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Zhang Q, Lin D, Yao S. Review on biomedical and bioengineering applications of cellulose sulfate. Carbohydr Polym 2015; 132:311-22. [DOI: 10.1016/j.carbpol.2015.06.041] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Revised: 06/11/2015] [Accepted: 06/12/2015] [Indexed: 02/06/2023]
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Mauck CK, Lai JJ, Weiner DH, Chandra N, Fichorova RN, Dezzutti CS, Hillier SL, Archer DF, Creinin MD, Schwartz JL, Callahan MM, Doncel GF. Toward early safety alert endpoints: exploring biomarkers suggestive of microbicide failure. AIDS Res Hum Retroviruses 2013; 29:1475-86. [PMID: 23885658 DOI: 10.1089/aid.2012.0345] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Several microbicides, including nonoxynol-9 (N-9) and cellulose sulfate (CS), looked promising during early trials but failed in efficacy trials. We aimed to identify Phase I mucosal safety endpoints that might explain that failure. In a blinded, randomized, parallel trial, 60 healthy premenopausal sexually abstinent women applied Universal HEC placebo, 6% CS or 4% N-9 gel twice daily for 13½ days. Endpoints included immune biomarkers in cervicovaginal lavage (CVL) and endocervical cytobrushes, inflammatory infiltrates in vaginal biopsies, epithelial integrity by naked eye, colposcopy, and histology, CVL anti-HIV activity, vaginal microflora, pH, and adverse events. Twenty women enrolled per group. Soluble/cellular markers were similar with CS and placebo, except secretory leukocyte protease inhibitor (SLPI) levels decreased in CVL, and CD3(+) and CD45(+) cells increased in biopsies after CS use. Increases in interleukin (IL)-8, IL-1, IL-1RA, and myeloperoxidase (MPO) and decreases in SLPI were significant with N-9. CVL anti-HIV activity was significantly higher during CS use compared to N-9 or placebo. CS users tended to have a higher prevalence of intermediate Nugent score, Escherichia coli, and Enterococcus and fewer gram-negative rods. Most Nugent scores diagnostic for bacterial vaginosis were in N-9 users. All cases of histological inflammation or deep epithelial disruption occurred in N-9 users. While the surfactant N-9 showed obvious biochemical and histological signs of inflammation, more subtle changes, including depression of SLPI, tissue influx of CD45(+) and CD3(+) cells, and subclinical microflora shifts were associated with CS use and may help to explain the clinical failure of nonsurfactant microbicides.
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Affiliation(s)
| | - Jaim Jou Lai
- FHI 360 (formerly Family Health International), Research Triangle Park, North Carolina
| | - Debra H. Weiner
- FHI 360 (formerly Family Health International), Research Triangle Park, North Carolina
| | - Neelima Chandra
- CONRAD, Eastern Virginia Medical School (EVMS), Norfolk, Virginia
| | - Raina N. Fichorova
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Charlene S. Dezzutti
- University of Pittsburgh and Magee-Womens Research Institute, Pittsburgh, Pennsylvania
| | - Sharon L. Hillier
- University of Pittsburgh and Magee-Womens Research Institute, Pittsburgh, Pennsylvania
| | - David F. Archer
- CONRAD, Eastern Virginia Medical School (EVMS), Norfolk, Virginia
| | | | - Jill L. Schwartz
- CONRAD, Eastern Virginia Medical School (EVMS), Arlington, Virginia
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Li W, Huang Z, Wu Y, Wang H, Zhou X, Xiao Z, Ding X, Xu J. Effectiveness of an optimized benzalkonium chloride gel as vaginal contraceptive: a randomized controlled trial among Chinese women. Contraception 2013; 87:756-65. [DOI: 10.1016/j.contraception.2012.09.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2012] [Revised: 09/01/2012] [Accepted: 09/12/2012] [Indexed: 10/27/2022]
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Sitruk-Ware R, Nath A, Mishell DR. Contraception technology: past, present and future. Contraception 2013; 87:319-30. [PMID: 22995540 PMCID: PMC3530627 DOI: 10.1016/j.contraception.2012.08.002] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2012] [Accepted: 08/06/2012] [Indexed: 11/22/2022]
Abstract
Steady progress in contraception research has been achieved over the past 50 years. Hormonal and nonhormonal modern contraceptives have improved women's lives by reducing different health conditions that contributed to considerable morbidity. However, the contraceptives available today are not suitable to all users, and the need to expand contraceptive choices still exists. Novel products such as new implants, contraceptive vaginal rings, transdermal patches and newer combinations of oral contraceptives have recently been introduced in family planning programs, and hormonal contraception is widely used for spacing and limiting births. Concerns over the adverse effects of hormonal contraceptives have led to research and development of new combinations with improved metabolic profile. Recent developments include use of natural compounds such as estradiol and estradiol valerate with the hope to decrease thrombotic risk, in combination with newer progestins derived from the progesterone structure or from spirolactone, in order to avoid the androgenic effects. Progesterone antagonists and progesterone receptor modulators are highly effective in blocking ovulation and preventing follicular rupture and are undergoing investigations in the form of oral pills and in semi-long-acting delivery systems. Future developments also include the combination of a contraceptive with an antiretroviral agent for dual contraception and protection against sexually transmitted diseases, to be used before intercourse or on demand, as well as for continuous use in dual-protection rings. Although clinical trials of male contraception have reflected promising results, limited involvement of industry in that area of research has decreased the likelihood of having a male method available in the current decade. Development of nonhormonal methods is still at an early stage of research, with the identification of specific targets within the reproductive system in ovaries and testes, as well as interactions between spermatozoa and ova. It is hoped that the introduction of new methods with additional health benefits would help women and couples with unmet needs to obtain access to a wider range of contraceptives with improved acceptability.
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Abstract
Vaginal microbicide gel trials for HIV prevention may require withdrawal of study product when a woman becomes pregnant. We assessed the potential impact of withdrawals in four trials by comparing self-reported sexual behavior pre- and post-pregnancy detection: (1) behavior in the month prior to positive pregnancy test versus behavior reported at the subsequent monthly visit; (2) behavior changes according to pregnancy status at the subsequent visit (continuing pregnancy versus not); (3) average sexual behaviors reported for all months prior to pregnancy detection versus all months after pregnancy was no longer detected; and (4) behavior changes among participants never testing positive for pregnancy. Pregnancy detection was associated with immediate reductions in self-reported numbers of partners and sex acts. The proportion of acts in which study gel was used following a negative pregnancy test did not return to pre-pregnancy levels. Pregnancies complicate the conduct and interpretation of vaginal microbicide trials when product must be withdrawn.
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Sibeko S, Cohen GM, Moodley J. Contraception and pregnancy in microbicide trials. Best Pract Res Clin Obstet Gynaecol 2012; 26:473-86. [PMID: 22386542 PMCID: PMC5523972 DOI: 10.1016/j.bpobgyn.2012.01.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2011] [Accepted: 01/23/2012] [Indexed: 11/26/2022]
Abstract
The distinctive feature of the human immunodeficiency virus (HIV) epidemic in Sub-Saharan Africa is the burden on women, in particular young women of reproductive age. Consequently, most late-phase effectiveness microbicide clinical trials are conducted in sub-Saharan Africa where fertility rates are high. Because late-phase clinical trials are conducted over prolonged periods of time, women participating in these trials may fall pregnant during the trial. Their unborn babies may be exposed to a drug whose teratogenic potential is unknown if the investigational drug is not withdrawn. High pregnancy rates in such trials may compromise statistical integrity, as women will be withdrawn from the study drug for the duration of the pregnancy. It is therefore imperative for microbicide trials to implement effective contraceptive and pregnancy management programmes that maintain low pregnancy rates and the safety of unborn babies while not compromising the conduct and statistical integrity of the trial.
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Affiliation(s)
- Sengeziwe Sibeko
- Centre for the AIDS Programme of Research in South Africa, 2nd Floor Doris Duke Medical Research Institute, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Private Bag X7, Congella, 4013, Durban, South Africa.
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Estimating contraceptive efficacy: the case of spermicides. Contraception 2012; 87:134-7. [PMID: 22840279 DOI: 10.1016/j.contraception.2012.06.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2012] [Revised: 06/05/2012] [Accepted: 06/22/2012] [Indexed: 11/23/2022]
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Multipurpose prevention technologies: biomedical tools to prevent HIV-1, HSV-2, and unintended pregnancies. Infect Dis Obstet Gynecol 2011; 2011:1-10. [PMID: 21836811 PMCID: PMC3152961 DOI: 10.1155/2011/429403] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2011] [Accepted: 06/15/2011] [Indexed: 11/18/2022] Open
Abstract
Statistics clearly show an unmet need for highly effective contraception, especially in less developed countries. Many of these countries are at the core of the HIV/AIDS epidemic and show very high prevalence rates for other sexually transmitted infections (STIs) such as that caused by HSV-2. A woman at risk of unintended pregnancy due to unprotected intercourse is also at risk for HIV/STI. Owing to their causative interrelationship, combining protection against these conditions will result in enhanced prevention and health benefits. Existing multipurpose prevention modalities such as condoms and physical barriers, albeit efficacious, face cultural hurdles that have so far hindered their widespread use. Success has recently been demonstrated in large clinical trials, demonstrating proof of concept of microbicides in reducing the incidence of HIV-1 and HSV-2 among at-risk populations. The challenge heretofore is to refine these products to make them more potent, convenient, accessible, and acceptable. Potent antiviral drugs released topically in the female reproductive tract by innovative delivered systems and formulations will provide safe, effective, and acceptable multipurpose prevention tools. This paper provides an overview of existing and novel approaches to multipurpose prevention strategies.
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Contraceptive efficacy, acceptability, and safety of C31G and nonoxynol-9 spermicidal gels: a randomized controlled trial. Obstet Gynecol 2011; 116:1265-1273. [PMID: 21099590 DOI: 10.1097/aog.0b013e3181fc3b1a] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To estimate whether a gel containing the spermicide C31G was noninferior to a commercially available product containing nonoxynol-9. METHODS Participants were healthy, sexually active women aged 18-40 years. Measured outcomes included pregnancy rates, continuation rates, adverse events, and acceptability. The primary study outcome was contraceptive efficacy. Sample size was calculated at a 2.5% significance level using a one-sided test based on assumed 6-month pregnancy probability of 15% in the nonoxynol-9 group. Sample size was sufficient to reject, with 80% power, the null hypothesis that pregnancy probability in the C31G arm would be more than 5% higher. RESULTS Nine hundred thirty-two women were randomized in the C31G group and 633 in the nonoxynol-9 group. For randomized patients with at least one episode of coitus (modified intent-to-treat group), 6-month pregnancy probabilities were 12.0% (95% confidence interval [CI] 9.3-14.7%) and 12.0% (95% CI 8.7-15.3%) for C31G and nonoxynol-9,respectively. Twelve-month pregnancy probabilities were 13.8% (95% CI 7.6-20%) for C31G and 19.8% (95% CI 10.9-28.7%) for nonoxynol-9. Two serious adverse events were deemed possibly related to study product and neither occurred in the C31G group. Three fourths of users in either group reported that they liked their assigned study product. Approximately 40% of patients discontinued prematurely for reasons other than pregnancy with 11% lost to follow-up. CONCLUSION C31G demonstrated noninferior contraceptive efficacy compared with nonoxynol-9. C31G may provide another marketable option for women seeking spermicidal contraception. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, www.ClinicalTrials.gov, NCT00274261.
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Agarwal HK, Kumar A, Doncel GF, Parang K. Synthesis, antiviral and contraceptive activities of nucleoside–sodium cellulose sulfate acetate and succinate conjugates. Bioorg Med Chem Lett 2010; 20:6993-7. [PMID: 20965725 DOI: 10.1016/j.bmcl.2010.09.133] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2010] [Revised: 09/23/2010] [Accepted: 09/24/2010] [Indexed: 10/19/2022]
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Anderson RA, Brown D, Jackson EM, Feathergill KA, Bremer JW, Morack R, Rawlins RG. Feasibility of Repurposing the Polyanionic Microbicide, PPCM, for Prophylaxis against HIV Transmission during ART. ISRN OBSTETRICS AND GYNECOLOGY 2010; 2011:524365. [PMID: 21647213 PMCID: PMC3099743 DOI: 10.5402/2011/524365] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/29/2010] [Accepted: 10/19/2010] [Indexed: 11/30/2022]
Abstract
HIV-serodiscordant couples wishing to conceive often seek assisted reproduction, during which spermatozoa from infected men are washed to minimize the risk of HIV transmission to partner and fetus. We sought to improve this method by adding a microbicide, PPCM, as an HIV prophylactic. HIV-1 (BaL) inhibition by PPCM appears irreversible and independent of added Ca2+. Without added Ca2+, PPCM
(≤10 mg/mL, ≤90 min), a stimulus of Ca2+-dependent acrosomal loss, has no effect on sperm motility, forward progression, or acrosomal status. PPCM-treated (10 mg/mL) sperm retain their ability to acrosome react when Ca2+ is added. Sperm DNA integrity/function is unaffected by PPCM (≤10 mg/mL). Adding PPCM (5 mg/mL, 30 min) to washing media reduces infectivity (viral antigen p24 and RNA) of ex-vivo HIV-infected semen by 3-4 Logs compared with washing alone. Sperm washing with appropriate extracellular Ca2+ levels and PPCM is significantly more effective than washing alone at reducing HIV infectivity.
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Affiliation(s)
- Robert A Anderson
- Department of Obstetrics and Gynecology, Rush University Medical Center, 1653 W. Congress Parkway, Chicago, IL 60612, USA
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Batár I. State-of-the-art of non-hormonal methods of contraception: II. Chemical barrier contraceptives. EUR J CONTRACEP REPR 2010; 15:89-95. [DOI: 10.3109/13625180903462326] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Harper MJK. Family planning: today and in the future. Handb Exp Pharmacol 2010:225-258. [PMID: 20839094 DOI: 10.1007/978-3-642-02062-9_12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
This review covers the state of contraceptive development noting new entries in the clinic (mainly steroidal and different delivery methods) and novel leads for nonsteroidal female- and male-methods in the pipeline. The time taken to market and the absence of partnerships with industry are stressed as major factors for the slow progress in their development.
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Affiliation(s)
- Michael J K Harper
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, 1911 N. Fort Meyer Drive, Suite 900, Arlington, VA 22209, USA.
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Anderson RA, Aroutcheva A, Feathergill KA, Anderson AB. Differential Sensitivity of Lactobacillus spp. to Inhibition by Candidate Topical Microbicides. Probiotics Antimicrob Proteins 2009; 1:24-35. [PMID: 26783129 DOI: 10.1007/s12602-009-9007-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2008] [Accepted: 02/10/2009] [Indexed: 10/21/2022]
Abstract
Preclinical evaluation of vaginal microbicides includes screening against lactobacilli. However, there is no consensus regarding the species to be tested. This study was carried out to determine if results with one species would apply to other species, and to evaluate the utility of turbidometry as a screening tool. One current (PPCM; previously designated sulfuric acid-modified mandelic acid, SAMMA) and two former (cellulose sulfate, CS; and polystyrene sulfonate, PSS) candidate microbicides were evaluated. Bacterial growth was measured turbidometrically and by direct cell count. No microbicide affected Lact. gasseri, measured by either method. Apparent inhibition of Lact. jensenii by CS, PSS, and PPCM, and of Lact. crispatus by CS, occurred with turbidometric measurement. This was not substantiated with direct cell count. PSS and PPCM inhibited Lact. crispatus and Lact. acidophilus with both methods. These findings agree with results from vaginal isolates, which included Lact. gasseri, jensenii, acidophillus, crispatus, rhamnosis, casei, and paracasei. We conclude that sensitivities of similar lactobacilli to at least three microbicides are different. A single species is inadequate for screening vaginal products. Turbidometric evaluation is a sensitive, but not specific, screening method. We recommend that this method be used to screen candidate microbicides against several species of prevalent Lactobacillus species as an initial measure of microbicide safety evaluation.
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Affiliation(s)
- Robert A Anderson
- Section of Obstetrics and Gynecology Research, The TOPCAD Program, Rush University Medical Center, 1653 W. Congress Parkway, Chicago, IL, 60612, USA.
| | - Alla Aroutcheva
- Department of Medicine, Stroger Hospital of Cook County, 1901 W. Harrison Street, Chicago, IL, 60612, USA.,Rush University Medical Center, 1653 W. Congress Parkway, Chicago, IL, 60612, USA
| | - Kenneth A Feathergill
- Section of Obstetrics and Gynecology Research, Rush University Medical Center, 1653 W. Congress Parkway, Chicago, IL, 60612, USA
| | - Amillia B Anderson
- Section of Obstetrics and Gynecology Research, Rush University Medical Center, 1653 W. Congress Parkway, Chicago, IL, 60612, USA
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Methods for Female Contraception: A Model for Innovation in Drug Delivery Systems. Clin Pharmacol Ther 2009; 85:553-7. [DOI: 10.1038/clpt.2009.29] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Halpern V, Ogunsola F, Obunge O, Wang CH, Onyejepu N, Oduyebo O, Taylor D, McNeil L, Mehta N, Umo-Otong J, Otusanya S, Crucitti T, Abdellati S. Effectiveness of cellulose sulfate vaginal gel for the prevention of HIV infection: results of a Phase III trial in Nigeria. PLoS One 2008; 3:e3784. [PMID: 19023429 PMCID: PMC2582655 DOI: 10.1371/journal.pone.0003784] [Citation(s) in RCA: 122] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2008] [Accepted: 10/29/2008] [Indexed: 11/25/2022] Open
Abstract
Background This trial evaluated the safety and effectiveness of 6% cellulose sulfate vaginal gel in preventing male-to-female vaginal transmission of HIV, gonorrhea and chlamydial infection. Methods This Phase III, double-blind, randomized, placebo-controlled trial was conducted between November 2004 and March 2007 in Lagos and Port Harcourt, Nigeria. We enrolled 1644 HIV-antibody negative women at high risk of HIV acquisition. Study participants were randomized 1∶1 to cellulose sulfate or placebo and asked to use gel plus a condom for each act of vaginal intercourse over one year of follow-up. The participants were evaluated monthly for HIV, gonorrhea and chlamydial infection, and for adverse events. Results The trial was stopped prematurely after the data safety monitoring board of a parallel trial concluded that cellulose sulfate might be increasing the risk of HIV. In contrast, we observed fewer infections in the active arm (10) than on placebo (13), a difference that was nonetheless not statistically significant (HR = 0.8, 95% CI 0.3–1.8; p = 0.56). Rates of gonorrhea and chlamydial infection were lower in the CS group but the difference was likewise not statistically significant (HR = 0.8, 95% CI 0.5–1.1; p = 0.19 for the combined STI outcome). Rates of adverse events were similar across study arms. No serious adverse events related to cellulose sulfate use were reported. Conclusions Cellulose sulfate gel appeared to be safe in the evaluated study population but we found insufficient evidence that it prevented male-to-female vaginal transmission of HIV, gonorrhea or chlamydial infection. The early closure of the trial compromised the ability to draw definitive conclusions about the effectiveness of cellulose sulfate against HIV. Trial Registration ClinicalTrials.gov NCT00120770
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Affiliation(s)
- Vera Halpern
- Family Health International, Research Triangle Park, North Carolina, United States of America.
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Harper MJK. Public-private partnerships advance contraceptive research and development. Contraception 2008; 78:S36-41. [PMID: 18847598 DOI: 10.1016/j.contraception.2008.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2008] [Accepted: 03/25/2008] [Indexed: 10/21/2022]
Abstract
The concept of public-private partnerships as a way to tackle global health problems is discussed. It is noted that surveys of such partnerships have not included contraception and contraceptive research and development (R&D), since pregnancy is not regarded as a disease. Nevertheless, there has been an attempt to apply the concept to improve maternal health through establishment of the Consortium for Industrial Collaboration in Contraceptive Research (CICCR) and its involvement with the AMPPA projects. The outcome of the CICCR initiative is discussed. Actions for the future are outlined.
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Van Damme L, Govinden R, Mirembe FM, Guédou F, Solomon S, Becker ML, Pradeep BS, Krishnan AK, Alary M, Pande B, Ramjee G, Deese J, Crucitti T, Taylor D. Lack of effectiveness of cellulose sulfate gel for the prevention of vaginal HIV transmission. N Engl J Med 2008; 359:463-72. [PMID: 18669425 DOI: 10.1056/nejmoa0707957] [Citation(s) in RCA: 333] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Women make up more than 50% of adults living with human immunodeficiency virus (HIV) infection or the acquired immunodeficiency syndrome (AIDS) in sub-Saharan Africa. Thus, female-initiated HIV prevention methods are urgently needed. METHODS We performed a randomized, double-blind, placebo-controlled trial of cellulose sulfate, an HIV-entry inhibitor formulated as a vaginal gel, involving women at high risk for HIV infection at three African and two Indian sites. The primary end point was newly acquired infection with HIV type 1 or 2. The secondary end point was newly acquired gonococcal or chlamydial infection. The primary analysis was based on a log-rank test of no difference in the distribution of time to HIV infection, stratified according to site. RESULTS A total of 1398 women were enrolled and randomly assigned to receive cellulose sulfate gel (706 participants) or placebo (692 participants) and had follow-up HIV test data. There were 41 newly acquired HIV infections, 25 in the cellulose sulfate group and 16 in the placebo group, with an estimated hazard ratio of infection for the cellulose sulfate group of 1.61 (P=0.13). This result, which is not significant, is in contrast to the interim finding that led to the trial being stopped prematurely (hazard ratio, 2.02 [corrected]; P=0.05 [corrected]) and the suggestive result of a preplanned secondary (adherence-based) analysis (hazard ratio, 2.02; P=0.05). No significant effect of cellulose sulfate as compared with placebo was found on the risk of gonorrheal infection (hazard ratio, 1.10; 95% confidence interval [CI], 0.74 to 1.62) or chlamydial infection (hazard ratio, 0.71; 95% CI, 0.47 to 1.08). CONCLUSIONS Cellulose sulfate did not prevent HIV infection and may have increased the risk of HIV acquisition. (ClinicalTrials.gov number, NCT00153777; and Current Controlled Trials number, ISRCTN95638385.)
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