Addressing gaps in the contraceptive method mix: methods in development

Continuation and user satisfaction of the levonorgestrel intrauterine system (LNG IUS) contraceptive in Nigeria

Background: The hormonal intrauterine device or intrauterine system (IUS) also known as the levonorgestrel intrauterine system (LNG-IUS) is a highly effective hormonal intra-uterine contraceptive. However, services offering the method are not widely available in Nigeria and little evidence exists on the dynamics of its use. We examined the continuation rate and satisfaction with the IUS among the user population. Methods: This prospective longitudinal phone survey involved a baseline survey of users at two-weeks post-insertion of the LNG IUS, recruited from 40 clinics across 17 states in Nigeria, with a follow-up survey at the 3rd and 12th months. A total of 208 users were interviewed at baseline, 98 at three months, and 73 at 12 months. User family planning and the IUS use experiences were elicited, as well as the continuation rate and satisfaction with the method at three and 12 months. Results: At three- and 12 months post-insertion, 96.9% (95% CI: 91.3, 99.3) and 91.8% (95% CI: 82.9, 96.9), respectively, reported still using the LNG IUS, with none out of the few users who discontinued the method reporting a method failure. Discontinuation was mainly a result of the experience of menstrual bleeding or amenorrhea (25.0%), experiences of pain with the method (18.8%), and partner complaining about strings (16.7%). High satisfaction with the LNG IUS (76.5% at three months and 86.3% at 12 months post-insertion) was reported. Satisfaction with LNG IUS was significantly associated with not having breast tenderness/pain (88.2%) and no vaginal bacterial infection (87.5%) at 12 months compared to experiencing breast tender/pain (50.0%) and vaginal infection (0.0%) (p<0.05). Conclusion: High user continuation and satisfaction with IUS indicates the positive potential of the method as a contraceptive in Nigeria.

Contraceptive technology research & development: a call for inclusion of trans and gender diverse individuals assigned female at birth

OBJECTIVE

Increased research efforts over the past decade provide a more in-depth understanding of the diverse fertility desires and family planning needs of trans and gender diverse individuals assigned female at birth (TGD AFAB). Despite this increased understanding and unmet need, global health researchers and contraceptive product developers have yet to include TGD AFAB individuals and considerations of their needs in the product development process, marginalising this historically underrepresented population. The aim of this perspective is to present the case for inclusion of TGD AFAB individuals in contraceptive research.

MAIN OUTCOMES

This perspective summarises the most recent literature characterising contraceptive access and use within TGD AFAB populations as well as the barriers to use. Furthermore, this perspective offers insight into how novel contraceptive technologies in the research and development pipeline could potentially appeal to TGD AFAB populations and recommends steps product developers can make towards being more inclusive.

CONCLUSIONS

With current research efforts in contraceptive product development aimed at expanding the method mix to appeal to a more diverse population of potential users, it behoves product developers to be more inclusive of TGD AFAB individuals in the development process and consider them as stakeholders of an expanded contraceptive method mix.

Optimizing the design of a contraceptive microarray patch: a discrete choice experiment on women's preferences in India and Nigeria

Background

Efforts are underway to develop an easy-to-use contraceptive microarray patch (MAP) that could expand the range of self-administrable methods. This paper presents results from a discrete choice experiment (DCE) designed to support optimal product design.

Methods

We conducted a DCE survey of users and non-users of contraception in New Delhi, India (496 women) and Ibadan, Nigeria (two versions with 530 and 416 women, respectively) to assess stated preferences for up to six potential product attributes: effect on menstruation, duration of effectiveness, application pain, location, rash after application, and patch size. We estimated Hierarchical Bayes coefficients (utilities) for each attribute level and ran simulations comparing women’s preferences for hypothetical MAPs with varying attribute combinations.

Results

The most important attributes of the MAP were potential for menstrual side effects (55% of preferences in India and 42% in Nigeria) and duration (13% of preferences in India and 24% in Nigeria). Women preferred a regular period over an irregular or no period, and a six-month duration to three or one month. Simulations show that the most ideal design would be a small patch, providing 6 months of protection, that would involve no pain on administration, result in a one-day rash, and be applied to the foot.

Conclusions

To the extent possible, MAP developers should consider method designs and formulations that limit menstrual side effects and provide more than one month of protection.

Improving Communication Messages by Using Perceptual Mapping: Family Planning Survey in East Java and West Nusa Tenggara, Indonesia

Objectives:

Contraceptive methods vary in effectiveness, actions required of users, and side effects. This article aims to analyze the perceptions about contraceptive methods among family planning clients of the East Java and West Nusa Tenggara (NTB) provinces in Indonesia.

Methods:

The data were obtained from the operational research of the Improving Contraceptive Method Mix Project in Indonesia, conducted in 2015–2016 in six districts in East Java and West Nusa Tenggara. The total sample size was 12,190 women aged 15–49 years. The perceptual mapping method uses cross-sectional surveys that require the respondent to rate the level to which they associate specific elements with each other, based on similarities and differences of perceived association. The correlation matrices for six contraceptive methods and five attributes were subjected to a multidimensional scaling analysis.

Results:

The results showed injectable to be the most preferred method, which was positioned closest to the attributes ‘easy to use’ and ‘easy to get’, followed by pills. Implants ranked higher than other long-acting and permanent method.

Conclusion:

Injectables and pills were the most preferred because people believe that they were ‘easy to use’ and ‘easy to get’. The least preferred methods were tubectomy and vasectomy because the respondents thought those were not close to any attributes at all. To increase the demand for the long-acting and permanent method choice in the provinces of East Java and West Nusa Tenggara, the attributes ‘easy to use’ and ‘easy to get’ should be emphasized in the long-acting and permanent method Information Education and Communication messages.

Current and future contraceptive options for women living with HIV

INTRODUCTION

Among women living with HIV, half of the pregnancies are unintended. Effective contraception can prevent unintended pregnancies and consequently reduce maternal mortality and perinatal transmission of HIV. While contraceptive options available for all women also apply to women living with HIV, specific considerations exist to the use of contraception by women living with HIV.

AREAS COVERED

First, general principles guiding the use of contraception among women living with HIV are discussed, such as choice, method mix, relative effectiveness, and drug-drug interactions. Second, a detailed discussion of each contraceptive method and issues surrounding the use of that method, such as drug-drug interactions, follows. Third, future contraceptive options in advanced development for use by women or men are briefly discussed.

EXPERT OPINION

Contraceptive methods available to all women should also be accessible to women living with HIV. When the relative effectiveness of a contraceptive method is reduced, for example due to drug-drug interactions with antiretrovirals, the method should still be made available to women living with HIV with the appropriate information sharing and counseling. Greater research on various aspects of contraceptive use by women living with HIV and more comprehensive testing of co-administration of hormonal contraceptives and common medications used by these women are warranted.

Attitudes and perceptions towards novel objective measures of ARV-based vaginal ring use: Results from a global stakeholder survey

Results of recent microbicide and pre-exposure prophylaxis clinical trials have shown adherence to be a significant challenge with new HIV prevention technologies. As the vaginal ring containing dapivirine moves into two open label follow-on studies (HOPE/MTN-025 and DREAM) and other antiretroviral-based and multi-purpose prevention technology ring products advance through the development pipeline, there is a need for more accurate and reliable measures of adherence to microbicide ring products. We previously conducted a comprehensive landscape analysis to identify new technologies that could be applied to adherence measurement of vaginal rings containing antiretrovirals. To explore attitudes and perceptions towards the approaches that we identified, we conducted a survey of stakeholders with experience and expertise in microbicide and HIV prevention clinical trials. From May to July 2015 an electronic survey was distributed via email to 894 stakeholders; a total of 206 eligible individuals responded to at least one question and were included in the data analysis. Survey respondents were presented with various objective measures and asked about their perceived acceptability to trial participants, feasibility of implementation by study staff, usefulness for measuring adherence and ethical concerns. Methods that require no additional input from the participant and require no modifications to the existing ring product (i.e., measurement of residual drug or excipient, or a vaginal analyte that enters the ring) were viewed as being more acceptable to trial participants and more feasible to implement in the field. Respondents saw value in using objective measures to provide real-time feedback on adherence. However, approaches that involve unannounced home visits for sample collection or spot checks of ring use, which could provide significant value to adherence feedback efforts, were met with skepticism. Additional research on the acceptability of these methods to potential trial participants and trial staff is recommended.

Biomarkers and biometric measures of adherence to use of ARV-based vaginal rings

Introduction

Poor adherence to product use has been observed in recent trials of antiretroviral (ARV)-based oral and vaginal gel HIV prevention products, resulting in an inability to determine product efficacy. The delivery of microbicides through vaginal rings is widely perceived as a way to achieve better adherence but vaginal rings do not eliminate the adherence challenges exhibited in clinical trials. Improved objective measures of adherence are needed as new ARV-based vaginal ring products enter the clinical trial stage.

Methods

To identify technologies that have potential future application for vaginal ring adherence measurement, a comprehensive literature search was conducted that covered a number of biomedical and public health databases, including PubMed, Embase, POPLINE and the Web of Science. Published patents and patent applications were also searched. Technical experts were also consulted to gather more information and help evaluate identified technologies. Approaches were evaluated as to feasibility of development and clinical trial implementation, cost and technical strength.

Results

Numerous approaches were identified through our landscape analysis and classified as either point measures or cumulative measures of vaginal ring adherence. Point measurements are those that give a measure of adherence at a particular point in time. Cumulative measures attempt to measure ring adherence over a period of time.

Discussion

Approaches that require modifications to an existing ring product are at a significant disadvantage, as this will likely introduce additional regulatory barriers to the development process and increase manufacturing costs. From the point of view of clinical trial implementation, desirable attributes would be high acceptance by trial participants, and little or no additional time or training requirements on the part of participants or clinic staff. We have identified four promising approaches as being high priority for further development based on the following measurements: intracellular drug levels, drug levels in hair, the accumulation of a vaginal analyte that diffuses into the ring, and the depletion of an intrinsic ring constituent.

Conclusions

While some approaches show significant promise over others, it is recommended that a strategy of using complementary biometric and behavioural approaches be adopted to best understand participants’ adherence to ARV-based ring products in clinical trials.