This work explores the use of different pharmaceutical-grade methacrylic acid-based polymers (EudragitⓇ RL, RS, L and S) for developing vaginal films allowing the pH-dependant release of the antiretroviral drug tenofovir (TFV). EudragitⓇ L 100 and EudragitⓇ S 100, containing triethyl citrate as plasticiser, proved to be suitable for manufacturing films with optimal dual in vitro drug-release behaviour. TFV-release can be sustained for several days after film administration and all the drug is released in a few hours in conditions simulating ejaculation. The films' mechanical properties were also deemed suitable for comfortable vaginal administration. Two optimized films were further assessed using HEC-1-A and Ca Ski cell monolayer models and were found to possess favourable drug permeability profiles and drug levels associated to cell monolayer as compared to free TFV. Overall, pH-dependant films containing tenofovir may constitute promising candidates for "smart" vaginal microbicides to protect women from sexual HIV transmission.
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Notario-Pérez F, Cazorla-Luna R, Martín-Illana A, Galante J, Ruiz-Caro R, Sarmento B, das Neves J, Veiga MD. Influence of Plasticizers on the pH-Dependent Drug Release and Cellular Interactions of Hydroxypropyl Methylcellulose/Zein Vaginal Anti-HIV Films Containing Tenofovir. Biomacromolecules 2021; 22:938-948. [PMID: 33405910 DOI: 10.1021/acs.biomac.0c01609] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Vaginal films featuring the pH-dependent release of tenofovir (TFV) were developed for the prevention of sexual transmission of human immunodeficiency syndrome (HIV). Films based on hydroxypropyl methylcellulose and zein were prepared incorporating different plasticizers [oleic acid, lactic acid, glycerol, and polyethylene glycol 400 (PEG)] and evaluated for in vitro drug release in an acidic simulated vaginal fluid (pH 4.2) and a slightly alkaline mixture of simulated seminal and vaginal fluids (pH 7.5). Results revealed that optimal biphasic TFV release was possible with proper combination of plasticizers (PEG and oleic acid, 1:7 w/w) and by adjusting the plasticizer/matrix-forming material ratio. The films had similar or higher levels of TFV associated with genital epithelial cells (Ca Ski or HEC-1-A cells) but lower drug permeability compared to the free drug. These data confirm that films have the potential to achieve suitable mucosal levels of TFV with low systemic exposure. The films developed could protect women from HIV sexual transmission.
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Affiliation(s)
- Fernando Notario-Pérez
- Departamento de Farmacia Galénica y Tecnología Alimentaria, Facultad de Farmacia, Universidad Complutense de Madrid, Plaza Ramón y Cajal s/n, 28040 Madrid, Spain
| | - Raúl Cazorla-Luna
- Departamento de Farmacia Galénica y Tecnología Alimentaria, Facultad de Farmacia, Universidad Complutense de Madrid, Plaza Ramón y Cajal s/n, 28040 Madrid, Spain
| | - Araceli Martín-Illana
- Departamento de Farmacia Galénica y Tecnología Alimentaria, Facultad de Farmacia, Universidad Complutense de Madrid, Plaza Ramón y Cajal s/n, 28040 Madrid, Spain
| | - Joana Galante
- i3S-Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Rua Alfredo Allen 208, 4200-135 Porto, Portugal.,INEB-Instituto de Engenharia Biomédica, Universidade do Porto, Rua Alfredo Allen 208, 4200-135 Porto, Portugal.,ICBAS-Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Rua Jorge de Viterbo Ferreira 228, 4050-313 Porto, Portugal
| | - Roberto Ruiz-Caro
- Departamento de Farmacia Galénica y Tecnología Alimentaria, Facultad de Farmacia, Universidad Complutense de Madrid, Plaza Ramón y Cajal s/n, 28040 Madrid, Spain
| | - Bruno Sarmento
- i3S-Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Rua Alfredo Allen 208, 4200-135 Porto, Portugal.,INEB-Instituto de Engenharia Biomédica, Universidade do Porto, Rua Alfredo Allen 208, 4200-135 Porto, Portugal.,CESPU, Instituto de Investigação e Formação Avançada em Ciências e Tecnologias da Saúde, Rua Central de Gandra 1317, 4585-116 Gandra, Portugal
| | - José das Neves
- i3S-Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Rua Alfredo Allen 208, 4200-135 Porto, Portugal.,INEB-Instituto de Engenharia Biomédica, Universidade do Porto, Rua Alfredo Allen 208, 4200-135 Porto, Portugal.,CESPU, Instituto de Investigação e Formação Avançada em Ciências e Tecnologias da Saúde, Rua Central de Gandra 1317, 4585-116 Gandra, Portugal
| | - María-Dolores Veiga
- Departamento de Farmacia Galénica y Tecnología Alimentaria, Facultad de Farmacia, Universidad Complutense de Madrid, Plaza Ramón y Cajal s/n, 28040 Madrid, Spain
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Tolley EE, Zissette S, Martinez A, Palanee-Phillips T, Mathebula F, Tenza S, Hartmann M, Montgomery ET. Development and initial validation of a simple tool to screen for partner support or opposition to HIV prevention product use. PLoS One 2020; 15:e0242881. [PMID: 33351805 PMCID: PMC7755213 DOI: 10.1371/journal.pone.0242881] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 11/10/2020] [Indexed: 11/25/2022] Open
Abstract
In HIV prevention trials, male partners have influenced women’s ability to adhere to investigational products, including antiretroviral (ARV) containing vaginal rings. Validated scales can be useful tools to systematically measure complex constructs, such as those related to male partner engagement. Although multiple scales exist to assess physical, psychological and sexual violence within intimate relationships, fewer scales focus on supportive behaviors within these relationships. Our intervention involved development of a Healthy Relationship Assessment Tool (HEART) that assessed both positive and negative aspects of male partner involvement in women’s HIV prevention. We identified and refined 127 potential items, representing intimate partner violence, agency and social support. A structured survey, including potential items and other sociodemographic and behavioral variables was administered to former microbicide trial and non-trial participants. We conducted an exploratory factor analysis (EFA) to identify a reduced set of constructs and items to screen women who might experience social harms or benefits from vaginal ring use. We examined associations between constructs and with other survey variables to assess content and construct validity. In a subset of 10 women who participated in the survey and qualitative interviews, we used qualitative data to predict survey scores. We retained five constructs with theoretical relevance and good-to-strong reliability for the tool, including: Traditional Values; Partner Support; Partner Abuse & Control; Partner Resistance to HIV Prevention; and HIV Prevention Readiness. Predicted associations between HEART constructs, and correspondence between participants’ qualitative data and HEART scores were generally correct, while those between constructs and other sociodemographic variables were more mixed. Initial validation of the HEART tool was promising. The tool will be used during the CHARISMA pilot study at the Johannesburg MTN 025/HOPE site and validated as part of a randomized controlled trial of CHARISMA within a PrEP demonstration project. Beyond clinical trial settings, HEART could assist PrEP or antiretroviral treatment (ART) providers with an easy-to-administer tool to identify risk and tailor risk reduction, empowerment and adherence counseling for microbicides, PrEP or ART related services.
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Affiliation(s)
- Elizabeth E. Tolley
- Behavioral, Epidemiological & Clinical Sciences, FHI 360, Durham, North Carolina, United States of America
- * E-mail:
| | - Seth Zissette
- Behavioral, Epidemiological & Clinical Sciences, FHI 360, Durham, North Carolina, United States of America
- Notre Dame University, South Bend, Indiana, United States of America
| | - Andres Martinez
- Behavioral, Epidemiological & Clinical Sciences, FHI 360, Durham, North Carolina, United States of America
| | - Thesla Palanee-Phillips
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Florence Mathebula
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Siyanda Tenza
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Miriam Hartmann
- Women’s Global Health Imperative, RTI International, San Francisco Project Office, California, United States of America
| | - Elizabeth T. Montgomery
- Women’s Global Health Imperative, RTI International, San Francisco Project Office, California, United States of America
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Miller L, Morar N, Kapiga S, Ramjee G, Hayes R. Prevention, Partners, and Power Imbalances: Women's Views on How Male Partners Affected Their Adherence to Vaginal Microbicide Gels During HIV Prevention Trials in Africa. J Acquir Immune Defic Syndr 2020; 85:458-465. [PMID: 33136745 PMCID: PMC7993915 DOI: 10.1097/qai.0000000000002463] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 06/16/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Low adherence has contributed to disappointing results for trials testing vaginal microbicides for HIV prevention. This study engaged former gel trial participants to understand the reasons behind low adherence and seek suggestions on how to improve products and adherence to microbicides. This analysis examines the impact of participant perceptions of male partners on participant adherence and suggestions on how to address those issues. METHODS Eight focus group discussion workshops were conducted with 46 former microbicide trial participants in South Africa and Tanzania. Participants provided feedback on why women join trials, barriers to using gels and reporting adherence accurately, and how adherence and adherence reporting can be improved. RESULTS Participants reported that male partners can affect women's ability to use gels. For some, the lubricating effects caused relationship conflicts due to suspicion of male partners about infidelity. Needing to provide sex to partners on demand was a barrier to gel use. Participants suggested a gel formulation which was thicker and less noticeable, and explicit male partner engagement to enhance understanding of the purpose of the gels. CONCLUSIONS The imbalance of power in intimate relationships affects the ability of women to use microbicides as directed. To improve adherence to HIV prevention methods within trials and for successful rollout of proven HIV prevention methods in populations, it is important that the complicated dynamics of sex and relationships be taken into greater consideration and that women receive targeted support to navigate product use and communication within the context of these gender dynamics.
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Affiliation(s)
- Lori Miller
- London School of Hygiene and Tropical Medicine, London, United Kingdom;
| | - Neetha Morar
- HIV Prevention Research Unit, Medical Research Council, Durban, South Africa;
| | - Saidi Kapiga
- London School of Hygiene and Tropical Medicine, London, United Kingdom;
- Mwanza Intervention Trials Unit, Mwanza, Tanzania; and
| | | | - Richard Hayes
- London School of Hygiene and Tropical Medicine, London, United Kingdom;
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45
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Musekiwa A, Fernando NB, Abariga SA. Effectiveness of vaginal microbicides in preventing HIV transmission. Trop Med Int Health 2020; 25:790-802. [PMID: 32306503 DOI: 10.1111/tmi.13401] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the evidence on the effectiveness of vaginal microbicides in preventing HIV transmission in women. METHODS Systematic review through a comprehensive search of relevant electronic databases for eligible randomised controlled trials (RCTs) published through June 2019. Two authors independently screened titles and abstracts according to eligibility criteria, then extracted data and assessed risk of bias of included studies. We conducted a random-effects meta-analysis of risk ratios (RR) of HIV infection and assessed heterogeneity using chi-squared and I2 tests. Sources of heterogeneity were investigated through subgroup analysis, publication bias was assessed using funnel plots, and certainty of evidence was graded using GRADEPro software. RESULTS We included 18 RCTs which enrolled 40,048 sexually active, HIV-negative, non-pregnant women, aged 16 years and older, mainly from sub-Saharan Africa. The intravaginal ring containing dapivirine significantly reduced HIV risk by 29% (RR 0.71, 95% CI: 0.57-0.89; 2 RCTs, 4,564 women, moderate certainty of evidence). Estimates of effect of tenofovir 1% (RR 0.83, 95% CI: 0.65-1.06), nonoxynol-9 (RR 1.15, 95% CI: 0.93-1.42), cellulose sulphate (RR 1.16, 95% CI: 0.61-2.21), SAVVY (RR 1.34, 95% CI: 0.69-2.59), Carraguard (RR 0.89, 95% CI: 0.71-1.10), BufferGel (RR 1.02, 95% CI: 0.71-1.46), 0.5% PRO2000 (RR 0.88, 95% CI: 0.60-1.28) and 2% PRO2000 (RR 0.81, 95% CI: 0.58-1.12) failed to reach statistical significance; each had low certainty of evidence. CONCLUSION The long-acting intravaginal ring containing dapivirine significantly reduced risk of HIV transmission in women by 29%. The remaining microbicides had no evident effect.
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Affiliation(s)
- Alfred Musekiwa
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,School of Health Systems and Public Health, University of Pretoria, Pretoria, South Africa
| | - Nimasha B Fernando
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Samuel A Abariga
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Helmold Hait S, Hogge CJ, Rahman MA, Ko EJ, Hunegnaw R, Mushtaq Z, Enyindah-Asonye G, Hoang T, Miller Jenkins LM, Appella E, Appella DH, Robert-Guroff M. An SAMT-247 Microbicide Provides Potent Protection against Intravaginal Simian Immunodeficiency Virus Infection of Rhesus Macaques, whereas an Added Vaccine Component Elicits Mixed Outcomes. THE JOURNAL OF IMMUNOLOGY 2020; 204:3315-3328. [PMID: 32393514 DOI: 10.4049/jimmunol.2000165] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 04/17/2020] [Indexed: 12/19/2022]
Abstract
Because of microbicide noncompliance and lack of a durable, highly effective vaccine, a combined approach might improve HIV prophylaxis. We tested whether a vaccine-microbicide combination would enhance protection against SIV infection in rhesus macaques. Four macaque groups included vaccine only, vaccine-microbicide, microbicide only, and controls. Vaccine groups were primed twice mucosally with replicating adenovirus type 5 host range mutant SIV env/rev, gag, and nef recombinants and boosted twice i.m. with SIV gp120 proteins in alum. Controls and the microbicide-only group received adenovirus type 5 host range mutant empty vector and alum. The microbicide was SAMT-247, a 2-mercaptobenzamide thioester that targets the viral nucleocapsid protein NCp7, causing zinc ejection and preventing RNA encapsidation. Following vaccination, macaques were challenged intravaginally with repeated weekly low doses of SIVmac251 administered 3 h after application of 0.8% SAMT-247 gel (vaccine-microbicide and microbicide groups) or placebo gel (vaccine-only and control groups). The microbicide-only group exhibited potent protection; 10 of 12 macaques remained uninfected following 15 SIV challenges. The vaccine-only group developed strong mucosal and systemic humoral and cellular immunity but did not exhibit delayed acquisition compared with adjuvant controls. However, the vaccine-microbicide group exhibited significant acquisition delay compared with both control and vaccine-only groups, indicating further exploration of the combination strategy is warranted. Impaired protection in the vaccine-microbicide group compared with the microbicide-only group was not attributed to a vaccine-induced increase in SIV target cells. Possible Ab-dependent enhancement will be further investigated. The potent protection provided by SAMT-247 encourages its movement into human clinical trials.
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Affiliation(s)
- Sabrina Helmold Hait
- Section on Immune Biology of Retroviral Infection, Vaccine Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892-5065
| | - Christopher James Hogge
- Section on Immune Biology of Retroviral Infection, Vaccine Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892-5065
| | - Mohammad Arif Rahman
- Section on Immune Biology of Retroviral Infection, Vaccine Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892-5065
| | - Eun-Ju Ko
- Section on Immune Biology of Retroviral Infection, Vaccine Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892-5065
| | - Ruth Hunegnaw
- Section on Immune Biology of Retroviral Infection, Vaccine Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892-5065
| | - Zuena Mushtaq
- Section on Immune Biology of Retroviral Infection, Vaccine Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892-5065
| | - Gospel Enyindah-Asonye
- Section on Immune Biology of Retroviral Infection, Vaccine Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892-5065
| | - Tanya Hoang
- Section on Immune Biology of Retroviral Infection, Vaccine Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892-5065
| | - Lisa M Miller Jenkins
- Laboratory of Cell Biology, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892-4256; and
| | - Ettore Appella
- Laboratory of Cell Biology, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892-4256; and
| | - Daniel H Appella
- Laboratory of Bioorganic Chemistry, Synthetic Bioactive Molecules Section, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD 20892-0820
| | - Marjorie Robert-Guroff
- Section on Immune Biology of Retroviral Infection, Vaccine Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892-5065;
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Browne EN, Montgomery ET, Mansfield C, Boeri M, Mange B, Beksinska M, Schwartz JL, Clark MR, Doncel GF, Smit J, Chirenje ZM, van der Straten A. Efficacy is Not Everything: Eliciting Women's Preferences for a Vaginal HIV Prevention Product Using a Discrete-Choice Experiment. AIDS Behav 2020; 24:1443-1451. [PMID: 31696371 PMCID: PMC6990865 DOI: 10.1007/s10461-019-02715-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
As new female-initiated HIV prevention products enter development, it is crucial to incorporate women’s preferences to ensure products will be desired, accepted, and used. A discrete-choice experiment was designed to assess the relative importance of six attributes to stated choice of a vaginally delivered HIV prevention product. Sexually active women in South Africa and Zimbabwe aged 18–30 were recruited from two samples: product-experienced women from a randomized trial of four vaginal placebo forms and product-naïve community members. In a tablet-administered survey, 395 women chose between two hypothetical products over eight choice sets. Efficacy was the most important, but there were identifiable preferences among other attributes. Women preferred a product that also prevented pregnancy and caused some wetness (p < 0.001). They disliked a daily-use product (p = 0.002) and insertion by finger (p = 0.002). Although efficacy drove preference, wetness, pregnancy prevention, and dosing regimen were influential to stated choice of a product, and women were willing to trade some level of efficacy to have other more desired attributes.
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Affiliation(s)
- Erica N Browne
- Women's Global Health Imperative, RTI International, 351 California Street, Suite 500, San Francisco, CA, 94104, USA.
| | - Elizabeth T Montgomery
- Women's Global Health Imperative, RTI International, 351 California Street, Suite 500, San Francisco, CA, 94104, USA
| | - Carol Mansfield
- Health Solutions, RTI International, Research Triangle Park, NC, USA
| | - Marco Boeri
- Health Solutions, RTI International, Research Triangle Park, NC, USA
| | - Brennan Mange
- Health Solutions, RTI International, Research Triangle Park, NC, USA
| | - Mags Beksinska
- MatCH Research Unit (MRU), Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | | | | | | | - Jenni Smit
- MatCH Research Unit (MRU), Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | - Zvavahera M Chirenje
- University of Zimbabwe College of Health Sciences Clinical Trials Research Centre, Harare, Zimbabwe
| | - Ariane van der Straten
- Women's Global Health Imperative, RTI International, 351 California Street, Suite 500, San Francisco, CA, 94104, USA
- Department of Medicine, Center for AIDS Prevention Studies, University of California, San Francisco, CA, USA
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A Subcutaneous Implant of Tenofovir Alafenamide Fumarate Causes Local Inflammation and Tissue Necrosis in Rabbits and Macaques. Antimicrob Agents Chemother 2020; 64:AAC.01893-19. [PMID: 31871073 PMCID: PMC7038301 DOI: 10.1128/aac.01893-19] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 12/08/2019] [Indexed: 12/22/2022] Open
Abstract
We describe the in vitro and in vivo evaluation of a subcutaneous reservoir implant delivering tenofovir alafenamide hemifumarate (TAF) for the prevention of HIV infection. These long-acting reservoir implants were able to deliver antiretroviral drug for over 90 days in vitro and in vivo. We evaluated the implants for implantation site histopathology and pharmacokinetics in plasma and tissues for up to 12 weeks in New Zealand White rabbit and rhesus macaque models. We describe the in vitro and in vivo evaluation of a subcutaneous reservoir implant delivering tenofovir alafenamide hemifumarate (TAF) for the prevention of HIV infection. These long-acting reservoir implants were able to deliver antiretroviral drug for over 90 days in vitro and in vivo. We evaluated the implants for implantation site histopathology and pharmacokinetics in plasma and tissues for up to 12 weeks in New Zealand White rabbit and rhesus macaque models. A dose-ranging study in rabbits demonstrated dose-dependent pharmacokinetics and local inflammation up to severe necrosis around the active implants. The matched placebos showed normal wound healing and fibrous tissue encapsulation of the implant. We designed a second implant with a lower release rate and flux of TAF and achieved a median cellular level of tenofovir diphosphate of 42 fmol per 106 rhesus macaque peripheral blood mononuclear cells at a TAF dose of 10 μg/kg/day. This dose and flux of TAF also resulted in adverse local inflammation and necrosis near the implant in rhesus macaques. The level of inflammation in the primates was markedly lower in the placebo group than in the active-implant group. The histological inflammatory response to the TAF implant at 4 and 12 weeks in primates was graded as a severe reaction. Thus, while we were able to achieve a sustained target dose, we observed an unacceptable inflammatory response locally at the implant tissue interface.
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Fernandes T, Baxi K, Sawarkar S, Sarmento B, das Neves J. Vaginal multipurpose prevention technologies: promising approaches for enhancing women's sexual and reproductive health. Expert Opin Drug Deliv 2020; 17:379-393. [PMID: 32036727 DOI: 10.1080/17425247.2020.1728251] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Introduction: Multipurpose prevention technologies (MPTs) have the potential to avert multiple concomitant sexual and reproductive health issues in women such as sexually transmitted infections and unintended pregnancy. MPTs incorporate one or more active pharmaceutical ingredients in a single product, which adds more convenience for users and may promote increased adherence. Various vaginal dosage forms/delivery systems have been studied for designing MPTs. However, several challenges remain that are mainly related to requirements of individual drugs or intended multiple applications.Areas covered: This review focuses on the emerging need and development of vaginal MPTs. It illustrates numerous examples that are currently in the preclinical and clinical development pipeline, highlighting the concept behind vaginal MPTs. The article also highlights the challenges associated with formulation design and development, including regulatory issues that need to be addressed.Expert opinion: Vaginal MPTs present great potential to empower women with novel, efficient, and safe products for protection against sexually transmitted infections and unintended pregnancy. However, several technological issues and regulatory gaps still need to be addressed in order to meet real-world needs.
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Affiliation(s)
- Trinette Fernandes
- Department of Pharmaceutics, SVKM's Dr. Bhanuben Nanavati College of Pharmacy, University of Mumbai,India
| | - Krishna Baxi
- Department of Pharmaceutics, SVKM's Dr. Bhanuben Nanavati College of Pharmacy, University of Mumbai,India
| | - Sujata Sawarkar
- Department of Pharmaceutics, SVKM's Dr. Bhanuben Nanavati College of Pharmacy, University of Mumbai,India
| | - Bruno Sarmento
- i3S - Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal.,INEB - Instituto de Engenharia Biomédica, Universidade do Porto, Porto, Portugal.,CESPU, Instituto de Investigação e Formação Avançada em Ciências e Tecnologias da Saúde, Gandra, Portugal
| | - José das Neves
- i3S - Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal.,INEB - Instituto de Engenharia Biomédica, Universidade do Porto, Porto, Portugal.,CESPU, Instituto de Investigação e Formação Avançada em Ciências e Tecnologias da Saúde, Gandra, Portugal
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Bowring AL, Ampt FH, Schwartz S, Stoové MA, Luchters S, Baral S, Hellard M. HIV pre-exposure prophylaxis for female sex workers: ensuring women's family planning needs are not left behind. J Int AIDS Soc 2020; 23:e25442. [PMID: 32064765 PMCID: PMC7025091 DOI: 10.1002/jia2.25442] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 11/28/2019] [Accepted: 12/05/2019] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Female sex workers (FSWs) experience overlapping burdens of HIV, sexually transmitted infections and unintended pregnancy. Pre-exposure prophylaxis (PrEP) is highly efficacious for HIV prevention. It represents a promising strategy to reduce HIV acquisition risks among FSWs specifically given complex social and structural factors that challenge consistent condom use. However, the potential impact on unintended pregnancy has garnered little attention. We discuss the potential concerns and opportunities for PrEP to positively or negatively impact the sexual and reproductive health and rights (SRHR) of FSWs. DISCUSSION FSWs have high unmet need for effective contraception and unintended pregnancy is common in low- and middle-income countries. Unintended pregnancy can have enduring health and social effects for FSWs, including consequences of unsafe abortion and financial impacts affecting subsequent risk-taking. It is possible that PrEP could negatively impact condom and other contraceptive use among FSWs due to condom substitution, normalization, external pressures or PrEP provision by single-focus services. There are limited empirical data available to assess the impact of PrEP on pregnancy rates in real-life settings. However, pregnancy rates are relatively high in PrEP trials and modelling suggests a potential two-fold increase in condomless sex among FSWs on PrEP, which, given low use of non-barrier contraceptive methods, would increase rates of unintended pregnancy. Opportunities for integrating family planning with PrEP and HIV services may circumvent these concerns and support improved SRHR. Synergies between PrEP and family planning could promote uptake and maintenance for both interventions. Integrating family planning into FSW-focused community-based HIV services is likely to be the most effective model for improving access to non-barrier contraception among FSWs. However, barriers to integration, such as provider skills and training and funding mechanisms, need to be addressed. CONCLUSIONS As PrEP is scaled up among FSWs, there is growing impetus to consider integrating family planning services with PrEP delivery in order to better meet the diverse SRHR needs of FSWs and to prevent unintended consequences. Programme monitoring combined with research can close data gaps and mobilize adequate resources to deliver comprehensive SRHR services respectful of all women's rights.
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Affiliation(s)
- Anna L Bowring
- Department of EpidemiologyJohns Hopkins School of Public HealthBaltimoreMDUSA
- Burnet InstituteMelbourneVictoriaAustralia
| | - Frances H Ampt
- Burnet InstituteMelbourneVictoriaAustralia
- Department of Epidemiology and Preventive MedicineMonash UniversityMelbourneVictoriaAustralia
| | - Sheree Schwartz
- Department of EpidemiologyJohns Hopkins School of Public HealthBaltimoreMDUSA
| | - Mark A Stoové
- Burnet InstituteMelbourneVictoriaAustralia
- Department of Epidemiology and Preventive MedicineMonash UniversityMelbourneVictoriaAustralia
| | - Stanley Luchters
- Burnet InstituteMelbourneVictoriaAustralia
- Department of Epidemiology and Preventive MedicineMonash UniversityMelbourneVictoriaAustralia
- Department of Population HealthAga Khan UniversityNairobiKenya
- International Centre for Reproductive HealthDepartment of Public Health and Primary CareGhent UniversityGhentBelgium
| | - Stefan Baral
- Department of EpidemiologyJohns Hopkins School of Public HealthBaltimoreMDUSA
| | - Margaret Hellard
- Burnet InstituteMelbourneVictoriaAustralia
- Department of Epidemiology and Preventive MedicineMonash UniversityMelbourneVictoriaAustralia
- Department of Infectious DiseasesThe Alfred HospitalMelbourneVictoriaAustralia
- Doherty Institute and Melbourne School of Population and Global HealthUniversity of MelbourneMelbourneVictoriaAustralia
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