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Abstract
INTRODUCTION Although only a minority of contracepting women rely solely on spermicides, they may soon be the only ongoing female method available without a prescription in the United States. Spermicides are also combined with other methods for additional pregnancy protection and/or lubrication. Nonoxynol-9 (N-9), the active ingredient in most spermicides, is cytotoxic and may increase risk of transmission of HIV and other sexually transmitted infections, especially in high-risk women. Amphora (previously called Acidform) is a noncytotoxic spermicide composed of a series of generally regarded as safe compounds, which maintains the acidity of the vagina following coitus to immobilize and kill sperm. Amphora is currently Food and Drug Administration-approved as a vaginal lubricant. Amphora is currently being tested in a multicenter Phase III contraceptive trial. AREAS COVERED This paper describes key properties of Amphora, including its acid-buffering abilities, viscosity, stability, bioadhesiveness, and tolerability. EXPERT OPINION Amphora is a nontoxic spermicide that maintains the pH within the vagina at levels less than 5.0 for hours, which immobilizes and kills sperm as well as many sexually transmitted pathogens. If the current clinical trial demonstrates safety, efficacy, and tolerability of Amphora as a contraceptive, it would represent a viable alternative to N-9. Its potential as a microbicide warrants further investigation.
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Affiliation(s)
- Anita L Nelson
- a Department of Obstetrics and Gynecology , Western University of Health Sciences , Pomona , CA , USA
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Weld ED, Hiruy H, Guthrie KM, Fava JL, Vargas SE, Buckheit K, Buckheit R, Spiegel H, Breakey J, Fuchs EJ, Hendrix CW. A Comparative Pre-Phase I Study of the Impact of Gel Vehicle Volume on Distal Colon Distribution, User Experience, and Acceptability. AIDS Res Hum Retroviruses 2017; 33:440-447. [PMID: 27824253 DOI: 10.1089/aid.2016.0167] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
For persons at risk of HIV infection who practice receptive anal intercourse (RAI), topical rectal microbicides represent a promising option for coitally dependent protection. The study compared colorectal distribution and user sensory experiences of two different volumes of rectal gel for suitability as rectal microbicide. Eight HIV-negative men with a history of recent RAI were enrolled into a two-period, sequence-randomized dosing study comparing 3.5 and 10 ml of radiolabeled (1 mCi 99mTc-DTPA) universal placebo, hydroxyethyl cellulose gel. Each participant received two doses in the research unit, one of each volume, separated by a washout period of at least 2 weeks. Each research unit dose was followed by a self-administered take-home dose in the context of preparing for RAI. Safety and gastrointestinal distribution were assessed after the research unit doses, safety, perceptibility, and acceptability, were assessed after take-home doses. There were no adverse effects of Grade 2 or higher and all resolved spontaneously. Both volumes were well tolerated and received high acceptability scores. Perceptibility scores showed meaningful effect size differences ranging from Cohen's d = 0.5 to d = 1.2. The 3.5 and 10 ml gel volumes distributed similarly (p > .2) within the rectosigmoid, ranging from 0.69 to 18.84 cm and 1.21 to 19.01 cm from the anorectal junction, respectively. Both volumes covered the typical gastrointestinal distribution of ejaculate following simulated intercourse based on other studies. Either of these gel volumes could reasonably be pursued for the next phase of development of rectal microbicides.
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Affiliation(s)
- Ethel D Weld
- 1 Department of Medicine (Division of Clinical Pharmacology), The Johns Hopkins University School of Medicine , Baltimore, Maryland
- 2 Department of Medicine (Division of Infectious Diseases), The Johns Hopkins University School of Medicine , Baltimore, Maryland
| | - Hiwot Hiruy
- 1 Department of Medicine (Division of Clinical Pharmacology), The Johns Hopkins University School of Medicine , Baltimore, Maryland
- 3 Department of Pediatrics (Division of Infectious Diseases), The Johns Hopkins University School of Medicine , Baltimore, Maryland
| | - Kate Morrow Guthrie
- 4 Centers for Behavioral and Preventive Medicine, The Miriam Hospital , Providence, Rhode Island
- 5 Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University . Providence, Rhode Island
| | - Joseph L Fava
- 4 Centers for Behavioral and Preventive Medicine, The Miriam Hospital , Providence, Rhode Island
| | - Sara E Vargas
- 4 Centers for Behavioral and Preventive Medicine, The Miriam Hospital , Providence, Rhode Island
- 5 Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University . Providence, Rhode Island
| | | | | | | | - Jennifer Breakey
- 1 Department of Medicine (Division of Clinical Pharmacology), The Johns Hopkins University School of Medicine , Baltimore, Maryland
| | - Edward J Fuchs
- 1 Department of Medicine (Division of Clinical Pharmacology), The Johns Hopkins University School of Medicine , Baltimore, Maryland
| | - Craig W Hendrix
- 1 Department of Medicine (Division of Clinical Pharmacology), The Johns Hopkins University School of Medicine , Baltimore, Maryland
- 2 Department of Medicine (Division of Infectious Diseases), The Johns Hopkins University School of Medicine , Baltimore, Maryland
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In Vivo Rectal Mucosal Barrier Function Imaging in a Large-Animal Model by Using Confocal Endomicroscopy: Implications for Injury Assessment and Use in HIV Prevention Studies. Antimicrob Agents Chemother 2016; 60:4600-9. [PMID: 27185807 DOI: 10.1128/aac.00134-16] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Accepted: 05/09/2016] [Indexed: 12/16/2022] Open
Abstract
Injury occurring on the surface of the rectal mucosal lining that causes defects in barrier function may result in increased risk for transmission of infection by HIV and other pathogens. Such injury could occur from microbicidal or other topical agents, mechanical trauma during consensual or nonconsensual intercourse, or inflammatory conditions. Tools for evaluation of rectal mucosal barrier function for assessing the mucosa under these conditions are lacking, particularly those that can provide in vivo structural and functional barrier integrity assessment and are adaptable to longitudinal imaging. We investigated confocal endomicroscopy (CE) as a means for in vivo imaging of the rectal epithelial barrier in the ovine model following spatially confined injury to the surface at a controlled site using a topical application of the microbicide test agent benzalkonium chloride. Topical and intravenous (i.v.) fluorescent probes were used with CE to provide subcellular resolution imaging of the mucosal surface and assessment of barrier function loss. A 3-point CE grading system based on cellular structure integrity and leakage of dye through the mucosa showed significant differences in score between untreated (1.19 ± 0.53) and treated (2.55 ± 0.75) tissue (P < 0.0001). Histological grading confirmed findings of barrier compromise. The results indicate that CE is an effective means for detecting epithelial injury and barrier loss following localized trauma in a large-animal model. CE is promising for real-time rectal mucosal evaluation after injury or trauma or topical application of emerging biomedical prevention strategies designed to combat HIV.
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Leyva F, Fuchs EJ, Bakshi R, Carballo-Dieguez A, Ventuneac A, Yue C, Caffo B, Du Y, Torbenson M, Li L, Mullin G, Lee L, Rohan L, Anton PA, Hendrix CW. Simultaneous Evaluation of Safety, Acceptability, Pericoital Kinetics, and Ex Vivo Pharmacodynamics Comparing Four Rectal Microbicide Vehicle Candidates. AIDS Res Hum Retroviruses 2015; 31:1089-97. [PMID: 26066390 DOI: 10.1089/aid.2015.0086] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Preexposure prophylaxis (PrEP) of HIV infection with tenofovir-containing regimens is effective, but plagued by poor adherence in some studies. Options for safe, effective, and acceptable PrEP products, especially for men and women at risk of HIV via receptive anal intercourse (RAI), are needed. We performed a randomized, partially blinded, first-in-human evaluation of four candidate rectal microbicide vehicles-aqueous gel, aqueous fluid, lipid gel, and lipid fluid-to select a prototype for further clinical development. Eight seronegative participants received three doses of each product with each dose separated by at least 2 weeks: one dose was given alone without simulated RAI in clinic, another dose was followed by simulated RAI in clinic, and another dose was self-administered at home in the context of RAI with a partner. Assessments included safety, acceptability, colon histology, ex vivo HIV infectivity of colon tissue explants, and colonic luminal distribution of vehicle and HIV surrogates. Adverse events were all mild and mainly sigmoidoscopy associated. There were minor differences in colon distribution of products and little effect of RAI. Vehicle distribution covered 95% (±7% standard deviation) of the distribution of an HIV surrogate in the colonic lumen. The lipid fluid vehicle increased HIV colon tissue infectability 5-fold [log10 p24 0.68 (95% confidence interval 0.08, 1.28)] and aqueous gel provided 6-fold protection [log10 p24 0.80 (95% confidence interval 0.20, 1.41)] compared to no product baseline. Colon permeability of lipid vehicles was more than 10-fold greater than aqueous vehicles. All products received similar acceptability ratings, though trends favored the gel products. Intensive simultaneous assessment of safety and toxicity, luminal and tissue distribution, ex vivo HIV infectivity, and product acceptability in relevant sexual contexts provided clear differentiation among candidate gels very early in product development. We selected the aqueous gel for further development as a rectal microbicide vehicle.
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Affiliation(s)
- Francisco Leyva
- Department of Medicine (Clinical Pharmacology), The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Edward J. Fuchs
- Department of Medicine (Clinical Pharmacology), The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rahul Bakshi
- Department of Medicine (Clinical Pharmacology), The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alex Carballo-Dieguez
- Department of Medicine (Gastroenterology), The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ana Ventuneac
- Department of Medicine (Gastroenterology), The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Chen Yue
- Department of Biostatistics, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | - Brian Caffo
- Department of Biostatistics, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | - Yong Du
- Department of Radiology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Liye Li
- Department of Medicine (Clinical Pharmacology), The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Gerald Mullin
- HIV Center for Clinical and Behavioral Studies, Columbia University, New York, New York
| | - Linda Lee
- HIV Center for Clinical and Behavioral Studies, Columbia University, New York, New York
| | - Lisa Rohan
- Magee Womens Research Institute, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Peter A. Anton
- UCLA Center for HIV Prevention Research, UCLA AIDS Institute, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Craig W. Hendrix
- Department of Medicine (Clinical Pharmacology), The Johns Hopkins University School of Medicine, Baltimore, Maryland
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Fuchs EJ, Schwartz JL, Friend DR, Coleman JS, Hendrix CW. A Pilot Study Measuring the Distribution and Permeability of a Vaginal HIV Microbicide Gel Vehicle Using Magnetic Resonance Imaging, Single Photon Emission Computed Tomography/Computed Tomography, and a Radiolabeled Small Molecule. AIDS Res Hum Retroviruses 2015; 31:1109-15. [PMID: 26077739 DOI: 10.1089/aid.2015.0054] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Vaginal microbicide gels containing tenofovir have proven effective in HIV prevention, offering the advantage of reduced systemic toxicity. We studied the vaginal distribution and effect on mucosal permeability of a gel vehicle. Six premenopausal women were enrolled. In Phase 1, a spreading gel containing (99m)technetium-DTPA ((99m)Tc) radiolabel and gadolinium contrast for magnetic resonance imaging (MRI) was dosed intravaginally. MRI was obtained at 0.5, 4, and 24 h, and single photon emission computed tomography with conventional computed tomography (SPECT/CT) at 1.5, 5, and 25 h postdosing. Pads and tissues were measured for activity to determine gel loss. In Phase 2, nonoxynol-9 (N-9), containing (99m)Tc-DTPA, was dosed as a permeability control; permeability was measured in blood and urine for both phases. SPECT/CT showed the distribution of spreading gel throughout the vagina with the highest concentration of radiosignal in the fornices and ectocervix; signal intensity diminished over 25 h. MRI showed the greatest signal accumulation in the fornices, most notably 1-4 h postdosing. The median (interquartile range) isotope signal loss from the vagina through 6 h was 29.1% (15.8-39.9%). Mucosal permeability to (99m)Tc-DTPA following spreading gel was negligible, in contrast to N-9, with detectable radiosignal in plasma, peaking at 8 h (5-12). Following spreading gel dosing, 0.004% (0.001-2.04%) of the radiosignal accumulated in urine over 12 h compared to 8.31% (7.07-11.01%) with N-9, (p=0.043). Spreading gel distributed variably throughout the vagina, persisting for 24 h, with signal concentrating in the fornices and ectocervix. The spreading gel had no significant effect on vaginal mucosal permeability.
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Affiliation(s)
- Edward J. Fuchs
- The Division of Clinical Pharmacology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Jill L. Schwartz
- CONRAD, Eastern Virginia Medical School (EVMS), Arlington, Virginia
| | - David R. Friend
- CONRAD, Eastern Virginia Medical School (EVMS), Arlington, Virginia
| | - Jenell S. Coleman
- The Division of Gynecologic Specialties, Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Craig W. Hendrix
- The Division of Clinical Pharmacology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
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Rectal pre-exposure prophylaxis (PrEP). Antiviral Res 2013; 100 Suppl:S17-24. [PMID: 24188705 DOI: 10.1016/j.antiviral.2013.09.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2013] [Revised: 09/09/2013] [Accepted: 09/21/2013] [Indexed: 01/19/2023]
Abstract
Rectal pre-exposure prophylaxis (PrEP) will be a critical component of HIV prevention products due to the prevalence of unprotected receptive anal intercourse among men who have sex with men and heterosexual couples. Given the biological considerations of this compartment and the complexity of HIV infection, design of a successful rectal microbicide product faces a number of challenges. Important information is being compiled to begin to address deficits in knowledge toward design of rectal PrEP products for men and women. Aspects of formulation development and preclinical and clinical evaluation of rectal products studied to date are summarized in this review. This article is based on a presentation at the "Product Development Workshop 2013: HIV and Multipurpose Prevention Technologies," held in Arlington, Virginia on February 21-22, 2013. It forms part of a special supplement to Antiviral Research.
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das Neves J, Araújo F, Andrade F, Michiels J, Ariën KK, Vanham G, Amiji M, Bahia MF, Sarmento B. In Vitro and Ex Vivo Evaluation of Polymeric Nanoparticles for Vaginal and Rectal Delivery of the Anti-HIV Drug Dapivirine. Mol Pharm 2013; 10:2793-807. [DOI: 10.1021/mp4002365] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- José das Neves
- Laboratory of Pharmaceutical
Technology, Faculty of Pharmacy, University of Porto, Rua de Jorge Viterbo Ferreira, 228, 4050-313 Porto, Portugal
- CICS—Centro de Investigação
em Ciências da Saúde, Department of Pharmaceutical Sciences, Instituto Superior de Ciências da Saúde-Norte, Rua Central de Gandra, 1317, 4585-116 Gandra, Portugal
| | - Francisca Araújo
- CICS—Centro de Investigação
em Ciências da Saúde, Department of Pharmaceutical Sciences, Instituto Superior de Ciências da Saúde-Norte, Rua Central de Gandra, 1317, 4585-116 Gandra, Portugal
- INEB—Instituto de Engenharia Biomédica, Rua do Campo Alegre,
823, 4150-180 Porto, Portugal
| | - Fernanda Andrade
- Laboratory of Pharmaceutical
Technology, Faculty of Pharmacy, University of Porto, Rua de Jorge Viterbo Ferreira, 228, 4050-313 Porto, Portugal
| | - Johan Michiels
- Virology Unit, Department of
Microbiology, Institute of Tropical Medicine, Nationalestraat 155, 2000 Antwerpen, Belgium
| | - Kevin K. Ariën
- Virology Unit, Department of
Microbiology, Institute of Tropical Medicine, Nationalestraat 155, 2000 Antwerpen, Belgium
| | - Guido Vanham
- Virology Unit, Department of
Microbiology, Institute of Tropical Medicine, Nationalestraat 155, 2000 Antwerpen, Belgium
| | - Mansoor Amiji
- Department of Pharmaceutical
Sciences, School of Pharmacy, Northeastern University, 110 Mugar Life Sciences Building, Boston, Massachusetts 02115,
United States
| | - Maria Fernanda Bahia
- Laboratory of Pharmaceutical
Technology, Faculty of Pharmacy, University of Porto, Rua de Jorge Viterbo Ferreira, 228, 4050-313 Porto, Portugal
| | - Bruno Sarmento
- Laboratory of Pharmaceutical
Technology, Faculty of Pharmacy, University of Porto, Rua de Jorge Viterbo Ferreira, 228, 4050-313 Porto, Portugal
- CICS—Centro de Investigação
em Ciências da Saúde, Department of Pharmaceutical Sciences, Instituto Superior de Ciências da Saúde-Norte, Rua Central de Gandra, 1317, 4585-116 Gandra, Portugal
- INEB—Instituto de Engenharia Biomédica, Rua do Campo Alegre,
823, 4150-180 Porto, Portugal
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