1
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Teigeler M, Schaudien D, Böhmer W, Länge R, Schäfers C. Effects of the Gestagen Levonorgestrel in a Life Cycle Test with Zebrafish (Danio rerio). ENVIRONMENTAL TOXICOLOGY AND CHEMISTRY 2022; 41:580-591. [PMID: 33539028 DOI: 10.1002/etc.5008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 10/25/2020] [Accepted: 01/31/2021] [Indexed: 06/12/2023]
Abstract
The amount of pharmaceuticals transferred to the aquatic environment via municipal and hospital waste water is steadily increasing. The progress in medical research has resulted in the manufacture of active substances of increased stability, specificity, and potency, which can trigger adverse effects in aquatic organisms. Moreover, advanced analytical methods allow the detection of pharmaceuticals in environmental matrices at very low concentrations, which increases the number of substances to be assessed. Levonorgestrel is a synthetic gestagen commonly used in medicinal products for contraception. Because progestogenic compounds could have an impact on fish maturation processes, a life cycle test was performed to assess the effects of levonorgestrel exposure of the embryonic to the adult stages of zebrafish (Danio rerio) at mean measured concentrations of 0.06, 0.16, 0.47, 1.64, and 5.45 ng/L. Apical endpoints were survival, growth, reproduction, and sex ratio. Determination of endocrine modulation was completed by measurement of vitellogenin and 11-keto testosterone in blood plasma, as well as by histopathological analysis of gonads. For all parameters, control values were within the recommended quality range. The most prominent levonorgestrel effect was a shift toward an increased number of male fish at 1.64 and especially 5.45 ng/L, at which point all fish were histologically determined to be males and no spawning occurred; 11-keto testosterone was significantly decreased. A no-observed-effect concentration (NOEC) of 0.47 ng levonorgestrel/L was confirmed by the fertilization capability of adult fish, the male maturation stages, and female gonad histopathology. Whereas hatch and juvenile growth were not affected, posthatch survival was significantly impeded at ≥0.47 ng levonorgestrel/L, although it was not clearly related to the test concentration. For male length and weight, the same NOEC of 0.16 ng/L was obtained at study termination. Environ Toxicol Chem 2022;41:580-591. © 2021 The Authors. Environmental Toxicology and Chemistry published by Wiley Periodicals LLC on behalf of SETAC.
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Affiliation(s)
- Matthias Teigeler
- Fraunhofer Institute for Molecular Biology and Applied Ecology IME, Schmallenberg, Germany
| | - Dirk Schaudien
- Fraunhofer Institute for Toxicology and Experimental Medicine ITEM, Hannover, Germany
| | - Walter Böhmer
- Fraunhofer Institute for Molecular Biology and Applied Ecology IME, Schmallenberg, Germany
| | | | - Christoph Schäfers
- Fraunhofer Institute for Molecular Biology and Applied Ecology IME, Schmallenberg, Germany
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2
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Bick AJ, Louw-du Toit R, Skosana SB, Africander D, Hapgood JP. Pharmacokinetics, metabolism and serum concentrations of progestins used in contraception. Pharmacol Ther 2021; 222:107789. [PMID: 33316287 PMCID: PMC8122039 DOI: 10.1016/j.pharmthera.2020.107789] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 11/24/2020] [Indexed: 02/07/2023]
Abstract
Many different forms of hormonal contraception are used by millions of women worldwide. These contraceptives differ in the dose and type of synthetic progestogenic compound (progestin) used, as well as the route of administration and whether or not they contain estrogenic compounds. There is an increasing awareness that different forms of contraception and different progestins have different side-effect profiles, in particular their cardiovascular effects, effects on reproductive cancers and susceptibility to infectious diseases. There is a need to develop new methods to suit different needs and with minimal risks, especially in under-resourced areas. This requires a better understanding of the pharmacokinetics, metabolism, serum and tissue concentrations of progestins used in contraception as well as the biological activities of progestins and their metabolites via steroid receptors. Here we review the current knowledge on these topics and identify the research gaps. We show that there is a paucity of research on most of these topics for most progestins. We find that major impediments to clear conclusions on these topics include a lack of standardized methodologies, comparisons between non-parallel clinical studies and variability of data on serum concentrations between and within studies. The latter is most likely due, at least in part, to differences in intrinsic characteristics of participants. The review highlights the importance of insight on these topics in order to provide the best contraceptive options to women with minimal risks.
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Affiliation(s)
- Alexis J Bick
- Department of Molecular and Cell Biology, University of Cape Town, Private Bag X3, Rondebosch 7700, South Africa
| | - Renate Louw-du Toit
- Department of Biochemistry, Stellenbosch University, Stellenbosch 7602, South Africa
| | - Salndave B Skosana
- Department of Molecular and Cell Biology, University of Cape Town, Private Bag X3, Rondebosch 7700, South Africa
| | - Donita Africander
- Department of Biochemistry, Stellenbosch University, Stellenbosch 7602, South Africa
| | - Janet P Hapgood
- Department of Molecular and Cell Biology, University of Cape Town, Private Bag X3, Rondebosch 7700, South Africa; Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa.
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3
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Marcus JL, Snowden JM, Murray Horwitz ME, Toh S, Horgan C, Tilney RC, Rajbhandari R, Back S, Westreich DJ. Use of Intrauterine Devices and Risk of Human Immunodeficiency Virus Acquisition Among Insured Women in the United States. Clin Infect Dis 2021; 70:2221-2223. [PMID: 31412356 DOI: 10.1093/cid/ciz791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 08/12/2019] [Indexed: 11/13/2022] Open
Abstract
Concerns have been raised about progestin-containing contraceptives and the risk of human immunodeficiency virus (HIV) acquisition. Based on health insurance data from women in the United States with intrauterine device (IUD) insertions during 2011-2018, there was no increased risk of incident HIV diagnosis for levonorgestrel-releasing IUDs versus copper IUDs.
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Affiliation(s)
- Julia L Marcus
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Jonathan M Snowden
- School of Public Health, Oregon Health & Science University─Portland State University
| | - Mara E Murray Horwitz
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Sengwee Toh
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Casie Horgan
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Rong Chen Tilney
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Rajani Rajbhandari
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Soowoo Back
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
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4
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Houshdaran S, Chen JC, Vallvé-Juanico J, Balayan S, Vo KC, Smith-McCune K, Greenblatt RM, Irwin JC, Giudice LC. Progestins Related to Progesterone and Testosterone Elicit Divergent Human Endometrial Transcriptomes and Biofunctions. Int J Mol Sci 2020; 21:ijms21072625. [PMID: 32283828 PMCID: PMC7177488 DOI: 10.3390/ijms21072625] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 03/28/2020] [Accepted: 04/02/2020] [Indexed: 12/30/2022] Open
Abstract
Progestins are widely used for the treatment of gynecologic disorders and alone, or combined with an estrogen, are used as contraceptives. While their potencies, efficacies and side effects vary due to differences in structures, doses and routes of administration, little is known about their effects on the endometrial transcriptome in the presence or absence of estrogen. Herein, we assessed the transcriptome and pathways induced by progesterone (P4) and the three most commonly used synthetic progestins, medroxyprogesterone acetate (MPA), levonorgestrel (LNG), and norethindrone acetate (NETA), on human endometrial stromal fibroblasts (eSF), key players in endometrial physiology and reproductive success. While there were similar transcriptional responses, each progestin induced unique genes and biofunctions, consistent with their structural similarities to progesterone (P4 and MPA) or testosterone (LNG and NETA), involving cellular proliferation, migration and invasion. Addition of estradiol (E2) to each progestin influenced the number of differentially expressed genes and biofunctions in P4 and MPA, while LNG and NETA signatures were more independent of E2. Together, these data suggest different mechanisms of action for different progestins, with progestin-specific altered signatures when combined with E2. Further investigation is warranted for a personalized approach in different gynecologic disorders, for contraception, and minimizing side effects associated with their use.
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Affiliation(s)
- Sahar Houshdaran
- Center for Reproductive Sciences, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, CA 94143, USA; (S.H.); (J.V.-J.); (S.B.); (K.C.V.); (K.S.-M.); (J.C.I.)
| | | | - Júlia Vallvé-Juanico
- Center for Reproductive Sciences, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, CA 94143, USA; (S.H.); (J.V.-J.); (S.B.); (K.C.V.); (K.S.-M.); (J.C.I.)
| | - Shayna Balayan
- Center for Reproductive Sciences, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, CA 94143, USA; (S.H.); (J.V.-J.); (S.B.); (K.C.V.); (K.S.-M.); (J.C.I.)
| | - Kim Chi Vo
- Center for Reproductive Sciences, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, CA 94143, USA; (S.H.); (J.V.-J.); (S.B.); (K.C.V.); (K.S.-M.); (J.C.I.)
| | - Karen Smith-McCune
- Center for Reproductive Sciences, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, CA 94143, USA; (S.H.); (J.V.-J.); (S.B.); (K.C.V.); (K.S.-M.); (J.C.I.)
| | - Ruth M. Greenblatt
- Departments of Clinical Pharmacy, Medicine, Epidemiology and Biostatistics, University of California, San Francisco, CA 94143, USA;
| | - Juan C. Irwin
- Center for Reproductive Sciences, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, CA 94143, USA; (S.H.); (J.V.-J.); (S.B.); (K.C.V.); (K.S.-M.); (J.C.I.)
| | - Linda C. Giudice
- Center for Reproductive Sciences, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, CA 94143, USA; (S.H.); (J.V.-J.); (S.B.); (K.C.V.); (K.S.-M.); (J.C.I.)
- Correspondence: ; Tel.: +1-4154762039
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5
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Rational Design of a Multipurpose Bioadhesive Vaginal Film for Co-Delivery of Dapivirine and Levonorgestrel. Pharmaceutics 2019; 12:pharmaceutics12010001. [PMID: 31861267 PMCID: PMC7023193 DOI: 10.3390/pharmaceutics12010001] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 12/13/2019] [Accepted: 12/15/2019] [Indexed: 12/12/2022] Open
Abstract
Human immunodeficiency virus (HIV) infection and unintended pregnancy, which can lead to life-threatening complications, are two major burdens for female reproductive health. To address these pressing health issues, multipurpose prevention technologies (MPTs) are proposed to deliver two or more drugs simultaneously. MPTs could offer several benefits for users such as improved convenience, increased effectiveness, reduced cost, and decreased environmental burden. Here, we report the development, and in vitro and in vivo assessment of a bioadhesive vaginal film as a coitally-independent MPT dosage form for delivering dapivirine (DPV) and levonorgestrel (LNG) to prevent HIV infection and unintended pregnancy, respectively. After confirming the feasibility of bioadhesive film use for weekly drug delivery in vivo through colpophotography and MRI evaluation, the pharmacokinetics (PK) of DPV/LNG single entity and combination bioadhesive films was investigated in pigtailed macaques (n = 5). Both drugs from single entity or combination films were able to provide sustained drug release in vivo. The combination film showed lower local tissue clearance for DPV and exhibited significantly increased plasma concentration for LNG as compared to the single entity film. This proof-of-concept study demonstrates the ability of this novel bioadhesive film platform to deliver LNG and DPV simultaneously as an MPT product for the prevention of HIV infection and unintended pregnancy.
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Ahmed K, Baeten JM, Beksinska M, Bekker LG, Bukusi EA, Donnell D, Gichangi PB, Heller KB, Hofmeyr GJ, Justman J, Kasaro MP, Kiarie J, Louw C, Mastro TD, Morrison CS, Mugo NR, Nair G, Nanda K, Nhlabatsi Z, Onono M, Palanee-Phillips T, Pleaner M, Rees H, Singata-Madliki M, Scoville CW, Selepe RAP, Shears K, Sibiya S, Smit J, Steyn PS, Stringer J, Taylor D, Thomas KK, Welch JD. HIV incidence among women using intramuscular depot medroxyprogesterone acetate, a copper intrauterine device, or a levonorgestrel implant for contraception: a randomised, multicentre, open-label trial. Lancet 2019; 394:303-313. [PMID: 31204114 PMCID: PMC6675739 DOI: 10.1016/s0140-6736(19)31288-7] [Citation(s) in RCA: 206] [Impact Index Per Article: 41.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 05/24/2019] [Accepted: 05/28/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Observational and laboratory studies suggest that some hormonal contraceptive methods, particularly intramuscular depot medroxyprogesterone acetate (DMPA-IM), might increase women's susceptibility to HIV acquisition. We aimed to compare DMPA-IM, a copper intrauterine device (IUD), and a levonorgestrel (LNG) implant among African women seeking effective contraception and living in areas of high HIV incidence. METHODS We did a randomised, multicentre, open-label trial across 12 research sites in eSwatini, Kenya, South Africa, and Zambia. We included HIV-seronegative women aged 16-35 years who were seeking effective contraception, had no medical contraindications to the trial contraceptive methods, agreed to use the assigned method for 18 months, and reported not using injectable, intrauterine, or implantable contraception for the previous 6 months. Participants were randomly assigned (1:1:1) to receive an injection of 150 mg/mL DMPA-IM every 3 months, a copper IUD, or a LNG implant with random block sizes between 15 and 30, stratified by site. Participants were assigned using an online randomisation system, which was accessed for each randomisation by study staff at each site. The primary endpoint was incident HIV infection in the modified intention-to-treat population, including all randomised participants who were HIV negative at enrolment and who contributed at least one HIV test. The primary safety endpoint was any serious adverse event or any adverse event resulting in method discontinuation, until the trial exit visit at 18 months and was assessed in all enrolled and randomly assigned women. This study is registered with ClinicalTrials.gov, number NCT02550067. FINDINGS Between Dec 14, 2015, and Sept 12, 2017, 7830 women were enrolled and 7829 were randomly assigned to the DMPA-IM group (n=2609), the copper IUD group (n=2607), or the LNG implant group (n=2613). 7715 (99%) participants were included in the modified intention-to-treat population (2556 in the DMPA-IM group, 2571 in the copper IUD group, and 2588 in the LNG implant group), and women used their assigned method for 9567 (92%) of 10 409 woman-years of follow-up time. 397 HIV infections occurred (incidence 3·81 per 100 woman-years [95% CI 3·45-4·21]): 143 (36%; 4·19 per 100 woman-years [3·54-4·94]) in the DMPA-IM group, 138 (35%: 3·94 per 100 woman-years [3·31-4·66]) in the copper IUD group, and 116 (29%; 3·31 per 100 woman-years [2·74-3·98]) in the LNG implant group. In the modified intention-to-treat analysis, the hazard ratios for HIV acquisition were 1·04 (96% CI 0·82-1·33, p=0·72) for DMPA-IM compared with copper IUD, 1·23 (0·95-1·59, p=0·097) for DMPA-IM compared with LNG implant, and 1·18 (0·91-1·53, p=0·19) for copper IUD compared with LNG implant. 12 women died during the study: six in the DMPA-IM group, five in the copper IUD group, and one in the LNG implant group. Serious adverse events occurred in 49 (2%) of 2609 participants in the DMPA-IM group, 92 (4%) of 2607 participants in the copper IUD group, and 78 (3%) of 2613 participants in the LNG implant group. Adverse events resulting in discontinuation of the randomly assigned method occurred in 109 (4%) women in the DMPA-IM group, 218 (8%) women in the copper IUD group, and 226 (9%) women in the LNG implant group (p<0·0001 for DMPA-IM vs copper IUD and for DMPA-IM vs LNG implant). 255 pregnancies occurred: 61 (24%) in the DMPA-IM group, 116 (45%) in the copper IUD group, and 78 (31%) in the LNG implant group. 181 (71%) pregnancies occurred after discontinuation of randomly assigned method. INTERPRETATION We did not find a substantial difference in HIV risk among the methods evaluated, and all methods were safe and highly effective. HIV incidence was high in this population of women seeking pregnancy prevention, emphasising the need for integration of HIV prevention within contraceptive services for African women. These results support continued and increased access to these three contraceptive methods. FUNDING Bill & Melinda Gates Foundation, US Agency for International Development and the President's Emergency Plan for AIDS Relief, Swedish International Development Cooperation Agency, South African Medical Research Council, and UN Population Fund. Contraceptive supplies were donated by the Government of South Africa and US Agency for International Development.
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7
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Young Holt B, Dellplain L, Creinin MD, Peine KJ, Romano J, Hemmerling A. A strategic action framework for multipurpose prevention technologies combining contraceptive hormones and antiretroviral drugs to prevent pregnancy and HIV. EUR J CONTRACEP REPR 2018; 23:326-334. [PMID: 30247084 DOI: 10.1080/13625187.2018.1508650] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Multipurpose prevention technologies (MPTs) are an innovative class of products that deliver varied combinations of human immunodeficiency virus (HIV) prevention, other sexually transmitted infection (STI) prevention, and contraception. Combining separate strategies for different indications into singular prevention products can reduce the stigma around HIV and STI prevention, improve acceptability of and adherence to more convenient products, and be more cost-effective by addressing overlapping risks. METHODS This article outlines a strategic action framework developed as an outcome of a series of expert meetings held between 2014 and 2016. The meetings focused on identifying opportunities and challenges for MPTs that combine hormonal contraception (HC) with antiretroviral drugs into single products. The framework aims to present an actionable strategy, by addressing key research gaps and outlining the key areas for progress, to guide current and future HC MPT development. RESULTS We identified eight primary action areas for the development of impactful HC MPTs, and includes aspects from epidemiology, pharmacology, clinical trial design, regulatory requirements, manufacturing and commercialisation, behavioural science, and investment needs for research and development. CONCLUSION Overall, the challenges involved with reconciling the critical social-behavioural context that will drive MPT product use and uptake with the complexities of research and development and regulatory approval are of paramount importance. To realise the potential of MPTs given their complexity and finite resources, researchers in the MPT field must be strategic about the way forward; increased support among policy-makers, advocates, funders and the pharmaceutical industry is critical.
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Affiliation(s)
- Bethany Young Holt
- a The Initiative for Multipurpose Prevention Technologies, Public Health Institute , Sacramento , CA , USA
| | - Laura Dellplain
- a The Initiative for Multipurpose Prevention Technologies, Public Health Institute , Sacramento , CA , USA
| | - Mitchell D Creinin
- b Department of Obstetrics and Gynecology , University of California, Davis , Sacramento , CA , USA
| | - Kevin J Peine
- c USAID Global Health Fellows Program, Office of Population and Reproductive Health , US Agency for International Development , Washington , DC , USA
| | - Joseph Romano
- a The Initiative for Multipurpose Prevention Technologies, Public Health Institute , Sacramento , CA , USA.,d NWJ Group , Wayne , PA , USA
| | - Anke Hemmerling
- a The Initiative for Multipurpose Prevention Technologies, Public Health Institute , Sacramento , CA , USA.,e Department of Obstetrics, Gynecology and Reproductive Sciences , University of California, San Francisco , San Francisco , CA , USA
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8
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Hapgood JP, Kaushic C, Hel Z. Hormonal Contraception and HIV-1 Acquisition: Biological Mechanisms. Endocr Rev 2018; 39:36-78. [PMID: 29309550 PMCID: PMC5807094 DOI: 10.1210/er.2017-00103] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 11/27/2017] [Indexed: 12/12/2022]
Abstract
Access to effective affordable contraception is critical for individual and public health. A wide range of hormonal contraceptives (HCs), which differ in composition, concentration of the progestin component, frequency of dosage, and method of administration, is currently available globally. However, the options are rather limited in settings with restricted economic resources that frequently overlap with areas of high HIV-1 prevalence. The predominant contraceptive used in sub-Saharan Africa is the progestin-only three-monthly injectable depot medroxyprogesterone acetate. Determination of whether HCs affect HIV-1 acquisition has been hampered by behavioral differences potentially confounding clinical observational data. Meta-analysis of these studies shows a significant association between depot medroxyprogesterone acetate use and increased risk of HIV-1 acquisition, raising important concerns. No association was found for combined oral contraceptives containing levonorgestrel, nor for the two-monthly injectable contraceptive norethisterone enanthate, although data for norethisterone enanthate are limited. Susceptibility to HIV-1 and other sexually transmitted infections may, however, be dependent on the type of progestin present in the formulation. Several underlying biological mechanisms that may mediate the effect of HCs on HIV-1 and other sexually transmitted infection acquisition have been identified in clinical, animal, and ex vivo studies. A substantial gap exists in the translation of basic research into clinical practice and public health policy. To bridge this gap, we review the current knowledge of underlying mechanisms and biological effects of commonly used progestins. The review sheds light on issues critical for an informed choice of progestins for the identification of safe, effective, acceptable, and affordable contraceptive methods.
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Affiliation(s)
- Janet P Hapgood
- Department of Molecular and Cell Biology, University of Cape Town, Cape Town, South Africa.,Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Charu Kaushic
- Department of Pathology and Molecular Medicine, McMaster University, Ontario, Canada.,McMaster Immunology Research Centre, McMaster University, Hamilton, Ontario, Canada
| | - Zdenek Hel
- Department of Pathology, University of Alabama at Birmingham, Birmingham, Alabama.,Center for AIDS Research, University of Alabama at Birmingham, Birmingham, Alabama
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9
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Smith JM, Moss JA, Srinivasan P, Butkyavichene I, Gunawardana M, Fanter R, Miller CS, Sanchez D, Yang F, Ellis S, Zhang J, Marzinke MA, Hendrix CW, Kapoor A, Baum MM. Novel multipurpose pod-intravaginal ring for the prevention of HIV, HSV, and unintended pregnancy: Pharmacokinetic evaluation in a macaque model. PLoS One 2017; 12:e0185946. [PMID: 28982161 PMCID: PMC5628903 DOI: 10.1371/journal.pone.0185946] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 09/21/2017] [Indexed: 12/19/2022] Open
Abstract
Globally, women bear an uneven burden for sexual HIV acquisition. Results from two clinical trials evaluating intravaginal rings (IVRs) delivering the antiretroviral agent dapivirine have shown that protection from HIV infection can be achieved with this modality, but high adherence is essential. Multipurpose prevention technologies (MPTs) can potentially increase product adherence by offering protection against multiple vaginally transmitted infections and unintended pregnancy. Here we describe a coitally independent, long-acting pod-IVR MPT that could potentially prevent HIV and HSV infection as well as unintended pregnancy. The pharmacokinetics of MPT pod-IVRs delivering tenofovir alafenamide hemifumarate (TAF2) to prevent HIV, acyclovir (ACV) to prevent HSV, and etonogestrel (ENG) in combination with ethinyl estradiol (EE), FDA-approved hormonal contraceptives, were evaluated in pigtailed macaques (N = 6) over 35 days. Pod IVRs were exchanged at 14 days with the only modification being lower ENG release rates in the second IVR. Plasma progesterone was monitored weekly to determine the effect of ENG/EE on menstrual cycle. The mean in vivo release rates (mg d-1) for the two formulations over 30 days ranged as follows: TAF2 0.35-0.40; ACV 0.56-0.70; EE 0.03-0.08; ENG (high releasing) 0.63; and ENG (low releasing) 0.05. Mean peak progesterone levels were 4.4 ± 1.8 ng mL-1 prior to IVR insertion and 0.075 ± 0.064 ng mL-1 for 5 weeks after insertion, suggesting that systemic EE/ENG levels were sufficient to suppress menstruation. The TAF2 and ACV release rates and resulting vaginal tissue drug concentrations (medians: TFV, 2.4 ng mg-1; ACV, 0.2 ng mg-1) may be sufficient to protect against HIV and HSV infection, respectively. This proof of principle study demonstrates that MPT-pod IVRs could serve as a potent biomedical prevention tool to protect women's sexual and reproductive health and may increase adherence to HIV PrEP even among younger high-risk populations.
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Affiliation(s)
- James M. Smith
- Laboratory Branch, Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - John A. Moss
- Department of Chemistry, Oak Crest Institute of Science, Monrovia, California, United States of America
| | - Priya Srinivasan
- Laboratory Branch, Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Irina Butkyavichene
- Department of Chemistry, Oak Crest Institute of Science, Monrovia, California, United States of America
| | - Manjula Gunawardana
- Department of Chemistry, Oak Crest Institute of Science, Monrovia, California, United States of America
| | - Rob Fanter
- Department of Chemistry, Oak Crest Institute of Science, Monrovia, California, United States of America
| | - Christine S. Miller
- Department of Chemistry, Oak Crest Institute of Science, Monrovia, California, United States of America
| | - Debbie Sanchez
- Department of Chemistry, Oak Crest Institute of Science, Monrovia, California, United States of America
| | - Flora Yang
- Department of Chemistry, Oak Crest Institute of Science, Monrovia, California, United States of America
| | - Shanon Ellis
- Libra Management Group, Decatur, Georgia, United States of America
| | - Jining Zhang
- Libra Management Group, Decatur, Georgia, United States of America
| | - Mark A. Marzinke
- Department of Medicine, Johns Hopkins University, Osler, Baltimore, Maryland, United States of America
- Department of Pathology, Johns Hopkins University, Sheikh Zayed Tower, Baltimore, Maryland, United States of America
| | - Craig W. Hendrix
- Department of Medicine, Johns Hopkins University, Osler, Baltimore, Maryland, United States of America
| | - Amita Kapoor
- Wisconsin National Primate Research Center, University of Wisconsin-Madison, Capitol Court, Madison, Wisconsin, United States of America
| | - Marc M. Baum
- Department of Chemistry, Oak Crest Institute of Science, Monrovia, California, United States of America
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10
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Brief Report: Dapivirine Vaginal Ring Use Does Not Diminish the Effectiveness of Hormonal Contraception. J Acquir Immune Defic Syndr 2017; 76:e47-e51. [PMID: 28542081 DOI: 10.1097/qai.0000000000001455] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To evaluate the potential for a clinically relevant drug-drug interaction with concomitant use of a dapivirine vaginal ring, a novel antiretroviral-based HIV-1 prevention strategy, and hormonal contraception by examining contraceptive efficacies with and without dapivirine ring use. DESIGN A secondary analysis of women participating in MTN-020/ASPIRE, a randomized, double-blind, placebo-controlled trial of the dapivirine vaginal ring for HIV-1 prevention. METHODS Use of a highly effective method of contraception was an eligibility criterion for study participation. Urine pregnancy tests were performed monthly. Pregnancy incidence by arm was calculated separately for each hormonal contraceptive method and compared using an Andersen-Gill proportional hazards model stratified by site and censored at HIV-1 infection. RESULTS Of 2629 women enrolled, 2310 women returned for follow-up and reported using a hormonal contraceptive method at any point during study participation (1139 in the dapivirine arm and 1171 in the placebo arm). Pregnancy incidence in the dapivirine arm versus placebo among women using injectable depot medroxyprogesterone acetate was 0.43% vs. 0.54%, among women using injectable norethisterone enanthate was 1.15% vs. 0%, among women using hormonal implants was 0.22% vs. 0.69%, and among women using oral contraceptive pills was 32.26% vs. 28.01%. Pregnancy incidence did not differ by study arm for any of the hormonal contraceptive methods. CONCLUSIONS Use of the dapivirine ring does not reduce the effectiveness of hormonal contraceptives for pregnancy prevention. Oral contraceptive pill use was associated with high pregnancy incidence, potentially because of poor pill adherence. Injectable and implantable methods were highly effective in preventing pregnancy.
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Hall OJ, Klein SL. Progesterone-based compounds affect immune responses and susceptibility to infections at diverse mucosal sites. Mucosal Immunol 2017; 10:1097-1107. [PMID: 28401937 DOI: 10.1038/mi.2017.35] [Citation(s) in RCA: 102] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Accepted: 03/04/2017] [Indexed: 02/04/2023]
Abstract
Over 100 million women worldwide are currently on progesterone-based contraceptives to improve their health outcomes through reduced maternal mortality and family planning. In addition to their role in reproduction, progesterone-based compounds modulate immune responses throughout the body, particularly at mucosal sites. By binding to receptors located in immune cells, including natural killer cells, macrophages, dendritic cells, and T cells, as well in non-immune cells, such as epithelial and endothelial cells, progesterone-based compounds alter cellular signaling and activity to affect the outcome of infections at diverse mucosal sites, including the genital, gastrointestinal, and respiratory tracts. As the use of progesterone-based compounds, in the form of contraceptives and hormone-based therapies, continue to increase worldwide, greater consideration should be given to how the immunomodulatory effects these compounds alter the outcome of diseases at mucosal sites beyond the reproductive tract, which has profound implications for women's health.
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Affiliation(s)
- Olivia J Hall
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland USA
| | - Sabra L Klein
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland USA
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Bassis CM, Allsworth JE, Wahl HN, Sack DE, Young VB, Bell JD. Effects of intrauterine contraception on the vaginal microbiota. Contraception 2017. [PMID: 28624570 DOI: 10.1016/j.contraception.2017.05.017] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVES There have been conflicting reports of altered vaginal microbiota and infection susceptibility associated with contraception use. The objectives of this study were to determine if intrauterine contraception altered the vaginal microbiota and to compare the effects of a copper intrauterine device (Cu-IUD) and a levonorgestrel intrauterine system (LNG-IUS) on the vaginal microbiota. STUDY DESIGN DNA was isolated from the vaginal swab samples of 76 women using Cu-IUD (n=36) or LNG-IUS (n=40) collected prior to insertion of intrauterine contraception (baseline) and at 6 months. A third swab from approximately 12 months following insertion was available for 69 (Cu-IUD, n=33; LNG-IUS, n=36) of these women. The V4 region of the bacterial 16S rRNA-encoding gene was amplified from the vaginal swab DNA and sequenced. The 16S rRNA gene sequences were processed and analyzed using the software package mothur to compare the structure and dynamics of the vaginal bacterial communities. RESULTS The vaginal microbiota from individuals in this study clustered into 3 major vaginal bacterial community types: one dominated by Lactobacillus iners, one dominated by Lactobacillus crispatus and one community type that was not dominated by a single Lactobacillus species. Changes in the vaginal bacterial community composition were not associated with the use of Cu-IUD or LNG-IUS. Additionally, we did not observe a clear difference in vaginal microbiota stability with Cu-IUD versus LNG-IUS use. CONCLUSIONS Although the vaginal microbiota can be highly dynamic, alterations in the community associated with the use of intrauterine contraception (Cu-IUD or LNG-IUS) were not detected over 12 months. IMPLICATIONS We found no evidence that intrauterine contraception (Cu-IUD or LNG-IUS) altered the vaginal microbiota composition. Therefore, the use of intrauterine contraception is unlikely to shift the composition of the vaginal microbiota such that infection susceptibility is altered.
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Affiliation(s)
- Christine M Bassis
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109.
| | - Jenifer E Allsworth
- Department of Biomedical & Health, University of Missouri - Kansas City School of Medicine, Kansas City, MO 64108; Department of Obstetrics & Gynecology, University of Missouri - Kansas City School of Medicine, Kansas City, MO 64108.
| | - Heather N Wahl
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI 48109.
| | - Daniel E Sack
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109.
| | - Vincent B Young
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109; Department of Microbiology and Immunology, University of Michigan, Ann Arbor, MI 48109.
| | - Jason D Bell
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI 48109.
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Cooper D, Harries J, Moodley J, Constant D, Hodes R, Mathews C, Morroni C, Hoffman M. Coming of age? Women's sexual and reproductive health after twenty-one years of democracy in South Africa. REPRODUCTIVE HEALTH MATTERS 2016; 24:79-89. [PMID: 28024682 DOI: 10.1016/j.rhm.2016.11.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2016] [Revised: 11/09/2016] [Accepted: 11/11/2016] [Indexed: 01/20/2023] Open
Abstract
This paper is a sequel to a 2004 article that reviewed South Africa's introduction of new sexual and reproductive health (SRH) and rights laws, policies and programmes, a decade into democracy. Similarly to the previous article, this paper focuses on key areas of women's SRH: contraception and fertility, abortion, maternal health, HIV, cervical and breast cancer and sexual violence. In the last decade, South Africa has retained and expanded its sexual and reproductive health and rights (SRHR) policies in the areas of abortion, contraception, youth and HIV treatment (with the largest antiretroviral treatment programme in the world). These are positive examples within the SRHR policy arena. These improvements include fewer unsafe abortions, AIDS deaths and vertical HIV transmission, as well as the public provision of a human papillomavirus vaccine to prevent cervical cancer. However, persistent socio-economic inequities and gender inequality continue to profoundly affect South African women's SRHR. The state shows mixed success over the past two decades in advancing measurable SRH social justice outcomes, and in confronting and ameliorating social norms that undermine SRHR.
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Affiliation(s)
- Diane Cooper
- Professor, School of Public Health, University of the Western Cape, South Africa.
| | - Jane Harries
- Associate Professor and Director, Women's Health Research Unit, School of Public Health and Family Medicine, University of Cape Town, South Africa
| | - Jennifer Moodley
- Director Cancer Research Initiative, Faculty of Health Sciences, University of Cape Town; Associate Professor Women's Health Research Unit, School of Public Health and Family Medicine, University of Cape Town; Deputy Director SAMRC/UCT Gynaecology Cancer Research Centre
| | - Deborah Constant
- Senior Researcher, Women's Health Research Unit, School of Public Health and Family Medicine, University of Cape Town, South Africa
| | - Rebecca Hodes
- Director, AIDS and Society Research Unit, University of Cape Town, South Africa
| | - Cathy Mathews
- Scientist, Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa; Associate Professor, Women's Health Research Unit, School of Public Health and Family Medicine, University of Cape Town, South Africa
| | - Chelsea Morroni
- Senior Clinical Lecturer, EGA Institute for Women's Health/Institute for Global Health, University College London, London UK; Botswana-Upenn Partnership, Gaborone, Botswana; Women's Health Research Unit, School of Public Health and Family Medicine, University of Cape Town, South Africa
| | - Margaret Hoffman
- Emeritus Professor, Women's Health Research Unit, School of Public Health and Family Medicine, University of Cape Town, South Africa
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