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Heck CJ, Dam A, Yohannes K, Deacon J, Kripke K, Meyers K, Poku O, Obermeyer C, Wiant S, Quigee D, Larson M, Malati C, Sobieszczyk ME, Torres-Rueda S, Castor D. Lessons learnt from daily oral PrEP delivery to inform national planning for PrEP ring introduction for women in low-income and middle-income countries: a qualitative inquiry of international stakeholders. BMJ Glob Health 2024; 9:e014709. [PMID: 38770814 DOI: 10.1136/bmjgh-2023-014709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 04/16/2024] [Indexed: 05/22/2024] Open
Abstract
INTRODUCTION Some African countries plan to introduce and scale-up new long-acting pre-exposure prophylaxis methods (LA-PrEP), like the monthly dapivirine vaginal ring (PrEP ring) and injectable cabotegravir. National costed implementation plans, roadmaps for successful product implementation, are often overlooked. International stakeholders engaged in oral PrEP planning, introduction and scale-up are an information resource of lessons learned to advise LA-PrEP planning. We consulted such international stakeholders and synthesised oral PrEP lessons to inform the development of a costed rollout plan template for LA-PrEP. METHODS From selected global health organisations (five international nongovernmental, four donor, four university/research and two multilateral), we interviewed 27 representatives based in America, Europe, Asia and Africa about strategic content and approaches for LA-PrEP policy, programming and implementation. We conducted a thematic analysis of the interview data for implementation considerations. RESULTS From the consultations, we identified six implementation themes for LA-PrEP introduction and scale-up: (1) ethically increasing choice and avoiding coercion; (2) de-stigmatising PrEP by focusing on preference rather than risk-based eligibility; (3) integrating LA-PrEP into services that are more woman-oriented, couple-oriented and family-oriented, and providing private spaces for LA-PrEP delivery; (4) de-medicalising delivery of relatively safe products (eg, PrEP ring); (5) constructing multilevel, nuanced communication strategies to address measured and perceived product efficacy and effectiveness; and (6) devising product-agnostic, modular approaches to service delivery. Despite the widespread emphasis on integration, few stakeholders offered empirical examples of successful integration approaches and frameworks. CONCLUSIONS Lessons learnt from stakeholder participants suggest standardised and modular processes can improve efficiencies in LA-PrEP planning and implementation. Tiered communication strategies addressing product efficacy and effectiveness will improve clients' and providers' efficacy in making informed decisions. Integration is important for LA-PrEP delivery, but data on empirical integration approaches and frameworks is minimal: further research in this discipline is needed.
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Affiliation(s)
- Craig J Heck
- Columbia University Mailman School of Public Health, New York, New York, USA
- Columbia University Irving Medical Center, New York, New York, USA
| | - Anita Dam
- United States Agency for International Development, Washington, District of Columbia, USA
| | - Kibret Yohannes
- University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | | | | | - Kathrine Meyers
- Columbia University Irving Medical Center, New York, New York, USA
| | - Ohemaa Poku
- New York State Psychiatric Institute, New York, New York, USA
| | | | - Sarah Wiant
- Columbia University Irving Medical Center, New York, New York, USA
| | - Daniela Quigee
- Columbia University Irving Medical Center, New York, New York, USA
| | | | - Christine Malati
- United States Agency for International Development, Washington, District of Columbia, USA
| | | | | | - Delivette Castor
- Columbia University Mailman School of Public Health, New York, New York, USA
- Columbia University Irving Medical Center, New York, New York, USA
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Davis S, Parthun K, Friend DR. A nine-month repeat-dose intravaginal ring (Ovaprene) irritation study in sheep. Contraception 2024; 133:110387. [PMID: 38342425 DOI: 10.1016/j.contraception.2024.110387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 02/05/2024] [Accepted: 02/06/2024] [Indexed: 02/13/2024]
Abstract
OBJECTIVES Ovaprene is a novel, investigational, intravaginal hormone-free monthly ring contraceptive designed for use in women of reproductive age to be worn over multiple weeks (one menstrual cycle). The objective of this work was to evaluate the safety of Ovaprene during a nine-month repeat-dose sheep study. STUDY DESIGN In addition to traditional safety endpoints such as histopathological evaluation of the sheep female reproductive tract, vaginal fluids were collected and tested for released iron over time. Also, the amount of iron in the rings was assessed following removal, and serum iron levels were measured. There were four sheep in each group (Ovaprene group and sham group). RESULTS There were no macroscopic clinical findings. There was minimal to mild, mixed or mononuclear cell infiltration present in all levels of vagina (cranial, mid, and caudal) from all animals including sham controls based on post-study necropsy. The female reproductive tract from animals treated with the Ovaprene ring was comparable to the sham controls. The concentrations of serum iron in sheep treated with Ovaprene ring were similar compared to a sham treated animal. The average amount of ferrous gluconate released from Ovaprene over the 29-day period of use was 175 mg of the approximately 512 mg nominally loaded into the rings. CONCLUSIONS Overall, the Ovaprene devices were well-tolerated in female sheep. IMPLICATIONS This study should support a chronic (e.g., one year) contraceptive efficacy study in women.
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Affiliation(s)
- Sarah Davis
- Surgery and Efficacy, Charles River Laboratories, Mattawan, MI, USA
| | - Kelsey Parthun
- Surgery and Efficacy, Charles River Laboratories, Mattawan, MI, USA
| | - David R Friend
- Research and Development, Daré Bioscience, Inc., San Diego, CA, USA.
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Manchana T. Long-term continuations rate of ring pessary use for symptomatic pelvic organ prolapse. Arch Gynecol Obstet 2024; 309:2203-2209. [PMID: 38189963 DOI: 10.1007/s00404-023-07299-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 11/07/2023] [Indexed: 01/09/2024]
Abstract
PURPOSE To evaluate long-term continuation rates, adverse events of ring pessary use at a minimum of 5 years follow-up, and factors associated with discontinuation in symptomatic pelvic organ prolapse (POP). METHODS Women with symptomatic POP who were treated with vaginal ring pessary and had successful fittings were included. Adverse events and reasons for discontinuation of pessary use were recorded. Patients who were lost to follow-up were defined as discontinuation. RESULTS During 12 year-period, 239 of 329 POP patients (72.6%) had successful fittings with ring pessary. The mean age was 67.8 ± 8.9 years (range 27-86) and 70% of patients had advanced stage. The cumulative probability of continued ring pessary use was 84.1%, 64.4%, 49.3%, and 33.5%, at 1, 3, 5, and 10 years, respectively. Most common reason for discontinuation was frequent expulsion (21.6%), followed by vaginal erosion (16.5%), no prolapse improvement (12.4%), and inability or inconvenience to do self-care (9.3%). However, 9 patients (9.3%) had improvement of prolapse and were able to discontinue pessary insertion. Age above 70 years, wide introitus, and incapability of self-care are independent factors associated with long-term discontinuation. Adverse events occurred in 23.4% of patients, 18.8% of them had vaginal erosion, 11.7% vaginal discharge/infection, and 18.4% de novo SUI. However, no statistical significance existed between those who continued and discontinued pessary use due to these adverse events. CONCLUSION Ring pessary is an effective treatment in symptomatic POP, with acceptable long-term continuation rates and minor adverse events. Self-care of pessary is very important aiming to minimize adverse events. Advanced age, wide introitus and incapability of self-care were associated factors for long-term discontinuation.
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Affiliation(s)
- Tarinee Manchana
- Department of Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, 10330, Thailand.
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Stalter RM, Dong TQ, Hendrix CW, Palanee-Phillips T, van der Straten A, Hillier SL, Kiweewa FM, Mgodi NM, Marzinke MA, Bekker LG, Soto-Torres L, Baeten JM, Brown ER. Assessing Per-Sex-Act HIV-1 Risk Reduction Among Women Using the Dapivirine Vaginal Ring. J Infect Dis 2024; 229:1158-1165. [PMID: 38099506 PMCID: PMC11011174 DOI: 10.1093/infdis/jiad550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 11/10/2023] [Accepted: 12/13/2023] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND Confounding introduced by individuals' sexual risk behavior is potentially a significant source of bias in HIV-1 prevention intervention studies. To more completely account for sexual behaviors when assessing the efficacy of the monthly dapivirine ring, a new longer-acting HIV-1 prevention option for women, we estimated per-sex-act risk reduction associated with product use. METHODS We conducted a secondary analysis of data from MTN-020/ASPIRE, a phase 3, randomized, placebo-controlled efficacy trial of the dapivirine ring that recruited HIV-uninfected, African women aged 18-45 years. With cumulative sex acts as the time scale, we used multivariable Cox regression with inverse probability of censoring weights to estimate HIV-1 risk reduction associated with a rate of dapivirine release indicative of consistent product use. RESULTS Women in the dapivirine ring group (n = 1187) had an estimated incidence rate of 2.3 (95% confidence interval [CI], 1.8-3.1) HIV-1 acquisition events per 10 000 sex acts versus 3.6 (95% CI, 2.9-4.4) per 10 000 acts in the placebo group (n = 1187). Dapivirine release indicative of consistent ring use was associated with a 63% (95% CI, 33%-80%) per-sex-act HIV-1 risk reduction. CONCLUSIONS These results support the efficacy of the dapivirine vaginal ring for HIV-1 prevention and help to inform decision-making for women, providers, and policymakers regarding product use. CLINICAL TRIALS REGISTRATION NCT01617096.
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Affiliation(s)
- Randy M Stalter
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Tracy Q Dong
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Craig W Hendrix
- Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Thesla Palanee-Phillips
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Wits Reproductive Health and HIV Research Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Ariane van der Straten
- Center for AIDS Prevention Studies, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
- ASTRA consulting, Kensington, CA, USA
| | - Sharon L Hillier
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Magee-Womens Research Institute, Pittsburgh, PA, USA
| | - Flavia M Kiweewa
- Research Department, Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda
| | - Nyaradzo M Mgodi
- Clinical Trials Research Centre, University of Zimbabwe, Harare, Zimbabwe
| | - Mark A Marzinke
- Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Linda-Gail Bekker
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Lydia Soto-Torres
- Division of AIDS, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Jared M Baeten
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Departments of Medicine and Global Health, University of Washington, Seattle, WA, USA
| | - Elizabeth R Brown
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
- Department of Biostatistics, University of Washington, Seattle, WA, USA
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Kusemererwa S, Ruzagira E, Onyango M, Kabarambi A, Abaasa A. Associations between intravaginal practices and incidence of sexually transmitted infections and bacterial vaginosis among women enrolled in the dapivirine vaginal ring trial (The Ring Study) in southwestern Uganda: a retrospective secondary analysis. BMJ Open 2024; 14:e079497. [PMID: 38589266 PMCID: PMC11015298 DOI: 10.1136/bmjopen-2023-079497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Accepted: 03/19/2024] [Indexed: 04/10/2024] Open
Abstract
OBJECTIVES We assessed associations between intravaginal practices (IVPs) and the incidence of sexually transmitted infections (STIs) and bacterial vaginosis (BV) among women using the dapivirine vaginal ring (DVR) or placebo vaginal ring in southwestern Uganda. METHODS This was a retrospective secondary analysis of data collected from women at risk of HIV infection recruited into the Ring Study. The latter evaluated the safety and efficacy of the DVR between 2013 and 2016. At baseline, a behavioural questionnaire was administered to obtain information on sexual activity and IVP (exposure) defined as; insertion inside the vagina of any items aimed at cleaning the vagina for any reason before, during or after sex other than practices to manage menses. Each participant self-inserted the DVR/placebo and replaced it every 4 weeks for 2 years. Outcomes were diagnosis of STIs, that is, Chlamydia trachomatis, Neisseria gonorrhoea, Trichomonas vaginalis (TV), HIV and BV. The incidence rate of STI/BV was estimated, overall, by IVP and trial arm in single-event-per-participant and multiple-event-per-participant analyses. RESULTS Of the 197 women enrolled, 66 (33.5%) were <25 years of age. Overall, 93 (47.2%) practised at least one form of IVP. During the follow-up, 172 (87.3%) women were diagnosed with an STI/BV at least once. The majority had TV (73.6%, n=145). Overall rate of STI/BV was 51.9/100 person-years, 95% CI 44.7 to 60.3 (IVP: yes, 51.0 (40.8-63.8) vs no, 52.6 (43.0-64.4)). IVPs were not statistically significantly associated with rate of individual STIs/BV. Similar results were observed when the analyses were conducted separately for each trial arm. CONCLUSIONS IVP was not associated with risk of STIs/BV in the Ring Study. TRIAL REGISTRATION NUMBER NCT01539226.
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Affiliation(s)
- Sylvia Kusemererwa
- Viral Pathogens Epidemiology and Interventions, MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Eugene Ruzagira
- Viral Pathogens Epidemiology and Interventions, MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
- Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Martin Onyango
- Viral Pathogens Epidemiology and Interventions, MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Anita Kabarambi
- International Centre for Child Health and Development, Masaka, Uganda
| | - Andrew Abaasa
- Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
- Statistics & Data Science, MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
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Mauck C, Thurman A, Jensen JT, Schreiber CA, Baker J, Hou MY, Chavoustie S, Dart C, Wu H, Zack N, Hatheway J, Friend D. Successful postcoital testing of Ovaprene: An investigational non-hormonal monthly vaginal contraceptive. Contraception 2024; 132:110373. [PMID: 38232942 DOI: 10.1016/j.contraception.2024.110373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 01/10/2024] [Accepted: 01/11/2024] [Indexed: 01/19/2024]
Abstract
OBJECTIVE Evaluate reduction in progressively motile sperm per high power field (HPF) in midcycle cervical mucus after intercourse with Ovaprene: an investigational monthly non-hormonal vaginal contraceptive consisting of a vaginal ring and mechanical barrier, releasing spermiostatic ferrous gluconate. STUDY DESIGN Open-label, multicenter study enrolling heterosexually-active women with previous permanent contraception. Participants underwent a baseline postcoital test cycle with no device to confirm the presence of sperm, followed by one diaphragm postcoital test cycle, one Ovaprene safety cycle, and two Ovaprene postcoital test cycles. In each postcoital test cycle, participants underwent a midcycle cervical mucus evaluation to confirm an Insler score ≥10 and absence of sperm, and then returned two to four hours after vaginal intercourse for repeat cervical mucus evaluation. We considered <5 progressively motile sperm/HPF indicative of preliminary contraceptive effectiveness. RESULTS We enrolled 38 participants; 23 completed the study. All participants had ≥5 progressively motile sperm/HPF in the baseline cycle and <5 progressively motile sperm/HPF in all 49 Ovaprene cycles and all 35 diaphragm cycles, meeting the definition of a successful postcoital test. This was true regardless of examiner blinding, prior vaginal delivery or vaginal ring use, body mass index, or dislodgements noted by the participant or investigator. The mean of 27.2 (±17.9) progressively motile sperm/HPF in baseline postcoital test cycles was reduced to 0.5 (±1.1) and 0.5 (±1.3) progressively motile sperm/HPF in the first and second Ovaprene cycles, respectively. Ovaprene fit all participants and all could insert, position, and remove it. CONCLUSION Use of Ovaprene resulted in meeting the prespecified criterion for contraceptive effect by all participants during all postcoital test cycles. IMPLICATIONS The finding that use of Ovaprene, an investigational monthly non-hormonal vaginal contraceptive, resulted in postcoital testing of cervical mucus that met the pre-specified definition of success (<5 progressively motile sperm/HPF) supports further evaluation of contraceptive efficacy of the device in users at risk for pregnancy.
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Affiliation(s)
| | - Andrea Thurman
- Daré Bioscience, Inc., San Diego, CA, United States; Formerly of Eastern Virginia Medical School, Norfolk, VA, United States
| | - Jeffrey T Jensen
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR, United States
| | - Courtney A Schreiber
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA, United States
| | - Jeff Baker
- Clinical Research Prime, Idaho Falls, ID, United States
| | - Melody Y Hou
- Department of Obstetrics and Gynecology, University of California Davis, Sacramento, CA, United States
| | - Steven Chavoustie
- Segal Institute for Clinical Research Inc., Miami, FL, United States
| | - Clint Dart
- Premier Research, Morrisville, NC, United States
| | - Hongsheng Wu
- Premier Research, Morrisville, NC, United States
| | - Nadene Zack
- Formerly of Daré Bioscience, Inc., San Diego, CA, United States
| | | | - David Friend
- Daré Bioscience, Inc., San Diego, CA, United States
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Naidoo K, Montgomery ET, Katz AWK, Garcia M, Naidoo S, Mansoor LE. Women's motivations for participating in the dapivirine vaginal ring open label extension study. AIDS Care 2024; 36:326-342. [PMID: 37734338 PMCID: PMC10922482 DOI: 10.1080/09540121.2023.2260145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 09/12/2023] [Indexed: 09/23/2023]
Abstract
Open-Label Extension (OLE) studies are important in the drug development process and are used to further support the licensing applications and regulatory approvals of products. We aimed to understand why women chose to join the HOPE OLE study - where women were offered the dapivirine vaginal ring after two pivotal trials were completed - through data collected from individual in-depth interviews. Ten women at each of the six HOPE research sites in Lilongwe, Malawi; Durban (2 sites) and Johannesburg, South Africa; Kampala, Uganda; and Chitungwiza, Zimbabwe, were enrolled (n = 60). Access to an effective user-initiated HIV prevention product was one of the main reasons women joined HOPE. Although many participants worried that their male partners might expose them to HIV, they chose to remain in their relationships and avoid conflict or confrontation with their partners by discreetly using the ring to protect themselves. Other reasons for joining were quality healthcare, reimbursement and altruism. Researchers should better understand social and personal motivators behind research participation in order to recognize community sociocultural norms and its influences on product acceptability and adherence challenges.
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Affiliation(s)
- Kalendri Naidoo
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
| | - Elizabeth T. Montgomery
- Women’s Global Health Imperative, RTI International, Berkeley, California, United States of America
| | - Ariana W. K. Katz
- Women’s Global Health Imperative, RTI International, Berkeley, California, United States of America
| | - Morgan Garcia
- Global Health Population and Nutrition, FHI 360, Durham, NC, United States of America
| | - Sarita Naidoo
- HIV and Other Infectious Diseases Research Unit, South African Medical Research Council, Durban, South Africa (Present affiliation: The Aurum Institute, Johannesburg, South Africa)
| | - Leila E. Mansoor
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
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Montgomery ET, Hawley I, Fairlie L, Bunge K, Mathebula F, Etima J, Mutero P, Senyama L, Mayo A, Stoner MCD, Piper J, Balan I, van der Straten A. Acceptability of the Dapivirine Vaginal Ring and Oral Truvada Among African Users in Late-Stage of Pregnancy. AIDS Behav 2024; 28:963-973. [PMID: 37932492 PMCID: PMC10896786 DOI: 10.1007/s10461-023-04203-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2023] [Indexed: 11/08/2023]
Abstract
The Microbicide Trials Network 042 study (MTN-042/DELIVER) is a two-arm, randomized, open-label Phase 3b trial that is evaluating the safety, adherence, and acceptability of the monthly ring and daily oral PrEP among HIV-uninfected pregnant people in four African countries. This analysis focuses on acceptability data captured qualitatively from a subset (n = 48) of the 150 people in the first cohort of the trial who were enrolled in late-stage pregnancy at 36 to 38 weeks gestational age and followed until after delivery. Single IDIs were conducted by trained interviewers at each clinic site using a semi-structured guide. Data excerpts of key codes pertaining to acceptability, pregnancy, and maternal health were summarized, reviewed and interpreted by multinational analyst teams. Although the product use period was relatively short, the data suggested several acceptability findings that may directly translate to longer durations of product use in pregnancy. The first was the overarching maternal sentiment that being able to protect both oneself and their baby was highly valued. The second was the importance of counseling support from providers not only because participants used methods that might generate side effects, but because pregnancy itself is a period with its own set of side effects. The third was that, similar to non-pregnant participants in other trials, here study products were generally liked and described as easy to use. Concerns about ring and oral PrEP use could be addressed with provider counseling and support and should form an essential component rollout among pregnant people.
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Affiliation(s)
- Elizabeth T Montgomery
- Women's Global Health Imperative, RTI International, 2150 Shattuck Avenue, Berkeley, CA, 94104, USA.
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA.
| | - Imogen Hawley
- Women's Global Health Imperative, RTI International, 2150 Shattuck Avenue, Berkeley, CA, 94104, USA
| | - Lee Fairlie
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Katie Bunge
- MMWRI, University of Pittsburgh, Pittsburgh, PA, USA
| | - Florence Mathebula
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Juliane Etima
- Makerere University - Johns Hopkins University (MU-JHU) Research Collaboration, Kampala, Uganda
| | - Prisca Mutero
- Clinical Trials Research Centre, University of Zimbabwe, Harare, Zimbabwe
| | - Linly Senyama
- Johns Hopkins Project, College of Medicine, University of Malawi, Blantyre, Malawi
| | | | - Marie C D Stoner
- Women's Global Health Imperative, RTI International, 2150 Shattuck Avenue, Berkeley, CA, 94104, USA
| | | | - Ivan Balan
- Department of Behavioral Science and Social Medicine, Florida State University College of Medicine, Tallahassee, FL, USA
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Parikh UM, Penrose KJ, Heaps AL, Sethi R, Goetz BJ, Szydlo D, Chandran U, Palanee-Phillips T, Mgodi NM, Baeten JM, Mellors JW. Brief Report: HIV Drug Resistance Assessment Among Women Who Seroconverted During the MTN-025/HOPE Open-Label Extension Dapivirine Vaginal Ring Trial. J Acquir Immune Defic Syndr 2024; 95:35-41. [PMID: 37732881 PMCID: PMC11042691 DOI: 10.1097/qai.0000000000003308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 08/21/2023] [Indexed: 09/22/2023]
Abstract
BACKGROUND Clinical trials of dapivirine (DPV) vaginal ring have shown it is safe, effective, and desired by women as an HIV prevention option. The risk of drug resistance is a potential concern for DPV ring users who acquire HIV. We conducted a comprehensive resistance evaluation of plasma samples from the women who seroconverted during the Microbicide Trials Network-025/HIV Open-label Prevention Extension (HOPE) study of DPV ring. METHODS Plasma collected on the visit at which seroconversion was detected was tested by next-generation sequencing with unique molecular identifiers for non-nucleoside reverse transcriptase inhibitor (NNRTI) drug resistance mutations (DRM) present at ≥1% frequency. Bulk-cloned plasma-derived recombinant HIV was phenotyped in a TZM-bl-based assay for susceptibility to DPV and other NNRTI. HIV-1 RNA was retrospectively quantified in plasma samples collected before HIV seroconversion. RESULTS Among 38 participants who seroconverted in HOPE, 7 (18%) had NNRTI DRM detected by next-generation sequencing with unique molecular identifiers including A98G, K103N, V106M, E138A, and V179D. Six of 7 samples with NNRTI DRM had <3-fold reduction in susceptibility to DPV. Only 1 sample with K103N and V179I polymorphism had 9-fold reduction in susceptibility to DPV, but this genotype occurred in an individual who did not use DPV ring, likely indicating transmitted resistance. Detection of NNRTI resistance was not higher in individuals who remained on DPV ring >3 months after acquiring HIV infection. CONCLUSIONS NNRTI resistance among women who seroconverted during HOPE was infrequent and selection of DPV-specific mutations was not detected. DPV ring is considered a safe and effective option for HIV prevention in women.
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Affiliation(s)
| | | | | | | | | | - Daniel Szydlo
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | | | - Thesla Palanee-Phillips
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
- University of Washington, WA, USA; current affiliation Gilead Sciences, Foster City, CA, USA
| | | | - Jared M. Baeten
- University of Washington, WA, USA; current affiliation Gilead Sciences, Foster City, CA, USA
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Browne EN, Torjesen K, Mirembe BG, Palanee-Phillips T, Jeenarain N, Chitukuta M, Stoner MCD, Mansoor LE, Reddy K, Tauya TT, Naidoo L, Siva S, Richardson B, Dadabhai S, Seyama L, Soto-Torres L, van der Straten A. Acceptability of the dapivirine vaginal ring for HIV-1 prevention among women reporting engagement in transactional sex. AIDS Care 2024; 36:80-86. [PMID: 37066990 PMCID: PMC10579446 DOI: 10.1080/09540121.2023.2198187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 03/27/2023] [Indexed: 04/18/2023]
Abstract
We assessed if acceptability of the dapivirine vaginal ring for HIV prevention differed among the subgroup of women who reported engaging in transactional sex prior to enrollment in MTN-020/ASPIRE (phase III trial in Malawi, South Africa, Uganda, and Zimbabwe, 2012-2015; n = 2629). Transactional sex was defined as receipt of money, goods, gifts, drugs, or shelter in exchange for sex in the past year. Dimensions of acceptability included: ease of use and physical sensation in situ, impacts on sex, partner's opinion, and likelihood of future use. We used Poisson regression models with robust standard errors to compare risk of acceptability challenges by baseline history of transactional sex. At product discontinuation, women exchanging sex found the ring comfortable (90%), easy to insert (92%) and nearly all (96%) were likely to use the ring in the future. Women who had exchanged sex were more likely to report feeling the ring during sex (ARR 1.43, 95% CI: 1.09, 1.89; p = 0.01) and slightly more likely to mind wearing the ring during menses (ARR 1.22, 95% CI: 1.01, 1,46; p = 0.04) and during sex (ARR 1.22, 95% CI: 1.02, 1.45; p = 0.03). Messaging and counseling should include enhanced support for use during sex and menses to support optimal use.
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Affiliation(s)
- Erica N. Browne
- Women’s Global Health Imperative, RTI International,
Berkeley, CA, USA
| | | | - Brenda Gati Mirembe
- Makerere University-Johns Hopkins University Research
Collaboration, Kampala, Uganda
| | - Thesla Palanee-Phillips
- Wits Reproductive Health and HIV Institute, Faculty of
Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Miria Chitukuta
- University of Zimbabwe Clinical Trials Research Centre,
Harare, Zimbabwe
| | | | - Leila E. Mansoor
- Centre for the AIDS Programme of Research in South Africa
(CAPRISA), University of KwaZulu-Natal, Durban, South Africa
| | - Krishnaveni Reddy
- Wits Reproductive Health and HIV Institute, Faculty of
Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Thelma T. Tauya
- University of Zimbabwe Clinical Trials Research Centre,
Harare, Zimbabwe
| | | | - Samantha Siva
- South African Medical Research Council, Durban, South
Africa
| | - Barbra Richardson
- Department of Biostatistics, University of Washington,
Seattle, WA, USA
| | - Sufia Dadabhai
- College of Medicine-John Hopkins University Research
Project, Blantyre, Malawi
| | - Linly Seyama
- College of Medicine-John Hopkins University Research
Project, Blantyre, Malawi
| | - Lydia Soto-Torres
- Division of AIDS, National Institute of Allergy and
Infectious Diseases, National Institutes of Mental Health, and Eunice Shriver
Kennedy, National Institute of Child Health and Human Development, National
Institutes of Health, Bethesda, MD, USA
| | - Ariane van der Straten
- University of California San Francisco, San Francisco, CA,
USA
- ASTRA Consulting, Kensington, PA, USA
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11
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Zhao X, Boyd P, Bashi YD, Murphy DJ, McCoy CF, Coulter S, Laverty G, Malcolm RK. Two into one does go: Formulation development of a multipurpose combination vaginal ring releasing dapivirine and metronidazole for prevention of HIV infection and treatment of bacterial vaginosis. Int J Pharm 2023; 648:123572. [PMID: 37926178 DOI: 10.1016/j.ijpharm.2023.123572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 10/20/2023] [Accepted: 10/31/2023] [Indexed: 11/07/2023]
Abstract
Bacterial vaginosis (BV) is a common but often asymptomatic dysbiosis of the human vagina characterized by an imbalance in the normal vaginal microbiota due to loss of lactobacilli and an overgrowth of certain anaerobic bacteria. While BV itself is not a sexually transmitted infection, it is associated with an increased risk in women of various sexually acquired infections, including human immunodeficiency virus (HIV) infection. There is, therefore, a strong rationale for pursuing new multipurpose products that seek to treat or prevent BV alongside preventing HIV infection. With the dapivirine-releasing vaginal ring for HIV prevention now approved in several African countries, here we report formulation development of a next-generation ring product that releases both dapivirine (DPV) and the antibiotic drug metronidazole (MET). Following thermal analysis studies to characterize the phase behaviour of DPV-MET mixtures and rheological analysis to assess the cure characteristics of the active silicone elastomer mixes, matrix-type rings were manufactured containing 25 or 200 mg DPV in combination with 100, 250, 500, 1000 or 2000 mg MET. The results for drug content, in vitro release, mechanical testing, and Gardnerella vaginalis time-kill experiments demonstrate the feasibility of incorporating both DPV and MET in a matrix-type ring formulation and indicate that clinically effective release rates may be possible.
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Affiliation(s)
- Xinyu Zhao
- School of Pharmacy, Medical Biology Centre, Queen's University Belfast, Belfast BT9 7BL, UK
| | - Peter Boyd
- School of Pharmacy, Medical Biology Centre, Queen's University Belfast, Belfast BT9 7BL, UK
| | - Yahya Dallal Bashi
- School of Pharmacy, Medical Biology Centre, Queen's University Belfast, Belfast BT9 7BL, UK
| | - Diarmaid J Murphy
- School of Pharmacy, Medical Biology Centre, Queen's University Belfast, Belfast BT9 7BL, UK
| | - Clare F McCoy
- School of Pharmacy, Medical Biology Centre, Queen's University Belfast, Belfast BT9 7BL, UK
| | - Sophie Coulter
- School of Pharmacy, Medical Biology Centre, Queen's University Belfast, Belfast BT9 7BL, UK
| | - Garry Laverty
- School of Pharmacy, Medical Biology Centre, Queen's University Belfast, Belfast BT9 7BL, UK
| | - R Karl Malcolm
- School of Pharmacy, Medical Biology Centre, Queen's University Belfast, Belfast BT9 7BL, UK.
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12
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Young AM, Mancuso N, Atujuna M, Tenza S, Chitukuta M, Kemigisha D, Ngure K, van der Straten A, Garcia M, Szydlo D, Soto-Torres L, Roberts ST. Adolescent Girls and Young Women's Experiences with Disclosing Oral PrEP or Dapivirine Vaginal Ring Use: a Multi-Country Qualitative Analysis. AIDS Behav 2023; 27:3941-3951. [PMID: 37392268 PMCID: PMC10598125 DOI: 10.1007/s10461-023-04109-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/02/2023] [Indexed: 07/03/2023]
Abstract
Effective use of oral pre-exposure prophylaxis (PrEP) has been low among adolescent girls and young women (AGYW) in Eastern and Southern Africa, partly due to stigma and opposition from key influencers. Understanding AGYW's experiences of disclosure of different PrEP modalities to key influencers may inform strategies to motivate uptake and adherence. We analyzed qualitative in-depth interviews and focus group discussions data from 119 participants in the MTN-034/REACH (Reversing the Epidemic in Africa with Choices in HIV Prevention) study of oral PrEP and the dapivirine vaginal ring (ring) to explore AGYW's disclosure experiences. We found that AGYW disclosure experiences varied across influencers and product type. The ring was disclosed less often to most influencers, except partners, because it was discreet. Oral PrEP was disclosed more often, because pills were more common and to avoid HIV stigma given that oral PrEP resembled HIV treatment. Ultimately, disclosure typically led most key influencers to support product use through reminders and encouragement. While disclosure yielded positive support from influencers, further community awareness of both PrEP products is essential to reduce potential opposition and perceived stigma.Clinical Trial Number: NCT03593655.
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Affiliation(s)
- Alinda M Young
- Women's Global Health Imperative, RTI International, 2150 Shattuck Avenue, Suite 800, Berkeley, CA, 94704, USA.
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Noah Mancuso
- Women's Global Health Imperative, RTI International, 2150 Shattuck Avenue, Suite 800, Berkeley, CA, 94704, USA
| | | | - Siyanda Tenza
- Wits Reproductive Health and HIV Institute (Wits RHI), University of the Witwatersrand, Johannesburg, South Africa
| | - Miria Chitukuta
- University of Zimbabwe Clinical Trials Research Centre (UZ-CTRC), Harare, Zimbabwe
| | - Doreen Kemigisha
- Makerere University - Johns Hopkins University Research Collaboration, Kampala, Uganda
| | - Kenneth Ngure
- School of Public Health, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | - Ariane van der Straten
- ASTRA Consulting, Kensington, CA and CAPS, Department of Medicine, University of California, San Francisco, San Francisco, USA
| | | | - Danny Szydlo
- Statistical Center for HIV/AIDS Research and Prevention, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Lydia Soto-Torres
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Maryland, MD, USA
| | - Sarah T Roberts
- Women's Global Health Imperative, RTI International, 2150 Shattuck Avenue, Suite 800, Berkeley, CA, 94704, USA
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13
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Qasba NT, Wallace KF, Yu V, Capoccia KL, Goff SL, Shcherbakova N. Online survey of consumer awareness and perceptions of a Massachusetts law for 12-month supply of contraception. Contraception 2023; 128:110138. [PMID: 37544574 DOI: 10.1016/j.contraception.2023.110138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 08/02/2023] [Accepted: 08/02/2023] [Indexed: 08/08/2023]
Abstract
OBJECTIVES This study aimed to characterize awareness of a 2017 Massachusetts (MA) law that ensures access to a 12-month supply of short-acting contraceptive methods (e.g., pill, patch, and vaginal ring) among short-acting contraceptive users in MA and to identify perceived benefits and concerns of a 12-month supply. STUDY DESIGN An online survey was administered to a Qualtrics panel of MA women who were using short-acting contraceptive methods and were insured by an eligible health plan. The survey's primary outcome was general awareness of the law; interest in, receipt of, and perceived benefits and risks of a 12-month supply were also elicited. Analysis included descriptive statistics and bivariate and multivariable analyses examining factors associated with awareness of the law. RESULTS Among the 207 survey respondents, 76% were aware of the law, and 93% expressed interest in receiving a 12-month supply of a short-acting method; however, only 9% received it. Respondents identified as White (66%), privately insured (59%), and pill users (44%). Concerns about a 12-month supply included privacy, product expiration, and change in personal medical status. Perceived benefits included avoiding multiple trips to pharmacy and increased compliance. Multivariable analyses showed general awareness of the law was only associated with employer-based insurance, with those respondents having 75% lower odds of being aware of the law than respondents with Medicaid coverage. CONCLUSION Although a high percentage of women surveyed were aware of the law and most were interested in receiving a 12-month supply of their short-acting method, the low percentage who have received a 12-month supply suggests barriers to policy uptake. IMPLICATIONS This study describes perceptions of the 12-month supply provision of the contraception Act Advancing Contraceptive Coverage and Economic Security in our State law. Addressing consumer concerns may be important to improve the implementation and dissemination of this state policy change.
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Affiliation(s)
- Neena T Qasba
- Department of OBGYN, University of Massachusetts Chan Medical School-Baystate, Springfield, MA, United States.
| | - Kate F Wallace
- Department of Biostatistics and Epidemiology, University of Massachusetts-Amherst School of Public Health and Health Sciences, Amherst, MA, United States
| | - Veronica Yu
- Department of Pharmacy Practice, Western New England University, College of Pharmacy and Health Sciences, Springfield, MA, United States
| | - Kam L Capoccia
- Department of Pharmacy Practice, Western New England University, College of Pharmacy and Health Sciences, Springfield, MA, United States
| | - Sarah L Goff
- Department of Health Promotion and Policy, University of Massachusetts, Amherst School of Public Health and Health Sciences, Amherst, MA, United States
| | - Natalia Shcherbakova
- Department of Pharmaceutical & Administrative Sciences, Western New England University, College of Pharmacy and Health Sciences, Springfield, MA, United States
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14
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Stoner MCD, Hawley I, Mathebula F, Horne E, Etima J, Kemigisha D, Mutero P, Dandadzi A, Seyama L, Fabiano Z, Scheckter R, Noguchi L, Owor M, Balkus JE, Montgomery ET. Acceptability and Use of the Dapivirine Vaginal Ring and Daily Oral Pre-exposure Prophylaxis (PrEP) During Breastfeeding in South Africa, Malawi, Zimbabwe, and Uganda. AIDS Behav 2023; 27:4114-4123. [PMID: 37432541 PMCID: PMC10615878 DOI: 10.1007/s10461-023-04125-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/01/2023] [Indexed: 07/12/2023]
Abstract
This study examines qualitative acceptability of the dapivirine vaginal ring (DVR) and oral daily pre-exposure prophylaxis (PrEP) among breastfeeding persons participating in Microbicide Trials Network 043/B-PROTECTED, a phase 3B safety and drug detectability study of DVR and oral PrEP in breastfeeding. A subsample of 52 participants were purposively sampled to participate in an in-depth interview (IDI). Breastfeeding participants found both study products to be acceptable, and easy to use. A common motivation for product use was to protect the baby from HIV, although participants' understanding of how the study drug would work to protect their babies was often unclear. While most participants did not report experiencing side effects, fears about side effects were common as both initial worries about how the study products would affect their health and the health of their baby, and increased anxiety that health issues experienced by them, or their baby were from the products.
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Affiliation(s)
- Marie C D Stoner
- Women's Global Health Imperative, RTI International, 2150 Shattuck Avenue, Berkeley, CA, 94104, USA.
| | - Imogen Hawley
- Women's Global Health Imperative, RTI International, 2150 Shattuck Avenue, Berkeley, CA, 94104, USA
| | - Florence Mathebula
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Elizea Horne
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Juliane Etima
- Makerere University-Johns Hopkins University (MU-JHU) Research Collaboration, Kampala, Uganda
| | - Doreen Kemigisha
- Makerere University-Johns Hopkins University (MU-JHU) Research Collaboration, Kampala, Uganda
| | - Prisca Mutero
- Clinical Trials Research Centre, University of Zimbabwe, Harare, Zimbabwe
| | - Adlight Dandadzi
- Clinical Trials Research Centre, University of Zimbabwe, Harare, Zimbabwe
| | - Linly Seyama
- Johns Hopkins Project, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Zayithwa Fabiano
- Johns Hopkins Project, College of Medicine, University of Malawi, Blantyre, Malawi
| | | | - Lisa Noguchi
- Division of Reproductive, Maternal, Newborn, Child and Adolescent Health, Jhpiego/Johns Hopkins University, Washington, DC, USA
| | - Maxensia Owor
- Makerere University-Johns Hopkins University (MU-JHU) Research Collaboration, Kampala, Uganda
| | - Jennifer E Balkus
- Department of Epidemiology, University of Washington School of Public Health, Seattle, USA
- Vaccine and Infectious Disease Division, Fred Hutch Cancer Center, Seattle, USA
| | - Elizabeth T Montgomery
- Women's Global Health Imperative, RTI International, 2150 Shattuck Avenue, Berkeley, CA, 94104, USA
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15
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Zhao X, Boyd P, Dallal Bashi YH, McCoy CF, Karl Malcolm R. Physicochemical considerations in the formulation development of silicone elastomer vaginal rings releasing 5-nitroimidazole drugs for the treatment of bacterial vaginosis. Int J Pharm 2023; 644:123296. [PMID: 37553058 DOI: 10.1016/j.ijpharm.2023.123296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 08/02/2023] [Accepted: 08/03/2023] [Indexed: 08/10/2023]
Abstract
Bacterial vaginosis (BV) is a common dysbiosis of the human vaginal microbiota characterized by depletion of hydrogen peroxide and lactic acid-producing Lactobacillus bacteria and an overgrowth of certain facultative anaerobic bacteria. Although short-term cure rates following treatment with frontline antibiotics (most notably oral metronidazole (MNZ), clindamycin vaginal cream, and MNZ vaginal gel) are generally high, longer-term recurrence rates are an issue. The development of vaginal formulations offering continuous/sustained administration of antibiotic drugs over one or more weeks might prove useful in reducing recurrence. Here, we report the manufacture and preclinical testing of matrix-type vaginal rings offering sustained release of four 5-nitroimidazole antimicrobial drugs either being used clinically or having potential in treatment of BV - MNZ, tinidazole (TNZ), secnidazole (SNZ) and ornidazole (ONZ). All four drugs showed good compatibility with a medical-grade addition-cure silicone elastomer based upon thermal analysis experiments, and matrix-type rings containing 250 mg (3.125 %w/w) of each drug were successfully manufactured by reaction injection molding. 28-day in vitro drug release studies demonstrated root-time kinetics, with daily release rates of 25, 22, 9 and 6 mg/day½ for SNZ, ONZ, MNZ and TNZ, respectively. The rank order of drug release from rings correlated with the simple molecular permeability parameter S/V, where S is the measured drug solubility in silicone fluid and V is the drug molecular volume. The relative merits of SNZ and ONZ over MNZ (the current reference treatment) are discussed. The data support development of vaginal rings for sustained release of 5-nitroimidazole compounds for treatment of BV.
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Affiliation(s)
- Xinyu Zhao
- School of Pharmacy, Queen's University Belfast, Belfast BT9 7BL, UK
| | - Peter Boyd
- School of Pharmacy, Queen's University Belfast, Belfast BT9 7BL, UK
| | | | - Clare F McCoy
- School of Pharmacy, Queen's University Belfast, Belfast BT9 7BL, UK
| | - R Karl Malcolm
- School of Pharmacy, Queen's University Belfast, Belfast BT9 7BL, UK.
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16
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Jensen JT, Archer DF, Westhoff CL, Nelson AL, Graham S, Bernick B. Satisfaction with a Segesterone Acetate and Ethinyl Estradiol Contraceptive Vaginal System Among Recent Oral Contraceptive or Hormonal Contraceptive Vaginal Ring Users. J Womens Health (Larchmt) 2023; 32:808-815. [PMID: 37253139 DOI: 10.1089/jwh.2022.0264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023] Open
Abstract
Background: We evaluated satisfaction with use of a segesterone acetate and ethinyl estradiol (0.15/0.013 mg) contraceptive vaginal system (CVS) among women who had recently used a monthly contraceptive vaginal ring or contraceptive pills. The CVS is a ring-shaped device used in a 21-days-in/7-days-out regimen for 13 cycles. Materials and Methods: We analyzed post hoc satisfaction responses at cycle 3 and end of study (EOS) from a subset of participants with documented recent use of the monthly ring or daily pills before enrollment in a multinational, phase 3, 13-cycle trial evaluating the CVS. EOS included results from participants who had completed ≥10 cycles. Results were summarized descriptively. Results: We identified 128 recent ring and 219 recent pill users at cycle 3 (of 1033 survey participants), and 92 and 148, respectively, at EOS (of 622 survey participants); overall satisfaction with CVS use was high (≥90%). At EOS, most ring (89%) and pill (97%) users liked the CVS as much/better than any previous method. The two most-liked CVS features included ease of use and 1-year duration; the two most disliked features included ring insertion and feeling it coming out. At EOS, ≥88% of both groups reported no concern about using the same CVS for a year, and most (>80%) had recommended it to friends or family members. Conclusion: The CVS clinical trial participants who were recent ring/pill users reported high satisfaction and liked it as much/better than any previously used contraceptive; the CVS may be a good contraceptive option for switchers. Clinical trial registration NCT00263341.
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Affiliation(s)
- Jeffrey T Jensen
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, Oregon, USA
| | - David F Archer
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, Virginia, USA
| | - Carolyn L Westhoff
- Department of Obstetrics and Gynecology, Columbia University, New York, New York, USA
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17
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Hull L, Stuckey BGA, Hartman K, Zack N, Friend DR. Evaluation of 28-day estradiol and progesterone vaginal rings in a phase 1 clinical pharmacokinetic study. Menopause 2023; 30:427-436. [PMID: 36727806 DOI: 10.1097/gme.0000000000002148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The aim of this work is to develop a combination of 17β-estradiol (E2) and progesterone (P4) in a single-dose intravaginal ring (IVR) for the treatment of vasomotor symptoms (VMS) and genitourinary syndrome of menopause while providing endometrial protection. The objective of this study was to evaluate DARE-HRT1, a 28-day IVR that continuously delivers E2 and P4, in a phase 1 clinical trial to assess its pharmacokinetics. METHODS This was an open-label, three-arm (group) study. Thirty-two (32) healthy postmenopausal women were recruited at two Australian sites. The average age was 57.2 years (47-69 y). The first arm received one ring for 28 days designed to release E2 at a rate of 80 μg/d and P4 at 4 mg/d (80/4 IVR); the second arm received a ring releasing E2 at 160 μg/d and P4 at 8 mg/d (160/8 IVR). The third arm received oral Estrofem (1 mg E2) and Prometrium (100 mg P4) both daily for 29 days. Blood samples were taken predose then intensively over the first day (day 1) and periodically thereafter over the remaining 27 days. After removal of the rings on the morning of day 29, intensive samples were collected. Similar procedures were conducted with women enrolled in the oral group. The plasma samples were analyzed for E2, estrone (E1), and P4 using validated bioanalytical methods. RESULTS The baseline-adjusted steady-state plasma levels of E2 and P4 from 80/4 IVR were 20.4 ± 17.1 pg/mL and 1.32 ± 0.19 ng/mL (n = 10), respectively. The baseline-adjusted steady-state plasma levels of E2 and P4 from 160/8 IVR were 30.9 ± 8.7 pg/mL and 2.08 ± 0.50 ng/mL (n = 10), respectively. The baseline-adjusted average plasma concentrations of E2 and P4 at day 29 of the oral group were 35.4 ± 11.2 pg/mL and 0.79 ± 0.72 ng/mL (n = 11), respectively. The baseline-adjusted steady state of E1 from the 80/4 IVR and the 160/8 IVR were 22.1 ± 16.6 pg/mL (n = 10) and 25.2 ± 12.3 pg/mL (n = 10), respectively. The baseline-adjusted concentration of E1 in the oral arm was 209 ± 67.7 ng/mL (n = 11). The IVR were well tolerated, and no serious adverse events were reported. CONCLUSIONS The 80/4 IVR and 160/8 IVR gave similar steady-state concentrations of E2 as seen with drug products approved by the US Food and Drug Administration for treatment of VMS and genitourinary symptoms of menopause. The E2 concentrations of this study support the potential of DARE-HRT1, a promising new option for hormone therapy for treatment of VMS and vaginal symptoms associated with menopause.
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Affiliation(s)
- Louise Hull
- From the PARC Clinical Research, University of Adelaide, Adelaide, Australia
| | - Bronwyn G A Stuckey
- Keogh Institute for Medical Research, Department of Endocrinology and Diabetes, Sir Charles Gairdner Hospital, University of Western Australia, Nedlands, Australia
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18
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Williams KM, Miller N, Tutegyereize L, Olisa AL, Chakare T, Jeckonia P, Mullick S, Atieno MA, Nhamo D, Rademacher KH. Defining principles for a choice-based approach to HIV prevention. The Lancet HIV 2023; 10:e269-e272. [PMID: 37001965 DOI: 10.1016/s2352-3018(23)00026-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 01/24/2023] [Accepted: 01/27/2023] [Indexed: 03/30/2023]
Abstract
The HIV prevention landscape is on the cusp of an unprecedented era of multiple biomedical prevention products available for distribution. Several HIV prevention options, such as oral pre-exposure prophylaxis (PrEP), dapivirine vaginal rings, and injectable cabotegravir for PrEP, are becoming more widely available. Although the future HIV prevention market promises to be rich in options, it would benefit from a core set of principles that uphold choice in all phases of product development, assessment, and introduction. These principles, as presented in this Viewpoint, show the applicability, opportunities, and challenges of choice in different contexts of HIV prevention and provide checkpoints of accountability. By committing to these principles, stakeholders at national and global levels can advance choice across all phases of the HIV prevention market, thereby ensuring that individuals can realise their right to choose when and how to prevent HIV in their own lives.
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Affiliation(s)
| | | | | | | | | | | | - Saiqa Mullick
- Wits Reproductive Health and HIV Institute, Johannesburg, South Africa
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19
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Mirembe BG, Cabrera MV, van der Straten A, Nakalega R, Cobbing M, Mgodi NM, Palanee-Phillips T, Mayo AJ, Dadabhai S, Mansoor LE, Siva S, Nair G, Chinula L, Akello CA, Nakabiito C, Soto-Torres LE, Baeten JM, Brown ER. Correlates of Dapivirine Vaginal Ring Acceptance among Women Participating in an Open Label Extension Trial. AIDS Behav 2023; 27:1030-1043. [PMID: 36066762 PMCID: PMC10102709 DOI: 10.1007/s10461-022-03841-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/27/2022] [Indexed: 11/01/2022]
Abstract
MTN-025/HOPE was an open-label trial of the dapivirine vaginal ring conducted in four African countries between 2016 and 2018. Women were first offered one ring monthly (at baseline, months 1 and 2), thereafter, transitioned to a more applicable real-world dispensation schedule, - 3 rings quarterly (at months 3, 6 and 9). Logistic regression analysis was used to assess correlates of ring acceptance at baseline and through follow-up. A total of 1456 women (median age 31 years) enrolled, 1342 (92.2%) accepted the ring at baseline and 1163 (79.9%) accepted the ring(s) at all visits. Changing ring dispensation from a monthly to a quarterly schedule had no negative effect on acceptance. Having a primary partner and him knowing about the ring being offered in HOPE, use of long-acting contraception (implants, injections, IUDs) or sterilization were associated with ring acceptance, along with prior strong intention to use the ring in the future. Efforts should consider these factors when rolling out the ring for HIV prevention.
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Affiliation(s)
- Brenda Gati Mirembe
- Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda.
- Vaccine and Infectious Disease and Public Health Sciences Divisions, Fred Hutchinson Cancer Research Center, Seattle, WA, USA.
- MU-JHU research Collaboration/MU-JHU CARE LTD, P.o. Box 23491, Kampala, Uganda.
| | | | - Ariane van der Straten
- Center for AIDS Prevention Studies, University of California San Francisco, San Francisco, CA, USA
- ASTRA Consulting, Kensington, CA, USA
| | - Rita Nakalega
- Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda
| | - Mandy Cobbing
- HIV Prevention Research Unit, South African Medical Research Council, Durban, South Africa
| | - Nyaradzo M Mgodi
- University of Zimbabwe Clinical Trials Research Centre, Harare, Zimbabwe
| | - Thesla Palanee-Phillips
- Wits Reproductive Health and HIV Institute (Wits RHI), University of the Witwatersrand, 8 FHI 360, Johannesburg, South Africa
| | | | - Sufia Dadabhai
- College of Medicine-Johns Hopkins Research Project, Blantyre, Malawi
| | - Leila E Mansoor
- Centre for AIDS Programme of Research in South Africa, University of KwaZulu-Natal, Durban, South Africa
| | - Samantha Siva
- HIV Prevention Research Unit, South African Medical Research Council, Durban, South Africa
| | - Gonasagrie Nair
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Lameck Chinula
- University of North Carolina (UNC) Project Malawi Clinical Research Site, Lilongwe, Malawi
| | - Carolyne A Akello
- Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda
| | - Clemensia Nakabiito
- Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda
| | - Lydia E Soto-Torres
- Division of AIDS, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Jared M Baeten
- Departments of Global Health, Medicine, and Epidemiology, University of Washington, Seattle, USA
- Gilead Sciences, Foster City, CA, USA
| | - Elizabeth R Brown
- Department of Biostatistics, University of Washington, Seattle, WA, USA
- Vaccine and Infectious Disease and Public Health Sciences Divisions, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
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Steytler J, van der Ryst E, Craig C, Van Baelen B, Nuttall J, van Niekerk N, Mellors J, Parikh U, Wallis C. Clinical Presentation, Treatment Response, and Virology Outcomes of Women Who Seroconverted in the Dapivirine Vaginal Ring Trials-The Ring Study and DREAM. Clin Infect Dis 2023; 76:389-397. [PMID: 36189636 PMCID: PMC10169386 DOI: 10.1093/cid/ciac804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 09/20/2022] [Accepted: 09/29/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Participants with human immunodeficiency virus (HIV) seroconversion in The Ring Study, a phase 3 trial of dapivirine vaginal ring (DVR), or in the open-label extension trial dapivirine ring extended access and monitoring (DREAM) were offered enrollment in an observational cohort study (IPM 007) to assess clinical presentation and response to antiretroviral therapy (ART). METHODS Participants' HIV infection was managed at local treatment clinics according to national treatment guidelines. IPM 007 study visits occurred 3 and 6 months after enrollment and every 6 months thereafter. Assessments included plasma HIV-1 RNA, CD4+ T-cell counts, and recording of HIV/AIDS-associated events and antiretroviral use. Post hoc virology analyses were performed for participants identified with virologic failure. RESULTS One hundred fifty-one of 179 eligible participants (84.4%) enrolled into IPM 007; 103 had previously received the DVR in the Ring or DREAM studies, and 48 had received placebo in The Ring Study. HIV-1 RNA and CD4+ T-cell counts after 12 months' follow-up were similar for participants who used the DVR in The Ring Study and DREAM, compared to those who received placebo. Of the 78 participants with a study visit approximately 6 months after ART initiation, 59 (75.6%) had HIV-1 RNA <40 copies/mL (The Ring Study: placebo: 13/23 [56.5%]; DVR: 32/39 [82.1%]; DREAM [DVR]: 14/16 [87.5%]). Post hoc virology analysis indicated that genotypic patterns observed at virologic failure were as expected of a nonnucleoside reverse transcriptase inhibitor (NNRTI)-based regimen. CONCLUSIONS Seroconversion during DVR use did not negatively affect clinical presentation or treatment outcome. Mutation patterns at virologic failure were in line with individuals failing an NNRTI-based regimen. CLINICAL TRIALS REGISTRATION NCT01618058.
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Affiliation(s)
- John Steytler
- International Partnership for Microbicides South Africa NPC, Johannesburg, South Africa
| | | | - Charles Craig
- Research Virology Consulting Ltd, Cambridgeshire, United Kingdom
| | | | - Jeremy Nuttall
- International Partnership for Microbicides, Silver Spring, Maryland, USA
| | - Neliëtte van Niekerk
- International Partnership for Microbicides South Africa NPC, Johannesburg, South Africa
| | - John Mellors
- Microbicide Trials Network Virology Core Laboratory, University of Pittsburgh, Pennsylvania, USA
| | - Urvi Parikh
- Microbicide Trials Network Virology Core Laboratory, University of Pittsburgh, Pennsylvania, USA
| | - Carole Wallis
- Bio-Analytical Research Corporation Laboratory, Johannesburg, South Africa
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21
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Morar NS, Mansoor LE, Naidoo K, Katz AWK, Garcia M, Duma C, Tshbalala T, Naidoo S, Montgomery ET. Male Partner Opinions of the Dapivirine Vaginal Ring Used During an Open-Label Extension HIV Prevention Trial in KwaZulu-Natal, South Africa. J Acquir Immune Defic Syndr 2023; 92:127-133. [PMID: 36302179 PMCID: PMC9839591 DOI: 10.1097/qai.0000000000003119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 10/04/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND The dapivirine vaginal ring ("the ring") reduced HIV acquisition by about 35% in phase III trials, with modeling from open-label extension trials estimating 50% HIV protection with consistent use. The ring may be used without male partner knowledge. The Assessment of ASPIRE and HOPE Adherence (AHA) substudy aimed to understand the impact of sociocontextual issues on ring adherence. This subanalysis provides insight into disclosure and male partner influence on ring acceptability. METHODS Data were collected using 4 focus group discussions with 18 male partners of phase III trial participants at 2 sites in KwaZulu-Natal, South Africa. Qualitative data were coded, summarized by urban vs. rural location, and analyzed thematically. RESULTS Male partners aged 23-49 years wanted to be informed about the ring use to maintain the trust in their relationships. Their initial response to the ring was characterized by fear due to perceived impact of the ring on their female partner's reproductive system, their penile safety, and that the ring would encourage women to engage in unprotected sex and infidelity. Over time and with information and experience with having a partner who had used the vaginal ring, this fear transformed to support for women to have their own HIV prevention option. CONCLUSION Male partners supported the ring as an HIV prevention method for women but wanted to be informed about its use. Engaging male partners on female-initiated HIV prevention methods and increased education among rural men may contribute to improved partner support and facilitate women's consistent use.
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Affiliation(s)
- Neetha S Morar
- HIV Prevention Research Unit, South African Medical Research Council (SAMRC), Durban, South Africa
| | - Leila E Mansoor
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
| | - Kalendri Naidoo
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
| | - Ariana WK Katz
- Women’s Global Health Imperative, RTI International, Berkeley, California, United States of America
| | - Morgan Garcia
- Global Health Population and Nutrition, FHI 360, Durham, NC, USA
| | - Cebo Duma
- HIV Prevention Research Unit, South African Medical Research Council (SAMRC), Durban, South Africa
| | | | - Themba Tshbalala
- HIV Prevention Research Unit, South African Medical Research Council (SAMRC), Durban, South Africa
| | - Sarita Naidoo
- HIV Prevention Research Unit, South African Medical Research Council (SAMRC), Durban, South Africa
- The Aurum Institute, Johannesburg, South Africa
| | - Elizabeth T Montgomery
- Women’s Global Health Imperative, RTI International, Berkeley, California, United States of America
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22
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Peebles K, Brown ER, Hendrix CW, Palanee-Phillips T, van der Straten A, Harkoo I, Reddy K, Mirembe BG, Jeenarain N, Hillier SL, Baeten JM, Barnabas RV. Brief Report: Dapivirine Ring HIV-1 Prevention Effectiveness for Women Engaged in Vaginal and Anal Intercourse: Insights From Mathematical Modeling. J Acquir Immune Defic Syndr 2023; 92:122-126. [PMID: 36184755 PMCID: PMC9839478 DOI: 10.1097/qai.0000000000003110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 09/13/2022] [Indexed: 01/21/2023]
Abstract
BACKGROUND The dapivirine vaginal ring reduces the risk of HIV-1 acquisition in acts of vaginal intercourse (VI), and although it does not offer HIV-1 protection in acts of anal intercourse (AI), it may provide some overall risk reduction for women for whom most sex acts are vaginal. We estimated the protective effect of the ring among women with high ring adherence engaged in both VI and AI. METHODS We developed a microsimulation model using data from the MTN-020/ASPIRE trial. Among women who reported any AI, we estimated the proportion of all sex acts that were AI. Model scenarios varied this proportion among women engaged in both VI and AI from 5% to 30%, including the trial-observed median proportion of 6.3% of all acts being AI. In primary analyses, dapivirine ring efficacy was model-calibrated at 70% for vaginal exposures and assumed to be 0% for anal exposures. RESULTS Among highly adherent women for whom 6.3% of sex acts were AI, the ring reduced HIV-1 risk by 53% (interquartile range: 44, 60), with a decline to 26% (interquartile range: 16, 36) among women for whom 30% of acts were AI. Ring effectiveness was less than 40% among women for whom AI accounted for greater than 16% of all sex acts, although this represented less than 5% of all women in the ASPIRE trial. CONCLUSIONS For most women, including those who engage in AI, because most HIV-1 risk occurs in acts of vaginal sex, the dapivirine vaginal ring can provide important HIV-1 protection.
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Affiliation(s)
- Kathryn Peebles
- Department of Global Health, University of Washington,
Seattle, United States
| | - Elizabeth R. Brown
- Vaccine and Infectious Disease and Public Health Sciences
Divisions, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
- Department of Biostatistics, University of Washington,
Seattle, WA, USA
| | - Craig W. Hendrix
- Department of Medicine (Clinical Pharmacology), Johns
Hopkins University, Baltimore, MD, USA
| | - Thesla Palanee-Phillips
- Wits Reproductive Health and HIV Institute, University of
the Witwatersrand, Johannesburg, South Africa
| | | | - Ishana Harkoo
- Centre for the AIDS Program of Research in South Africa,
Durban, South Africa
| | - Krishnaveni Reddy
- RTI International, Women’s Global Health Imperative
(WGHI), San Francisco, CA, USA
| | - Brenda G. Mirembe
- Makerere University - Johns Hopkins University Research
Collaboration, Kampala, Uganda
| | | | - Sharon L. Hillier
- Department of Obstetrics, Gynecology and Reproductive
Sciences, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jared M. Baeten
- Department of Global Health, University of Washington,
Seattle, United States
- Department of Epidemiology, University of Washington,
Seattle, United States
- Department of Medicine, University of Washington,
Seattle, United States
| | - Ruanne V. Barnabas
- Department of Global Health, University of Washington,
Seattle, United States
- Department of Epidemiology, University of Washington,
Seattle, United States
- Department of Medicine, University of Washington,
Seattle, United States
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23
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Naidoo K, T ME, Katz AW, Morgan G, Krishnaveni R, Lydia ST, Sarita N, Leila ME. Efficacy and Action of the Dapivirine Vaginal Ring as Understood by Women Participating in an Open Label Extension Study. AIDS Behav 2023; 27:75-81. [PMID: 35672549 DOI: 10.1007/s10461-022-03745-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/29/2022] [Indexed: 01/24/2023]
Abstract
The concept of efficacy, and how HIV prevention products biologically work can be complex. We report on women's interpretation of efficacy of the dapivirine vaginal ring and how they understood it to work to prevent HIV during the MTN-025/HOPE study through data collected from individual in-depth interviews. Ten women at each of the 6 HOPE research sites in Lilongwe, Malawi; Durban (2 sites) and Johannesburg, South Africa; Kampala, Uganda; and Chitungwiza, Zimbabwe, were enrolled (n = 60). Despite its partial efficacy, women trusted the ring to prevent HIV even when condoms were not used. The action of the ring was understood by most, however, there were misunderstandings around how quickly or slowly protection was offered when the ring was inserted or removed. Counselling sessions adapted to address partial efficacy, a multi-layered HIV prevention plan and how study products work could alleviate inconsistent adherence and diminished protection and further support women in receiving the best protection from their HIV prevention product of choice.
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Affiliation(s)
- Kalendri Naidoo
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu- Natal, Durban, South Africa.
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Doris Duke Medical Research Institute (2nd Floor), 719 Umbilo Road, Private Bag X7, 4013, Congella, Durban, South Africa.
| | - Montgomery Elizabeth T
- Women's Global Health Imperative, RTI International, Berkeley, California, United States of America
| | - Ariana Wk Katz
- Women's Global Health Imperative, RTI International, Berkeley, California, United States of America
| | - Garcia Morgan
- Global Health Population and Nutrition, FHI 360, Durham, NC, United States of America
| | - Reddy Krishnaveni
- Wits Reproductive Health and HIV Institute (Wits RHI), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Soto-Torres Lydia
- Division of AIDS, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, Maryland, United States of America
| | - Naidoo Sarita
- HIV and Other Infectious Diseases Research Unit (HIDRU), South African Medical Research Council, Durban, South Africa
- The Aurum Institute, Johannesburg, South Africa
| | - Mansoor E Leila
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu- Natal, Durban, South Africa
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24
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Musara P, Hartmann M, Ryan JH, Reddy K, Ggita J, Mutero P, Macagna N, Taulo F, Mgodi NM, Piper J, van der Straten A. Understanding the role of men in women's use of the vaginal ring and oral PrEP during pregnancy and breastfeeding: multi-stakeholder perspectives. Afr J AIDS Res 2022; 21:354-363. [PMID: 36538544 PMCID: PMC9983781 DOI: 10.2989/16085906.2022.2138474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 07/01/2022] [Accepted: 10/01/2022] [Indexed: 12/24/2022]
Abstract
We examined men's influence on women's interest in biomedical HIV prevention during pregnancy and breastfeeding through structured questionnaires and focus group discussions with currently or recently pregnant and breastfeeding (P/BF) women (n = 65), men with P/BF partners (n = 63) and mothers/mothers-in-law of P/BF women (n = 68) in eastern and southern Africa. Data were transcribed, coded and summarised into analytical memos. Men were depicted by most participants as joint decision-makers and influencers of women's use of HIV prevention. Cultural and religious norms depicting men as heads, breadwinners and protectors of the family were cited to legitimise their involvement in decision-making. Male partner education and engagement were recommended to garner their support in women's HIV prevention. This study elucidates how P/BF women's ability to prevent HIV is shaped by traditional and contemporary gender norms in social settings and locations where the study was conducted. Findings may aid intervention design to engage men for P/BF women's effective use of microbicide and oral PrEP.
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Affiliation(s)
- Petina Musara
- Clinical Trials Research Centre, University of Zimbabwe, Harare, Zimbabwe
| | - Miriam Hartmann
- Women’s Global Health Imperative, RTI International, Berkeley, USA
| | - Julia H Ryan
- Women’s Global Health Imperative, RTI International, Berkeley, USA
| | - Krishnaveni Reddy
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Joseph Ggita
- Johns Hopkins University Research Collaboration, Makerere University, Uganda
| | - Prisca Mutero
- Clinical Trials Research Centre, University of Zimbabwe, Harare, Zimbabwe
| | | | - Frank Taulo
- Johns Hopkins Project-College of Medicine, University of Malawi, Blantyre, Malawi
| | - Nyaradzo M Mgodi
- Clinical Trials Research Centre, University of Zimbabwe, Harare, Zimbabwe
| | | | - Ariane van der Straten
- Center for AIDS Prevention Studies, University of California San Francisco, USA; and ASTRA Consulting, Kensington, USA
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25
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Katz AWK, Balán IC, Reddy K, Etima J, Weber K, Tauya T, Atujuna M, Scheckter R, Ngure K, Soto-Torres L, Mgodi N, Palanee-Phillips T, Baeten JM, van der Straten A. Women's experience receiving drug feedback and adherence counseling in MTN-025/HOPE - an HIV Prevention open-label trial of the Dapivirine Vaginal Ring. AIDS Behav 2022; 26:3607-3619. [PMID: 35536519 PMCID: PMC9561023 DOI: 10.1007/s10461-022-03663-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2022] [Indexed: 11/01/2022]
Abstract
In the Phase IIIB MTN-025/HOPE open label extension trial, participants were offered the dapivirine vaginal ring as HIV prophylaxis, and those who accepted the ring received semi real-time individual adherence feedback, based on residual drug level (RDL) from returned rings, during Motivational Interviewing-based counseling. Counseling messages, based on the best knowledge at the time, framed RDL results in terms of ring use and HIV protection, from no use /no protection (0 RDL) to high use /high protection (3 RDL). At six HOPE sites, in-depth-Interviews (IDIs) about RDL were conducted with 64 participants who had received at least one RDL result. We found mixed interpretations of what the RDL meant and strong emotional reactions with a focus on the external validation of the level itself. Counseling was critical to help participants process their reactions to the RDL and make decisions accordingly (i.e., persistence, adherence improvement, and/or switching to another HIV prevention method). Providing drug adherence feedback was complex to implement yet proved useful as a component of a multi-pronged adherence support strategy.
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Affiliation(s)
| | - Iván C Balán
- HIV Center for Clinical and Behavioral Studies, Columbia University, New York, New York, United States
- Present affiliation Florida State University College of Medicine, Tallahassee, FL, USA
| | - Krishnaveni Reddy
- Wits Reproductive Health and HIV Institute (Wits RHI), Johannesburg, South Africa
| | - Juliane Etima
- Makerere University, Johns Hopkins University Research Collaboration, Kampala, Uganda
| | | | - Thelma Tauya
- College of Health Sciences Clinical Trials Unit, University of Zimbabwe, Harare, Zimbabwe
| | - Millicent Atujuna
- Desmond Tutu AIDS Foundation, University of Cape Town, Cape Town, South Africa
| | | | - Kenneth Ngure
- Department of Community Health, Jomo Kenyatta University of Agriculture and Technology, Juja, Kenya
| | | | - Nyaradzo Mgodi
- College of Health Sciences Clinical Trials Unit, University of Zimbabwe, Harare, Zimbabwe
| | | | - Jared M Baeten
- University of Washington, Seattle, WA, USA
- Present affiliation Gilead Sciences, Foster City, CA, USA
| | - Ariane van der Straten
- Center for AIDS Prevention Studies (CAPS), University of California San Francisco, San Francisco, CA, USA
- Present affiliation ASTRA Consulting, Kensington, CA, USA
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26
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Thurman AR, Brache V, Cochon L, Ouattara LA, Chandra N, Jacot T, Yousefieh N, Clark MR, Peet M, Hanif H, Schwartz JL, Ju S, Marzinke MA, Erikson DW, Parikh U, Herold BC, Fichorova RN, Tolley E, Doncel GF. Randomized, placebo controlled phase I trial of the safety, pharmacokinetics, pharmacodynamics and acceptability of a 90 day tenofovir plus levonorgestrel vaginal ring used continuously or cyclically in women: The CONRAD 138 study. PLoS One 2022; 17:e0275794. [PMID: 36215267 PMCID: PMC9550080 DOI: 10.1371/journal.pone.0275794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 08/29/2022] [Indexed: 11/04/2022] Open
Abstract
Multipurpose prevention technologies (MPTs), which prevent sexually transmitted infection(s) and unintended pregnancy, are highly desirable to women. In this randomized, placebo-controlled, phase I study, women used a placebo or tenofovir (TFV) and levonorgestrel (LNG) intravaginal ring (IVR), either continuously or cyclically (three, 28-day cycles with a 3 day interruption in between each cycle), for 90 days. Sixty-eight women were screened; 47 were randomized to 4 arms: TFV/LNG or placebo IVRs used continuously or cyclically (4:4:1:1). Safety was assessed by adverse events and changes from baseline in mucosal histology and immune mediators. TFV concentrations were evaluated in multiple compartments. LNG concentration was determined in serum. Modeled TFV pharmacodynamic antiviral activity was evaluated in vaginal and rectal fluids and cervicovaginal tissue ex vivo. LNG pharmacodynamics was assessed with cervical mucus quality and anovulation. All IVRs were safe with no serious adverse events nor significant changes in genital tract histology, immune cell density or secreted soluble proteins from baseline. Median vaginal fluid TFV concentrations were >500 ng/mg throughout 90d. TFV-diphosphate tissue concentrations exceeded 1,000 fmol/mg within 72hrs of IVR insertion. Mean serum LNG concentrations exceeded 200 pg/mL within 2h of TFV/LNG use, decreasing quickly after IVR removal. Vaginal fluid of women using TFV-containing IVRs had significantly greater inhibitory activity (87-98% versus 10% at baseline; p<0.01) against HIV replication in vitro. There was a >10-fold reduction in HIV p24 antigen production from ectocervical tissues after TFV/LNG exposure. TFV/LNG IVR users had significantly higher rates of anovulation, lower Insler scores and poorer/abnormal cervical mucus sperm penetration. Most TFV/LNG IVR users reported no change in menstrual cycles or fewer days of and/or lighter bleeding. All IVRs were safe. Active rings delivered high TFV concentrations locally. LNG caused changes in cervical mucus, sperm penetration, and ovulation compatible with contraceptive efficacy. Trial registration: ClinicalTrials.gov #NCT03279120.
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Affiliation(s)
- Andrea R. Thurman
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA, United States of America
- * E-mail:
| | | | | | - Louise A. Ouattara
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA, United States of America
| | - Neelima Chandra
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA, United States of America
| | - Terry Jacot
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA, United States of America
| | - Nazita Yousefieh
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA, United States of America
| | - Meredith R. Clark
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA, United States of America
| | - Melissa Peet
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA, United States of America
| | - Homaira Hanif
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA, United States of America
| | - Jill L. Schwartz
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA, United States of America
| | - Susan Ju
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA, United States of America
| | - Mark A. Marzinke
- Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - David W. Erikson
- Endocrine Technologies Core (ETC), Oregon National Primate Research Center (ONPRC), Beaverton, OR, United States of America
| | - Urvi Parikh
- Department of Medicine, Division of Infectious Diseases and Magee-Womens Research Institute, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Betsy C. Herold
- Albert Einstein College of Medicine, Bronx, NY, United States of America
| | - Raina N. Fichorova
- Laboratory of Genital Tract Biology, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, United States of America
| | - Elizabeth Tolley
- Family Health International 360, Research Triangle, NC, United States of America
| | - Gustavo F. Doncel
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA, United States of America
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27
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Palacios S, Algorta J, Colli E, Regidor PA, Mayr M, Roemer T. Multicenter, international observational study on quality of life and acceptability of a vaginal contraceptive ring containing etonogestrel/ethinylestradiol 11.00/3.474 mg over six months of use. Eur Rev Med Pharmacol Sci 2022; 26:7204-7211. [PMID: 36263530 DOI: 10.26355/eurrev_202210_29911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
OBJECTIVE The current post-market study aimed at analyzing women's menstrual bleeding intensity, vaginal infections, and quality of life parameters using the contraceptive vaginal ring Ornibel®. PATIENTS AND METHODS In Germany and Spain, a multicenter study of healthy female adults (n=211) aged 18 to 45 used the vaginal ring Ornibel® for at least six months. Data collection was conducted using a patient questionnaire. The menstrual bleeding intensity was analyzed using visual analog scales (VAS). A Chi-square linear trend test assessed associations between quality-of-life parameters and continuation and recommendation of vaginal ring use. RESULTS Three out of four women experienced six menstrual bleedings during the first six months of using the vaginal ring, with a median duration of four days during the study. The use of the vaginal ring led to a significant reduction in menstrual flow intensity (from 60 VAS points to 40 VAS points, p<0.001). In the German cohort, it was shown that dysmenorrhea and unscheduled bleeding and spotting were reduced with the use of Ornibel® as well. Most women (93.7%) agreed or strongly agreed that the vaginal ring was easy to insert, and its use was rated as comfortable or very comfortable by 97.5%. Both parameters were significantly associated with the continuation of the ring (easy to insert p=0.01, feeling comfortable: p=0.002) or its recommendation (easy to insert p=0.002, feeling comfortable: p=0.002). CONCLUSIONS The observational data demonstrate that the contraceptive vaginal ring provides high acceptability and comfort. It is a well-accepted contraceptive method characterized by high efficacy and positive effects on cycle control.
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Affiliation(s)
- S Palacios
- Instituto Palacios, Salud y Medicina de la Mujer, Madrid, Spain.
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28
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Abstract
The dapivirine monthly vaginal ring-a discreet, anti-HIV microbicide created specifically for women-has received a positive scientific opinion by the European Medicines Agency and is included in the WHO HIV prevention guidelines. It has received regulatory approvals in several countries in southern and eastern Africa. During the review of the New Drug Application that was submitted in December 2020, FDA advised the developer, International Partnership for Microbicides, that it was unlikely to be approved in the United States; the application has since been withdrawn. This commentary will present the case for FDA approval for the dapivirine ring. Advocacy is urgently needed to protect U.S. women's access to user-controlled HIV prevention technologies, consistent with both global regulatory decisions to date and with a reproductive justice framework. Women continue to need the fullest range of HIV prevention methods to integrate into their lives in the most practical and effective way possible.
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Affiliation(s)
- Erica L Gollub
- Health Science Program, College of Health Professions, Pace University, Pleasantville, New York
| | - Raven Vaughan
- Health Science Program, College of Health Professions, Pace University, Pleasantville, New York
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Browne EN, Brown ER, Palanee-Phillips T, Reddy K, Naidoo L, Jeenarain N, Nair G, Husnik MJ, Singh D, Scheckter R, Soto-Torres L, Baeten JM, van der Straten A. Patterns of Adherence to a Dapivirine Vaginal Ring for HIV-1 Prevention Among South African Women in a Phase III Randomized Controlled Trial. J Acquir Immune Defic Syndr 2022; 90:418-424. [PMID: 35344520 PMCID: PMC9342948 DOI: 10.1097/qai.0000000000002990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 03/03/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Persistent use of HIV prevention methods can be a challenge, particularly for some younger women. The long-acting, discreet, woman-centric dapivirine vaginal ring offers promise as a prevention method with less user burden, which could support continued use. We assessed dapivirine vaginal ring use to understand adherence patterns and identify characteristics influencing patterns. SETTING Participants enrolled in South Africa in the MTN-020/ASPIRE randomized placebo-controlled trial. METHODS We used group-based trajectory modeling to identify clusters of participants with similar longitudinal patterns of adherence in the last year of participation and potential predictors of group membership. Women with at least 1 year of follow-up were included (n = 626). RESULTS Five adherence patterns were identified: (1) consistently high, 34%, (2) consistently moderate, 34%, (3) consistently low, 16%, (4) decreasing, 9%, and (5) increasing, 7%. Women younger than 22 years [adjusted odds ratio (AOR) 1.8, 95% confidence interval (CI): 1.0 to 3.0], using an intrauterine device (AOR 3.3, 95% CI: 1.4 to 7.8) or oral contraceptives (AOR 3.9, 95% CI: 1.7 to 8.9), experiencing menses (AOR 1.8, 95% CI: 1.1 to 3.0), and who reported inconsistent condom use (AOR 1.8, 95% CI: 1.0 to 3.3) were more likely to be classified as consistently low compared to consistently high (referent). CONCLUSIONS Most South African women successfully persisted with a moderate or high level of use. Encouraging ring replacement with completion of menses may help to decrease concerns about hygiene and improve persistence. Associations between contraception and persistent low adherence suggest efforts may be needed to ensure contraceptive method choice does not interfere with ring use.
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Affiliation(s)
- Erica N Browne
- Women's Global Health Imperative, RTI International, Berkeley, CA
| | - Elizabeth R Brown
- Fred Hutchinson Cancer Research Center, Seattle, WA
- Department of Biostatistics, University of Washington, Seattle, WA
| | - Thesla Palanee-Phillips
- Wits Reproductive Health and HIV Institute (Wits RHI), University of the Witwatersrand, Faculty of Health, Sciences, Johannesburg, South Africa
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA; and
| | - Krishnaveni Reddy
- Wits Reproductive Health and HIV Institute (Wits RHI), University of the Witwatersrand, Faculty of Health, Sciences, Johannesburg, South Africa
| | | | | | | | | | - Devika Singh
- University of Pittsburgh, and Magee-Women's Research Institute, Pittsburgh, PA
| | | | - Lydia Soto-Torres
- Division of AIDS, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Jared M Baeten
- Department of Global Health, Medicine, and Epidemiology, University of Washington, Seattle, WA
- Current, Gilead Sciences, Foster City, CA
| | - Ariane van der Straten
- Center for AIDS Prevention Studies, Department of Medicine, University of California, San Francisco, CA
- ASTRA consulting, Kensington, CA
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Roberts ST, Hawley I, Luecke E, Mensch B, Wagner T, Hoesley C, McClure T, Dominguez Islas CP, Piper JM, Liu AY, van der Straten A. Acceptability and Preference for 3-Month Versus 1-Month Vaginal Rings for HIV-1 Risk Reduction Among Participants in a Phase 1 Trial. J Womens Health (Larchmt) 2022; 31:1029-1039. [PMID: 34665672 PMCID: PMC9299526 DOI: 10.1089/jwh.2021.0121] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: The monthly dapivirine vaginal ring provides partial protection against HIV, and a longer duration ring may reduce user burden and improve adherence. We examined acceptability and preference for 3-month versus 1-month rings for HIV-1 risk reduction in a phase 1 clinical trial. Materials and Methods: In Microbicide Trials Network-036/International Partnership for Microbicides 047, 49 HIV-negative participants aged 18-45 were randomized to one of two 3-month rings or the 1-month ring. Acceptability ratings were collected at enrollment, week 4, and study exit (week 13). At exit, ring preference was assessed quantitatively among all participants and a randomly selected subset of 24 participants completed in-depth interviews. Quantitative and qualitative findings were integrated to explore factors influencing acceptability and preference. Results: Acceptability of each ring was initially moderate and increased during the trial. Ratings were lower in the 3-month ring arms than the 1-month arm at each time point, including baseline. Most participants (34/47; 72%) preferred a 3-month ring at exit; however, this proportion was significantly lower within some subgroups characterized by site, education, race/ethnicity, and experiences with ring use. Qualitative interviews revealed reservations about hygiene and safety of the 3-month ring, including discomfort with use during menses, but these were usually outweighed by its increased convenience. Conclusions: Both ring durations were highly acceptable at study exit. Although most participants preferred a 3-month ring, preference was more divided in certain subgroups, highlighting the benefit of offering different duration options. Providing additional support to address concerns about hygiene and safety may improve acceptability of a 3-month vaginal ring.
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Affiliation(s)
- Sarah T. Roberts
- Women's Global Health Imperative (WGHI), RTI International, Berkeley, California, USA
| | - Imogen Hawley
- Women's Global Health Imperative (WGHI), RTI International, Berkeley, California, USA
| | - Ellen Luecke
- Women's Global Health Imperative (WGHI), RTI International, Berkeley, California, USA
| | | | - Theresa Wagner
- Bridge HIV, San Francisco Department of Public Health, San Francisco, California, USA
| | - Craig Hoesley
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | | | - Clara P. Dominguez Islas
- Statistical Center for HIV/AIDS Research and Prevention, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Jeanna M. Piper
- Division of AIDS, National Institutes of Health, Bethesda, Maryland, USA
| | - Albert Y. Liu
- Bridge HIV, San Francisco Department of Public Health, San Francisco, California, USA
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Ariane van der Straten
- Women's Global Health Imperative (WGHI), RTI International, Berkeley, California, USA
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
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31
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Wagner LD, Minnis AM, Shea J, Agot K, Ahmed K, van der Straten A. Female and male partner perspectives on placebo Multipurpose Prevention Technologies (MPTs) used by women in the TRIO study in South Africa and Kenya. PLoS One 2022; 17:e0265303. [PMID: 35551318 PMCID: PMC9097999 DOI: 10.1371/journal.pone.0265303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 02/28/2022] [Indexed: 11/19/2022] Open
Abstract
Background
Male partner awareness and acceptance of microbicide and family planning product use has been shown to increase women’s own acceptance and adherence of a product. However, little is known about preferences regarding potential Multipurpose Prevention Technology (MPT) product delivery forms. As part of the TRIO study, men’s reactions to their female partner’s TRIO product use and comparisons of men’s and women’s views of TRIO product attributes and use acceptability were explored to better understand product preferences.
Methods
Women in TRIO used three placebo products that represented potential MPTs: daily oral tablets, monthly vaginal rings, and monthly dual injections. Male partners (N = 39) and women (N = 88) completed in-depth interviews on their own and their partner’s experiences with these products. Qualitative coding and analyses followed a conceptual model of HIV prevention product acceptability, and here, we explored themes of disclosure, trust and infidelity as they informed barriers and facilitators to product use.
Results
Men expressed a desire to know of their partner’s product use decisions and be informed and educated on the products to better support their partners, in some cases, expressing a high level of concern regarding maximizing the ease of product adherence for their partner. They also wanted to understand the effects of products on sexual encounters with their partner, but in some cases, wanted more knowledge in order to control their partner’s product use decisions. Similarly to women, men found long-acting, discreet products that have little to no effect on sexual encounters or libido the most acceptable for their female partners’ use. Product use was most acceptable to men if they were informed of use without inadvertent discovery.
Conclusions
Men’s product attribute preferences often aligned with women’s opinions of the same products. To support women’s correct use of MPTs, further research is needed to determine the best strategy for achieving male partner acceptance and support of product use, particularly for less familiar delivery forms, such as the vaginal ring.
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Affiliation(s)
- Laura Danielle Wagner
- Women’s Global Health Imperative, RTI International, Berkeley, California, United States of America
- * E-mail: ,
| | - Alexandra M. Minnis
- Women’s Global Health Imperative, RTI International, Berkeley, California, United States of America
| | - Jaclyn Shea
- Youth + Tech + Health, Oakland, California, United States of America
| | - Kawango Agot
- Impact Research and Development Organization, Kisumu, Kenya
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Young A, Ryan J, Reddy K, Palanee-Phillips T, Chitukuta M, Mwenda W, Kemigisha D, Musara P, van der Straten A. Religious leaders' role in pregnant and breastfeeding women's decision making and willingness to use biomedical HIV prevention strategies: a multi-country analysis. Cult Health Sex 2022; 24:612-626. [PMID: 33810781 PMCID: PMC8627258 DOI: 10.1080/13691058.2021.1874054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
Oral Pre-Exposure Prophylaxis (PrEP) is an established option, and the dapivirine vaginal ring is emerging as a promising strategy for HIV prevention option for women. Because of this, understanding the contextual and cultural factors that will support the increased uptake of these products is crucial. In sub-Saharan Africa, religious leaders may be important stakeholders to involve in product information, education and roll-out. We conducted a sub-analysis of data from 232 participants taking part in the MTN-041/MAMMA study to explore religious leaders' involvement in pregnant and breastfeeding women's health. Study participants viewed biomedicine and spirituality as interlinked and believed that women could seek health-related care from medical experts and turn to faith-based organisations for religious or spiritual needs. Religious leaders were invested in the health of their congregations, endorsed a variety of sexual health strategies, and were eager to learn more about emerging HIV prevention technologies. These data signal the role of religious leaders in supporting their communities, and the importance of involving religious leaders in efforts to roll out new HIV prevention products to facilitate uptake.
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Affiliation(s)
- Alinda Young
- Women’s Global Health Imperative (WGHI), RTI International, Berkeley, CA, USA
| | - Julia Ryan
- Women’s Global Health Imperative (WGHI), RTI International, Berkeley, CA, USA
| | - Krishnaveni Reddy
- Wits Reproductive Health and HIV Institute (Wits RHI), University of the Witwatersrand, Johannesburg, South Africa
| | - Thesla Palanee-Phillips
- Wits Reproductive Health and HIV Institute (Wits RHI), University of the Witwatersrand, Johannesburg, South Africa
| | - Miria Chitukuta
- University of Zimbabwe College of Health Sciences Clinical Trials Research Centre, Harare, Zimbabwe
| | - Wezi Mwenda
- Johns Hopkins Project, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Doreen Kemigisha
- Makerere University–Johns Hopkins University Research Collaboration, Kampala, Uganda
| | - Petina Musara
- University of Zimbabwe College of Health Sciences Clinical Trials Research Centre, Harare, Zimbabwe
| | - Ariane van der Straten
- Women’s Global Health Imperative (WGHI), RTI International, Berkeley, CA, USA
- Center for AIDS Prevention Studies (CAPS), University of California San Francisco, San Francisco, CA, USA
- ASTRA Consulting, Kensington, CA, USA
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33
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Hawley I, Song M, Scheckter R, McClure T, Piper J, Chen BA, Hoesley C, Liu AY, van der Straten A. Users' Preferred Characteristics of Vaginal Rings for HIV Prevention: A Qualitative Analysis of Two Phase I Trials. AIDS Res Hum Retroviruses 2022; 38:313-326. [PMID: 34969254 PMCID: PMC9048173 DOI: 10.1089/aid.2021.0077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Vaginal rings address a critical need for an independently initiated, long-acting HIV prevention method, but their design must be acceptable to promote uptake and adherence. Human-centered design (HCD) may help address design preference questions. In two Phase I studies of vaginal rings for HIV prevention conducted in the United States, we used qualitative interviews to assess participants' perceptions and opinions of the physical characteristics of the ring they used and of a ring's physical characteristics after comparing four ring designs presented via a visual tool. Users were found to prefer ring designs that appear easy to use, are physically comfortable, that function well, and are aesthetically pleasing. The parameters for these features varied widely. Product developers and marketers should consider marketing messages in which the target users feel this product is made to meet their needs and desires. Product developers are encouraged to design using HCD early in ring development (Clinical Trial Registration number: NCT03234400 and NCT03670355).
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Affiliation(s)
- Imogen Hawley
- Global Public Health Impact Center, RTI International, Berkeley, California, USA
| | - Mei Song
- Magee-Womens Research Institute, Microbicide Trials Network, Pittsburgh, Pennsylvania, USA
| | | | - Tara McClure
- Family Health International 360, Durham, North Carolina, USA
| | - Jeanna Piper
- National Institute of Allergy and Infectious Disease, DAIDS, Bethesda, Maryland, USA
| | - Beatrice A. Chen
- University of Pittsburgh/Magee-Womens Research Institute, Pittsburgh, Pennsylvania, USA
| | - Craig Hoesley
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Albert Y. Liu
- Bridge HIV at the San Francisco Department of Public Health, San Francisco, California, USA
- Department of Medicine, Center for AIDS Prevention Studies, University of California, San Francisco, San Francisco, California, USA
| | - Ariane van der Straten
- Department of Medicine, Center for AIDS Prevention Studies, University of California, San Francisco, San Francisco, California, USA
- ASTRA Consulting, Kensington, California, USA
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34
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Zhao X, Milford C, Smit J, Zulu B, Boyd P, Malcolm RK, Beksinska M. Color, Scent and Size: Exploring Women's Preferences Around Design Characteristics of Drug-Releasing Vaginal Rings. AIDS Behav 2022; 26:2954-2968. [PMID: 35294694 PMCID: PMC8924943 DOI: 10.1007/s10461-022-03596-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2022] [Indexed: 11/30/2022]
Abstract
Steroid-releasing vaginal rings are available for contraception and estrogen replacement therapy, and a new antiretroviral-releasing ring was recently approved for HIV prevention. Marketed rings are white or transparent in appearance, non-scented, and supplied as one-size-fits-all devices with diameters ranging from 54 to 56 mm. In this study, drug-free silicone elastomer rings were manufactured in different sizes, colors and scents, and the opinions/preferences of 16 women (eThekwini District, South Africa; 20–34 years) assessed through focus group discussions and thematic analysis. Opinions varied on ring color and scent, with some women preferring specific colors or scent intensities, while for others these attributes were unimportant. Concerns about color and scent were linked to perceptions around vaginal health and safety related to chemical composition. There was greater agreement on preferred ring size; flexibility and width were considered important factors for insertion and comfort. Greater choice with ring products could facilitate acceptability and overall uptake.
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Affiliation(s)
- Xinyu Zhao
- School of Pharmacy, Queen’s University Belfast, Belfast, BT9 7BL UK
| | - Cecilia Milford
- MRU (MatCH Research Unit), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | - Jenni Smit
- MRU (MatCH Research Unit), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | - Bongiwe Zulu
- MRU (MatCH Research Unit), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | - Peter Boyd
- School of Pharmacy, Queen’s University Belfast, Belfast, BT9 7BL UK
| | - R. Karl Malcolm
- School of Pharmacy, Queen’s University Belfast, Belfast, BT9 7BL UK
| | - Mags Beksinska
- MRU (MatCH Research Unit), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
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Thurman AR, Ravel J, Gajer P, Marzinke MA, Ouattara LA, Jacot T, Peet MM, Clark MR, Doncel GF. Vaginal Microbiota and Mucosal Pharmacokinetics of Tenofovir in Healthy Women Using a 90-Day Tenofovir/Levonorgestrel Vaginal Ring. Front Cell Infect Microbiol 2022; 12:799501. [PMID: 35350436 PMCID: PMC8957918 DOI: 10.3389/fcimb.2022.799501] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 02/09/2022] [Indexed: 01/04/2023] Open
Abstract
Background A relationship between the vaginal microbiota and tenofovir (TFV) concentrations and activity after topical administration has been previously reported. Objective CONRAD A15-138 was a randomized, placebo-controlled Phase I study aimed at characterizing the safety, pharmacokinetics (PK), and pharmacodynamics (PD) of TFV and levonorgestrel (LNG) administered through a vaginal ring (IVR) for 90 days. Herein, we describe changes from baseline in the vaginal microbiota with IVR use and the impact of the vaginal microbiota on mucosal TFV PK. Methods The study screened 68 participants and randomized 47 (37 TFV/LNG, 10 placebo), assessing the vaginal microbiota by sequencing the V3–V4 regions of 16S rRNA genes prior to IVR insertion and monthly for 3 months. Concentrations of TFV in vaginal fluid (VF), and TFV and TFV-diphosphate (TFV-DP) in vaginal tissue, and modeled PD against HIV-1 in vitro were measured before and after treatment. Results There were no clinically significant changes in relative abundance of vaginal bacterial phylotypes from pre-insertion baseline at any month among active and placebo IVR users. There were no significant changes in community state type (CST) with IVR use. Participants with diverse, anaerobic CST IVA/B microbiota had higher in vivo release of TFV from the IVR compared to women with Lactobacillus-dominated (LbD) microbiota, who had expected in vivo TFV release rates. Median VF TFV concentrations were significantly higher among women with CST IVA/B microbiota in months 1 (3,135 ng/mg VF) and 2 (3,800 ng/mg). Women with LbD microbiota had significantly higher median VF TFV concentration (1,423 ng/mg) and median TFV (103 ng/mg) and TFV-DP (5,877 fmol/mg) tissue concentrations versus women with CST IVA/B microbiota at month 3. All women demonstrated a significant increase from pre-insertion baseline of in vitro HIV-1 inhibition by VF (p values <0.05). PD differences in tissue according to CST, however, were not statistically significant. Conclusion TFV/LNG IVR use did not change the vaginal microbiota nor increase the incidence of CST IVA/B. Vaginal microbiota, and in particular CST IVA/B, possibly through increased vaginal pH, impacted in vivo TFV release and cervicovaginal (CV) PK, but both PK and PD data suggest CV protection against HIV-1. Clinical Trial Registration ClinicalTrials.gov (#NCT03279120)
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Affiliation(s)
- Andrea R. Thurman
- Department of Obstetrics and Gynecology, CONRAD, Eastern Virginia Medical School, Norfolk, VA, United States
- *Correspondence: Andrea R. Thurman,
| | - Jacques Ravel
- Institute for Genome Sciences and Department of Microbiology and Immunology, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Pawel Gajer
- Institute for Genome Sciences and Department of Microbiology and Immunology, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Mark A. Marzinke
- Departments of Pathology and Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Louise A. Ouattara
- Department of Obstetrics and Gynecology, CONRAD, Eastern Virginia Medical School, Norfolk, VA, United States
| | - Terry Jacot
- Department of Obstetrics and Gynecology, CONRAD, Eastern Virginia Medical School, Norfolk, VA, United States
| | - M. Melissa Peet
- Department of Obstetrics and Gynecology, CONRAD, Eastern Virginia Medical School, Norfolk, VA, United States
| | - Meredith R. Clark
- Department of Obstetrics and Gynecology, CONRAD, Eastern Virginia Medical School, Norfolk, VA, United States
| | - Gustavo F. Doncel
- Department of Obstetrics and Gynecology, CONRAD, Eastern Virginia Medical School, Norfolk, VA, United States
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Abstract
PURPOSE OF REVIEW This paper provides a critical review of recent therapeutic advances in long-acting (LA) modalities for human immunodeficiency virus (HIV) treatment and prevention. RECENT FINDINGS LA injectable antiretroviral therapy (ART) has been approved in the United States, Canada and Europe; the United States also has approved LA injectable preexposure prophylaxis (PrEP) and the World Health Organization has recommended the vaginal PrEP ring. Current LA PrEP modalities in clinical trials include injections, films, rings, and implants; LA ART modalities in trials include subcutaneous injections and long-term oral pills. Although LA modalities hold incredible promise, global availability is inhibited by long-standing multilevel perils including declining multilateral funding, patent protections and lack of political will. Once available, access and uptake are limited by factors such as insurance coverage, clinic access, labor markets, stigma, and structural racism and sexism. These must be addressed to facilitate equitable access for all. SUMMARY There have been tremendous recent advances in the efficacy of LA ART and PrEP modalities, providing renewed hope that 'ending the HIV epidemic' is within reach. However, pervasive socio-structural inequities limit the promise of LA modalities, highlighting the need for cautious optimism in light of the embedded inequities in the trajectory of research, development, and population-level implementation.
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Affiliation(s)
- Morgan M. Philbin
- Department of Sociomedical Sciences, Columbia University Mailman School of Public Health, New York City, New York, USA
| | - Amaya Perez-Brumer
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
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Stoner MCD, Browne EN, Gundacker HM, Hawley I, Chen BA, Hoesley C, Scheckter R, Piper J, Singh D, Song M, Liu A, van der Straten A. Acceptability of an extended duration vaginal ring for HIV prevention and interest in a multi-purpose ring. PLoS One 2022; 17:e0263664. [PMID: 35192655 PMCID: PMC8863232 DOI: 10.1371/journal.pone.0263664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 01/21/2022] [Indexed: 11/30/2022] Open
Abstract
Given challenges with adherence to existing HIV prevention products, the development of an extended duration vaginal ring could improve adherence while reducing patient and provider burden. Additionally, women have other interlinked sexual health concerns such as unintended pregnancy. We evaluated acceptability of a 90-day ring to prevent HIV and hypothetical preferences for a dual (HIV and contraceptive) indication. This was a secondary analysis of a Phase 1, two-arm, multi-site, placebo-controlled randomized trial evaluating safety and pharmacokinetics of a 90-day vaginal ring containing tenofovir for HIV prevention (N = 49). We used a mixed methods approach to assess quantitative data on acceptability (n = 49) and used qualitative data from a random subset to explain the quantitative findings (N = 25). The 3-month extended duration tenofovir ring was highly acceptable. Participants perceived the ring to be easy to use, comfortable and reported liking it more over time. About half felt the ring during sex but most of those participants said it bothered them only a little. Concerns about hygiene increased over the study period but were often outweighed by the benefits of an extended duration ring. Interest in a multi-purpose ring was high (77%) and even higher among those who were sexually active and had male partners. The 3-month extended duration tenofovir ring for HIV prevention was highly acceptable among women and interest in an MPT was high.
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Affiliation(s)
- Marie C D Stoner
- Women's Global Health Imperative, RTI International, Berkeley, CA, United States of America
| | - Erica N Browne
- Women's Global Health Imperative, RTI International, Berkeley, CA, United States of America
| | - Holly M Gundacker
- Statistical Center for HIV/AIDS Research & Prevention, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
| | - Imogen Hawley
- Women's Global Health Imperative, RTI International, Berkeley, CA, United States of America
| | - Beatrice A Chen
- Magee-Womens Research Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, United States of America
| | - Craig Hoesley
- University of Alabama at Birmingham, Birmingham, AL, United States of America
| | | | - Jeanna Piper
- US National Institutes of Health, Bethesda, MD, United States of America
| | - Devika Singh
- Magee-Womens Research Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, United States of America
| | - Mei Song
- Magee-Womens Research Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, United States of America
| | - Albert Liu
- Bridge HIV, San Francisco Department of Public Health, San Francisco, CA, United States of America
- Department of Medicine, University of California, San Francisco, San Francisco, CA, United States of America
| | - Ariane van der Straten
- Women's Global Health Imperative, RTI International, Berkeley, CA, United States of America
- Center for AIDS Prevention Studies, University of California San Francisco, San Francisco, CA, United States of America
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Bhavaraju N, Shears K, Schwartz K, Mullick S, Jeckonia P, Murungu J, Persaud U, Vij A, Torjesen K. Introducing the Dapivirine Vaginal Ring in Sub-Saharan Africa: What Can We Learn from Oral PrEP? Curr HIV/AIDS Rep 2021; 18:508-517. [PMID: 34910276 PMCID: PMC8671875 DOI: 10.1007/s11904-021-00577-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/04/2021] [Indexed: 11/30/2022]
Abstract
Purpose of review Clinical trials have found that the dapivirine vaginal ring (DVR) is safe to use and effective at reducing women’s risk of acquiring HIV infection. As countries prepare for the introduction of this novel long-acting, woman-controlled prevention method, an examination of key learnings from oral pre-exposure prophylaxis (PrEP) delivery will help programs leverage successful innovations and approaches to support DVR scale-up and expand the method mix for HIV prevention. Recent findings Intensive efforts over the past 5 years have yielded lessons on how to facilitate access to oral PrEP; expand service delivery for PrEP; address the knowledge, attitudes, and skills providers need to support PrEP initiation and effective use; develop messaging that builds community and partner support and combats stigma; and understand the cyclical nature of PrEP use. Summary Evidence from oral PrEP introduction and scale-up can help inform and expedite DVR introduction.
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Affiliation(s)
| | - Kathleen Shears
- FHI 360, 1825 Connecticut Avenue NW, Washington, DC 20009 USA
| | | | - Saiqa Mullick
- Wits Reproductive Health and HIV Institute, 8 Blackwood Avenue, Parktown, Johannesburg, South Africa
| | - Patriciah Jeckonia
- LVCT Health, Batian Lane, Off Argwings Kodhek Road, Hurlingam, Nairobi, Kenya
| | - Joseph Murungu
- Pangaea Zimbabwe AIDS Trust, 27 Rowland Square, Milton Park, Harare, Zimbabwe
| | - Udita Persaud
- United States Agency for International Development, 1300 Pennsylvania Avenue NW, Washington, DC 20523 USA
| | - Ashley Vij
- United States Agency for International Development, 1300 Pennsylvania Avenue NW, Washington, DC 20523 USA
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Gichane MW, Katz AWK, Ngure K, Scheckter R, Woeber K, Reddy K, Tauya T, Zimba C, Etima J, Mangxilana N, Palanee-Phillips T, van der Straten A. Impact of Women's Home Environment on Use of the Dapivirine Vaginal Ring for HIV Prevention in Sub-Saharan Africa. AIDS Behav 2021; 25:3847-3857. [PMID: 34009480 PMCID: PMC8602444 DOI: 10.1007/s10461-021-03311-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/12/2021] [Indexed: 11/27/2022]
Abstract
The monthly dapivirine vaginal ring has proven efficacious in reducing HIV incidence in two Phase 3 clinical trials. When considering the potential future availability of the ring to the public, key questions remain about the feasibility of integrating the ring as an HIV prevention intervention into women's lives. We conducted qualitative mapping interviews (n = 66) among women enrolled in MTN-025/HOPE, an open-label trial conducted in Malawi, South Africa, Uganda and Zimbabwe, to examine how home environments influenced use of the dapivirine vaginal ring. Most women had secure places to store their rings including wardrobes, suitcases, and bags. The primary concerns for ring storage were potential tampering from children or rodents. Household overcrowding limited the privacy some women had which made removal and insertion of vaginal rings challenging. Despite these challenges, ring storage, insertion, and removal was feasible across social and living contexts.
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Affiliation(s)
- Margaret W Gichane
- Substance Use Gender, and Applied Research Group, RTI International, Research Triangle Park, Durham, NC, USA
| | - Ariana W K Katz
- Women's Global Health Imperative, RTI International, Berkley, CA, USA.
| | - Kenneth Ngure
- Department of Community Health, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | | | - Kubashni Woeber
- South African Medical Research Council, Durban, Kwazulu Natal, South Africa
| | - Krishnaveni Reddy
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Thelma Tauya
- University of Zimbabwe College of Health Sciences Clinical Trials Unit, Harare, Zimbabwe
| | | | - Juliane Etima
- Makerere University - Johns Hopkins University, Research Collaboration, Kampala, Uganda
| | - Nomvuyo Mangxilana
- Desmond Tutu HIV Foundation, University of Cape Town, Cape Town, South Africa
| | - Thesla Palanee-Phillips
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
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Krovi SA, Johnson LM, Luecke E, Achilles SL, van der Straten A. Advances in long-acting injectables, implants, and vaginal rings for contraception and HIV prevention. Adv Drug Deliv Rev 2021; 176:113849. [PMID: 34186143 DOI: 10.1016/j.addr.2021.113849] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 06/15/2021] [Accepted: 06/22/2021] [Indexed: 12/22/2022]
Abstract
Worldwide, women face compounding reproductive health risks, including human immunodeficiency virus (HIV), sexually-transmitted infections (STIs), and unintended pregnancy. Multipurpose prevention technologies (MPTs) offer combined protection against these overlapping risks in singular prevention products that offer potential for simplified use, lower burden, higher acceptability, and increased public health benefits. Over the past decade, substantial progress has been made in development of extended-release MPTs, which have further potential to grant sexual and reproductive health autonomy to women globally and to offer choice for women to accommodate varying needs during their reproductive lives. Here, we highlight the advances made in injectable, implant, and ring delivery forms, and the importance of incorporating end-user preferences early in the research and development of these products.
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Affiliation(s)
| | | | - Ellen Luecke
- Women's Global Health Imperative, RTI International, Berkeley, CA, USA
| | - Sharon L Achilles
- University of Pittsburgh, School of Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, Pittsburgh, PA, USA; Magee-Womens Research Institute, Pittsburgh, PA, USA
| | - Ariane van der Straten
- Center for AIDS Prevention Studies, Dept of Medicine, University of California San Francisco, San Francisco, CA, USA; ASTRA Consulting, Kensington, CA, USA
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Husnik MJ, Brown ER, Dadabhai SS, Gaffoor Z, Jeenarain N, Kiweewa FM, Livant E, Mansoor LE, Mirembe BG, Palanee-Phillips T, Singh D, Siva S, Soto-Torres L, van der Straten A, Baeten JM. Correlates of Adherence to the Dapivirine Vaginal Ring for HIV-1 Prevention. AIDS Behav 2021; 25:2801-2814. [PMID: 34117592 PMCID: PMC8577988 DOI: 10.1007/s10461-021-03231-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/10/2021] [Indexed: 12/31/2022]
Abstract
Understanding characteristics associated with adherence to pre-exposure prophylaxis (PrEP) methods for HIV-1 prevention may assist with optimizing implementation efforts. The dapivirine vaginal ring is a novel topical PrEP delivery method. Using data from a randomized, double-blind, placebo-controlled, phase III trial of the dapivirine vaginal ring conducted in four African countries, generalized estimating equation models were used to evaluate correlates of ring adherence. Two levels of quarterly dapivirine blood plasma, and dapivirine released from returned rings defined measures of adherence for recent and cumulative use, respectively. Time on study, calendar time, primary partner knowledge that the participant was taking part in the study, and use of long-acting contraceptive methods were associated with ring adherence whereas younger age, ring worries, condom use, episodes of menstrual bleeding and vaginal washing were associated with non-adherence. These findings may be useful for recruitment into future clinical studies and dapivirine ring implementation efforts.
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Affiliation(s)
- Marla J Husnik
- Fred Hutchinson Cancer Research Center, Seattle, USA
- University of Washington, Seattle, USA
| | | | - Sufia S Dadabhai
- Johns Hopkins Bloomberg School of Public Health, Blantyre, Malawi
| | - Zakir Gaffoor
- South African Medical Research Council, Durban, South Africa
| | | | | | | | - Leila E Mansoor
- Centre for the AIDS Programme of Research in South Africa, Durban, South Africa
| | | | - Thesla Palanee-Phillips
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, School of Clinical Medicine, Johannesburg, South Africa
| | - Devika Singh
- Magee-Womens Research Institute, Pittsburgh, USA
| | - Samantha Siva
- South African Medical Research Council, Durban, South Africa
| | | | - Ariane van der Straten
- RTI International, Women's Global Health Imperative, San Francisco, CA, USA
- Center for AIDS Prevention Studies, Department of Medicine, UCSF, San Francisco, CA, USA
| | - Jared M Baeten
- University of Washington, Seattle, USA.
- Department of Global Health, University of Washington, 325 Ninth Avenue, Box 359927, Seattle, WA, 98104, USA.
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Lindh I, Othman J, Hansson M, Ekelund AC, Svanberg T, Strandell A. New types of diaphragms and cervical caps versus older types of diaphragms and different gels for contraception: a systematic review. BMJ Sex Reprod Health 2021; 47:e12. [PMID: 32868337 DOI: 10.1136/bmjsrh-2020-200632] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 07/08/2020] [Accepted: 07/27/2020] [Indexed: 06/11/2023]
Abstract
INTRODUCTION Our primary objective was to evaluate whether new types of single-size diaphragms or cervical caps differ in prevention of pregnancy compared with older types of diaphragms, and whether different types of gels differ in their ability to prevent pregnancy. A secondary aim was to evaluate method discontinuation and complications. METHODS A comprehensive search was conducted in PubMed, Embase and the Cochrane Library. The certainty of evidence was assessed according to the GRADE system. RESULTS Four randomised controlled studies were included in the assessment. When comparing the new and old types of female barrier contraceptives the 6-month pregnancy rate varied between 11%-15% and 8%-12%, respectively. More women reported inability to insert or remove the FemCap device (1.1%) compared with the Ortho All-Flex diaphragm (0%) (p<0.0306). Urinary tract infections were lower when using the single-size Caya, a difference of -6.4% (95% CI -8.9 to -4.09) compared with the Ortho All-Flex diaphragm. The 6-month pregnancy rate for acid-buffering gel and spermicidal nonoxynol-9 gel varied between 10% and 12%. The discontinuation rate was lower in women who used acid-buffering gel compared with nonoxynol-9 gel (risk ratio (RR) 0.77, 95% CI 0.68 to 0.97). CONCLUSIONS Pregnancy rates were generally high in women using female barrier contraceptives. There was no difference in the efficacy for pregnancy prevention between the new types of diaphragms and cervical caps and the older diaphragms. The new types of diaphragms and cervical caps resulted in fewer urinary tract infections. Acid-buffering gels did not differ from spermicidal nonoxynol-9 gels regarding pregnancies but seemed to be better tolerated.
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Affiliation(s)
- Ingela Lindh
- Department of Obstetrics and Gynecology, Sahlgrenska Academy at Gothenburg University, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jwan Othman
- Department of Obstetrics and Gynecology, Sahlgrenska Academy at Gothenburg University, Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | | | - Therese Svanberg
- Medical Library, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Annika Strandell
- Department of Obstetrics and Gynecology, Sahlgrenska Academy at Gothenburg University, Sahlgrenska University Hospital, Gothenburg, Sweden
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Baker Z, Javanbakht M, Moore J, Brosnan H, Squires K, Bunge K, Zimet G, Mensch B, Soto-Torres L, Kapogiannis B, Levy L, Hoesley C, Reirden D, Gaur A, Mayer K, Futterman D, Gorbach P. Qualitative Study on the Acceptability of and Adherence to a Vaginal Ring for HIV Prophylaxis Among Adolescent Girls. J Acquir Immune Defic Syndr 2021; 87:944-950. [PMID: 33675614 PMCID: PMC8192420 DOI: 10.1097/qai.0000000000002674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 12/30/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This study aims to assess the product-related, relationship-related, and sex-related factors that act as facilitators and barriers to the acceptability of a vaginal ring (VR) for HIV prevention among adolescent girls. DESIGN Qualitative study. METHODS Ninety-six girls aged 15-17 years from 6 urban US sites were enrolled in MTN-023/IPM 030, a 24-week randomized controlled trial, for assessing the safety and acceptability of a dapivirine VR for HIV prevention. At week 24, 21 girls were randomly selected to participate in in-depth interviews. Interviews were transcribed verbatim and data analyzed using a thematic analysis approach. Facilitators and barriers to VR acceptability related to participants' relationships, sexual activity, and characteristics of the VR product were identified. RESULTS Factors related to relationships rarely seemed to act as barriers to VR acceptability; most participants disclosed VR use to sexual partners, and positive reactions from sexual partners, which were common, seemed to facilitate VR acceptability. Emotional and/or physical discomfort surrounding VR use during sex was mentioned occasionally as a barrier to VR acceptability. Product characteristics were most frequently mentioned as barriers to VR acceptability. Many participants reported concerns about the large size of the VR on first impression. Although most found the VR comfortable, some reported pain with VR insertion. Several participants were concerned about VR cleanliness, particularly during menstruation. CONCLUSION Product considerations, specifically size and use during menstruation, were the most commonly reported barriers to VR acceptability in this study. Adolescent girls may require additional counseling to assuage product concerns regarding a VR for HIV prevention.
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Affiliation(s)
- Zoë Baker
- Division of Urology, Children's Hospital Los Angeles, Los Angeles, CA
| | - Marjan Javanbakht
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA
| | - Janell Moore
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA
| | - Hannah Brosnan
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA
| | - Kathleen Squires
- Division of Infectious Diseases, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA
- Global Center of Scientific Affairs, Merck Research Labs, Rahway, NJ
| | - Katherine Bunge
- Department of Obstetrics, Gynecology & Reproductive Services, University of Pittsburgh, Pittsburgh, PA
| | - Gregory Zimet
- Department of Pediatrics, Indiana University, Bloomington, IA
| | | | - Lydia Soto-Torres
- National Institute of Allergy and Infectious Diseases, Division of AIDS, Bethesda, MD
| | - Bill Kapogiannis
- Maternal and Pediatric Infectious Disease Branch, National Institute of Child Health and Human Development, Bethesda, MD
| | | | - Craig Hoesley
- Division of Infectious Diseases, University of Alabama, Birmingham, AL
| | - Daniel Reirden
- Department of Adolescent Medicine, Children's Hospital Colorado, Aurora, CO
| | - Aditya Gaur
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, TN
| | - Kenneth Mayer
- Department of Global Health and Population, Harvard School of Public Health, The Fenway Institute, Boston, MA; and
| | - Donna Futterman
- Department of Pediatrics, Albert Einstein College of Medicine, the Bronx, NY
| | - Pamina Gorbach
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA
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Naidoo K, Mansoor LE, Katz AWK, Garcia M, Kemigisha D, Morar NS, Zimba CC, Chitukuta M, Reddy K, Soto-Torres L, Naidoo S, Montgomery ET. Qualitative Perceptions of Dapivirine VR Adherence and Drug Level Feedback Following an Open-Label Extension Trial. J Acquir Immune Defic Syndr 2021; 86:e90-e96. [PMID: 33278181 PMCID: PMC7902420 DOI: 10.1097/qai.0000000000002590] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 11/20/2020] [Indexed: 01/13/2023]
Abstract
BACKGROUND There continues to be a need for HIV prevention options that women can initiate and use autonomously. The dapivirine vaginal ring (VR) has been shown to have a favorable safety profile and reduce the risk of HIV-1 acquisition. We report on women's experiences with VR adherence during the MTN-025/HIV Open-label Prevention Extension (HOPE) study and responses to Residual Drug Level (RDL) results. SETTING Ten women at each of the 6 HOPE research sites in Lilongwe, Malawi; Durban (2 sites) and Johannesburg, South Africa; Kampala, Uganda; and Chitungwiza, Zimbabwe, were randomly selected (n = 60). METHODS After confirmation of eligibility criteria, in-depth interviews were conducted where available RDL results were presented. RESULTS Many women with low RDL release measurements deflected blame onto other factors (the ring, the drug, and faulty testing machines) and distrust of the testing method. The disclosure of RDL results enabled some users to discuss their challenges experienced (fear of partner objections, perceived side effects, and removals during menses). Consistent users reported important motivators (support from others, protection from HIV, and enhanced sexual experiences from the VR). CONCLUSION The VR provided a sense of security for some women; however, adherence was still challenging for others regardless of it being a female controlled, long-acting HIV prevention technology. Adherence measurements may not be sustainable in the real-world implementation of the VR, although they can be seen as a benefit as they provide a better understanding of actual product use and provide women with a platform to discuss their experiences.
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Affiliation(s)
- Kalendri Naidoo
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
| | - Leila E. Mansoor
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
| | - Ariana WK. Katz
- Women’s Global Health Imperative, RTI International, Berkeley, California, United States of America
| | - Morgan Garcia
- FHI 360, Durham, North Carolina, United States of America
| | - Doreen Kemigisha
- Makerere University, Johns Hopkins University Research Collaboration, Kampala, Uganda
| | - Neetha S. Morar
- HIV Prevention Research Unit, South African Medical Research Council (SAMRC), Durban, South Africa
| | | | - Miria Chitukuta
- University of Zimbabwe College of Health Sciences Clinical Trials Research Centre (UZCHS-CTRC), Harare, Zimbabwe
| | - Krishnaveni Reddy
- Wits Reproductive Health and HIV Institute (Wits RHI), Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Lydia Soto-Torres
- Division of AIDS, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, Maryland, United States of America
| | - Sarita Naidoo
- HIV Prevention Research Unit, South African Medical Research Council, Durban, South Africa (Present affiliation: The Aurum Institute, Johannesburg, South Africa)
| | - Elizabeth T. Montgomery
- Women’s Global Health Imperative, RTI International, Berkeley, California, United States of America
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Farr Zuend C, Noël-Romas L, Hoger S, McCorriser S, Westmacott G, Marrazzo J, Hillier SL, Dezzutti C, Squires K, Bunge KE, Burgener A. Influence of dapivirine vaginal ring use on cervicovaginal immunity and functional microbiome in adolescent girls. AIDS 2021; 35:369-380. [PMID: 33181534 PMCID: PMC7924934 DOI: 10.1097/qad.0000000000002751] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 04/15/2020] [Accepted: 04/21/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The antiretroviral-based dapivirine vaginal ring reduced HIV risk among women in phase III clinical trials. However, limited data exists on the impact of dapivirine on the vaginal microenvironment in adolescents. DESIGN A comprehensive metaproteomics approach was used to assess host proteome and microbiome changes in cervicovaginal mucus with dapivirine ring use in adolescents enrolled in the MTN-023/IPM 030 (MTN-023) trial. METHODS Participants were randomized 3 : 1 to use dapivirine or placebo vaginal rings monthly for 6 months. Cervicovaginal samples from a subset of 35 participants (8 placebo, 27 dapivirine) were analyzed. RESULTS Mass spectrometry analysis identified 405 human and 2467 bacterial proteins belonging to 15 unique genera. The host proteome belonged to many functional pathways primarily related to inflammation. When stratified by study treatment arm, 18 (4.4%) and 28 (6.9%) human proteins were differentially abundant (adjusted P < 0.05) between baseline and follow-up in the placebo and dapivirine arms, respectively. The vaginal microbiome was predominantly composed of Lactobacillus, Gardnerella, and Prevotella. Although bacterial taxa did not differ by arm or change significantly, Lactobacillus crispatus increased (P < 0.001) and Lactobacillus iners decreased (P < 0.001) during the 6-month follow-up. There were no significant differences in bacterial functions by arm or time in the trial. Protected vaginal sex significantly associated with decreased neutrophil inflammatory biomarkers and may be associated with changes in bacterial taxa and metabolism. CONCLUSION Condom use may associate with differences to inflammation and bacterial function but dapivirine ring use does not, thereby supporting the mucosal safety profile of this vaginal ring for adolescents.
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Affiliation(s)
- Christina Farr Zuend
- Center for Global health and Diseases, Case Western Reserve University, Cleveland, Ohio, USA
| | - Laura Noël-Romas
- Center for Global health and Diseases, Case Western Reserve University, Cleveland, Ohio, USA
- Departments of Obstetrics and Gynecology and Medical Microbiology, University of Manitoba
| | - Sarah Hoger
- Departments of Obstetrics and Gynecology and Medical Microbiology, University of Manitoba
| | - Stuart McCorriser
- Mass Spectrometry and Proteomics Core Facility, National Microbiology Laboratory, Public Health Agency of Canada, Winnipeg, Manitoba, Canada
| | - Garrett Westmacott
- Mass Spectrometry and Proteomics Core Facility, National Microbiology Laboratory, Public Health Agency of Canada, Winnipeg, Manitoba, Canada
| | - Jeanne Marrazzo
- University of Alabama at Birmingham School of Medicine, Birmingham, Alabama
| | - Sharon L. Hillier
- University of Pittsburgh School of Medicine
- Magee-Women's Research Institute, Pittsburgh
| | - Charlene Dezzutti
- University of Pittsburgh School of Medicine
- Magee-Women's Research Institute, Pittsburgh
| | - Kathleen Squires
- Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Katherine E. Bunge
- University of Pittsburgh School of Medicine
- Magee-Women's Research Institute, Pittsburgh
| | - Adam Burgener
- Center for Global health and Diseases, Case Western Reserve University, Cleveland, Ohio, USA
- Departments of Obstetrics and Gynecology and Medical Microbiology, University of Manitoba
- Department of Medicine Solna, Center for Molecular Medicine, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
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Nel A, van Niekerk N, Van Baelen B, Malherbe M, Mans W, Carter A, Steytler J, van der Ryst E, Craig C, Louw C, Gwetu T, Mabude Z, Kotze P, Moraba R, Tempelman H, Gill K, Kusemererwa S, Bekker LG, Devlin B, Rosenberg Z. Safety, adherence, and HIV-1 seroconversion among women using the dapivirine vaginal ring (DREAM): an open-label, extension study. Lancet HIV 2021; 8:e77-e86. [PMID: 33539761 DOI: 10.1016/s2352-3018(20)30300-3] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 10/13/2020] [Accepted: 10/21/2020] [Indexed: 05/15/2023]
Abstract
BACKGROUND The Ring Study, a phase 3 trial in 1959 sexually active women (randomised 2:1), showed a favourable safety profile and a 31% HIV-1 infection risk reduction for a vaginal ring containing 25 mg of dapivirine, compared with a placebo ring. We report here the DREAM study, which aimed to evaluate safety, adherence, and HIV-1 incidence in those using the dapivirine vaginal ring (DVR) in open-label use. METHODS The DREAM study is an open-label extension of The Ring Study, done at five research centres in South Africa and one research centre in Uganda. Former participants from The Ring Study, who remained HIV-negative and who did not discontinue the study due to an adverse event or safety concern that was considered to be related to the investigational product, were eligible. Women who were pregnant, planning to become pregnant, or breastfeeding at screening for DREAM were excluded. All participants received the DVR for insertion at the enrolment visit. Participants attended a 1-month follow-up visit and could either proceed with visits once every 3 months or attend monthly visits up to month 3 and then continue with visits once every 3 months. At each visit, HIV testing and safety evaluations were done, and residual dapivirine measured in used rings (approximately 4 mg is released from the DVR over 28 days of consistent use). HIV-1 incidence was compared descriptively with the simulated incidence rate obtained from bootstrap sampling of participants in the placebo group of The Ring Study, matched for research centre, age, and presence of sexually transmitted infections at enrolment. This study is registered with ClinicalTrials.gov, NCT02862171. FINDINGS Between July 12, 2016, and Jan 11, 2019, 1034 former participants from The Ring Study were screened, 941 were enrolled and 848 completed the trial. 616 (65·5%) of 941 participants reported treatment-emergent adverse events. Of these, six (0·6%) had events considered to be treatment-related. No treatment-related serious adverse events were reported. Measurements of monthly ring residual amounts in participants enrolled in both trials showed consistently lower mean values in DREAM than in The Ring Study. Arithmetic mean ring residual amounts of participants in The Ring Study DVR group who enrolled in DREAM were 0·25 mg lower (95% CI 0·03-0·47; p=0·027) than the mean ring residual amounts of these participants in The Ring Study. 18 (1·9%) HIV-1 infections were confirmed during DVR use, resulting in an incidence of 1·8 (95% CI 1·1-2·6) per 100 person-years, 62% lower than the simulated placebo rate. INTERPRETATION Although efficacy estimation is limited by the absence of a placebo group, the observed low HIV-1 incidence and improved adherence observed in DREAM support the hypothesis that increased efficacy due to improved adherence occurs when women know the demonstrated safety and efficacy of the DVR. The feasibility of a visit schedule of once every 3 months was shown, indicating that the DVR can be used in a real-world situation in usual clinical practice. FUNDING The Ministry of Foreign Affairs (MFA) Denmark, Flanders MFA, Irish Aid, Dutch MFA, UK Aid from the UK Government's Foreign, Commonwealth and Development Office, and the US President's Emergency Plan for AIDS Relief through the US Agency for International Development.
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Affiliation(s)
- Annalene Nel
- Medinel CC Clinical Consulting, Paarl, South Africa
| | | | | | | | - Winél Mans
- Independent Consultant, Paarl, South Africa
| | | | - John Steytler
- International Partnership for Microbicides, Paarl, South Africa
| | | | | | - Cheryl Louw
- Madibeng Centre for Research, Brits, South Africa; Department of Family Medicine, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | | | | | - Philip Kotze
- Qhakaza Mbokodo Research Clinic, Ladysmith, South Africa
| | | | | | - Katherine Gill
- Desmond Tutu HIV Centre, University of Cape Town, Observatory, Cape Town, South Africa
| | - Sylvia Kusemererwa
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine, Uganda Research Unit, Entebbe, Uganda
| | - Linda-Gail Bekker
- Desmond Tutu HIV Centre, University of Cape Town, Observatory, Cape Town, South Africa
| | - Brid Devlin
- International Partnership for Microbicides, Silver Spring, MD, USA
| | - Zeda Rosenberg
- International Partnership for Microbicides, Silver Spring, MD, USA.
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47
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Baeten JM, Palanee-Phillips T, Mgodi NM, Mayo AJ, Szydlo DW, Ramjee G, Gati Mirembe B, Mhlanga F, Hunidzarira P, Mansoor LE, Siva S, Govender V, Makanani B, Naidoo L, Singh N, Nair G, Chinula L, Parikh UM, Mellors JW, Balán IC, Ngure K, van der Straten A, Scheckter R, Garcia M, Peda M, Patterson K, Livant E, Bunge K, Singh D, Jacobson C, Jiao Y, Hendrix CW, Chirenje ZM, Nakabiito C, Taha TE, Jones J, Torjesen K, Nel A, Rosenberg Z, Soto-Torres LE, Hillier SL, Brown ER. Safety, uptake, and use of a dapivirine vaginal ring for HIV-1 prevention in African women (HOPE): an open-label, extension study. Lancet HIV 2021; 8:e87-e95. [PMID: 33539762 PMCID: PMC8038210 DOI: 10.1016/s2352-3018(20)30304-0] [Citation(s) in RCA: 64] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 10/15/2020] [Accepted: 11/02/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Two phase 3 clinical trials showed that use of a monthly vaginal ring containing 25 mg dapivirine was well tolerated and reduced HIV-1 incidence in women by approximately 30% compared with placebo. We aimed to evaluate use and safety of the dapivirine vaginal ring (DVR) in open-label settings with high background rates of HIV-1 infection, an important step for future implementation. METHODS We did a phase 3B open-label extension trial of the DVR (MTN-025/HIV Open-label Prevention Extension [HOPE]). Women who were HIV-1-negative and had participated in the MTN-020/ASPIRE phase 3 trial were offered 12 months of access to the DVR at 14 clinical research centres in Malawi, South Africa, Uganda, and Zimbabwe. At each visit (monthly for 3 months, then once every 3 months), women chose whether or not to accept the offer of the ring. Used, returned rings were tested for residual amounts of dapivirine as a surrogate marker for adherence. HIV-1 serological testing was done at each visit. Dapivirine amounts in returned rings and HIV-1 incidence were compared with data from the ASPIRE trial, and safety was assessed. This study is registered with ClinicalTrials.gov, NCT02858037. FINDINGS Between July 16, 2016, and Oct 10, 2018, of 1756 women assessed for eligibility, 1456 were enrolled and participated in the study. Median age was 31 years (IQR 27-37). At baseline, 1342 (92·2%) women chose to take the DVR; ring acceptance was more than 79% at each visit up until 12 months and 936 (73·2%) of 1279 chose to take the ring at all visits. 12 530 (89·3%) of 14 034 returned rings had residual dapivirine amounts consistent with some use during the previous month (>0·9 mg released) and the mean dapivirine amount released was greater than in the ASPIRE trial (by 0·21 mg; p<0·0001). HIV-1 incidence was 2·7 per 100 person-years (95% CI 1·9-3·8, 35 infections), compared with an expected incidence of 4·4 per 100 person-years (3·2-5·8) among a population matched on age, site, and presence of a sexually transmitted infection from the placebo group of ASPIRE. No serious adverse events or grade 3 or higher adverse events observed were assessed as related to the DVR. INTERPRETATION High uptake and persistent use in this open-label extension study support the DVR as an HIV-1 prevention option for women. With an increasing number of HIV-1 prophylaxis choices on the horizon, these results suggest that the DVR will be an acceptable and practical option for women in Africa. FUNDING The Microbicide Trials Network and the National Institute of Allergy and Infectious Diseases, The Eunice Kennedy Shriver National Institute of Child Health and Human Development, and the National Institute of Mental Health, all components of the US National Institutes of Health.
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Affiliation(s)
- Jared M Baeten
- Department of Global Health, University of Washington, Seattle, WA, USA; Department of Medicine, University of Washington, Seattle, WA, USA; Department of Epidemiology, University of Washington, Seattle, WA, USA.
| | - Thesla Palanee-Phillips
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Nyaradzo M Mgodi
- University of Zimbabwe College of Health Sciences Clinical Trials Research Centre, Harare, Zimbabwe
| | | | - Daniel W Szydlo
- Statistical Center for HIV/AIDS Research and Prevention, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Gita Ramjee
- HIV Prevention Research Unit, South African Medical Research Council, Durban, South Africa; Aurum Institute, Johannesburg, South Africa
| | - Brenda Gati Mirembe
- Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda
| | - Felix Mhlanga
- University of Zimbabwe College of Health Sciences Clinical Trials Research Centre, Harare, Zimbabwe
| | - Portia Hunidzarira
- University of Zimbabwe College of Health Sciences Clinical Trials Research Centre, Harare, Zimbabwe
| | - Leila E Mansoor
- Centre for AIDS Programme of Research in South Africa, University of KwaZulu-Natal, Durban, South Africa
| | - Samantha Siva
- HIV Prevention Research Unit, South African Medical Research Council, Durban, South Africa
| | - Vaneshree Govender
- HIV Prevention Research Unit, South African Medical Research Council, Durban, South Africa; Aurum Institute, Johannesburg, South Africa
| | - Bonus Makanani
- College of Medicine-Johns Hopkins Research Project, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Logashvari Naidoo
- HIV Prevention Research Unit, South African Medical Research Council, Durban, South Africa
| | - Nishanta Singh
- HIV Prevention Research Unit, South African Medical Research Council, Durban, South Africa
| | - Gonasagrie Nair
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Lameck Chinula
- University of North Carolina Project, Lilongwe, Malawi; Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC, USA
| | - Urvi M Parikh
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - John W Mellors
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Iván C Balán
- HIV Center for Clinical and Behavioral Studies at New York State Psychiatric Institute and Columbia University, New York, NY, USA
| | - Kenneth Ngure
- Department of Community Health, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | - Ariane van der Straten
- Women's Global Health Imperative, RTI International, San Francisco, CA, USA; Center for AIDS Prevention Studies, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | | | | | - Melissa Peda
- Statistical Center for HIV/AIDS Research and Prevention, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Karen Patterson
- Statistical Center for HIV/AIDS Research and Prevention, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Edward Livant
- Magee-Womens Research Institute, Pittsburgh, PA, USA
| | - Katherine Bunge
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh, Pittsburgh, PA, USA
| | - Devika Singh
- Magee-Womens Research Institute, Pittsburgh, PA, USA
| | | | - Yuqing Jiao
- Statistical Center for HIV/AIDS Research and Prevention, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Craig W Hendrix
- Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Zvavahera M Chirenje
- University of Zimbabwe College of Health Sciences Clinical Trials Research Centre, Harare, Zimbabwe
| | - Clemensia Nakabiito
- Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda
| | - Taha E Taha
- College of Medicine-Johns Hopkins Research Project, Queen Elizabeth Central Hospital, Blantyre, Malawi; Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA
| | - Judith Jones
- Magee-Womens Research Institute, Pittsburgh, PA, USA
| | | | - Annalene Nel
- International Partnership for Microbicides, Silver Spring, MD, USA
| | - Zeda Rosenberg
- International Partnership for Microbicides, Silver Spring, MD, USA
| | - Lydia E Soto-Torres
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Sharon L Hillier
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh, Pittsburgh, PA, USA
| | - Elizabeth R Brown
- Department of Biostatistics, University of Washington, Seattle, WA, USA; Statistical Center for HIV/AIDS Research and Prevention, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
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Battaglia C, Battaglia B, Casadio P, Rizzo R, Artini PG. Metformin metabolic and vascular effects in normal weight hyperinsulinemic polycystic ovary syndrome patients treated with contraceptive vaginal ring. A pilot study. Gynecol Endocrinol 2020; 36:1062-1069. [PMID: 32544018 DOI: 10.1080/09513590.2020.1770213] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
PURPOSE The aim of this longitudinal, controlled, and retrospective pilot study was to assess how metformin, associated with a contraceptive vaginal ring, may influence lipid and carbohydrate metabolism, and surrogate markers of arterial function in normal weight polycystic ovary syndrome patients. MATERIAL AND METHODS Among 28 lean patients, 15 were treated with vaginal ring plus metformin and 13 women with only vaginal ring. The effects were assessed after six months. The patients were submitted to evaluation of lipid and carbohydrate metabolism; Doppler analysis of ophthalmic artery; brachial artery flow-mediated vasodilatation; and oral glucose tolerance test. RESULTS After six months, the fasting insulin, glucose/insulin ratio, and homeostatic model assessment estimates for insulin resistance were significantly improved in metformin group. The ophthalmic artery pulsatility index did not significantly improve in either group. The brachial artery vasodilation was better in metformin treated patients. CONCLUSION Metformin, associated with vaginal ring, improves the insulin and carbohydrate metabolism. This, associated with the significant improvements of surrogate markers of arterial function, may be responsible of a slight possible cardiovascular and cerebrovascular protective effect.
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Affiliation(s)
- Cesare Battaglia
- Department of Obstetrics and Perinatal Medicine, Alma Mater Studiorum-University of Bologna, Bologna, Italy
| | - Bruno Battaglia
- Department of Ophthalmology, University of Modena-Reggio-Emilia, Italy
| | - Paolo Casadio
- Department of Gynecology and Pathophysiology of Human Reproduction, Alma Mater Studiorum-University of Bologna, Italy
| | - Roberta Rizzo
- Department of Obstetrics and Perinatal Medicine, Alma Mater Studiorum-University of Bologna, Bologna, Italy
| | - Paolo G Artini
- Department of Obstetrics and Gynecology "P. Fioretti" University of Pisa, Italy
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49
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Brown ER, Hendrix CW, van der Straten A, Kiweewa FM, Mgodi NM, Palanee‐Philips T, Marzinke MA, Bekker L, Soto‐Torres L, Hillier SL, Baeten JM. Greater dapivirine release from the dapivirine vaginal ring is correlated with lower risk of HIV-1 acquisition: a secondary analysis from a randomized, placebo-controlled trial. J Int AIDS Soc 2020; 23:e25634. [PMID: 33206462 PMCID: PMC7673220 DOI: 10.1002/jia2.25634] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 10/01/2020] [Accepted: 10/06/2020] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION A vaginal ring containing 25 mg of the antiretroviral dapivirine has demonstrated efficacy in reducing women's risk of sexually acquiring HIV-1; however, imperfect ring use likely diluted efficacy estimates in clinical trials. The amount of dapivirine remaining in returned rings may reflect the extent of product use, permitting estimation of HIV protection in the context of consistent use. METHODS We measured the amount of dapivirine in returned rings from a placebo-controlled trial of the dapivirine vaginal ring conducted between August 2012 and June 2015 among 2629 African women. Phase I/II studies established that greater than 4 mg of dapivirine on average is released from the ring when used consistently over 28 days and ≤0.9 mg released suggested non-use. We assessed the relative risk reduction associated with levels of ring use using residual dapivirine in returned rings as a time-dependent covariate for HIV-1 infection in multivariable Cox models, including multiple exploratory analyses designed to estimate upper limits of efficacy given uncertainty in timing of HIV-1 acquisition. All models were adjusted for baseline covariates associated with HIV risk and adherence. RESULTS Residual dapivirine levels indicating at least some use (>0.9 mg released over a month) were associated with a 48% relative reduction in HIV-1 acquisition risk (95% confidence interval (CI): 21% to 66%; p = 0.002) compared to the placebo. Exploratory analyses accounting for potential misclassification in timing of HIV-1 acquisition estimated 75% to 91% HIV-1 risk reduction with> 4 mg released when compared to placebo. Results limited to the subgroup of women <25 years of age, who tended to have lower adherence, were generally consistent to those overall. CONCLUSIONS Residual dapivirine levels, an objective measure of adherence, were correlated with HIV-1 protection in a secondary analysis of a randomized trial. Periods of ring use were associated with approximately 50% protection, with exploratory analyses suggesting higher protection with more consistent use. The dapivirine vaginal ring is the first method to fulfil the promise of a fully reversible, long-acting, woman-initiated approach for discreet HIV-1 prevention.
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Affiliation(s)
- Elizabeth R Brown
- Vaccine and Infectious Disease and Public Health Sciences DivisionsFred Hutchinson Cancer Research CenterSeattleWAUSA
- Department of BiostatisticsUniversity of WashingtonSeattleWAUSA
| | - Craig W Hendrix
- Department of MedicineJohns Hopkins UniversityBaltimoreMDUSA
| | | | - Flavia M Kiweewa
- Makerere University‐Johns Hopkins University Research CollaborationKampalaUganda
| | - Nyaradzo M Mgodi
- University of Zimbabwe College of Health Sciences Clinical Trials Research CentreHarareZimbabwe
| | - Thesla Palanee‐Philips
- Wits Reproductive Health and HIV Research InstituteSchool of Clinical MedicineUniversity of the WitswatersrandJohannesburgSouth Africa
| | - Mark A Marzinke
- Department of MedicineJohns Hopkins UniversityBaltimoreMDUSA
| | - Linda‐Gail Bekker
- Desmond Tutu HIV Foundation Clinical Research SiteCape TownSouth Africa
| | - Lydia Soto‐Torres
- Division of AIDSNational Institute of Allergy and Infectious DiseasesNational Institutes of HealthBethesdaMDUSA
| | - Sharon L Hillier
- Department of Obstetrics, Gynecology and Reproductive SciencesUniversity of Pittsburgh School of Medicine and Magee‐Womens Research InstitutePittsburghPAUSA
| | - Jared M Baeten
- Departments of Medicine, Epidemiology, and Global HealthUniversity of WashingtonSeattleWAUSA
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50
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Konstantinus IN, Balle C, Jaumdally SZ, Galmieldien H, Pidwell T, Masson L, Tanko RF, Happel AU, Sinkala M, Myer L, Bosinger SE, Gill K, Bekker LG, Jaspan HB, Passmore JAS. Impact of Hormonal Contraceptives on Cervical T-helper 17 Phenotype and Function in Adolescents: Results from a Randomized, Crossover Study Comparing Long-acting Injectable Norethisterone Oenanthate (NET-EN), Combined Oral Contraceptive Pills, and Combined Contraceptive Vaginal Rings. Clin Infect Dis 2020; 71:e76-e87. [PMID: 31675420 PMCID: PMC7755094 DOI: 10.1093/cid/ciz1063] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 10/25/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Adolescents in sub-Saharan Africa are at risk for human immunodeficiency virus (HIV) infection and unintended pregnancies. Observational studies suggest that injectable hormonal contraceptives (HCs) increase the HIV risk, although their effects on genital inflammation, particularly HIV-susceptible T-helper 17 (Th17) cells, are unknown. In a randomized crossover study, the effect of injectable norethisterone oenanthate (NET-EN), combined contraceptive vaginal rings (CCVR; NuvaRing), and combined oral contraceptive pills (COCPs) on cervical Th17 cells and cytokines were compared. METHODS Adolescents (n = 130; 15-19 years) were randomly assigned 1:1:1 to NET-EN, CCVR, or COCPs for 16 weeks, then subsequently crossed over to another HC for 16 weeks. Estrogen, follicular stimulating hormone (FSH), and luteinizing hormone (LH) levels were measured. Chemokine receptor 5 (CCR5), human leukocyte antigen (HLA) DR isotope, and cluster of differentiation 38 (CD38) expression by cervical cytobrush-derived CD4+ T cells was assessed by fluorescence-activated cell sorting. Th17 cells were defined as CCR6+ and CCR10-. Cervicovaginal Th17-related cytokines were measured by Luminex. RESULTS CCVR use for the first 16 weeks was associated with reduced Th17 frequencies and lower FSH and LH concentrations, as compared to NET-EN and COCPs, with FSH concentrations and Th17 frequencies correlating significantly. However, Th17-related cytokine concentrations (interleukin [IL]-21, IL-1β, tumor necrosis factor-α, interferon-γ) and CCR5, HLA-DR, CD38, and Th17 frequencies were significantly higher in CCVR than NET-EN and COCP. At crossover, CCVR users changing to COCPs or NET-EN did not resolve activation or cytokines, although switching from COCP to CCVRs increased cytokine concentrations. CONCLUSIONS CCVR use altered endogenous hormone levels and associated cervical Th17 cell frequencies to a greater extent than use of NET-EN or COCPs, although Th17 cells were more activated and Th17-related cytokine concentrations were elevated. While CCVRs may impact the HIV risk by regulating Th17 numbers, increased activation and inflammation may balance any risk gains.
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Affiliation(s)
- Iyaloo N Konstantinus
- Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Christina Balle
- Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Shameem Z Jaumdally
- Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Hoyam Galmieldien
- Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Tanya Pidwell
- Desmond Tutu Human Immunodeficiency Virus Centre, University of Cape Town, Cape Town, South Africa
| | - Lindi Masson
- Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Ramla F Tanko
- Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Anna-Ursula Happel
- Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Musalula Sinkala
- Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Landon Myer
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Steven E Bosinger
- Department of Pathology & Laboratory Medicine, Emory University School of Medicine, Atlanta, USA
- Division of Microbiology and Immunology, Yerkes National Primate Research Center, Atlanta, USA
| | - Katherine Gill
- Desmond Tutu Human Immunodeficiency Virus Centre, University of Cape Town, Cape Town, South Africa
| | - Linda-Gail Bekker
- Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Desmond Tutu Human Immunodeficiency Virus Centre, University of Cape Town, Cape Town, South Africa
| | - Heather B Jaspan
- Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Seattle Children’s Research Institute, Seattle, Washington, USA
- University of Washington Department of Pediatrics and Global Health, Seattle, Washington, USA
| | - Jo-Ann S Passmore
- Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- National Health Laboratory Service, Cape Town, South Africa
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