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Thurman AR, Moench TR, Hoke M, Politch JA, Cabral H, Mausser E, Nador E, Morton J, Hamorsky K, Swope K, Bratcher B, Anderson DJ, Whaley KJ. ZB-06, a vaginal film containing an engineered human contraceptive antibody (HC4-N), demonstrates safety and efficacy in a phase 1 postcoital test and safety study. Am J Obstet Gynecol 2023; 228:716.e1-716.e12. [PMID: 36870409 PMCID: PMC10247457 DOI: 10.1016/j.ajog.2023.02.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 01/31/2023] [Accepted: 02/25/2023] [Indexed: 03/06/2023]
Abstract
BACKGROUND With an unplanned pregnancy rate of 50% or more in many countries, there is an urgent need for contraceptives that are more accessible and acceptable. To meet the growing demand for new contraceptives, ZabBio developed ZB-06, a vaginal film containing HC4-N, a human contraceptive antibody that inactivates sperm. OBJECTIVE This study aimed to assess the potential contraceptive activity of the ZB-06 film using a surrogate assessment for contraceptive efficacy, the postcoital test. We also assessed clinical safety of film use among healthy heterosexual couples. Serum, cervical mucus, and vaginal fluid HC4-N antibody concentrations and sperm agglutination potency were determined after single film use. Changes in the concentration of soluble proinflammatory cytokines and vaginal Nugent score after film use were measured as subclinical safety endpoints. STUDY DESIGN This was a phase 1, first-in-woman, open-label, proof-of-concept, postcoital test and safety study. RESULTS A total of 20 healthy women were enrolled in the study, and 8 heterosexual couples completed all study visits. The product was safe for both female participants and their male sexual partners. The postcoital test performed on ovulatory cervical mucus at baseline (no product use) revealed a mean of 25.9 (±30.6) progressively motile sperm per high-power field. After use of a single ZB-06 film before intercourse, this number dropped to 0.04 (±0.06) progressively motile sperm per high-power field (P<.0001). At the follow-up postcoital test visit approximately 1 month later (no product use), a mean of 47.4 (±37.4) progressively motile sperm per high-power field was observed, indicating contraceptive reversibility. CONCLUSION A single dose of the ZB-06 film applied before intercourse was safe and met efficacy surrogate benchmarks of excluding progressively motile sperm from ovulatory cervical mucus. These data indicate that ZB-06 is a viable contraceptive candidate warranting further development and testing.
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Affiliation(s)
- Andrea R Thurman
- CONRAD, Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA.
| | | | | | - Joseph A Politch
- Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
| | - Howard Cabral
- Department of Biostatistics, Boston University School of Public Health, Boston, MA
| | - Emilie Mausser
- Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
| | - Ellena Nador
- Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
| | | | | | | | | | - Deborah J Anderson
- Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
| | - Kevin J Whaley
- Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
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Hexavalent sperm-binding IgG antibody released from vaginal film for development of potent on-demand nonhormonal female contraception. Proc Natl Acad Sci U S A 2021; 118:2107832118. [PMID: 34815336 PMCID: PMC8640842 DOI: 10.1073/pnas.2107832118] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/20/2021] [Indexed: 11/18/2022] Open
Abstract
Nearly half of all pregnancies in the United States are unintended due to millions of women avoiding available hormonal contraceptive methods as a result of real and/or perceived side effects associated with the use of exogenous hormones. Topical vaginal delivery of antisperm monoclonal antibodies that could agglutinate sperm into clusters too large to penetrate mucus and prevent sperm from reaching the egg represents a potentially safe and potent mechanism for nonhormonal contraception. We report here the engineering of a vaginal film loaded with hexavalent (i.e., 6 Fab) antisperm IgG, made using GMP manufacturing processes, that possesses significantly superior agglutination potency than the parent IgG, enabling potent on-demand nonhormonal contraception via effectively agglutinating all human sperm within minutes. Nonhormonal products for on-demand contraception are a global health technology gap; this unmet need motivated us to pursue the use of sperm-binding monoclonal antibodies to enable effective on-demand contraception. Here, using the cGMP-compliant Nicotiana-expression system, we produced an ultrapotent sperm-binding IgG antibody possessing 6 Fab arms per molecule that bind a well-established contraceptive antigen target, CD52g. We term this hexavalent antibody “Fab-IgG-Fab” (FIF). The Nicotiana-produced FIF had at least 10-fold greater sperm-agglutination potency and kinetics than the parent IgG, while preserving Fc-mediated trapping of individual spermatozoa in mucus. We formulated the Nicotiana-produced FIF into a polyvinyl alcohol–based water-soluble contraceptive film and evaluated its potency in reducing progressively motile sperm in the sheep vagina. Two minutes after vaginal instillation of human semen, no progressively motile sperm were recovered from the vaginas of sheep receiving FIF Film. Our work supports the potential of multivalent contraceptive antibodies to provide safe, effective, on-demand nonhormonal contraception.
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Mauck CK, Vincent KL. The postcoital test in the development of new vaginal contraceptives†. Biol Reprod 2021; 103:437-444. [PMID: 32657328 PMCID: PMC7401356 DOI: 10.1093/biolre/ioaa099] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 05/21/2020] [Accepted: 06/12/2020] [Indexed: 12/27/2022] Open
Abstract
Postcoital tests (PCTs) have been used for over a century in the clinical evaluation of infertile couples, and for nearly 70 years in the evaluation of new vaginal contraceptive products. PCTs have been largely replaced by more modern methods in the study of infertility, but they remain the most useful way to obtain preliminary data on the effectiveness of vaginal contraceptive products. The World Health Organization has described important aspects of the procedure. It involves collection of cervical mucus at a certain time point after intercourse and the counting and characterization of sperm found in the mucus. A wide range of progressively motile sperm (PMS) has been associated with pregnancy rates in infertility studies. Eligibility for contraceptive trials includes the requirement that couples achieve a certain threshold number of PMS per high power field at midcycle in a baseline cycle without the test product. The primary endpoint, or definition of a satisfactory result in test cycles, is predefined. A literature review identified 10 PCT studies of vaginal contraceptives involving nine test products. Phase II trials of vaginal contraceptives have not been deemed feasible in the development of any vaginal contraceptive to date. A PCT study of a test product can be predictive of contraceptive efficacy, although ultimate contraceptive effectiveness is influenced by the ease of use of the product, along with patient compliance. PCT results similar to results seen with products that later showed satisfactory performance in efficacy trials is the best indicator of likely success of a test product.
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Affiliation(s)
| | - Kathleen L Vincent
- Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, TX, USA
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Shrestha B, Schaefer A, Zhu Y, Saada J, Jacobs TM, Chavez EC, Omsted SS, Cruz-Teran CA, Vaca GB, Vincent K, Moench TR, Lai SK. Engineering sperm-binding IgG antibodies for the development of an effective nonhormonal female contraception. Sci Transl Med 2021; 13:13/606/eabd5219. [PMID: 34380769 DOI: 10.1126/scitranslmed.abd5219] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 03/08/2021] [Accepted: 07/23/2021] [Indexed: 12/25/2022]
Abstract
Many women risk unintended pregnancy because of medical contraindications or dissatisfaction with contraceptive methods, including real and perceived side effects associated with the use of exogenous hormones. We pursued direct vaginal delivery of sperm-binding monoclonal antibodies (mAbs) that can limit progressive sperm motility in the female reproductive tract as a strategy for effective nonhormonal contraception. Here, motivated by the greater agglutination potencies of polyvalent immunoglobulins but the bioprocessing ease and stability of immunoglobulin G (IgG), we engineered a panel of sperm-binding IgGs with 6 to 10 antigen-binding fragments (Fabs), isolated from a healthy immune-infertile woman against a unique surface antigen universally present on human sperm. These highly multivalent IgGs (HM-IgGs) were at least 10- to 16-fold more potent and faster at agglutinating sperm than the parent IgG while preserving the crystallizable fragment (Fc) of IgG that mediates trapping of individual spermatozoa in mucus. The increased potencies translated into effective (>99.9%) reduction of progressively motile sperm in the sheep vagina using as little as 33 μg of the 10-Fab HM-IgG. HM-IgGs were produced at comparable yields and had identical thermal stability to the parent IgG, with greater homogeneity. HM-IgGs represent not only promising biologics for nonhormonal contraception but also a promising platform for engineering potent multivalent mAbs for other biomedical applications.
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Affiliation(s)
- Bhawana Shrestha
- Department of Microbiology and Immunology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Alison Schaefer
- UNC/NCSU Joint Department of Biomedical Engineering, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Yong Zhu
- Department of Pathology, University of Texas Medical Branch, Galveston, TX 77555, USA
| | - Jamal Saada
- Department of Ophthalmology, University of Texas Medical Branch, Galveston, TX 77555, USA
| | - Timothy M Jacobs
- Division of Pharmacoengineering and Molecular Pharmaceutics, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA.,Dualogics LLC, Durham, NC 27713, USA
| | - Elizabeth C Chavez
- Department of Biology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Stuart S Omsted
- Department of Biophysics, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Carlos A Cruz-Teran
- Division of Pharmacoengineering and Molecular Pharmaceutics, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Gabriela Baldeon Vaca
- Divisions of Infectious Disease and Obstetrics & Gynecology, Boston University School of Medicine, Boston, MA 02118, USA
| | - Kathleen Vincent
- Division of Gynecology, Department of Obstetrics and Gynecology, Center for Biomedical Engineering, University of Texas Medical Branch, Galveston, TX 77555, USA
| | - Thomas R Moench
- Department of Biophysics, Johns Hopkins University, Baltimore, MD 21218, USA.,Mucommune LLC, Durham, NC 27709, USA.,Mapp Biopharmaceutical Inc., San Diego, CA 92121, USA
| | - Samuel K Lai
- Department of Microbiology and Immunology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA. .,UNC/NCSU Joint Department of Biomedical Engineering, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA.,Division of Pharmacoengineering and Molecular Pharmaceutics, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA.,Mucommune LLC, Durham, NC 27709, USA
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Anderson DJ, Politch JA, Cone RA, Zeitlin L, Lai SK, Santangelo PJ, Moench TR, Whaley KJ. Engineering monoclonal antibody-based contraception and multipurpose prevention technologies†. Biol Reprod 2020; 103:275-285. [PMID: 32607584 PMCID: PMC7401387 DOI: 10.1093/biolre/ioaa096] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 05/20/2020] [Accepted: 06/02/2020] [Indexed: 12/16/2022] Open
Abstract
Sexually transmitted infections are highly prevalent, and over 40% of pregnancies are unplanned. We are producing new antibody-based multipurpose prevention technology products to address these problems and fill an unmet need in female reproductive health. We used a Nicotiana platform to manufacture monoclonal antibodies against two prevalent sexually transmitted pathogens, HIV-1 and HSV-2, and incorporated them into a vaginal film (MB66) for preclinical and Phase 1 clinical testing. These tests are now complete and indicate that MB66 is effective and safe in women. We are now developing an antisperm monoclonal antibody to add contraceptive efficacy to this product. The antisperm antibody, H6-3C4, originally isolated by Shinzo Isojima from the blood of an infertile woman, recognizes a carbohydrate epitope on CD52g, a glycosylphosphatidylinositol-anchored glycoprotein found in abundance on the surface of human sperm. We engineered the antibody for production in Nicotiana; the new antibody which we call "human contraception antibody," effectively agglutinates sperm at concentrations >10 μg/ml and maintains activity under a variety of physiological conditions. We are currently seeking regulatory approval for a Phase 1 clinical trial, which will include safety and "proof of principle" efficacy endpoints. Concurrently, we are working with new antibody production platforms to bring the costs down, innovative antibody designs that may produce more effective second-generation antibodies, and delivery systems to provide extended protection.
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Affiliation(s)
- Deborah J Anderson
- Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Joseph A Politch
- Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Richard A Cone
- Biophysics Department, Johns Hopkins University, Baltimore, MD, USA
- Mucommune, LLC, Durham, NC, USA
| | | | - Samuel K Lai
- Division of Pharmacoengineering and Molecular Pharmaceutics, Department of Microbiomology & Immunology, University of North Carolina, Chapel Hill, NC, USA
| | - Philip J Santangelo
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University Atlanta, GA, USA
| | - Thomas R Moench
- Mucommune, LLC, Durham, NC, USA
- ZabBio, Inc., San Diego, CA, USA
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Cottrell ML, Kashuba ADM. Topical microbicides and HIV prevention in the female genital tract. J Clin Pharmacol 2014; 54:603-15. [PMID: 24664786 DOI: 10.1002/jcph.292] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2014] [Accepted: 03/19/2014] [Indexed: 11/05/2022]
Abstract
Worldwide, HIV disproportionately affects women who are often unable to negotiate traditional HIV preventive strategies such as condoms. In the absence of an effective vaccine or cure, chemoprophylaxis may be a valuable self-initiated alternative. Topical microbicides have been investigated as one such option. The first generation topical microbicides were non-specific, broad-spectrum antimicrobial agents, including surfactants, polyanions, and acid buffering gels, that generally exhibited contraceptive properties. After extensive clinical study, none prevented HIV infection, and their development was abandoned. Second generation topical microbicides include agents with selective mechanisms of antiviral activity. Most are currently being used for, or have previously been explored as, drugs for treatment of HIV. The most advanced of these is tenofovir 1% gel: the first topical agent shown to significantly reduce HIV infection by 39% compared to placebo. This review summarizes the evolution of topical microbicides for HIV chemoprophylaxis, highlights important concepts learned, and offers current and future considerations for this area of research.
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Affiliation(s)
- Mackenzie L Cottrell
- University of North Carolina at Chapel Hill, UNC Eshelman School of Pharmacy, Chapel Hill, NC, USA
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Friend DR, Kiser PF. Assessment of topical microbicides to prevent HIV-1 transmission: Concepts, testing, lessons learned. Antiviral Res 2013; 99:391-400. [DOI: 10.1016/j.antiviral.2013.06.021] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2013] [Revised: 06/26/2013] [Accepted: 06/28/2013] [Indexed: 11/30/2022]
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Nelson AL. New frontiers in female contraception (and male condoms): 2012. Expert Opin Investig Drugs 2012; 21:677-93. [DOI: 10.1517/13543784.2012.679342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Anita L Nelson
- Harbor UCLA Medical Center,
1457 3rd Street, Manhattan Beach, CA 90266, USA ;
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Adams JL, Kashuba ADM. Formulation, pharmacokinetics and pharmacodynamics of topical microbicides. Best Pract Res Clin Obstet Gynaecol 2012; 26:451-62. [PMID: 22306523 DOI: 10.1016/j.bpobgyn.2012.01.004] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2011] [Accepted: 01/16/2012] [Indexed: 11/26/2022]
Abstract
The development of safe topical microbicides that effectively prevent human immunodeficiency virus (HIV) infection is a major goal in curbing the human immunodeficiency virus pandemic. A number of past failures resulting from mucosal toxicity or lack of efficacy have informed the field. Products that caused toxicity to the female genital tract mucosa, and thereby increased the likelihood of HIV acquisition, included nonoxynol 9, cellulose sulfate, and C31 G vaginal gel Savvy. Topical products that were ineffective in preventing HIV infection include BufferGel, Carraguard, and PRO 2000. Antiretroviral drugs such as tenofovir and dapivirine formulated into microbicide products have shown promise, but there is much to learn about ideal product formulation and acceptability, and drug distribution and disposition (pharmacokinetics). Current formulations for water-soluble molecules include vaginally or rectally applied gels, vaginal rings, films and tablets. Dosing strategies (e.g. coitally dependent or independent) will be based on the pharmacokinetics of the active ingredient and the tolerance for less than perfect adherence.
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Affiliation(s)
- Jessica L Adams
- University of North Carolina at Chapel Hill, Eshelman School of Pharmacy 3315 Kerr Hall CB# 7569, Chapel Hill, North Caroina 27599-7569, USA.
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Cervicovaginal safety of the formulated, biguanide-based human immunodeficiency virus type 1 (HIV-1) inhibitor NB325 in a murine model. J Biomed Biotechnol 2011; 2011:941061. [PMID: 22131821 PMCID: PMC3202145 DOI: 10.1155/2011/941061] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2011] [Revised: 08/04/2011] [Accepted: 08/11/2011] [Indexed: 11/30/2022] Open
Abstract
Vaginal microbicides that reduce or eliminate the risk of HIV-1 sexual transmission must do so safely without adversely affecting the integrity of the cervicovaginal epithelium. The present studies were performed to assess the safety of the biguanide-based antiviral compound NB325 in a formulation suitable for topical application. Experiments were performed using a mouse model of cervicovaginal microbicide application, which was previously shown to be predictive of topical agent toxicity revealed in microbicide clinical trials. Mice were exposed vaginally to unformulated NB325 or NB325 formulated in the hydroxyethyl cellulose “universal placebo.” Following exposures to formulated 1% NB325 for 10 min to 24 h, the vaginal and cervical epithelia were generally intact, although some areas of minimal vaginal epithelial damage were noted. Although formulated NB325 appeared generally safe for application in these studies, the low but observable level of toxicity suggests the need for improvements in the compound and/or formulation.
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Contraceptive efficacy, acceptability, and safety of C31G and nonoxynol-9 spermicidal gels: a randomized controlled trial. Obstet Gynecol 2011; 116:1265-1273. [PMID: 21099590 DOI: 10.1097/aog.0b013e3181fc3b1a] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To estimate whether a gel containing the spermicide C31G was noninferior to a commercially available product containing nonoxynol-9. METHODS Participants were healthy, sexually active women aged 18-40 years. Measured outcomes included pregnancy rates, continuation rates, adverse events, and acceptability. The primary study outcome was contraceptive efficacy. Sample size was calculated at a 2.5% significance level using a one-sided test based on assumed 6-month pregnancy probability of 15% in the nonoxynol-9 group. Sample size was sufficient to reject, with 80% power, the null hypothesis that pregnancy probability in the C31G arm would be more than 5% higher. RESULTS Nine hundred thirty-two women were randomized in the C31G group and 633 in the nonoxynol-9 group. For randomized patients with at least one episode of coitus (modified intent-to-treat group), 6-month pregnancy probabilities were 12.0% (95% confidence interval [CI] 9.3-14.7%) and 12.0% (95% CI 8.7-15.3%) for C31G and nonoxynol-9,respectively. Twelve-month pregnancy probabilities were 13.8% (95% CI 7.6-20%) for C31G and 19.8% (95% CI 10.9-28.7%) for nonoxynol-9. Two serious adverse events were deemed possibly related to study product and neither occurred in the C31G group. Three fourths of users in either group reported that they liked their assigned study product. Approximately 40% of patients discontinued prematurely for reasons other than pregnancy with 11% lost to follow-up. CONCLUSION C31G demonstrated noninferior contraceptive efficacy compared with nonoxynol-9. C31G may provide another marketable option for women seeking spermicidal contraception. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, www.ClinicalTrials.gov, NCT00274261.
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Garg AB, Nuttall J, Romano J. The future of HIV microbicides: challenges and opportunities. Antivir Chem Chemother 2009; 19:143-50. [PMID: 19374141 DOI: 10.1177/095632020901900401] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
HIV microbicides are topical, self-administered products aimed at preventing or reducing HIV infection in women and may represent the most promising strategy for combating the HIV/AIDS epidemic at the present time. Although a safe and effective microbicide has yet to be identified, all products tested in Phase III trials to date have been vaginal gels containing non-specific compounds with modest potency that had to be applied close to the time of sexual intercourse. Issues regarding these early generation products were further complicated by widely publicized cases of halted efficacy trials. However, as a result of each of these challenges, new information and essential lessons have emerged for the field. These lessons have resulted in a meaningful increase in microbicide development efforts focusing on compounds with highly potent and HIV-specific mechanisms of action, combination products, novel formulations, and carefully designed pharmacokinetic and pharmacodynamic evaluations, all of which are reasons for renewed confidence that a safe and effective microbicide is achievable.
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Affiliation(s)
- Anita B Garg
- International Partnership for Microbicides, Inc, Silver Spring, MD, USA.
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SILCS diaphragm: postcoital testing of a new single-size contraceptive device. Contraception 2008; 78:237-44. [PMID: 18692615 DOI: 10.1016/j.contraception.2008.04.118] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2008] [Revised: 04/01/2008] [Accepted: 04/24/2008] [Indexed: 11/20/2022]
Abstract
BACKGROUND This study was conducted to compare the effectiveness of a new, single-size silicone contraceptive diaphragm used with either spermicide [2% nonoxynol-9 (N-9)] or lubricant in preventing sperm from penetrating midcycle cervical mucus. STUDY DESIGN A crossover postcoital test (PCT) in healthy, sexually active women not at risk for pregnancy due to tubal occlusion was conducted. Couples had a baseline PCT without a device to verify normal fertility parameters. Qualified couples underwent up to two test cycles using the SILCS diaphragm with a metal spring. A subgroup of couples underwent a third test cycle with the SILCS polymer spring diaphragm used with N-9 gel. RESULTS Fifteen couples completed a baseline cycle and were randomized to order of study gel. Of these, 14 couples completed a baseline cycle and at least one test cycle, 12 couples completed a baseline cycle and two test cycles and 8 couples completed a third test cycle with the polymer spring prototype. Sperm was detected in the vaginal pool in all completed test cycles. The SILCS metal spring diaphragms used with N-9 gel reduced the average number of progressively motile sperm per high power field in the cervical mucus from a baseline of 12.5 to 0, while use of this device with lubricant reduced the number to 0.5. The SILCS polymer spring diaphragm used with N-9 performed the same as the metal spring used with N-9. CONCLUSION The SILCS diaphragm used with N-9 gel performed well. It is likely that the SILCS diaphragm will give acceptable results in a contraceptive effectiveness study but that adjunctive use of a chemical barrier such as N-9 gel will be necessary for it to be most effective.
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Feldblum PJ, Adeiga A, Bakare R, Wevill S, Lendvay A, Obadaki F, Olayemi MO, Wang L, Nanda K, Rountree W. SAVVY vaginal gel (C31G) for prevention of HIV infection: a randomized controlled trial in Nigeria. PLoS One 2008; 3:e1474. [PMID: 18213382 PMCID: PMC2190795 DOI: 10.1371/journal.pone.0001474] [Citation(s) in RCA: 212] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2007] [Accepted: 12/17/2007] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The objective of this trial was to determine the effectiveness of 1.0% C31G (SAVVY) in preventing male-to-female vaginal transmission of HIV infection among women at high risk. METHODOLOGY/PRINCIPAL FINDINGS This was a Phase 3, double-blind, randomized, placebo-controlled trial. Participants made up to 12 monthly follow-up visits for HIV testing, adverse event reporting, and study product supply. The study was conducted between September 2004 and December 2006 in Lagos and Ibadan, Nigeria, where we enrolled 2153 HIV-negative women at high risk of HIV infection. Participants were randomized 1 ratio 1 to SAVVY or placebo. The effectiveness endpoint was incidence of HIV infection as indicated by detection of HIV antibodies in oral mucosal transudate (rapid test) or blood (ELISA), and confirmed by Western blot or PCR testing. We observed 33 seroconversions (21 in the SAVVY group, 12 in the placebo group). The Kaplan-Meier estimates of the cumulative probability of HIV infection at 12 months were 0.028 in the SAVVY group and 0.015 in the placebo group (2-sided p-value for the log-rank test of treatment effect 0.121). The point estimate of the hazard ratio was 1.7 for SAVVY versus placebo (95% confidence interval 0.9, 3.5). Because of lower-than-expected HIV incidence, we did not observe the required number of HIV infections (66) for adequate power to detect an effect of SAVVY. Follow-up frequencies of adverse events, reproductive tract adverse events, abnormal pelvic examination findings, chlamydial infections and vaginal infections were similar in the study arms. No serious adverse event was attributable to SAVVY use. CONCLUSIONS/SIGNIFICANCE SAVVY did not reduce the incidence of HIV infection. Although the hazard ratio was higher in the SAVVY than the placebo group, we cannot conclude that there was a harmful treatment effect of SAVVY.
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Affiliation(s)
- Paul J Feldblum
- Family Health International, Research Triangle Park, North Carolina, USA.
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Peterson L, Nanda K, Opoku BK, Ampofo WK, Owusu-Amoako M, Boakye AY, Rountree W, Troxler A, Dominik R, Roddy R, Dorflinger L. SAVVY (C31G) gel for prevention of HIV infection in women: a Phase 3, double-blind, randomized, placebo-controlled trial in Ghana. PLoS One 2007; 2:e1312. [PMID: 18091987 PMCID: PMC2129116 DOI: 10.1371/journal.pone.0001312] [Citation(s) in RCA: 151] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2007] [Accepted: 09/06/2007] [Indexed: 11/18/2022] Open
Abstract
Objective The objective of this trial was to determine the effectiveness of 1.0% C31G (SAVVY) in preventing male-to-female vaginal transmission of HIV infection among women at high risk. Methodology/Principal Findings This was a Phase 3, double-blind, randomized, placebo-controlled trial. Participants made up to 12 monthly visits for HIV testing, adverse event reporting, and study product supply. The study was conducted between March 2004 and February 2006 in Accra and Kumasi, Ghana. We enrolled 2142 HIV-negative women at high risk of HIV infection, and randomized them to SAVVY or placebo gel. Main outcome measures were the incidence of HIV-1 and HIV-2 infection as determined by detection of HIV antibodies from oral mucosal transudate specimens and adverse events. We accrued 790 person-years of follow-up in the SAVVY group and 772 person-years in the placebo group. No clinically significant differences in the overall frequency of adverse events, abnormal pelvic examination findings, or abnormal laboratory results were seen between treatment groups. However, more participants in the SAVVY group reported reproductive tract adverse events than in the placebo group (13.0% versus 9.4%). Seventeen HIV seroconversions occurred; eight in participants randomized to SAVVY and nine in participants receiving placebo. The Kaplan-Meier estimates of the cumulative probability of HIV infection through 12 months were 0.010 in the SAVVY group and 0.011 in the placebo group (p = 0.731), with a hazard ratio (SAVVY versus placebo) of 0.88 (95% confidence interval 0.33, 2.27). Because of a lower-than-expected HIV incidence, we were unable to achieve the required number of HIV infections (66) to obtain the desired study power. Conclusions/Significance SAVVY was not associated with increased adverse events overall, but was associated with higher reporting of reproductive adverse events. Our data are insufficient to conclude whether SAVVY is effective at preventing HIV infection relative to placebo. Trial Registration ClinicalTrials.gov NCT00129532
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Affiliation(s)
- Leigh Peterson
- Family Health International, Durham, North Carolina, United States
| | - Kavita Nanda
- Family Health International, Durham, North Carolina, United States
- * To whom correspondence should be addressed. E-mail:
| | - Baafuor Kofi Opoku
- Komfo Anokye Teaching Hospital, Kwame Nkrumah University of Science & Technology, Kumasi, Ghana
| | | | | | - Andrew Yiadom Boakye
- Komfo Anokye Teaching Hospital, Kwame Nkrumah University of Science & Technology, Kumasi, Ghana
| | - Wes Rountree
- Family Health International, Durham, North Carolina, United States
| | - Amanda Troxler
- Family Health International, Durham, North Carolina, United States
| | - Rosalie Dominik
- Family Health International, Durham, North Carolina, United States
| | - Ronald Roddy
- Duke Clinical Research Institute, Durham, North Carolina, United States
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16
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Nikolic DS, Garcia E, Piguet V. Microbicides and other topical agents in the prevention of HIV and sexually transmitted infections. Expert Rev Anti Infect Ther 2007; 5:77-88. [PMID: 17266456 DOI: 10.1586/14787210.5.1.77] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
According to information from UNAIDS, more than 42 million individuals are living with HIV worldwide. Most infected individuals live in developing countries where the availability of antiretroviral agents is still limited. As this pandemic is increasing largely through mucosal transmission, new methods of prevention are urgently needed. If available, agents that block HIV prior to or early after contact with mucosal epithelia would decrease the incidence of HIV infection and, therefore, potentially save millions of lives over the next few decades. Topically applied microbicides acting against HIV-1 can be subdivided into four subgroups, including agents directly inhibiting pathogens, agents acting on genital pH, agents blocking pathogen entry and replication inhibitors. In addition, microbicides might also allow fighting against other sexually transmitted infections, such as herpes simplex viruses. With concerted efforts directed towards developing efficient microbicides, topical anti-infective compounds may well become a new weapon against sexually transmitted infections, including HIV, in everyday clinical practice.
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Affiliation(s)
- Damjan S Nikolic
- Department of Dermatology and Venereology, University Hospital and Medical School of Geneva, Geneva, Switzerland.
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17
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McGowan I. Microbicides: a new frontier in HIV prevention. Biologicals 2006; 34:241-55. [PMID: 17097303 DOI: 10.1016/j.biologicals.2006.08.002] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2006] [Accepted: 08/24/2006] [Indexed: 01/01/2023] Open
Abstract
Microbicides are products that can be applied to vaginal or rectal mucosal surfaces with the goal of preventing, or at least significantly reducing, the transmission of sexually transmitted infections (STIs) including HIV-1. Despite more than two decades of HIV-1 vaccine research, there is still no efficacious HIV-1 vaccine, and the scientific community appears skeptical about the short or long-term feasibility of developing a vaccine that has the ability to induce sterilizing immunity against HIV-1. In this setting, microbicide research has gathered momentum. Currently, 16 candidate microbicides are in clinical development and five products are being evaluated in large-scale Phase 2B/3 effectiveness studies. Initial data from these trials will be available within the next 2-3 years, and it is feasible that there could be one or more licensed microbicides by the end of the decade. The first generation of surfactant microbicides had a non-specific mechanism of action. However, subsequent candidate microbicides have been developed to target specific steps in the process of viral transmission. The purpose of this article is to provide an overview of microbicide development and an update on the candidate pipeline.
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Affiliation(s)
- Ian McGowan
- Center for Prevention Research, David Geffen School of Medicine at UCLA, Los Angeles, 10940 Wilshire Boulevard, Suite 1250, Los Angeles, CA 90025, USA.
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18
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Trapp S, Turville SG, Robbiani M. Slamming the door on unwanted guests: why preemptive strikes at the mucosa may be the best strategy against HIV. J Leukoc Biol 2006; 80:1076-83. [PMID: 16908515 DOI: 10.1189/jlb.0206121] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Susanna Trapp
- Center for Biomedical Research, Population Council, 1230 York Avenue, New York, NY 10021, USA
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19
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Madan RP, Keller MJ, Herold BC. Prioritizing prevention of HIV and sexually transmitted infections: first-generation vaginal microbicides. Curr Opin Infect Dis 2006; 19:49-54. [PMID: 16374218 DOI: 10.1097/01.qco.0000200291.37909.3b] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW As the HIV/AIDS pandemic continues unabated, novel control measures for the spread of HIV and other sexually transmitted infections are urgently needed. Topical microbicides are designed to prevent transmission of sexually transmitted infections when applied vaginally. The microbicides discussed in this review may provide a new opportunity for decreasing the spread of HIV and other sexually transmitted infections. RECENT FINDINGS Epidemiological studies suggest a synergistic relationship between HIV and sexually transmitted infections, particularly between HIV and genital herpes infection. Compounds have been developed to block transmission of HIV-1 and herpes simplex virus, as well as Neisseria gonorrhoea and Chlamydia trachomatis. Several of these compounds have advanced to clinical trials as candidate microbicides. Candidate compounds fall into the following categories: detergents or surfactants that inactivate viral particles, anionic polymers that block attachment of virus to target cells, vaginal acid-buffering agents that maintain a protective vaginal pH, and antiretroviral drugs specific for HIV. Evaluation of the safety of topical microbicides remains problematic. Clinical experiences indicate that current models to assess safety in vitro and in vivo may be insufficient to assess the safety of vaginal microbicides. A critical direction of future studies is to identify which assay(s) provide surrogate laboratory markers of safety that correlate with clinical outcomes. SUMMARY The spread of HIV, and its increasing burden of disease in women, necessitates the development of novel prophylactic strategies. Topical microbicides offer women an empowering preventative option but require vigorous testing for safety and effectiveness.
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20
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Catalone BJ, Ferguson ML, Miller SR, Malamud D, Kish-Catalone T, Thakkar NJ, Krebs FC, Howett MK, Wigdahl B. Prolonged exposure to the candidate microbicide C31G differentially reduces cellular sensitivity to agent re-exposure. Biomed Pharmacother 2006; 59:460-8. [PMID: 16154719 DOI: 10.1016/j.biopha.2005.07.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2005] [Indexed: 10/25/2022] Open
Abstract
Comparative assays of in vitro cytotoxicity using nonoxynol-9 (N-9) and the candidate microbicides C31G and sodium dodecyl sulfate (SDS) demonstrated that these agents, which are, respectively, characterized as nonionic, amphoteric, and anionic surfactants, differed in their concentration-dependent effects on cell viability, especially after prolonged exposure. We hypothesized that differences in cellular sensitivity may have been due, in part, to cellular changes induced by long-term exposure to each agent. To examine this possibility, HeLa cells were exposed to N-9, C31G, or SDS for extended periods of time and subsequently reassessed for sensitivity to each of these agents. Following 10 continuous days of C31G exposure, HeLa cells were less sensitive to a subsequent C31G exposure compared to cells that had not undergone long-term C31G treatment. Interestingly, long-term C31G exposure also changed subsequent sensitivity to N-9 but not SDS. In contrast, prolonged exposure to either N-9 or SDS did not reduce sensitivity to re-exposure. The effect of long-term C31G exposure was both concentration-dependent and transient, as treated cells reverted to pre-exposure sensitivity in a time-dependent manner following the cessation of C31G exposure. Lipid analyses of cells exposed to C31G for extended durations revealed altered phospholipid profiles relative to C31G-naïve cells. Experiments examining the individual components of C31G demonstrated the involvement of the amine oxide moiety in reductions in cellular sensitivity. These studies, which provide new information concerning the cytotoxicity of surfactant microbicides, suggest that cervicovaginal epithelial cells may have greater in vivo tolerance for products containing C31G through unique interactions between C31G and components of the cellular membranes.
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Affiliation(s)
- Bradley J Catalone
- Department of Microbiology and Immunology, Pennsylvania State University College of Medicine, Hershey, PA 17033, USA
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21
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Catalone BJ, Miller SR, Ferguson ML, Malamud D, Kish-Catalone T, Thakkar NJ, Krebs FC, Howett MK, Wigdahl B. Toxicity, inflammation, and anti-human immunodeficiency virus type 1 activity following exposure to chemical moieties of C31G. Biomed Pharmacother 2006; 59:430-7. [PMID: 16154721 DOI: 10.1016/j.biopha.2005.07.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2005] [Indexed: 11/29/2022] Open
Abstract
C31G, which has potent activity against the human immunodeficiency virus type 1 (HIV-1) and an established record of safety in animal studies and human trials, is a microbicidal agent comprised of a buffered equimolar mixture of two amphoteric, surface-active agents: an alkyl amine oxide (C14AO) and an alkyl betaine (C16B). Studies of long-term in vitro exposure to C31G and its constituents have suggested that the components of C31G may contribute differentially to its toxicity and efficacy. In the present studies, in vitro assays of cytotoxicity and anti-HIV-1 activity demonstrated that C16B was slightly less cytotoxic compared to either C31G or C14AO, whereas the anti-HIV-1 activities of C31G and its individual constituents were similar. In the murine model of cervicovaginal microbicide toxicity, in vivo exposure to C14AO resulted in severe cervical inflammation followed by a delayed disruption of the columnar epithelium. In contrast, exposure to C16B caused severe cervical epithelial disruption and a secondary, less intense inflammatory response. These results demonstrate that (i) there are both mechanistic and temporal differences in toxicity associated with the components of C31G not necessarily predicted by in vitro assessments of cytotoxicity and (ii) contributions of each component to the anti-HIV-1 activity of C31G appear to be equal. In addition, these findings indicate that direct and indirect mechanisms of in vivo toxicity can be observed as separate but interrelated events. These results provide further insight into the activity of C31G, as well as mechanisms potentially associated with microbicide toxicity.
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Affiliation(s)
- Bradley J Catalone
- Department of Microbiology and Immunology, Pennsylvania State University College of Medicine, Hershey, PA 17033, USA
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22
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Catalone BJ, Kish-Catalone TM, Neely EB, Budgeon LR, Ferguson ML, Stiller C, Miller SR, Malamud D, Krebs FC, Howett MK, Wigdahl B. Comparative safety evaluation of the candidate vaginal microbicide C31G. Antimicrob Agents Chemother 2005; 49:1509-20. [PMID: 15793133 PMCID: PMC1068583 DOI: 10.1128/aac.49.4.1509-1520.2005] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
C31G is currently the focus of clinical trials designed to evaluate this agent as a microbicidal and spermicidal agent. In the following studies, the in vivo safety of C31G was assessed with a Swiss Webster mouse model of cervicovaginal toxicity and correlated with results from in vitro cytotoxicity experiments and published clinical observations. A single exposure of unformulated 1% C31G resulted in mild-to-moderate epithelial disruption and inflammation at 2 and 4 h postapplication. The columnar epithelium of the cervix was the primary site of damage, while no perturbation of the vaginal mucosa was observed. In contrast, application of unformulated 1.7% C31G resulted in greater levels of inflammation in the cervical epithelium at 2 h postapplication and severe epithelial disruption that persisted to 8 h postapplication. Application of a nonionic aqueous gel formulation containing 1% C31G resulted in no apparent cervicovaginal toxicity at any time point evaluated. However, formulation of 1.7% C31G did not substantially reduce the toxicity associated with unformulated C31G at that concentration. These observations correlate with findings gathered during a recent clinical trial, in which once-daily applications resulted in no adverse events in women receiving the formulation containing 1% C31G, compared to moderate-to-severe adverse events in 30% of women receiving the 1.7% C31G formulation. The Swiss Webster mouse model was able to effectively discriminate between concentrations and formulations of C31G that produced distinct clinical effects in human trials. The Swiss Webster animal model may be a highly valuable tool for preclinical evaluation of candidate vaginal microbicides.
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MESH Headings
- Administration, Intravaginal
- Animals
- Anti-Infective Agents, Local
- Betaine/administration & dosage
- Betaine/adverse effects
- Betaine/analogs & derivatives
- Betaine/toxicity
- Cell Line
- Cervix Uteri/cytology
- Cervix Uteri/drug effects
- Fatty Acids, Unsaturated/administration & dosage
- Fatty Acids, Unsaturated/adverse effects
- Fatty Acids, Unsaturated/toxicity
- Female
- HeLa Cells
- Humans
- Mice
- Nonoxynol/administration & dosage
- Nonoxynol/adverse effects
- Nonoxynol/toxicity
- Vagina/cytology
- Vagina/drug effects
- Vaginal Creams, Foams, and Jellies/administration & dosage
- Vaginal Creams, Foams, and Jellies/adverse effects
- Vaginal Creams, Foams, and Jellies/toxicity
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Affiliation(s)
- Bradley J Catalone
- Department of Microbiology, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
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23
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Mauck CK, Frezieres RG, Walsh TL, Schmitz SW, Callahan MM, Bax R. Male tolerance study of 1% C31G. Contraception 2005; 70:221-5. [PMID: 15325891 DOI: 10.1016/j.contraception.2003.12.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2003] [Revised: 12/14/2003] [Accepted: 12/21/2003] [Indexed: 10/26/2022]
Abstract
BACKGROUND C31G is being studied as a vaginal contraceptive and microbicide. This study was conducted to ensure that male partners of the women in future trials of C31G will not be subjected to an undue risk of penile irritation. METHODS This was a randomized, double-blinded, single-center Phase I study in circumcised and uncircumcised men to assess penile irritation, safety and acceptability of seven consecutive daily doses of 1.0% C31G compared with a marketed spermicide, Extra Strength Gynol II(R) (3% nonoxynol-9) (ES Gynol II). Each participant was instructed to apply the study product to his penis at bedtime, to wash it off 6-10 h later, and to record any symptoms on a diary card. At the follow-up visit, a genital examination was performed and participants were again asked about adverse events and to complete an acceptability questionnaire. RESULTS Of the 36 men enrolled, 12.5% of C31G users and 16.7% of Extra Strength Gynol II users reported product-related adverse events (AEs). All product-related AEs were considered mild by the investigator, except for one in the ES Gynol II group. Both products were acceptable. CONCLUSION The manner in which the products were used in this study is not the route by which men will be exposed to such products in actual use, and results should be considered in this light. Based on the observations in this study, C31G appears to be at least as safe and acceptable for male penile exposure as the marketed product ES Gynol II.
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Affiliation(s)
- Christine K Mauck
- CONRAD, Eastern Virginia Medical School, 1611 North Kent Street, Suite 806, Arlington, VA 22209, USA.
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Abstract
At the end of 2003, 42 million people were HIV infected and the epidemic continues to spread, despite the availability and effectiveness of male condoms. For many women negotiating condom use is not feasible. Therefore there is an urgent need for a female controlled method for HIV prevention. This article gives an overview of the clinical research done with microbicides, chemicals with the potential to prevent an HIV infection. In the 1990s most research was done with spermicides, mainly nonoxynol-9. Since the results of the COL-1492 trial became available, new products were evaluated and some of them are now in phase III trials.
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