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Kestelyn E, Van Nuil JI, Umulisa MM, Umutoni G, Uwingabire A, De Baetselier I, Uwineza M, Agaba S, Crucitti T, Delvaux T, van de Wijgert JHHM. High adherence to intermittent and continuous use of a contraceptive vaginal ring among women in a randomized controlled trial in Kigali, Rwanda. Front Glob Womens Health 2024; 5:1278981. [PMID: 38680542 PMCID: PMC11047128 DOI: 10.3389/fgwh.2024.1278981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 03/20/2024] [Indexed: 05/01/2024] Open
Abstract
Background The introduction of female-initiated drug-delivery methods, including vaginal rings, have proven to be a promising avenue to address sexually transmitted infections and unintended pregnancies, which disproportionally affects women and girls in sub-Saharan Africa. Efficient uptake of existing and new technologies such as vaginal rings requires in depth understanding of product adherence. This remains a major challenge as data on adherence to vaginal rings from African countries is limited. In this study, we explored adherence of contraceptive vaginal ring (NuvaRing®) use in Kigali, Rwanda using a mixed methods approach. Methods We collected quantitative and qualitative data at multiple time points from women participating in a clinical trial exploring the safety and acceptability of either intermittent or continuous use of the NuvaRing®. Various adherence categories were used including monthly and cumulative adherence measurement. The quantitative data were analysed using R and the qualitative data were analysed using a deductive, content-analytical approach based on categories related to the quantitative adherence measures. All data were compared and triangulated. Results Data from 120 enrolled participants showed that self-reported adherence was high at every study visit in both study groups. At first study visit 80% of the intermittent ring users and 79.7% of the continuous ring users reported perfect adherence (assessed as "the ring was never out"). Reporting of ring expulsions and removals were highest (28.3%) at the beginning of the trial. Self-reported perfect ring adherence increased during the study and reports of ring expulsions and removals declined as familiarity with this contraceptive method increased. The percentage of women with perfect cumulative adherence was non-significantly higher in the intermittent (61.7%) than in the continuous use group (54.3%). The low rate of discrepant adherence data after triangulation (6%) is in line with the perception of the participants as adherent throughout the study. Conclusions Self-reported adherence in both study groups was high with removals and expulsions being within the expected product range. Comprehensive adherence data triangulation allowed for a deeper understanding of context-driven behaviour that shaped adherence patterns and challenges. Our data categorisation and triangulation approach has shown potential for implementation in future vaginal ring studies aiming to better understand and measure adherence.
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Affiliation(s)
- Evelyne Kestelyn
- Rinda Ubuzima, Kigali, Rwanda
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | - Jennifer Ilo Van Nuil
- Rinda Ubuzima, Kigali, Rwanda
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | | | | | | | - Irith De Baetselier
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | | | | | - Tania Crucitti
- Experimental Bacteriology Unit, Institut Pasteur Madagascar, Antananarivo, Madagascar
| | - Thérèse Delvaux
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Janneke H. H. M. van de Wijgert
- Rinda Ubuzima, Kigali, Rwanda
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
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Johnson LF, Myer L, Jamieson L, Meyer-Rath G, Delany-Moretlwe S, Joseph Davey D. The potential benefits of long-acting injectable cabotegravir in pregnant and breastfeeding women and their infants. AIDS 2024; 38:589-594. [PMID: 38016171 PMCID: PMC10906189 DOI: 10.1097/qad.0000000000003803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 11/21/2023] [Accepted: 11/23/2023] [Indexed: 11/30/2023]
Abstract
BACKGROUND Pregnant and breastfeeding women (PBW) in sub-Saharan Africa have high HIV incidence rates and associated risk of vertical transmission to their infants. Oral preexposure prophylaxis (PrEP) and injectable PrEP (long-acting cabotegravir, or CAB-LA) can potentially reduce this HIV transmission, but population-level impacts are uncertain. METHODS We extended a previously developed model of HIV and PrEP in South Africa to allow for variable PrEP duration and preference in PBW. We considered three potential scenarios for PrEP provision to PBW: oral PrEP only, CAB-LA only, and allowing oral/CAB-LA choice, with uptake and retention assumptions informed by South African data, each compared with a 'base' scenario without PrEP for PBW. RESULTS Without PrEP for PBW, the model estimates 1.31 million new infections will occur between 2025 and 2035 in South African adults and children, including 100 000 in PBW, 16 800 in infants at/before birth, and 35 200 in children through breastmilk. In the oral PrEP-only scenario, these numbers would reduce by 1.2% (95% CI: 0.7-1.7%), 8.6% (4.8-12.9%), 4.0% (2.1-5.8%), and 5.3% (3.0-8.2%) respectively. In the CAB-LA-only scenario, the corresponding reductions would be 6.1% (2.9-9.6%), 41.2% (19.8-65.0%), 12.6% (6.0-19.4%), and 29.5% (13.9-46.8%), respectively, and in the oral/CAB-LA choice scenario, similar reductions would be achieved [5.6% (3.4-8.0%), 39% (23.4-55.9%), 12.4% (7.4-16.8%) and 27.6% (16.5-39.9%) respectively]. CONCLUSION CAB-LA has the potential to be substantially more effective than oral PrEP in preventing HIV acquisition in PBW and vertical transmission, and can also modestly reduce HIV incidence at a population level.
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Affiliation(s)
| | - Landon Myer
- Division of Epidemiology and Biostatistics, School of Public Health, University of Cape Town, Cape Town
| | - Lise Jamieson
- Health Economics and Epidemiology Research Office, University of Witwatersrand, Johannesburg, South Africa
- Department of Medical Microbiology, Amsterdam University Medical Centre, Amsterdam, Netherlands
- The South African Department of Science and Innovation/National Research Foundation Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa
| | - Gesine Meyer-Rath
- Health Economics and Epidemiology Research Office, University of Witwatersrand, Johannesburg, South Africa
- The South African Department of Science and Innovation/National Research Foundation Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa
- Department of Global Health, Boston University, Boston, MA, USA
| | | | - Dvora Joseph Davey
- Division of Epidemiology and Biostatistics, School of Public Health, University of Cape Town, Cape Town
- Division of Infectious Diseases, Geffen School of Medicine, University of California Los Angeles, Los Angeles CA, USA
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Friedland BA, Mgodi NM, Palanee-Phillips T, Mathur S, Plagianos MG, Bruce IV, Lansiaux M, Murombedzi C, Musara P, Dandadzi A, Reddy K, Ndlovu N, Zulu SK, Shale LR, Zieman B, Haddad LB. Assessing the acceptability of, adherence to and preference for a dual prevention pill (DPP) for HIV and pregnancy prevention compared to oral pre-exposure prophylaxis (PrEP) and oral contraception taken separately: protocols for two randomised, controlled, cross-over studies in South Africa and Zimbabwe. BMJ Open 2024; 14:e075381. [PMID: 38479746 PMCID: PMC10936506 DOI: 10.1136/bmjopen-2023-075381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 02/07/2024] [Indexed: 03/17/2024] Open
Abstract
INTRODUCTION Oral pre-exposure prophylaxis (PrEP) is a highly effective HIV prevention method; however, uptake and persistence have been low among southern African women. A dual prevention pill (DPP) that combines PrEP with oral contraception (OC) may increase PrEP use and better meet women's sexual and reproductive health needs. We will gauge the DPP's acceptability in two cross-over clinical trials. METHODS AND ANALYSIS PC952 (Zimbabwe) and PC953 (South Africa) will compare acceptability, adherence and preference for an over-encapsulated DPP versus PrEP and OCs taken separately. HIV-negative, non-pregnant cisgender females in Johannesburg, South Africa (n=96, 16-40 years) and Harare, Zimbabwe (n=30, 16-24 years) will be randomised 1:1 to the order of regimens-DPP or two separate tablets-each used for three 28-day cycles, followed by a 6-month choice period in South Africa. Monthly clinic visits include HIV and pregnancy testing; safety assessments and risk reduction and adherence counselling. We will assess adherence (monthly) based on tenofovir diphosphate drug levels in dried blood spots and by self-report. We will evaluate acceptability (monthly) and preference (end of cross-over) via computer-assisted self-interviewing and in-depth interviews with a subset of participants. Data collection started in September 2022 and ended in January 2024. ETHICS AND DISSEMINATION PC952 was approved by the Ministry of Health and Child Care, Medical Research Council, Research Council and Medicines Control Authority of Zimbabwe; the Chitungwiza City Health Ethics Committee; and the Joint Research Ethics Committee for the University of Zimbabwe Faculty of Medicine and Health Sciences and Parirenyatwa Group of Hospitals. PC953 was approved by the South African Health Products Regulatory Authority and the University of the Witwatersrand's Human Research Ethics Committee. The Population Council IRB approved both studies. We will disseminate results in open-access journals, clinical trials registries, and at local and international meetings and conferences. TRIAL REGISTRATION NUMBERS NCT04778514, NCT04778527.
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Affiliation(s)
| | - Nyaradzo M Mgodi
- University of Zimbabwe - Clinical Trials Research Centre, Harare, Zimbabwe
| | - Thesla Palanee-Phillips
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Faculty of Health Sciences, School of Public Health, Johannesburg, South Africa
- University of Washington, Department of Epidemiology, School of Public Health, Seattle, Washington, USA
| | | | | | - Irene V Bruce
- Population Council, Center for Biomedical Research, New York, New York, USA
| | - Maud Lansiaux
- Population Council, Center for Biomedical Research, New York, New York, USA
| | | | - Petina Musara
- University of Zimbabwe - Clinical Trials Research Centre, Harare, Zimbabwe
| | - Adlight Dandadzi
- University of Zimbabwe - Clinical Trials Research Centre, Harare, Zimbabwe
| | - Krishnaveni Reddy
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Faculty of Health Sciences, School of Public Health, Johannesburg, South Africa
| | - Nkosiphile Ndlovu
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Faculty of Health Sciences, School of Public Health, Johannesburg, South Africa
| | - Sihle K Zulu
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Faculty of Health Sciences, School of Public Health, Johannesburg, South Africa
| | - Lerato R Shale
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Faculty of Health Sciences, School of Public Health, Johannesburg, South Africa
| | - Brady Zieman
- Population Council, Center for Biomedical Research, New York, New York, USA
| | - Lisa B Haddad
- Population Council, Center for Biomedical Research, New York, New York, USA
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Wong CM, Munthali T, Mangunje FG, Katoka ML, Burke HM, Musonda B, Musonda M, Todd CS. Creating allies: qualitative exploration of young women's preferences for PrEP methods and parents' role in PrEP uptake and user support in urban and rural Zambia. BMC Womens Health 2024; 24:71. [PMID: 38273282 PMCID: PMC10809647 DOI: 10.1186/s12905-024-02913-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 01/17/2024] [Indexed: 01/27/2024] Open
Abstract
BACKGROUND Zambian adolescent girls and young women (AGYW) have high HIV incidence and face barriers to the use of pre-exposure prophylaxis (PrEP). Parental support improves PrEP use and adherence in some settings, but negative parental attitudes toward HIV prevention may inhibit engagement with AGYW. We explored perceptions of future PrEP methods among AGYW and parents and parent-youth engagement on HIV prevention and PrEP use. METHODS We conducted a qualitative descriptive study among AGYW and parents of AGYW in five provinces in Zambia in September-October 2021. We conducted 10 focus group discussions (FGDs) and four in-depth interviews (IDIs) with AGYW participants (n = 87) and seven FGDs and four IDIs among parents of AGYW (n = 62). All FGDs and IDIs were audio-recorded, transcribed verbatim, and analyzed to identify qualitative themes. RESULTS Most AGYW participants preferred the discreet nature and longer duration of injectable PrEP compared to the PrEP ring and oral PrEP. Many AGYWs reported inability to disclose PrEP use to their parents due to lack of parental support based on cultural taboos against premarital sex. Nevertheless, AGYW participants said they would like to talk to their parents about PrEP so their parents could support their use. Many parents also described difficulties discussing PrEP with their daughters because of cultural and religious beliefs about abstinence from sex before marriage. However, parents acknowledged that the threat of HIV is real and said they need PrEP knowledge and guidance on speaking with their children about HIV prevention and PrEP. CONCLUSIONS Although many parents are currently not playing a role in daughters' decisions about PrEP use, both parents and AGYW are willing to engage with each other on HIV prevention issues. To foster parent-child engagement, HIV prevention programs should not only provide information about PrEP but also address social norms that impede discussion of HIV prevention and equip both parents and AGYW with skills and support for such conversations. Community sensitization is also needed as new PrEP products are introduced, to create an enabling environment for parent-child engagement by increasing awareness, countering misconceptions, and reducing stigma.
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Affiliation(s)
- Christina Misa Wong
- Global Health & Population, FHI 360, 359 Blackwell Street, Suite 200, Durham, NC, 27701, USA.
| | - Tendai Munthali
- Ministry of Health, Government of the Republic of Zambia, Ndeke House, Haile Selassie Avenue, P.O. Box 30205, Lusaka, Zambia
| | - Featherstone G Mangunje
- FHI 360 Zambia, Tiyende Pamodzi Road, Off Nangwenya Road, Farmers Village, Showgrounds Area, P.O. Box 320303, Lusaka, 10101, Zambia
| | - Mercy L Katoka
- FHI 360 Zambia, Tiyende Pamodzi Road, Off Nangwenya Road, Farmers Village, Showgrounds Area, P.O. Box 320303, Lusaka, 10101, Zambia
| | - Holly M Burke
- Reproductive, Maternal, Newborn, and Child Health, FHI 360, 359 Blackwell Street, Suite 200, Durham, NC, 27701, USA
| | - Bupe Musonda
- Ministry of Health, Government of the Republic of Zambia, Ndeke House, Haile Selassie Avenue, P.O. Box 30205, Lusaka, Zambia
| | - Musonda Musonda
- United States Agency for International Development (USAID), Embassy of the United States of America, Subdivision 694/Stand 100 Ibex Hill Road, P.O. Box 320373, Lusaka, 10101, Zambia
| | - Catherine S Todd
- Global Health & Population, FHI 360, 359 Blackwell Street, Suite 200, Durham, NC, 27701, USA
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Fynn L, Gill K, Wallace M, Atujuna M, Duyver M, Ngcobo P, Spiegel H, Rinehart A, Hosek S, Bekker LG. "It's already in your body and it's preventing": a qualitative study of African female adolescent's acceptability and preferences for proxy HIV prevention methods in Cape Town, South Africa. BMC Public Health 2023; 23:2143. [PMID: 37919697 PMCID: PMC10621226 DOI: 10.1186/s12889-023-16955-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 10/06/2023] [Indexed: 11/04/2023] Open
Abstract
BACKGROUND Advances in biomedical HIV prevention will soon offer young women a choice of HIV prevention methods, including various pre-exposure prophylaxis (PrEP) modalities such as daily oral pills, dapivirine vaginal ring, and long-acting injectable agents. By understanding preferences for contraceptive methods, we may draw analogies for the HIV prevention needs of young women. The UChoose Study was an open-label randomised cross-over study designed to evaluate the acceptability and preference for several contraceptive options as a proxy for HIV prevention methods that use similar types of administration. The study enrolled healthy HIV uninfected young women aged 15 to 19 years. At enrolment, participants were randomly assigned to a contraceptive method for a period of 16 weeks in the form of monthly Nuvaring® (vaginal ring), daily combined oral contraceptive (daily pills), or bi-monthly injectable contraceptive (injectable). After 16 weeks, participants crossed over to another contraceptive method, and those who had received the injectable and the daily pills received the vaginal ring for another 16 weeks, whereas those who had received the vaginal ring were able to choose between the injectable and daily pills, to ensure that all participants tried the vaginal ring-the least familiar option to the study population. RESULTS Thirty-three participants were purposively recruited to participate in seven focus group discussions (FGD) and completed a pre-survey for their assigned group. Our sample comprised 14 participants randomised to use of the vaginal ring and daily pills and 19 participants randomised to use of the vaginal ring and injectable. For most participants, their preferences for a prevention method were based primarily on their desire to avoid negative aspects of one method rather than their positive user experience with another method. Most participants expressed initial hesitancy for trying new contraception method products; however, a lack of familiarity was moderated by a strong interest in diverse user-controlled prevention methods. Participants valued methods that had infrequent dosing and simplified use requirements. The injection and vaginal ring were preferred over daily pills as a potential HIV prevention method. CONCLUSION Expanding the availability of diverse products could provide adolescents with multiple choices in HIV prevention for the uninitiated. TRIAL REGISTRATION ClinicalTrials.gov ( NCT02404038 ). Registered March 31, 2015-Registered.
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Affiliation(s)
- Lauren Fynn
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa.
| | - Katherine Gill
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Melissa Wallace
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Millicent Atujuna
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Menna Duyver
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Penelope Ngcobo
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Hans Spiegel
- Department of Health and Human Services, Kelly Government Solutions, Contractor to National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD, USA
| | | | - Sybil Hosek
- Stroger Hospital of Cook County, Chicago, IL, USA
| | - Linda-Gail Bekker
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
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Shapley-Quinn MK, Song M, Chen BA, Devlin B, Luecke E, Brown J, Blithe DL, Achilles SL, van der Straten A. Participant experiences with a multipurpose vaginal ring for HIV and pregnancy prevention during a phase 1 clinical trial: learning from users to improve acceptability. FRONTIERS IN REPRODUCTIVE HEALTH 2023; 5:1147628. [PMID: 37484873 PMCID: PMC10359149 DOI: 10.3389/frph.2023.1147628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 06/01/2023] [Indexed: 07/25/2023] Open
Abstract
Introduction With high concurrent global rates of HIV incidence and unintended pregnancy, there is a need to provide options beyond condoms to enable users to simultaneously prevent HIV acquisition and pregnancy. Multiple vaginal rings are in development as "MPTs" (multipurpose prevention technologies) as they are shown to provide several co-occurring benefits such as discretion, convenience, reversibility and user control. Methods In this Phase 1 trial of a 3-month MPT ring in the U.S., 25 participants (low-risk for HIV and pregnancy) were randomized to use the study ring for 90 days continuously or in 28-day cycles with 2-day removal periods in between. All participants completed in-depth interviews at the end of their study participation. Results Overall, the ring was well tolerated. Participants resoundingly endorsed the concept of an extended-use, dual-purpose vaginal ring, but reported too many functional challenges and side effects to endorse this particular ring. Participants assigned to the continuous regimen reported more positive experiences with ring use than those in the cyclic group. A minority of participants who experienced minimal side effects and did not experience challenges with vaginal retention of the ring found it appealing. However, the majority of participants experienced challenges (ring slippage, expulsions, side effects, vaginal bleeding changes) with product use that outweighed the potential benefits and led them to report that - in the future - they would not be interested in using this specific version of the ring in its current form. A subset expressed interest in using the current MPT ring under certain conditions (e.g., if fewer expulsions, less bleeding, higher risk for HIV/pregnancy). Discussion User feedback regarding participant experiences and challenges with the study ring was continuously shared with the product developer, underscoring the value of early-stage end-user feedback in product development.
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Affiliation(s)
| | - Mei Song
- Magee-Womens Research Institute, Pittsburgh, PA, United States
| | - Beatrice A. Chen
- Magee-Womens Research Institute, Pittsburgh, PA, United States
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh, School of Medicine, Pittsburgh, PA, United States
| | - Brid Devlin
- Center for Biomedical Research, Population Council, New York, NY, United States
| | - Ellen Luecke
- Women’s Global Health Imperative, RTI International, Berkeley, CA, United States
| | - Jill Brown
- Contraceptive Development Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, United States
| | - Diana L. Blithe
- Contraceptive Development Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, United States
| | - Sharon L. Achilles
- Magee-Womens Research Institute, Pittsburgh, PA, United States
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh, School of Medicine, Pittsburgh, PA, United States
| | - Ariane van der Straten
- Center for AIDS Prevention Studies, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
- ASTRA Consulting, Kensington, CA, United States
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Dietrich JJ, Ahmed N, Tshabalala G, Wu M, Mulaudzi M, Hornschuh S, Atujuna M, Muhumuza R, Ssemata AS, Stranix-Chibanda L, Nematadzira T, Bekker LG, Martinson N, Seeley J, Fox J. A qualitative study to explore daily versus on-demand oral pre-exposure prophylaxis (PrEP) in young people from South Africa, Uganda and Zimbabwe. PLoS One 2023; 18:e0287627. [PMID: 37384792 PMCID: PMC10310032 DOI: 10.1371/journal.pone.0287627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Accepted: 06/12/2023] [Indexed: 07/01/2023] Open
Abstract
BACKGROUND Adolescents in sub-Saharan Africa (SSA) remain vulnerable to HIV infection. While pre-exposure prophylaxis (PrEP) is highly effective in preventing HIV transmission as a daily or on-demand regimen, tailored approaches are necessary. The Combined HIV Adolescent PrEP and Prevention Study (CHAPS) is a mixed-methods research program investigating the acceptability and feasibility of implementing daily and on-demand PrEP among young people in SSA. It also aims to determine an on-demand dosing schedule for insertive sex. For this paper, we explored preferences for daily versus on-demand PrEP amongst adolescents as part of CHAPS. METHODS Purposive sampling was used to recruit participants from Soweto and Cape Town (South Africa), Wakiso district (Uganda) and Chitungwiza (Zimbabwe). At the time of the study in 2018/2019, Uganda had not rolled out PrEP to the general population; in Zimbabwe, PrEP for young people was only available at selected sites with one located within the study recruitment area. In South Africa, PrEP was made available to selected high-risk groups. We conducted 60 in-depth interviews and 24 group discussions amongst young people aged 13-24 without HIV in South Africa, Uganda, and Zimbabwe. All in-depth interviews and group discussions were audio-recorded, transcribed verbatim and translated to English. Data were analysed using framework analysis. The main themes were centered around preferences for daily and on-demand PrEP. RESULTS Reasons for on-demand preferences included stigma, pill fatigue, adherence and side effects. Reasons for daily PrEP preferences included factors related to sexual risk behaviour, continuous protection against incidents of unintentional exposure, and the increased efficacy of a daily dose. Participants at all sites preferring daily PrEP identified the same reasons, with more males than females citing inadvertent blood contact or perceived increased efficacy. Similarly, participants at all sites preferring on-demand PrEP gave the same reasons for their preferences for on-demand PrEP; the exception was South Africans who did not mention the hope of having fewer side effects by not taking daily PrEP. Additionally, more males than females cited intermittent sex as a reason for opting for on-demand PrEP. CONCLUSIONS Our study is the first known to explore and describe youth preferences for daily versus on-demand PrEP. While the choice is clear-cut, the reasons cited in the different options provide invaluable insights into their decisions, and the actual and perceived facilitators and barriers to access to PrEP. Further education is needed amongst young people, not only about PrEP but also in other areas of comprehensive sexuality education. Exploring all options of HIV prevention is crucial to provide a tailored, one-size-does-not-fit-all approach to adolescent care in SSA to reduce and, the continued and increasing risk of this preventable infection.
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Affiliation(s)
- Janan Janine Dietrich
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Health Systems Research Unit, South African Medical Research Council, Bellville, South Africa
- African Social Sciences Unit of Research and Evaluation (ASSURE), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Nadia Ahmed
- Mortimer Market Centre, Central North West London NHS Trust, London, United Kingdom
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Gugulethu Tshabalala
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Minju Wu
- Harvard College, Cambridge, MA, United States of America
| | - Mamakiri Mulaudzi
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Stefanie Hornschuh
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Millicent Atujuna
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Richard Muhumuza
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene & Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Andrew Sentoogo Ssemata
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene & Tropical Medicine Uganda Research Unit, Entebbe, Uganda
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Lynda Stranix-Chibanda
- University of Zimbabwe Clinical Trials Research Centre, Faculty of Medicine and Health Sciences, Harare, Zimbabwe
| | - Teacler Nematadzira
- University of Zimbabwe Clinical Trials Research Centre, Faculty of Medicine and Health Sciences, Harare, Zimbabwe
| | - Linda-Gail Bekker
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Neil Martinson
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Janet Seeley
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene & Tropical Medicine Uganda Research Unit, Entebbe, Uganda
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Julie Fox
- King’s College London, London, United Kingdom
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Happel AU, Balle C, Havyarimana E, Brown B, Maust BS, Feng C, Yi BH, Gill K, Bekker LG, Passmore JAS, Jaspan HB, Varsani A. Cervicovaginal Human Papillomavirus Genomes, Microbiota Composition and Cytokine Concentrations in South African Adolescents. Viruses 2023; 15:758. [PMID: 36992467 PMCID: PMC10054107 DOI: 10.3390/v15030758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 03/10/2023] [Accepted: 03/13/2023] [Indexed: 03/18/2023] Open
Abstract
The interaction between cervicovaginal virome, bacteriome and genital inflammation has not been extensively investigated. We assessed the vaginal DNA virome from 33 South African adolescents (15-19 years old) using shotgun DNA sequencing of purified virions. We present analyses of eukaryote-infecting DNA viruses, with a focus on human papillomavirus (HPV) genomes and relate these to the vaginal bacterial microbiota (assessed by 16S rRNA gene sequencing) and cytokines (assessed by Luminex). The DNA virome included single-stranded (Anelloviridae, Genomoviridae) and double-stranded DNA viruses (Adenoviridae, Alloherpesviridae, Herpesviridae, Marseilleviridae, Mimiviridae, Polyomaviridae, Poxviridae). We identified 110 unique, complete HPV genomes within two genera (Alphapapillomavirus and Gammapapillomavirus) representing 40 HPV types and 12 species. Of the 40 HPV types identified, 35 showed positive co-infection patterns with at least one other type, mainly HPV-16. HPV-35, a high-risk genotype currently not targeted by available vaccines, was the most prevalent HPV type identified in this cohort. Bacterial taxa commonly associated with bacterial vaginosis also correlated with the presence of HPV. Bacterial vaginosis, rather than HPV, was associated with increased genital inflammation. This study lays the foundation for future work characterizing the vaginal virome and its role in women's health.
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Affiliation(s)
- Anna-Ursula Happel
- Department of Pathology, University of Cape Town, Anzio Road, Observatory, Cape Town 7925, South Africa
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Anzio Road, Observatory, Cape Town 7925, South Africa
| | - Christina Balle
- Department of Pathology, University of Cape Town, Anzio Road, Observatory, Cape Town 7925, South Africa
| | - Enock Havyarimana
- Department of Pathology, University of Cape Town, Anzio Road, Observatory, Cape Town 7925, South Africa
| | - Bryan Brown
- Seattle Children’s Research Institute, 307 Westlake Ave. N, Seattle, WA 98109, USA
- Department of Pediatrics, University of Washington, 1510 San Juan Road NE, Seattle, WA 98195, USA
| | - Brandon S. Maust
- Seattle Children’s Research Institute, 307 Westlake Ave. N, Seattle, WA 98109, USA
- Department of Pediatrics, University of Washington, 1510 San Juan Road NE, Seattle, WA 98195, USA
| | - Colin Feng
- Seattle Children’s Research Institute, 307 Westlake Ave. N, Seattle, WA 98109, USA
| | - Byung H. Yi
- Seattle Children’s Research Institute, 307 Westlake Ave. N, Seattle, WA 98109, USA
| | - Katherine Gill
- Desmond Tutu Health Foundation, 3 Woodlands Rd, Woodstock, Cape Town 7915, South Africa
| | - Linda-Gail Bekker
- Desmond Tutu Health Foundation, 3 Woodlands Rd, Woodstock, Cape Town 7915, South Africa
| | - Jo-Ann S. Passmore
- Department of Pathology, University of Cape Town, Anzio Road, Observatory, Cape Town 7925, South Africa
- National Health Laboratory Service, Observatory, Cape Town 7925, South Africa
- NRF-DST Center of Excellence in HIV Prevention, Centre for the AIDS Programme of Research in South Africa, 719 Umbilo Road, Congella, Durban 4013, South Africa
| | - Heather B. Jaspan
- Department of Pathology, University of Cape Town, Anzio Road, Observatory, Cape Town 7925, South Africa
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Anzio Road, Observatory, Cape Town 7925, South Africa
- Seattle Children’s Research Institute, 307 Westlake Ave. N, Seattle, WA 98109, USA
- Department of Pediatrics, University of Washington, 1510 San Juan Road NE, Seattle, WA 98195, USA
- Department of Global Health, University of Washington, 1959 NE Pacific St., Seattle, WA 98195, USA
| | - Arvind Varsani
- The Biodesign Center for Fundamental and Applied Microbiomics, Center for Evolution and Medicine and School of Life Sciences, Arizona State University, Tempe, AZ 85287, USA
- Structural Biology Research Unit, Department of Integrative Biomedical Sciences, University of Cape Town, Observatory, Cape Town 7925, South Africa
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Jimoh AO, Balle C, Brown B, Feng C, Havyarimana E, Konstantinus IN, Gill K, Bekker LG, Passmore JAS, Jaspan HB, Varsani A, Happel AU. Genome Sequences of Anelloviruses, a Genomovirus, Microviruses, Polyomaviruses, and an Unclassified Caudovirus Identified in Vaginal Secretions from South African Adolescents. Microbiol Resour Announc 2023; 12:e0114322. [PMID: 36533922 PMCID: PMC9872636 DOI: 10.1128/mra.01143-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 12/03/2022] [Indexed: 12/23/2022] Open
Abstract
Other than for papillomaviruses, there is a paucity of whole-genome sequences for bacteriophages and eukaryote-infecting viruses isolated from the female genital tract. Here, we report the genome sequences of 16 microviruses, 3 anelloviruses, 2 polyomaviruses, 1 genomovirus, and 1 caudovirus that were identified in vaginal secretion samples from adolescents in South Africa.
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Affiliation(s)
- Adijat O. Jimoh
- Department of Pathology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Genetics, Genomics, and Bioinformatics Department, National Biotechnology Development Agency, Abuja, Nigeria
| | - Christina Balle
- Department of Pathology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Bryan Brown
- Seattle Children’s Research Institute, Seattle, Washington, USA
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
| | - Colin Feng
- Seattle Children’s Research Institute, Seattle, Washington, USA
| | - Enock Havyarimana
- Department of Pathology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- School of Infection and Immunity, University of Glasgow, Glasgow, United Kingdom
| | - Iyaloo N. Konstantinus
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Namibia Institute of Pathology, Windhoek, Namibia
- NRF-DST Centre of Excellence in HIV Prevention, Centre for the AIDS Programme of Research in South Africa, Durban, South Africa
| | | | - Linda-Gail Bekker
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Jo-Ann S. Passmore
- Department of Pathology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
- National Health Laboratory Service, Cape Town, South Africa
- Division of Medical Virology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Heather B. Jaspan
- Department of Pathology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Seattle Children’s Research Institute, Seattle, Washington, USA
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Arvind Varsani
- The Biodesign Center for Fundamental and Applied Microbiomics, Center for Evolution and Medicine and School of Life Sciences, Arizona State University, Tempe, Arizona, USA
- Structural Biology Research Unit, Department of Integrative Biomedical Sciences, University of Cape Town, Cape Town, South Africa
| | - Anna-Ursula Happel
- Department of Pathology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
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10
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Duby Z, Bunce B, Fowler C, Jonas K, Bergh K, Govindasamy D, Wagner C, Mathews C. "These Girls Have a Chance to be the Future Generation of HIV Negative": Experiences of Implementing a PrEP Programme for Adolescent Girls and Young Women in South Africa. AIDS Behav 2023; 27:134-149. [PMID: 35793053 PMCID: PMC9258476 DOI: 10.1007/s10461-022-03750-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/06/2022] [Indexed: 01/24/2023]
Abstract
Daily oral pre-exposure prophylaxis (PrEP) is highly efficacious for HIV prevention. Adolescent girls and young women (AGYW) have been prioritised for PrEP delivery in South Africa. A combination HIV prevention intervention providing integrated biomedical, behavioural and structural interventions for AGYW aged 15-24 in twelve districts in South Africa characterised by high HIV prevalence, was implemented 2019-2022. We conducted qualitative interviews to explore PrEP implementation experiences with 38 individuals involved in the implementation of the combination HIV prevention programme, including programme managers and project coordinators, health care providers / nurses, social workers, counsellors, peer group trainers and outreach workers. Narratives included various challenges associated with PrEP uptake, adherence and acceptability experienced by implementers. Barriers to PrEP acceptability included AGYW fears of side effects and preference for injectable versus daily oral PrEP; resistance towards PrEP from AGYW, communities and parents due to a lack of accurate information; PrEP stigma linked to associations with antiretrovirals and assumptions of promiscuity; and issues pertaining to parental consent. Additionally, implementers faced logistical challenges related to procurement, stockouts, and supply of PrEP. Findings highlighted the critical role of parental and community acceptability of PrEP for successful implementation. Overall, PrEP was perceived by implementers as a valuable HIV prevention tool. In order to ensure the accessibility of PrEP for AGYW in South Africa, efforts to reduce stigma and foster social support for PrEP use, campaigns to raise awareness, ensure positive framing of PrEP, and build community acceptability of PrEP, are needed.
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Affiliation(s)
- Zoe Duby
- Health Systems Research Unit, South African Medical Research Council, Francie van Zijl Drive, Parow Valley, Tygerberg, Cape Town, South Africa ,Division of Social and Behavioural Sciences in the School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Brittany Bunce
- Institute for Global Sustainable Development (IGSD), University of Sheffield, Sheffield, United Kingdom
| | - Chantal Fowler
- Division of Social and Behavioural Sciences in the School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Kim Jonas
- Health Systems Research Unit, South African Medical Research Council, Francie van Zijl Drive, Parow Valley, Tygerberg, Cape Town, South Africa
| | - Kate Bergh
- Health Systems Research Unit, South African Medical Research Council, Francie van Zijl Drive, Parow Valley, Tygerberg, Cape Town, South Africa
| | - Darshini Govindasamy
- Health Systems Research Unit, South African Medical Research Council, Francie van Zijl Drive, Parow Valley, Tygerberg, Cape Town, South Africa
| | - Colleen Wagner
- NACOSA (Networking HIV/AIDS Community of South Africa), Cape Town, South Africa
| | - Catherine Mathews
- Health Systems Research Unit, South African Medical Research Council, Francie van Zijl Drive, Parow Valley, Tygerberg, Cape Town, South Africa
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11
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Jamieson L, Johnson LF, Nichols BE, Delany-Moretlwe S, Hosseinipour MC, Russell C, Meyer-Rath G. Relative cost-effectiveness of long-acting injectable cabotegravir versus oral pre-exposure prophylaxis in South Africa based on the HPTN 083 and HPTN 084 trials: a modelled economic evaluation and threshold analysis. Lancet HIV 2022; 9:e857-e867. [PMID: 36356603 PMCID: PMC9708606 DOI: 10.1016/s2352-3018(22)00251-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 08/29/2022] [Accepted: 08/31/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Long-acting injectable cabotegravir, a drug taken every 2 months, has been shown to be more effective at preventing HIV infection than daily oral tenofovir disoproxil fumarate and emtricitabine, but its cost-effectiveness in a high-prevalence setting is not known. We aimed to estimate the incremental cost-effectiveness of long-acting injectable cabotegravir compared with tenofovir disoproxil fumarate and emtricitabine in South Africa, using methods standard to government planning, and to determine the threshold price at which long-acting injectable cabotegravir is as cost-effective as tenofovir disoproxil fumarate and emtricitabine. METHODS In this modelled economic evaluation and threshold analysis, we updated a deterministic model of the South African HIV epidemic with data from the HPTN 083 and HPTN 084 trials to evaluate the effect of tenofovir disoproxil fumarate and emtricitabine and long-acting injectable cabotegravir provision to heterosexual adolescents and young women and men aged 15-24 years, female sex workers, and men who have sex with men. We estimated the average intervention cost, in 2021 US$, using ingredients-based costing, and modelled the cost-effectiveness of two coverage scenarios (medium or high, assuming higher uptake of long-acting injectable cabotegravir than tenofovir disoproxil fumarate and emtricitabine throughout) and, for long-acting injectable cabotegravir, two duration subscenarios (minimum: same pre-exposure prophylaxis duration as for tenofovir disoproxil fumarate and emtricitabine; maximum: longer duration than tenofovir disoproxil fumarate and emtricitabine) over 2022-41. FINDINGS Across long-acting injectable cabotegravir scenarios, 15-28% more new HIV infections were averted compared with the baseline scenario (current tenofovir disoproxil fumarate and emtricitabine roll-out). In scenarios with increased coverage with oral tenofovir disoproxil fumarate and emtricitabine, 4-8% more new HIV infections were averted compared with the baseline scenario. If long-acting injectable cabotegravir drug costs were equal to those of tenofovir disoproxil fumarate and emtricitabine for the same 2-month period, the incremental cost of long-acting injectable cabotegravir to the HIV programme was higher than that of tenofovir disoproxil fumarate and emtricitabine (5-10% vs 2-4%) due to higher assumed uptake of long-acting injectable cabotegravir. The cost per infection averted was $6053-6610 (tenofovir disoproxil fumarate and emtricitabine) and $4471-6785 (long-acting injectable cabotegravir). The cost per long-acting cabotegravir injection needed to be less than twice that of a 2-month supply of tenofovir disoproxil fumarate and emtricitabine to remain as cost-effective, with threshold prices ranging between $9·03 per injection (high coverage; maximum duration) and $14·47 per injection (medium coverage; minimum duration). INTERPRETATION Long-acting injectable cabotegravir could potentially substantially change HIV prevention. However, for its implementation to be financially feasible across low-income and middle-income countries with high HIV incidence, long-acting injectable cabotegravir must be reasonably priced. FUNDING United States Agency for International Development, The Bill & Melinda Gates Foundation.
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Affiliation(s)
- Lise Jamieson
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Department of Medical Microbiology, Amsterdam University Medical Centre, Amsterdam, Netherlands.
| | - Leigh F Johnson
- Centre of Infectious Disease Epidemiology and Research (CIDER), University of Cape Town, Rondebosch, Western Cape, South Africa
| | - Brooke E Nichols
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Department of Medical Microbiology, Amsterdam University Medical Centre, Amsterdam, Netherlands; Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Sinead Delany-Moretlwe
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mina C Hosseinipour
- Division of Infectious Diseases, Department of Medicine, University of North Carolina, Chapel Hill, NC, USA; UNC Project, Lilongwe, Malawi
| | - Colin Russell
- Department of Medical Microbiology, Amsterdam University Medical Centre, Amsterdam, Netherlands; Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Gesine Meyer-Rath
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Department of Global Health, Boston University School of Public Health, Boston, MA, USA
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12
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Johnson LF, Meyer-Rath G, Dorrington RE, Puren A, Seathlodi T, Zuma K, Feizzadeh A. The Effect of HIV Programs in South Africa on National HIV Incidence Trends, 2000-2019. J Acquir Immune Defic Syndr 2022; 90:115-123. [PMID: 35125471 DOI: 10.1097/qai.0000000000002927] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 01/18/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Recent studies have shown HIV incidence declines at a population level in several African countries. However, these studies have not directly quantified the extent to which incidence declines are attributable to different HIV programs. METHODS We calibrated a mathematical model of the South African HIV epidemic to age- and sex-specific data from antenatal surveys, household surveys, and death registration, using a Bayesian approach. The model was also parameterized using data on self-reported condom use, voluntary medical male circumcision (VMMC), HIV testing, and antiretroviral treatment (ART). Model estimates of HIV incidence were compared against the incidence rates that would have been expected had each program not been implemented. RESULTS The model estimated incidence in 15-49 year olds of 0.84% (95% CI: 0.75% to 0.96%) at the start of 2019. This represents a 62% reduction (95% CI: 55% to 66%) relative to 2000, a 47% reduction (95% CI: 42% to 51%) relative to 2010, and a 73% reduction (95% CI: 68% to 77%) relative to the incidence that would have been expected in 2019 in the absence of any interventions. The reduction in incidence in 2019 because of interventions was greatest for ART and condom promotion, with VMMC and behavior change after HIV testing having relatively modest impacts. HIV program impacts differed significantly by age and sex, with condoms and VMMC having greatest impact in youth, and overall incidence reductions being greater in men than in women. CONCLUSIONS HIV incidence in South Africa has declined substantially since 2000, with ART and condom promotion contributing most significantly to this decline.
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Affiliation(s)
- Leigh F Johnson
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine University of Cape Town, Cape Town, South Africa
| | - Gesine Meyer-Rath
- Health Economics and Epidemiology Research Office, Wits Health Consortium, University of Witwatersrand, Johannesburg, South Africa
- Department of Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University School of Public Health, Boston, MA
| | - Rob E Dorrington
- Centre for Actuarial Research, School of Management Studies, University of Cape Town, Cape Town, South Africa
| | - Adrian Puren
- Division of Virology, School of Pathology, University of Witwatersrand, Johannesburg, South Africa
| | - Thapelo Seathlodi
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine University of Cape Town, Cape Town, South Africa
| | - Khangelani Zuma
- Human Sciences Research Council, Pretoria, South Africa ; and
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13
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Happel AU, Gasper M, Balle C, Konstantinus I, Gamieldien H, Dabee S, Gill K, Bekker LG, Passmore JAS, Jaspan HB. Persistent, Asymptomatic Colonization with Candida is Associated with Elevated Frequencies of Highly Activated Cervical Th17-Like Cells and Related Cytokines in the Reproductive Tract of South African Adolescents. Microbiol Spectr 2022; 10:e0162621. [PMID: 35348351 PMCID: PMC9045181 DOI: 10.1128/spectrum.01626-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 02/25/2022] [Indexed: 11/20/2022] Open
Abstract
Cervicovaginal inflammation, nonoptimal microbiota, T-cell activation, and hormonal contraceptives may increase HIV risk, yet associations between these factors and subclinical Candida colonization or hyphae are unknown. We collected cervicovaginal samples from 94 South African adolescents, aged 15 to 19 years, who were randomized to injectable norethisterone enanthate (Net-En), an etonorgesterol/ethinyl estradiol vaginal ring (NuvaRing), or oral contraceptives in the UChoose trial (NCT02404038) at baseline and 16 weeks post-randomization. We assessed cervicovaginal samples for subclinical Candida colonization (by quantitative PCR [qPCR]), hyphae (by Gram stain), microbiota composition (by 16S rRNA gene sequencing), cytokine concentrations (by Luminex), and cervical T-cell phenotypes and activation (by multiparameter flow cytometry). While hormonal contraceptive type did not influence incidence of Candida colonization or hyphae, hyphae presence was associated with significantly elevated concentrations of IL-22, IL-17A and IL-17F, all produced by Th17 cells, but not of other cytokines, such as IL-1β or IL-6, after adjustment for confounders. Subclinical Candida colonization was associated with reduced frequencies of Th17-like cells and elevated frequencies of CCR6-CCR10 T cells. Women with Candida hyphae were less likely to have bacterial vaginosis (BV). Persistent, subclinical colonization with Candida over 16 weeks was associated with significant increases in Th17-related cytokine concentrations and highly activated Th17-like and CCR6-CCR10 T-cell frequencies. These data suggest that vaginal Candida colonization and hyphae increase Th17-related cytokines, but not overall female genital tract inflammation in Sub-Saharan African adolescents. Persistent Candida colonization, even when asymptomatic, may increase Th17 cell frequencies and related cytokines and thereby could subsequently increase HIV risk, although the causal relationship requires confirmation. IMPORTANCE Sub-Saharan African female adolescents are globally at the highest risk of HIV acquisition, and genital inflammation, microbial dysbiosis, and cervical HIV target cell activation are thought to contribute to this risk. Previously, the relationship between these mucosal factors and subclinical vaginal Candida colonization or hyphae has not been described, and the role of HIV-susceptible Th17 cells in mediating anti-Candida immunity in the human female genital tract has not been clearly established. We show that presence of yeast hyphae was associated with increases in Th17 cell-related cytokines and the absence of microbial dysbiosis, and that persistent Candida colonization resulted in significant increases in Th17-related cytokines and highly activated Th17-like cell frequencies. Our results suggest that Th17 cells are important for anti-Candida immunity in the human female genital tract and that prolonged vaginal Candida colonization may contribute to increased HIV risk in Sub-Saharan African adolescents by increasing HIV target cell frequencies and activation.
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Affiliation(s)
- Anna-Ursula Happel
- Department of Pathology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Melanie Gasper
- Seattle Children’s Research Institute, Seattle, Washington, USA
| | - Christina Balle
- Department of Pathology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Iyaloo Konstantinus
- Department of Pathology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Namibia Institute of Pathology, Windhoek, Namibia
| | - Hoyam Gamieldien
- Department of Pathology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Smritee Dabee
- Seattle Children’s Research Institute, Seattle, Washington, USA
| | - Katherine Gill
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Linda-Gail Bekker
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Jo-Ann S. Passmore
- Department of Pathology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- DST-NRF CAPRISA Centre of Excellence in HIV Prevention, Cape Town, South Africa
- National Health Laboratory Service, Cape Town, South Africa
| | - Heather B. Jaspan
- Department of Pathology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Seattle Children’s Research Institute, Seattle, Washington, USA
- Department of Pediatrics and Global Health, University of Washington, Seattle, Washington, USA
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14
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Balle C, Gupta PM, Tharp GK, Nelson SA, Konstantinus IN, Lennard K, Jaumdally SZ, Happel AU, Barnabas SL, Gill K, Bekker LG, Passmore JAS, Jaspan HB, Bosinger SE. Systems Analysis Reveals Contraceptive-Induced Alteration of Cervicovaginal Gene Expression in a Randomized Trial. FRONTIERS IN REPRODUCTIVE HEALTH 2022; 4:781687. [PMID: 36303659 PMCID: PMC9580795 DOI: 10.3389/frph.2022.781687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 01/31/2022] [Indexed: 12/15/2022] Open
Abstract
Hormonal contraceptives (HCs) are vital in managing the reproductive health of women. However, HC usage has been linked to perturbations in cervicovaginal immunity and increased risk of sexually transmitted infections. Here, we evaluated the impact of three HCs on the cervicovaginal environment using high-throughput transcriptomics. From 2015 to 2017, 130 adolescent females aged 15-19 years were enrolled into a substudy of UChoose, a single-site, open-label randomized, crossover trial (NCT02404038) and randomized to injectable norethisterone-enanthate (Net-En), combined oral contraceptives (COC), or etonorgesterol/ethinyl-estradiol-combined contraceptive vaginal ring (CCVR). Cervicovaginal samples were collected after 16 weeks of randomized HC use and analyzed by RNA-Seq, 16S rRNA gene sequencing, and Luminex analysis. Participants in the CCVR arm had a significant elevation of transcriptional networks driven by IL-6, IL-1, and NFKB, and lower expression of genes supporting epithelial barrier integrity. An integrated multivariate analysis demonstrated that networks of microbial dysbiosis and inflammation best discriminated the CCVR arm from the other contraceptive groups, while genes involved in epithelial cell differentiation were predictive of the Net-En and COC arms. Collectively, these data from a randomized trial represent the most comprehensive "omics" analyses of the cervicovaginal response to HCs and provide important mechanistic guidelines for the provision of HCs in sub-Saharan Africa.
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Affiliation(s)
- Christina Balle
- Department of Pathology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Prachi M. Gupta
- Yerkes Genomics Core Laboratory, Yerkes National Primate Research Center, Atlanta, GA, United States
| | - Gregory K. Tharp
- Yerkes Genomics Core Laboratory, Yerkes National Primate Research Center, Atlanta, GA, United States
| | - Sydney A. Nelson
- Yerkes Genomics Core Laboratory, Yerkes National Primate Research Center, Atlanta, GA, United States
| | - Iyaloo N. Konstantinus
- Department of Pathology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa,Namibia Institute of Pathology, Windhoek, Namibia
| | - Katie Lennard
- Department of Integrative Biomedical Sciences, University of Cape Town, Cape Town, South Africa
| | - Shameem Z. Jaumdally
- Department of Pathology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Anna-Ursula Happel
- Department of Pathology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Shaun L. Barnabas
- Department of Pathology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa,Desmond Tutu Health Centre, University of Cape Town, Cape Town, South Africa,Family Clinical Research Center, Stellenbosch University, Tygerberg, South Africa
| | - Katherine Gill
- Desmond Tutu Health Centre, University of Cape Town, Cape Town, South Africa
| | - Linda-Gail Bekker
- Desmond Tutu Health Centre, University of Cape Town, Cape Town, South Africa
| | - Jo-Ann S. Passmore
- Department of Pathology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa,National Health Laboratory Service, Cape Town, South Africa
| | - Heather B. Jaspan
- Department of Pathology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa,Center for Global Infectious Disease Research, Seattle Children's Research Institute, Seattle, WA, United States,Department of Pediatrics and Global Health, University of Washington, Seattle, WA, United States
| | - Steven E. Bosinger
- Yerkes Genomics Core Laboratory, Yerkes National Primate Research Center, Atlanta, GA, United States,Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA, United States,Emory Vaccine Center, Emory University, Atlanta, GA, United States,*Correspondence: Steven E. Bosinger
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15
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Palmeira-de-Oliveira R, Oliveira AS, Rolo J, Tomás M, Palmeira-de-Oliveira A, Simões S, Martinez-de-Oliveira J. Women's preferences and acceptance for different drug delivery routes and products. Adv Drug Deliv Rev 2022; 182:114133. [PMID: 35104506 DOI: 10.1016/j.addr.2022.114133] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 01/22/2022] [Accepted: 01/26/2022] [Indexed: 12/14/2022]
Abstract
To use or not to use, that is the first decision to take regarding a drug product. This mandatory step for adherence dictates product efficacy. The determinants for such decision do not only rely on the priority of the therapeutic or preventive strategy, but are related to a complex network of perceptions, preferences, personal and cultural backgrounds, and results from previous experiences. Women's preferences for dosage forms and even for drug delivery routes have been mainly studied in the fields of contraception and HIV prevention (and their related multipurpose approaches). Much less attention has been devoted to other therapeutic or preventive strategies. In a time when patient-centred approaches and shared decisions are increasingly valued, considering women's preferences and their main determinants is essential for product development and selection. Such products will be more likely to be chosen and used as intended, increasing efficacy, and reducing the overall costs related with these treatments. This knowledge shall be integrated in early stages of product development. This article reviews the state of the art related with women's preferences and acceptance for different dosage forms and drug delivery routes involved in women's health. The methodologies used for collecting these data and their major drawbacks are discussed. Results obtained from acceptability studies and the main determinants for selection of preventive and treatment drug products are discussed as tools for new developments in the field.
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Affiliation(s)
- Rita Palmeira-de-Oliveira
- CICS-UBI Health Sciences Research Center, Faculty of Health Sciences, University of Beira Interior Av. Infante D. Henrique, Covilhã, Portugal; Labfit-HPRD Health Products Research and Development, Lda, Edifício UBIMEDICAL Estrada Municipal 506, 6200-284 Covilhã, Portugal; CNC - Center for Neuroscience and Cell Biology, Center for Innovative Biomedicine and Biotechnology (CIBB), University of Coimbra, Rua Larga, 3004-504 Coimbra, Portugal; Faculty of Health Sciences, University of Beira Interior, Av. Infante D. Henrique, Covilhã, Portugal.
| | - Ana Sofia Oliveira
- CICS-UBI Health Sciences Research Center, Faculty of Health Sciences, University of Beira Interior Av. Infante D. Henrique, Covilhã, Portugal; Faculty of Health Sciences, University of Beira Interior, Av. Infante D. Henrique, Covilhã, Portugal
| | - Joana Rolo
- CICS-UBI Health Sciences Research Center, Faculty of Health Sciences, University of Beira Interior Av. Infante D. Henrique, Covilhã, Portugal
| | - Mariana Tomás
- CICS-UBI Health Sciences Research Center, Faculty of Health Sciences, University of Beira Interior Av. Infante D. Henrique, Covilhã, Portugal; Faculty of Health Sciences, University of Beira Interior, Av. Infante D. Henrique, Covilhã, Portugal
| | - Ana Palmeira-de-Oliveira
- CICS-UBI Health Sciences Research Center, Faculty of Health Sciences, University of Beira Interior Av. Infante D. Henrique, Covilhã, Portugal; Labfit-HPRD Health Products Research and Development, Lda, Edifício UBIMEDICAL Estrada Municipal 506, 6200-284 Covilhã, Portugal; Faculty of Health Sciences, University of Beira Interior, Av. Infante D. Henrique, Covilhã, Portugal
| | - Sérgio Simões
- CNC - Center for Neuroscience and Cell Biology, Center for Innovative Biomedicine and Biotechnology (CIBB), University of Coimbra, Rua Larga, 3004-504 Coimbra, Portugal; Faculty of Pharmacy, University of Coimbra, Pólo das Ciências da Saúde, Azinhaga de Santa Comba, 3000-548 Coimbra, Portugal
| | - José Martinez-de-Oliveira
- CICS-UBI Health Sciences Research Center, Faculty of Health Sciences, University of Beira Interior Av. Infante D. Henrique, Covilhã, Portugal
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16
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Ridgeway K, Montgomery ET, Smith K, Torjesen K, van der Straten A, Achilles SL, Griffin JB. Vaginal ring acceptability: A systematic review and meta-analysis of vaginal ring experiences from around the world. Contraception 2022; 106:16-33. [PMID: 34644609 PMCID: PMC9128798 DOI: 10.1016/j.contraception.2021.10.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 09/28/2021] [Accepted: 10/03/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The vaginal ring (ring) is a female-initiated, long-acting drug delivery system for different indications, including HIV prevention. Our aim was to provide evidence for acceptability of the vaginal ring across indications to support dapivirine and multipurpose prevention technology ring introduction and roll out. STUDY DESIGN This systematic review and meta-analysis followed PRISMA guidelines. We searched PubMed, Web of Science, Embase, and grey literature for publications reporting favorable ring acceptability and secondary outcomes involving actual ring use (comfort, ease of ring use, ring comfort during sex, expulsions, and vaginal symptoms) or hypothetical acceptability for any indication published January 1, 1970-June 15, 2021. We estimated random-effects pooled prevalence, assessing between-study variation using meta-regression. RESULTS Of 2,234 records, we included 123 studies with 40,434 actual and hypothetical ring users. The primary outcome assessment included 50 studies with 60 ring subgroups totaling 19,271 ring users. The favorable acceptability pooled prevalence was 85.6% (95%CI 81.3, 89.0), while hypothetical acceptability among non-ring users was 27.6% (95%CI 17.5, 40.5). In meta-regression, acceptability was higher in menopause (95.4%; 95%CI 88.4, 98.2) compared to contraceptive rings (83.7%; 95%CI 75.6, 89.5). Acceptability was lower in pharmacokinetic studies (50%; 95%CI 22.1, 77.9) compared to RCTs (89.5%; 95%CI 85.8.92.4) and in studies assessing acceptability at ≥12 months (78.5%; 95%CI 66.5, 87.1) versus studies assessing acceptability at <3 months (91.9%; 95%CI 83.7, 96.1). European (90.6%; 95%CI 83.9, 94.7), Asian (97.1%; 95%CI 92.0, 99.0), and multi-region studies (93.5%; 95%CI 84.6, 97.4) reported more favorable acceptability compared to African studies (59.4%; 95%CI 38.3, 77.5). Secondary outcomes were similarly favorable, including ring comfort (92.9%; 95%CI 89.2, 95.4), ease of use (90.9%; 95%CI 86.5, 94.0), and comfort during sex (82.7%; 95%CI 76.4, 87.6). Limitations include inconsistent outcome definitions and unmeasured factors affecting acceptability. CONCLUSIONS Women who used vaginal rings reported they were acceptable across indications geographic regions and indications. Policy makers should consider the ring as an important option for pregnancy and HIV prevention drug development. IMPLICATIONS This review found favorable acceptability among vaginal ring users across indications and geographic areas, in contrast to low hypothetical acceptability among non-users. Vaginal rings are an important drug delivery system for pregnancy and HIV preventions, and scale-up should plan to address initial hesitancy among new users.
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Affiliation(s)
- Kathleen Ridgeway
- FHI 360, Global Health Population Nutrition, Durham, NC, United States
| | - Elizabeth T. Montgomery
- RTI International, Women’s Global Health Imperative, Berkeley, CA, United States,Center for AIDS Pervention Studies, Department of Medicine, University of California San Francisco, San Francisco, CA, United States
| | - Kevin Smith
- Centre for Global Health, RTI International, Durham, NC, United States
| | - Kristine Torjesen
- FHI 360, Global Health Population Nutrition, Durham, NC, United States
| | - Ariane van der Straten
- RTI International, Women’s Global Health Imperative, Berkeley, CA, United States,Center for AIDS Pervention Studies, Department of Medicine, University of California San Francisco, San Francisco, CA, United States
| | - Sharon L. Achilles
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States,Magee-Womens Research Institute, Pittsburgh, PA, USA
| | - Jennifer B. Griffin
- Centre for Global Health, RTI International, Durham, NC, United States,Corresponding author. J. B. Griffin, (J.B. Griffin)
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17
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Bekker LG, Pike C, Hillier SL. HIV prevention: better choice for better coverage. J Int AIDS Soc 2022; 25:e25872. [PMID: 35030296 PMCID: PMC8759757 DOI: 10.1002/jia2.25872] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 11/05/2021] [Indexed: 11/15/2022] Open
Abstract
Introduction Antiretroviral‐based pre‐exposure prophylaxis (PrEP) is today an established, effective and safe method of HIV prevention used in multiple countries worldwide by a broad range of populations at risk of HIV infection. Biomedical innovations are critical in supporting the primary prevention of HIV; however, their potential can only be maximized if end‐user challenges are recognized, described and used to develop next‐generation models. Discussion First‐generation PrEP, a daily oral pill, is highly efficacious, discreet and affords users the ability to commence and conclude treatment rapidly. However, consistent daily adherence and persistence is challenging, especially among younger populations, due in part to side effects, the risk of stock‐outs and a lack of pill storage options. Second‐generation PrEP, longer acting agents that require less frequent dosing, could overcome such challenges. Agents that have shown efficacy in clinical trials include a monthly vaginal ring and PrEP injectables to be administered every 8 weeks, while products in development include 6 monthly injectables, oral therapy that uses monthly rather than daily pills, implants and the potential for long‐acting passive immunization. Conclusions Second‐generation PrEP agents will have the potential to offer improved adherence and less frequent reminders once they have undergone further development and the delivery systems that will best support them have been established. In order to pursue global UNAIDS targets of reducing new HIV infections to fewer than 500,000 annually by 2025, and to ensure that all people have access to prevention options that meet their specific prevention needs, both early and next‐generation PrEP options are needed.
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Affiliation(s)
- Linda-Gail Bekker
- The Desmond Tutu HIV Centre, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Carey Pike
- The Desmond Tutu HIV Centre, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Sharon L Hillier
- Department of Obstetrics, Gynaecology, and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Magee-Womens Research Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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18
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Delvaux T, Jespers V, Benova L, van de Wijgert J. Acceptability and Satisfaction of Contraceptive Vaginal Rings in Clinical Studies: A Systematic Review and Narrative Synthesis. Front Glob Womens Health 2022; 2:799963. [PMID: 34970653 PMCID: PMC8712726 DOI: 10.3389/fgwh.2021.799963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 11/11/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: Acceptability of and satisfaction with contraceptive methods are paramount for uptake and continuation. In the current context of multipurpose prevention of pregnancy and sexually transmitted diseases/HIV development, it is critical to have a better understanding of acceptability of and satisfaction with the contraceptive vaginal ring (CVR) including sexual satisfaction. The objective of this study was to review the evidence about acceptability of CVRs and general and sexual satisfaction of users. Methods: We searched PubMed, CINAHL, and Web of Science (until December 31, 2020) and selected original studies documenting actual use of hormonal CVR and explicitly addressing any of the 3 outcomes. Results: Of a total of 1,129 records screened, 46 studies were included. Most studies (n = 43, 93%) were prospective, conducted in high-income settings (n = 35), and reported on NuvaRing® use (n = 31). Overall, 27 (59%) studies included a comparison group, 38 (82%) studies used exclusively quantitative questionnaires, with qualitative only (n = 4, 9%), or mixed methods (n = 4, 9%) studies being less common. Ease of CVR insertion/removal/reinsertion was high in all the settings and improved with time of use, with qualitative studies supporting these findings. When mentioned, ring-related events were associated with discontinuation, and results on continuation of use were mixed. Among NuvaRing® studies, general satisfaction (being satisfied or very satisfied) was between 80 and 90% and tended to mirror continuation. Sexual satisfaction was less commonly reported and results were mixed. Overall, limited information was provided on actual CVR experiences of women (and men) and cultural norms that may affect sexuality and CVR use. Conclusion: Positive aspects of acceptability of and satisfaction with CVRs were reported, but ring-related events and factors, which may affect long-term CVR use, deserve further study. More information is needed on actual experiences of women using CVRs, relationship aspects, male partner opinions, and contextual norms to better understand the acceptability of and satisfaction with CVRs.
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Affiliation(s)
| | - Vicky Jespers
- Belgian Health Care Knowledge Centre, Brussels, Belgium
| | - Lenka Benova
- Institute of Tropical Medicine, Antwerp, Belgium
| | - Janneke van de Wijgert
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
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19
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Palanee-Phillips T, Baum MM, Moss JA, Clark MR, Nuttall J, Romano JW. Drug-releasing vaginal rings for HIV/STI and pregnancy prevention: A review of recent advances and clinical applications. Expert Opin Drug Deliv 2021; 19:47-58. [PMID: 34958283 DOI: 10.1080/17425247.2022.2020242] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Adolescent girls and young women (AGYW), as well as pre- and post-menopausal women globally would benefit from expanded choice to address their sexual and reproductive health (SRH) needs related to Human Immunodeficiency Virus (HIV), sexually transmitted infections (STIs) and pregnancy prevention. Lack of adequate preventative vaccines for HIV/STIs reinforces public health prioritization for options women may use independently to mitigate risk for infectious disease and unplanned pregnancy. Drug releasing intravaginal rings (IVR) represent one such technology that has garnered attention based on the modality's success recently as a pre-exposure prophylaxis (PrEP) delivery option and its impact on reduction in HIV risk. AREAS COVERED : This article provides a synopsis of three IVR technologies in active clinical development for prevention of HIV, STI, and unintended pregnancy demonstrating advancements in terms of compatibility with a wide range of drug types with a focus on dapivirine-based silicone rings (International Partnership for Microbicides (IPM), tenofovir-based polyurethane rings (CONRAD), and pod-based rings (Oak Crest Institute of Science). EXPERT OPINION The goals of IVR research are to reduce burdens of HIV/STIs and unplanned pregnancies. Through the evolution of IVR technologies, the potential exists to trigger integration of healthcare services through formulation of products with multiple indications.
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Affiliation(s)
- Thesla Palanee-Phillips
- Faculty of Health Sciences, Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Marc M Baum
- Oak Crest Institute of Science, Monrovia, CA, USA
| | - John A Moss
- Oak Crest Institute of Science, Monrovia, CA, USA
| | | | - Jeremy Nuttall
- International Partnership for Microbicides, Silver Spring, MD, USA
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20
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Dabee S, Tanko RF, Brown BP, Bunjun R, Balle C, Feng C, Konstantinus IN, Jaumdally SZ, Onono M, Nair G, Palanee-Phillips T, Gill K, Baeten JM, Bekker LG, Passmore JAS, Heffron R, Jaspan HB, Happel AU. Comparison of Female Genital Tract Cytokine and Microbiota Signatures Induced by Initiation of Intramuscular DMPA and NET-EN Hormonal Contraceptives - a Prospective Cohort Analysis. Front Immunol 2021; 12:760504. [PMID: 34956191 PMCID: PMC8696178 DOI: 10.3389/fimmu.2021.760504] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 11/22/2021] [Indexed: 01/17/2023] Open
Abstract
Background Cervicovaginal inflammation, bacterial microbiota and hormonal contraceptives all influence sexual and reproductive health. To date, the effects of intramuscular depo-medroxyprogesterone acetate (DMPA-IM) versus injectable norethisterone enanthate (NET-EN) on vaginal microbiota or cytokines have not been compared back-to-back, although in-vitro data suggest that DMPA-IM and NET-EN have different pharmacokinetic and biologic activities. This study aimed at comparing the effects of DMPA-IM versus NET-EN initiation on cervicovaginal cytokines and microbiota in women at high risk for sexually transmitted infections (STIs) assigned to the respective contraceptives. Methods We collected socio-demographic characteristics and vaginal samples from women initiating DMPA-IM (ECHO Trial; n = 53) and NET-EN (UChoose Trial; n = 44) at baseline and after two consecutive injections to assess cytokine concentrations by Luminex, vaginal microbiota by 16S rRNA gene sequencing, STIs, bacterial vaginosis (BV) and candidiasis. Results Cytokine concentrations did not change significantly after initiating DMPA-IM or NET-EN, although NET-EN versus DMPA-IM-associated profiles were distinct. While the abundance of bacterial taxa associated with optimal and non-optimal microbiota fluctuated with DMPA-IM use, overall community composition did not significantly change with either contraceptive. HSV-2 serology, chlamydial infection, gonorrhoea and candidiasis did not influence the associations between contraceptive type and cervicovaginal cytokines or microbiota. Conclusions Both DMPA-IM and NET-EN use did not lead to broad inflammatory or microbiota changes in the female genital tract of sub-Saharan African women. This suggests that NET-EN is likely a viable option for contraception in African women at high risk of BV and STIs.
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Affiliation(s)
- Smritee Dabee
- Center for Global Infectious Disease, Seattle Children’s Research Institute, Seattle, WA, United States
| | - Ramla F. Tanko
- Institute of Infectious Disease and Molecular Medicine (IDM), University of Cape Town, Cape Town, South Africa,Centre for the AIDS Programme of Research in South Africa (CAPRISA) Centre of Excellence in HIV Prevention, University of Cape Town, Cape Town, South Africa,The Medical Research Centre, Institute of Medical Research and Medicinal Plant Studies (IMPM), Ministry of Scientific Research and Innovation, Yaoundé, Cameroon
| | - Bryan P. Brown
- Center for Global Infectious Disease, Seattle Children’s Research Institute, Seattle, WA, United States
| | - Rubina Bunjun
- Institute of Infectious Disease and Molecular Medicine (IDM), University of Cape Town, Cape Town, South Africa
| | - Christina Balle
- Institute of Infectious Disease and Molecular Medicine (IDM), University of Cape Town, Cape Town, South Africa
| | - Colin Feng
- Center for Global Infectious Disease, Seattle Children’s Research Institute, Seattle, WA, United States
| | | | - Shameem Z. Jaumdally
- Institute of Infectious Disease and Molecular Medicine (IDM), University of Cape Town, Cape Town, South Africa
| | | | | | - Thesla Palanee-Phillips
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Jared M. Baeten
- Department of Global Health, University of Washington, Seattle, WA, United States,Gilead Sciences, Foster City, CA, United States
| | | | - Jo-Ann S. Passmore
- Institute of Infectious Disease and Molecular Medicine (IDM), University of Cape Town, Cape Town, South Africa,Centre for the AIDS Programme of Research in South Africa (CAPRISA) Centre of Excellence in HIV Prevention, University of Cape Town, Cape Town, South Africa,National Health Laboratory Service, Cape Town, South Africa
| | - Renee Heffron
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Heather B. Jaspan
- Center for Global Infectious Disease, Seattle Children’s Research Institute, Seattle, WA, United States,Institute of Infectious Disease and Molecular Medicine (IDM), University of Cape Town, Cape Town, South Africa,Department of Global Health, University of Washington, Seattle, WA, United States,*Correspondence: Heather B. Jaspan,
| | - Anna-Ursula Happel
- Institute of Infectious Disease and Molecular Medicine (IDM), University of Cape Town, Cape Town, South Africa
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21
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Ngure K, Mugo NR, Bukusi EA, Kiptinness C, Oware K, Gakuo S, Musinguzi N, Pyra M, Garrison L, Baeten JM, Haberer JE. Pills, Injections, Rings, or Implants? PrEP Formulation Preferences of PrEP-Experienced African Women for HIV Prevention. J Acquir Immune Defic Syndr 2021; 88:e30-e32. [PMID: 34446676 PMCID: PMC8556312 DOI: 10.1097/qai.0000000000002793] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- Kenneth Ngure
- Department of Community Health, Jomo Kenyatta University of Agriculture and Technology
- Department of Global Health, University of Washington, Seattle, USA
| | - Nelly R. Mugo
- Department of Global Health, University of Washington, Seattle, USA
- Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Elizabeth A. Bukusi
- Department of Global Health, University of Washington, Seattle, USA
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
- Department of Obstetrics and Gynecology, University of Washington, Seattle, USA
| | | | - Kevin Oware
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Stephen Gakuo
- Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Nicholas Musinguzi
- Global Health Collaborative, Mbarara University of Science and Technology, Mbarara, Uganda
| | | | - Lindsey Garrison
- Massachusetts General Hospital, Center for Global Health, Boston, MA, USA
| | - Jared M. Baeten
- Department of Global Health, University of Washington, Seattle, USA
- Department of Epidemiology, University of Washington, Seattle, USA
- Department of Medicine, University of Washington, Seattle, USA
- Gilead, Foster City, CA, United States
| | - Jessica E. Haberer
- Massachusetts General Hospital, Center for Global Health, Boston, MA, USA
- Harvard Medical School, Department of Medicine, Boston, MA, USA
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22
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Lahoti A, Yu C, Brar PC, Dalgo A, Gourgari E, Harris R, Kamboj MK, Marks S, Nandagopal R, Page L, Raman V, Reynolds DG, Sarafoglou K, Terrell C, Stanley TL. An endocrine perspective on menstrual suppression for adolescents: achieving good suppression while optimizing bone health. J Pediatr Endocrinol Metab 2021; 34:1355-1369. [PMID: 34388330 DOI: 10.1515/jpem-2020-0539] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 07/19/2021] [Indexed: 11/15/2022]
Abstract
Suppression of menstruation and/or ovarian function in adolescent girls may be desired for a variety of reasons. Numerous medical options exist. The choice of the appropriate modality for an individual patient depends on several factors based on differences in the efficacy of achieving menstrual suppression as well as in their side effect profiles. Adolescence is also a period of bone mass accrual in girls, and several of these modalities may negatively influence peak bone mass. This review focuses on the efficacy of achieving menstrual suppression and the effect on bone health of the various options through an overview of the current literature and also highlights areas in need of further research.
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Affiliation(s)
- Amit Lahoti
- Pediatric Endocrine Division, Le Bonheur Children's Hospital and University of Tennessee Health Science Center, Memphis, TN, USA
| | - Christine Yu
- Section of Adult and Pediatric Endocrinology, Diabetes, & Metabolism, University of Chicago, Chicago, IL, USA
| | - Preneet Cheema Brar
- Division of Pediatric Endocrinology and Diabetes, NYU Grossman School of Medicine, New York, NY, USA
| | - Austin Dalgo
- Center for Bioethics and Health Equity, Le Bonheur Children's Hospital and University of Tennessee Health Science Center, Memphis, TN, USA
| | - Evgenia Gourgari
- Pediatric Endocrinology Division, Department of Pediatrics, Georgetown University, Washington, DC, USA
| | - Rebecca Harris
- Division of Endocrinology, Boston Children's Hospital, Boston, MA, USA
| | - Manmohan K Kamboj
- Section of Endocrinology, Department of Pediatrics, Nationwide Children's Hospital at The Ohio State University, Columbus, OH, USA
| | - Seth Marks
- Section of Pediatric Endocrinology and Metabolism, Department of Pediatrics and Child Health, Children's Hospital HSC Winnipeg, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Radha Nandagopal
- Department of Medical Education and Clinical Sciences, Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, USA
| | - Laura Page
- Division of Endocrinology, Department of Pediatrics, Duke University, Durham, NC, USA
| | | | - Danielle G Reynolds
- Diabetes and Endocrinology Center, University of South Florida, Tampa, FL, USA
| | - Kyriakie Sarafoglou
- Division of Pediatric Endocrinology, Department of Pediatrics, University of Minnesota Masonic Children's Hospital, Minneapolis, MN, USA.,Department of Experimental and Clinical Pharmacology, University of Minnesota College of Pharmacy, Minneapolis, MN, USA
| | - Carrie Terrell
- Division of General Obstetrics, Gynecology, Midwifery and Family Planning at the University of Minnesota Medical School, Minneapolis, MN, USA
| | - Takara L Stanley
- Pediatric Endocrine Unit and Metabolism Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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23
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Happel AU, Balle C, Maust BS, Konstantinus IN, Gill K, Bekker LG, Froissart R, Passmore JA, Karaoz U, Varsani A, Jaspan H. Presence and Persistence of Putative Lytic and Temperate Bacteriophages in Vaginal Metagenomes from South African Adolescents. Viruses 2021; 13:2341. [PMID: 34960611 PMCID: PMC8708031 DOI: 10.3390/v13122341] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 11/18/2021] [Accepted: 11/18/2021] [Indexed: 12/11/2022] Open
Abstract
The interaction between gut bacterial and viral microbiota is thought to be important in human health. While fluctuations in female genital tract (FGT) bacterial microbiota similarly determine sexual health, little is known about the presence, persistence, and function of vaginal bacteriophages. We conducted shotgun metagenome sequencing of cervicovaginal samples from South African adolescents collected longitudinally, who received no antibiotics. We annotated viral reads and circular bacteriophages, identified CRISPR loci and putative prophages, and assessed their diversity, persistence, and associations with bacterial microbiota composition. Siphoviridae was the most prevalent bacteriophage family, followed by Myoviridae, Podoviridae, Herelleviridae, and Inoviridae. Full-length siphoviruses targeting bacterial vaginosis (BV)-associated bacteria were identified, suggesting their presence in vivo. CRISPR loci and prophage-like elements were common, and genomic analysis suggested higher diversity among Gardnerella than Lactobacillus prophages. We found that some prophages were highly persistent within participants, and identical prophages were present in cervicovaginal secretions of multiple participants, suggesting that prophages, and thus bacterial strains, are shared between adolescents. The number of CRISPR loci and prophages were associated with vaginal microbiota stability and absence of BV. Our analysis suggests that (pro)phages are common in the FGT and vaginal bacteria and (pro)phages may interact.
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Affiliation(s)
- Anna-Ursula Happel
- Department of Pathology, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Anzio Road, Cape Town 7925, South Africa; (A.-U.H.); (C.B.); (I.N.K.); (J.-A.P.)
| | - Christina Balle
- Department of Pathology, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Anzio Road, Cape Town 7925, South Africa; (A.-U.H.); (C.B.); (I.N.K.); (J.-A.P.)
| | - Brandon S. Maust
- Seattle Children’s Research Institute, 307 Westlake Ave. N, Seattle, WA 98109, USA;
- Department of Pediatrics, University of Washington School of Medicine, 1959 NE Pacific St., Seattle, WA 98195, USA
| | - Iyaloo N. Konstantinus
- Department of Pathology, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Anzio Road, Cape Town 7925, South Africa; (A.-U.H.); (C.B.); (I.N.K.); (J.-A.P.)
- Namibia Institute of Pathology, Hosea Kutako, Windhoek 10005, Namibia
| | - Katherine Gill
- Desmond Tutu HIV Centre, University of Cape Town, Anzio Road, Cape Town 7925, South Africa; (K.G.); (L.-G.B.)
- NRF-DST CAPRISA Centre of Excellence in HIV Prevention, 719 Umbilo Road, Congella, Durban 4013, South Africa
| | - Linda-Gail Bekker
- Desmond Tutu HIV Centre, University of Cape Town, Anzio Road, Cape Town 7925, South Africa; (K.G.); (L.-G.B.)
- NRF-DST CAPRISA Centre of Excellence in HIV Prevention, 719 Umbilo Road, Congella, Durban 4013, South Africa
| | - Rémy Froissart
- CNRS, IRD, Université Montpellier, UMR 5290, MIVEGEC, 34394 Montpellier, France;
| | - Jo-Ann Passmore
- Department of Pathology, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Anzio Road, Cape Town 7925, South Africa; (A.-U.H.); (C.B.); (I.N.K.); (J.-A.P.)
- Desmond Tutu HIV Centre, University of Cape Town, Anzio Road, Cape Town 7925, South Africa; (K.G.); (L.-G.B.)
- NRF-DST CAPRISA Centre of Excellence in HIV Prevention, 719 Umbilo Road, Congella, Durban 4013, South Africa
- National Health Laboratory Service, Anzio Road, Cape Town 7925, South Africa
| | - Ulas Karaoz
- Earth and Environmental Science, Lawrence Berkeley National Laboratories, 1 Cyclotron Rd., Berkeley, CA 94720, USA;
| | - Arvind Varsani
- The Biodesign Center of Fundamental and Applied Microbiomics, Center for Evolution and Medicine, School of Life Sciences, Arizona State University, 1001 S. McAllister Ave., Tempe, AZ 85281, USA
- Structural Biology Research Unit, Department of Integrative Biomedical Sciences, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Anzio Road, Cape Town 7925, South Africa
| | - Heather Jaspan
- Department of Pathology, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Anzio Road, Cape Town 7925, South Africa; (A.-U.H.); (C.B.); (I.N.K.); (J.-A.P.)
- Seattle Children’s Research Institute, 307 Westlake Ave. N, Seattle, WA 98109, USA;
- Department of Pediatrics, University of Washington School of Medicine, 1959 NE Pacific St., Seattle, WA 98195, USA
- Department of Global Health, University of Washington School of Public Health, 1510 San Juan Road NE, Seattle, WA 98195, USA
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24
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Gill K, Happel AU, Pidwell T, Mendelsohn A, Duyver M, Johnson L, Meyer L, Slack C, Strode A, Mendel E, Fynn L, Wallace M, Spiegel H, Jaspan H, Passmore JA, Hosek S, Smit D, Rinehart A, Bekker LG. An open-label, randomized crossover study to evaluate the acceptability and preference for contraceptive options in female adolescents, 15 to 19 years of age in Cape Town, as a proxy for HIV prevention methods (UChoose). J Int AIDS Soc 2021; 23:e25626. [PMID: 33034421 PMCID: PMC7545920 DOI: 10.1002/jia2.25626] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 07/22/2020] [Accepted: 09/16/2020] [Indexed: 12/24/2022] Open
Abstract
Introduction Young women in Southern Africa have extremely high HIV incidence rates necessitating the availability of female‐controlled prevention methods. Understanding adolescent preference for seeking contraception would improve our understanding of acceptability, feasibility and adherence to similar modes of delivery for HIV prevention. Methods UChoose was an open‐label randomized crossover study over 32 weeks which aimed to evaluate the acceptability and preference for contraceptive options in healthy, HIV‐uninfected, female adolescents aged 15 to 19 years, as a proxy for similar HIV prevention methods. Participants were assigned to a contraceptive method for a period of 16 weeks in the form of a bi‐monthly injectable contraceptive, monthly vaginal Nuvaring® or daily combined oral contraceptive (COC) and then asked to state their preference. At 16 weeks, participants crossed over to another contraceptive method, to ensure that all participants tried the Nuvaring® (least familiar modality) and additionally, either the injection or COC. Primary outcomes were contraceptive acceptability and preference. At the end of the 32 weeks they were also asked to imagine their preference for an HIV prevention modality. Secondary endpoints included changes in sexual behaviour, contraceptive adherence and preference for biomedical and behavioural HIV prevention methods. Results Of the 180 participants screened, 130 were enrolled and randomized to the Nuvaring® (n = 45), injection (n = 45) or COC (n = 40). Significantly more Nuvaring® users (24/116; 20.7%) requested to change to another contraceptive option compared to injection (1/73; 1.4% p = 0.0002) and COC users (4/49; 8% p = 0.074). Of those that remained on the Nuvaring®, adherence was significantly higher than to COC (p < 0.0001). Significantly more injection users (77/80; 96.3%) thought this delivery mode was convenient to use compared to Nuvaring® (74/89; 83.1%; p = 0.0409) or COC (38/50; 76.0%; p = 0.0034). Overall, the preferred contraceptive choice was injection, followed by the ring and lastly the pill. Conclusions Adherence to daily COC was difficult for adolescents in this cohort and the least favoured potential HIV prevention option. While some preferred vaginal ring use, these data suggest that long‐acting injectables would be the preferred prevention method for adolescent girls and young women. This study highlights the need for additional options for HIV prevention in youth.
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Affiliation(s)
- Katherine Gill
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Anna-Ursula Happel
- Institute of Infectious Diseases and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Tanya Pidwell
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Andrea Mendelsohn
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Menna Duyver
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Leigh Johnson
- Centre for Infectious Diseases Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Landon Meyer
- Centre for Infectious Diseases Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.,Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Catherine Slack
- HIV AIDS Vaccines Ethics Group, University of KwaZulu-Natal, Durban, South Africa
| | - Ann Strode
- HIV AIDS Vaccines Ethics Group, University of KwaZulu-Natal, Durban, South Africa
| | - Eve Mendel
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Lauren Fynn
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Melissa Wallace
- Cancer Association of South Africa, Johannesburg, South Africa
| | - Hans Spiegel
- Department of Health and Human Services, Kelly Government Solutions, Contractor to National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD, USA
| | - Heather Jaspan
- Institute of Infectious Diseases and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.,Departments of Pediatrics and Global Health, University of Washington, Seattle, WA, USA.,Centre for Global Infectious Disease Research, Seattle Children's Research Institute, Seattle, WA, USA
| | - Jo-Ann Passmore
- Institute of Infectious Diseases and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.,National Health Laboratory Service (NHLS), Cape Town, South Africa
| | - Sybil Hosek
- Stroger Hospital of Cook County, Chicago, IL, USA
| | | | | | - Linda-Gail Bekker
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
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25
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Balle C, Konstantinus IN, Jaumdally SZ, Havyarimana E, Lennard K, Esra R, Barnabas SL, Happel AU, Moodie Z, Gill K, Pidwell T, Karaoz U, Brodie E, Maseko V, Gamieldien H, Bosinger SE, Myer L, Bekker LG, Passmore JAS, Jaspan HB. Hormonal contraception alters vaginal microbiota and cytokines in South African adolescents in a randomized trial. Nat Commun 2020; 11:5578. [PMID: 33149114 PMCID: PMC7643181 DOI: 10.1038/s41467-020-19382-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Accepted: 10/12/2020] [Indexed: 12/11/2022] Open
Abstract
Young women in sub-Saharan Africa are disproportionally affected by HIV infection and unintended pregnancies. However, hormonal contraceptive (HC) use may influence HIV risk through changes in genital tract microbiota and inflammatory cytokines. To investigate this, 130 HIV negative adolescent females aged 15-19 years were enrolled into a substudy of UChoose, an open-label randomized crossover study (NCT02404038), comparing acceptability and contraceptive product preference as a proxy for HIV prevention delivery methods. Participants were randomized to injectable norethisterone enanthate (Net-En), combined oral contraceptives (COC) or etonorgesterol/ethinyl estradiol combined contraceptive vaginal ring (CCVR) for 16 weeks, then crossed over to another HC for 16 weeks. Cervicovaginal samples were collected at baseline, crossover and exit for characterization of the microbiota and measurement of cytokine levels; primary endpoints were cervical T cell activation, vaginal microbial diversity and cytokine concentrations. Adolescents randomized to COCs had lower vaginal microbial diversity and relative abundance of HIV risk-associated taxa compared to Net-En or CCVR. Cervicovaginal inflammatory cytokine concentrations were significantly higher in adolescents randomized to CCVR compared to COC and Net-En. This suggests that COC use may induce an optimal vaginal ecosystem by decreasing bacterial diversity and inflammatory taxa, while CCVR use is associated with genital inflammation.
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Affiliation(s)
- Christina Balle
- Department of Pathology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Iyaloo N Konstantinus
- Department of Pathology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Shameem Z Jaumdally
- Department of Pathology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Enock Havyarimana
- Department of Pathology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Katie Lennard
- Department of Integrative Biomedical Sciences, University of Cape Town, Cape Town, South Africa
| | - Rachel Esra
- Department of Pathology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Shaun L Barnabas
- Department of Pathology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa.,Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Anna-Ursula Happel
- Department of Pathology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Zoe Moodie
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Katherine Gill
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Tanya Pidwell
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Ulas Karaoz
- Earth and Environmental Science, Lawrence Berkeley National Laboratories, Berkeley, CA, 94720, USA
| | - Eoin Brodie
- Earth and Environmental Science, Lawrence Berkeley National Laboratories, Berkeley, CA, 94720, USA.,University of California, Berkeley, CA, USA
| | - Venessa Maseko
- National Institute for Communicable Diseases, Sandringham, Johannesburg, South Africa
| | - Hoyam Gamieldien
- Department of Pathology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Steven E Bosinger
- Department of Pathology & Laboratory Medicine, Emory University School of Medicine; Division of Microbiology and Immunology, Yerkes National Primate Research Center, Atlanta, GA, USA
| | - Landon Myer
- Division of Epidemiology, Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Linda-Gail Bekker
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Jo-Ann S Passmore
- Department of Pathology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa.,National Health Laboratory Service, Cape Town, South Africa
| | - Heather B Jaspan
- Department of Pathology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa. .,Seattle Children's Research Institute, Seattle, WA, USA. .,University of Washington Department of Pediatrics and Global Health, Seattle, WA, USA.
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