Microbicides: Information, Beliefs, and Preferences for Insertion

Women's preferences and acceptance for different drug delivery routes and products

To use or not to use, that is the first decision to take regarding a drug product. This mandatory step for adherence dictates product efficacy. The determinants for such decision do not only rely on the priority of the therapeutic or preventive strategy, but are related to a complex network of perceptions, preferences, personal and cultural backgrounds, and results from previous experiences. Women's preferences for dosage forms and even for drug delivery routes have been mainly studied in the fields of contraception and HIV prevention (and their related multipurpose approaches). Much less attention has been devoted to other therapeutic or preventive strategies. In a time when patient-centred approaches and shared decisions are increasingly valued, considering women's preferences and their main determinants is essential for product development and selection. Such products will be more likely to be chosen and used as intended, increasing efficacy, and reducing the overall costs related with these treatments. This knowledge shall be integrated in early stages of product development. This article reviews the state of the art related with women's preferences and acceptance for different dosage forms and drug delivery routes involved in women's health. The methodologies used for collecting these data and their major drawbacks are discussed. Results obtained from acceptability studies and the main determinants for selection of preventive and treatment drug products are discussed as tools for new developments in the field.

Pregnant young women's attitudes about microbicides: the anticipated influence of the grandmother and father of the baby on microbicide use

Grandmothers and fathers of the baby may influence pregnant women's microbicide use. Pregnant young women's attitudes about grandmothers' and fathers' role in decision-making and their involvement in microbicide use were assessed. Participants (n=108) had a mean age of 20.2 years. The majority anticipated that the grandmother, father or both would have a decision-making role. Greater grandmother involvement in microbicide use was significantly associated with being younger, having no reproductive tract infection or contraceptive-ring-use history. Greater father involvement in use was associated with being in a relationship with him. Strategies for engaging grandmothers and fathers in microbicide use should be developed.

Pregnant women's attitudes about topical microbicides for the prevention and treatment of bacterial vaginosis during pregnancy

We sought to understand pregnant women's product preference and likelihood of use of topical microbicides for bacterial vaginosis (BV) prevention and treatment. Pregnant women (N = 196) in a obstetrics clinic completed a survey between June 2014 and January 2015 about vaginal product use for BV. This cross-sectional study explored product preferences, likelihood of product use for BV management and father of the baby (FOB) involvement. Most participants were under 30 (68%) and underrepresented minorities (47% Hispanic, 21% African-American). Most women preferred the gel (69%). Only 30% were likely to use either product for prevention of BV; 76% if high risk for BV; 83% treatment of BV. Anticipated FOB involvement in decision-making included that 46% would ask his opinion, 38% would inform him of the decision and 7% would need approval. Most (87%) would ask the FOB for reminders and 66% for insertion help. Those under 30 were more likely to agree to ask the FOB for reminders (p < 0.01) and insertion help (p = 0.05). African-American women were less likely to have their FOB help with insertion (p < 0.01). Product preferences may be less critical than risk perception. Involvement of the FOB in decision-making may be vital.

Recent advances on anti-HIV vaginal delivery systems development

A review of the recent outcomes regarding technologies to prevent vaginal transmission of HIV, mainly by using antiretroviral (ARV) drugs formulated as microbicides. An introduction about the HIV transmission mechanisms by the vaginal route is included, together with the recent challenges faced for development of successful microbicide products. The outcomes of clinical evaluations are mentioned, and the different formulation strategies studied to-date, with the requirements, advantages, disadvantages and limitations of each dosage-form type, are presented. Finally, the recent attempts to apply various types of nanotechnologies in order to develop advanced microbicide-products and overcome existing limitations, are discussed.

Attitudes towards microbicide use for bacterial vaginosis in pregnancy

Background Bacterial vaginosis (BV) is the most common reproductive tract infection (RTI) and is a significant risk factor for preterm birth. Microbicides could be an option for the prevention and treatment of BV in pregnancy, and understanding use of the product will be crucial. The present study explored attitudes of women in the third trimester of pregnancy regarding topical microbicide use for the prevention and treatment of BV.

METHODS

Twenty-six women in their third trimester were interviewed regarding their knowledge and beliefs about RTIs during pregnancy and attitudes concerning the use of topical microbicides for prevention and treatment of BV.

RESULTS

Participants had a mean age of 24.9 years, were largely under-represented minorities and the majority had had past pregnancies. Participants had knowledge and experience with RTIs but not BV. They were open to the use of microbicides for prevention or treatment of BV, but believed that women requiring treatment would be more motivated. Rationales for acceptability were most commonly related to the baby's health. Practical issues that may interfere with use were often, but not always, related to pregnancy. There was a range of attitudes about partner involvement in decision-making and the practicalities of product use.

CONCLUSION

Pregnant women are knowledgeable about RTIs but not necessarily BV. The women in this study found microbicide use acceptable, particularly for treatment. To improve acceptability and use, education would be needed about BV and possible complications, how to overcome practical problems and the value of involving partners in the decision.

Using integrated mixed methods to develop behavioral measures of factors associated with microbicide acceptability

Our current understanding of factors associated with microbicide acceptability and consistent use typically has been derived from separate and distinct qualitative or quantitative studies. Specifically, rarely have investigators used mixed methods to both develop and validate behavioral measures. We utilized an integrated mixed methods design, including qualitative metasyntheses, cognitive interviews and expert reviews, psychometric evaluation, and confirmatory qualitative analyses of the correspondence between quantitative items and original qualitative data to develop and validate measures of factors associated with microbicide acceptability and use. We describe this methodology and use the development of the Relationship Context Scale to illustrate it. As a result of independent confirmatory analyses of qualitative passages corresponding to survey items, we demonstrated that items from the same subscales are frequently double coded within a particular textual passage, and thematically related, suggesting associations that resulted in a unique factor structure within the subscale. This integrated mixed method design was critical to the development of this psychometrically validated behavioral measure, and could serve as a model for future measure development.

Research on adolescents and microbicides: a review

Adolescents are an important target for microbicide research, as they are disproportionately affected by sexually transmitted infections and currently are underrepresented in the microbicide research literature. Furthermore, adolescents are psychosocially and biologically different from adults, and findings from adult research cannot be assumed to apply universally to adolescents. Adolescents, to date have rarely been included in clinical trials and acceptability research for microbicides, in part because their participation requires attention to unique developmental issues, including parental consent and confidentiality. Despite these challenges, adolescents should be included in microbicide clinical research. If adolescents are ultimately expected to use microbicides, it is essential that we understand the developmental, contextual, and relationship variables that may influence use and acceptability. Accordingly, the goal of this paper was to examine the issues affecting the inclusion of adolescents in microbicide clinical research as well as review the existing adolescent-specific microbicide research, which highlights the various factors that may influence use and acceptability. It is hoped that this review can provide guidance for future work with this important, specialized population.

Relationship context associated with microbicide-like product use

STUDY OBJECTIVE

Topical microbicides are being developed to provide an alternative method of prevention of HIV and sexually transmitted infections. Although topical microbicides would be a female-controlled method of prevention, their use is likely to be disclosed to partners. Thus, the characteristics of the partner relationship may play a role in their use. We sought to examine whether qualities of the relationship and of the partner were associated with using a microbicide-like product.

DESIGN

We studied 166 females (14 to 21 years of age) who were participating in a 6-month study of microbicide-like products (vaginal lubricants). They described partner relationships and characteristics of the partners.

RESULTS

Of the 166 participants, 118 used the product. In bivariate analyses, those whose relationships were longer, monogamous, more mutual, and more satisfying were more likely to use the product. Further, when sex occurred in the young women's or couples' homes, use also was more likely. There was no relationship between product use and whether the partner had a job or was in school or between the partners' levels of substance use. In a multivariable logistic regression with backwards elimination, only relationship satisfaction remained significant in the model.

CONCLUSION

Topical microbicides will be used within the context of a relationship, and characteristics of the relationship most likely will influence use. These findings suggest that special attention may have to be given to supporting use in high-risk relationships and that all interventions to enhance uptake should consider the relationship context.

Vaginal drug delivery systems for HIV prevention

Microbicides have become a principal focus for HIV prevention strategies. The successful design of drug delivery systems for vaginal microbicide drug candidates brings with it a multitude of challenges. It is imperative that the chemical and physical characteristics of the drug candidate and its mechanism of action be clearly understood and considered to successfully deliver and target drug candidates efficiently. In addition, an understanding of the dynamic nature of the vaginal environment, the tissue and innate barriers present, as well as patient preferences are critical considerations in the design of effective microbicide products. Although the majority of drug candidates clinically evaluated to date have been delivered using conventional semisolid aqueous-based gel dosage forms, drug delivery system design has recently been extended to include advanced delivery systems such as vaginal rings, quick-dissolve films, and tablets. Ultimately, it may be necessary to develop multiple dosage platforms for a single active agent to provide users with options that can be used within the constraints of their social environment, personal choice, and environmental conditions.