The protective effect of nonoxynol-9 against HIV infection

Antiviral Activity of a Sulphated Polysaccharide Extracted from the Marine Pseudomonas and Marine Plant Dinoflagellata against Human Immunodeficiency Viruses and other Enveloped Viruses

A natural sulphated mucopolysaccharide (OKU40), extracted from a marine plant Dinoflagellata, and an artificial sulphated polysaccharide (OKU41), prepared from a marine Pseudomonas, displayed antiviral activities against several enveloped viruses. OKU40 and OKU41 were found to be homogenous in electrophoresis and sedimation velocity and had a molecular weight of 8.0 × 1065.0 × 105respectively. The sulphation rate of OKU40 and OKU41 was 8.9% and 5.4%, respectively. Each OKU40 and OKU41 inhibited the cytopathic effect of human immunodeficiency virus type 1 (HIV-1), type 2 (HIV-2) and zidovudineresistant HIV-1 in MT-4 cells at similar concentrations to those of dextran sulphate (molecular weight: 5000) (50% inhibitory concentrations: 0.86-1.95 μg mL−1), whereas these compounds did not affect the growth and viability of mock-infected MT-4 cells at concentrations up to 500 μg mL−1. These compounds proved inhibitory not only to HIV-1 and HIV-2 but also to other enveloped viruses, i.e. herpes simplex virus type 1, influenza virus A and B, respiratory syncytial virus and measles virus. OKU40 and OKU41 suppressed syncytium formation induced by cocultivation of MOLT-4/IIIb and MOLT-4 cells at concentrations higher than 20 μg mL−1. Although OKU41 inhibited the binding of HIV-1 to the host cells and the binding of anti-gp120 monoclonal antibody to HIV-1 gp120, OKU40 did not inhibit these bindings, suggesting that the mechanism of anti-HIV activity of OKU40 and OKU41 may be primarily due to the inhibition of virus-cell fusion and viral adsorption to the host cells, respectively. Furthermore, these compounds did not inhibit to the blood coagulation process at a concentration that was significantly inhibitory to HIV replication. The compounds appear to have an interesting potential as virucidal agents.

Subchronic (26- and 52-week) toxicity and irritation studies of a novel microbicidal gel formulation containing sodium lauryl sulfate in animal models

The safety of an ethylene oxide/propylene oxide gel formulation containing sodium lauryl sulfate (2%, w/w), that could be a potent candidate as a topical microbicide, has been evaluated. More specifically, the subchronic (26- and 52-week) toxicity of the formulation when applied intravaginally as well as its irritating potential for the rectal, penile, eye, skin and buccal mucosa have been examined in animal models. The results showed that the vaginal administration of the gel formulation containing sodium lauryl sulfate once and twice daily (with doses 12 +/- 2 h apart) for 26 weeks to rats and for 52 weeks to rabbits induced slight to moderate histopathological alterations. When the formulation was applied intrarectally to male and female rabbits once and twice daily (with doses 12 +/- 2 h apart) for 14 days, no macroscopic or microscopic changes were reported. For both vaginal and rectal dosing, no effect was seen on the haematology, coagulation and serum chemistry parameters as well as on the body weight of animals and the relative organ weights. Other sporadic macroscopic and histopathological findings were incidental in origin and of no toxicological significance. The gel formulation containing sodium lauryl sulfate was considered as mildly irritating for the penile mucosa of rabbits, non-irritating for the eye of rabbits, mildly irritating for the skin in a rabbit model and non-irritating for the hamster cheek pouch. It is suggested that the gel formulation containing sodium lauryl sulfate is safe for most tissues that could be exposed to the product under normal use.

"We have our protector": misperceptions of protection against HIV among participants in a microbicide efficacy trial

OBJECTIVES

We examined perceptions of the effectiveness and acceptability of a candidate microbicide among 94 South African female sex workers who had participated in a phase 3 microbicide trial for HIV prevention.

METHODS

Sixteen focus groups were conducted in 2001, 12 to 15 months after participants were informed that the candidate microbicide had been determined to be ineffective in preventing HIV and other sexually transmitted infections (STIs).

RESULTS

Participants clearly indicated that they understood the experimental nature of the candidate microbicide, and they recognized that they had been informed after the trial that the product was ineffective. Nevertheless, most continued to believe that the candidate microbicide helped prevent HIV and other STIs, alleviated reproductive tract pain and STI symptoms, and helped to clean the vagina.

CONCLUSIONS

These findings underscore the importance of understanding women's perceptions of the efficacy of candidate microbicides and the rationale for these beliefs. These issues need to be addressed in counseling throughout microbicide trials for HIV prevention. These results also demonstrate how desperate many women at high risk of HIV infection may be for new HIV prevention technologies.

Thermoreversible gel formulation containing sodium lauryl sulfate as a potential contraceptive device

The contraceptive properties of a gel formulation containing sodium lauryl sulfate were investigated in both in vitro and in vivo models. Results showed that sodium lauryl sulfate inhibited, in a concentration-dependent manner, the activity of sheep testicular hyaluronidase. Sodium lauryl sulfate also completely inhibited human sperm motility as evaluated by the 30-sec Sander-Cramer test. The acid-buffering capacity of gel formulations containing sodium lauryl sulfate increased with the molarity of the citrate buffers used for their preparations. Furthermore, experiments in which semen was mixed with undiluted gel formulations in different proportions confirmed their physiologically relevant buffering capacity. Intravaginal application of the gel formulation containing sodium lauryl sulfate to rabbits before their artificial insemination with freshly ejaculated semen completely prevented egg fertilization. The gel formulation containing sodium lauryl sulfate was fully compatible with nonlubricated latex condoms. Taken together, these results suggest that the gel formulation containing sodium lauryl sulfate could represent a potential candidate for use as a topical vaginal spermicidal formulation to provide fertility control in women.

Synthesis of novel iodinated derivatives of nonoxynol-9 and their bioavailability in rats

The absorption and distribution of iodinated derivatives of nonoxynol-9, after vaginal administration in rats, were compared with results reported for [14C] nonoxynol-9. Mono-iodinated nonoxynol-9 was synthesized in addition to the radiolabeled derivative incorporating iodide-125 ([125I]). Six hours after dosing, test rats were euthanized and selected tissues were excised and assessed for radioactivity. Levels of radioactive markers in the reproductive system were substantial for both [14C] and [125I]. It was concluded that [125I] mono-iodinated nonoxynol-9 and [14C] nonoxynol-9 possessed similar bioavailability.

Comparative study of mechanisms of herpes simplex virus inactivation by sodium lauryl sulfate and n-lauroylsarcosine

The mechanisms of herpes simplex virus (HSV) inactivation by sodium lauryl sulfate (SLS) and n-lauroylsarcosine (LS), two anionic surfactants with protein denaturant potency, have been evaluated in cultured cells. Results showed that pretreatment of HSV type 1 (HSV-1) strain F and HSV-2 strain 333 with either surfactant inhibited, in a concentration- and time-dependent manner, their infectivities on Vero cells. SLS was a more potent inhibitor of HSV-2 strain 333 infectivity than LS with respect to the concentration (4.8-fold lower) and time (2.4-fold shorter) required to completely inactivate the virus. No inhibition of both herpesvirus strains infectivities was observed when Vero cells were pretreated with either surfactant. LS prevented the binding of HSV-2 strain 333 to cells without affecting the stable attachment and the rate of penetration into cells, whereas SLS exerted the opposite effect. Both SLS and LS inhibited, in a concentration-dependent manner, the HSV-2 strain 333-induced cytopathic effect, probably by affecting newly synthesized virions that come into contact with surfactant molecules present in culture medium. The pretreatment of HSV-2 strain 333 with specific combinations of SLS and LS concentrations inhibited the viral infectivity in a synergistic manner and resulted in only a small increase in their toxicities for exponentially growing Vero cells compared with that caused by each compound alone. Taken together, these results suggest that SLS and LS, alone or combined, could represent potent candidates as microbicides in topical vaginal formulations to prevent the transmission of herpes and possibly other pathogens that cause sexually transmitted diseases, including human immunodeficiency virus type 1.

Contraception for adolescents: social, clinical and service-delivery considerations

A large proportion of the millions of adolescents worldwide who are sexually active have sex without using modern contraceptives or protection against sexually transmitted infections (STI). In many cases, this results in too-early (and often unwanted) pregnancies and STI, with negative consequences at different levels. Adolescents in general--and unmarried adolescents in particular--often find it difficult to obtain the contraceptives they need. Health workers are often unaware of the special needs of adolescents, and contraceptive services are only rarely provided in a manner that is accessible to adolescents. The World Health Organization stresses that age alone does not constitute a medical reason for denying any available contraceptive method to adolescents. However, it recommends that it is important for health workers to be well aware of the biomedical, psychological and social issues that affect how they can assist adolescents in making well-informed choices of contraceptive methods that suit their special needs, and in using the contraceptives, they choose in an effective manner.

Thermoreversible gel formulations containing sodium lauryl sulfate or n-Lauroylsarcosine as potential topical microbicides against sexually transmitted diseases

The microbicidal efficacies of two anionic surfactants, sodium lauryl sulfate (SLS) and n-lauroylsarcosine (LS), were evaluated in cultured cells and in a murine model of herpes simplex type 2 (HSV-2) intravaginal infection. In vitro studies showed that SLS and LS were potent inhibitors of the infectivity of HSV-2 strain 333. The concentrations of SLS which inhibit viral infectivity by 50% (50% inhibitory dose) and 90% (90% inhibitory dose) were 32.67 and 46.53 microM, respectively, whereas the corresponding values for LS were 141.76 and 225.30 microM. In addition, intravaginal pretreatment of mice with thermoreversible gel formulations containing 2.5% SLS or 2.5% LS prior to the inoculation of HSV-2 strain 333 completely prevented the development of genital herpetic lesions and the lethality associated with infection. Of prime interest, no infectious virus could be detected in mouse vaginal mucosa. Both formulations still provided significant protection when viral challenge was delayed until 1 h after pretreatment. Finally, intravaginal application of gel formulations containing 2.5% SLS or 2.5% LS once daily for 14 days to rabbits did not induce significant irritations to the genital mucosa, as demonstrated from macroscopic and histopathologic examinations. These results suggest that thermoreversible gel formulations containing SLS or LS could represent potent and safe topical microbicides for the prevention of HSV-2 and possibly other sexually transmitted pathogens, including human immunodeficiency virus.

Thermoreversible gel as a candidate barrier to prevent the transmission of HIV-1 and herpes simplex virus type 2

BACKGROUND

Sexually transmitted diseases (STDs) caused by HIV, herpes simplex virus (HSV), and other pathogens are spreading dramatically. The need to develop active products and vehicles to reduce this epidemic is urgent.

GOAL

The efficacy of a thermoreversible gel formulation as a possible barrier to prevent the transmission of pathogens causing STDs was evaluated.

STUDY DESIGN

This evaluation investigated the ability of the gel formulation to prevent infection of susceptible cells by HIV-1 and HSV-2 in vitro, the diffusion of radiolabeled herpes virus and micelles of polymer through an insertion membrane, and the electron microscopic appearance of herpes virus and gel alone or mixed together.

RESULTS

The gel formulation prevents infection of susceptible cells by HIV-1 and HSV-2. It acts as an effective artificial physical barrier against the herpes virus within the first 4 hours of incubation. Herpes virus is coated by the gel or entrapped within micelles of the gel, which could hinder its attachment to target cells and inhibit its infectivity.

CONCLUSION

This thermoreversible gel formulation represents an attractive matrix for the incorporation of microbicides to prevent the spread of STDs.

Sodium lauryl sulfate abrogates human immunodeficiency virus infectivity by affecting viral attachment

The microbicidal activity of sodium lauryl sulfate (SLS) against human immunodeficiency virus type 1 (HIV-1) was studied in cultured cells. Pretreatment of HIV-1(NL4-3) with SLS decreased, in a concentration-dependent manner, its infectivity when using 1G5 as target cells. In the absence of a viral pretreatment period or when 1G5 cells were pretreated with SLS, the surfactant-induced inactivation of viral infectivity was less pronounced, especially at concentrations between 375 and 550 microM. SLS had no effect on HIV-1 when the virus was adsorbed to 1G5 cells by a 2-h incubation period. SLS almost completely inhibited the fusion process by decreasing the attachment of HIV-1 to target cells. SLS also inhibited the infectivity of HIV-1-based luciferase reporter viruses pseudotyped with the amphotropic murine leukemia virus envelope (which enters cells in a CD4-, CCR5-, and CXCR4-independent manner), indicating that SLS may inactivate other envelope viruses. In contrast, no effect was seen with vesicular stomatitis virus envelope glycoprotein G (which enters cells through receptor-mediated endocytosis) pretreated with up to 700 microM SLS. SLS also decreased, in a dose-dependent manner, the HIV-1-dependent syncytium formation between 1G5 and J1.1 cells after a 24-h incubation. The reduction of luciferase activity was more pronounced when J1.1 cells (which express HIV-1 proteins on their surface) were pretreated with SLS rather than 1G5 cells. Taken together, our results suggest that SLS could represent a candidate of choice for use in vaginal microbicides to prevent the sexual transmission of HIV and possibly other pathogens causing sexually transmitted diseases.

Male-condom and female-condom use among women after counseling in a risk-reduction hierarchy for STD prevention

BACKGROUND

A concern with hierarchy messages, which promote male condoms and female-controlled barrier methods along a prevention continuum, is that they may discourage condom use.

GOAL

To measure male-condom and female-condom use among women who received hierarchy counseling and compare this with women counseled about condoms only.

STUDY DESIGN

Three observational cohorts that correspond to prevention message received were assembled, and consisted of female sexually transmitted disease clinic patients who were counseled about male condoms, female condoms, or a hierarchy message. The hierarchy message promoted male and female condoms, the diaphragm and cervical cap, spermicides, and withdrawal, in descending order of effectiveness against sexually transmitted diseases. After counseling, women were interviewed and returned for follow-up visits at 2 weeks, 4 months, and 6 months. The outcome was the mean proportion of male condom- or female condom-protected coital acts at each follow-up visit in the hierarchy cohort. The outcome was dichotomized as high (> or = 70% of coital acts protected) or low (< 70%), and generalized estimating equations were used to compare observed follow-up condom use with baseline within the hierarchy cohort and observed follow-up condom use between cohorts. It was assumed that condom use in persons not present at 6 months was equal to baseline levels, and condom use estimates were calculated for each full cohort that was initially enrolled.

In vitro and in vivo evaluations of sodium lauryl sulfate and dextran sulfate as microbicides against herpes simplex and human immunodeficiency viruses

The efficacy of sodium lauryl sulfate (SLS), a sulfated anionic chaotropic surfactant, and dextran sulfate (DS), a polysulfated carbohydrate, against herpes simplex virus (HSV) and human immunodeficiency virus (HIV) infections was evaluated in cultured cells and in different murine models of HSV infection. Results showed that both SLS and DS were potent inhibitors of the infectivities of various HSV-1 and HSV-2 strains. Pretreatment of HIV-1 (strain NL4-3) with SLS also reduced its infectivity to 1G5 cells. DS prevented the binding of HSV to cell surface receptors and therefore its entry into cells. Pretreatment of HSV-1 (strain F) with 50 microM SLS resulted in a complete loss of virus infectivity to Vero cells. However, viruses were able to enter into cells and to produce in the nuclei capsid shells devoid of a DNA core. The amount of the glycoprotein D gene produced in these cells remained unchanged compared to controls, suggesting that SLS could interfere with the maturation of the virus. At a higher SLS concentration (100 microM), HSV was highly damaged by SLS pretreatment and only a few viral particles could enter into cells to produce abnormal capsids. Although DS was a more potent inhibitor of HSV infectivity in vitro, it was unable to provide any protection in murine models of HSV infection. However, SLS conferred a complete protection of animals infected cutaneously with pretreated viruses. In addition, skin pretreatment of mice with a polymer formulation containing SLS completely prevented the development of cutaneous lesions. More interestingly, intravaginal pretreatment of mice with SLS in a buffered solution also completely protected against lethal HSV-2 infection. Taken together, our results suggest that SLS could thus represent a candidate of choice as a microbicide to prevent the sexual transmission of HIV, HSV, and possibly other pathogens that cause sexually transmitted diseases.

Safety and toxicity of nonoxynol-9 gel as a rectal microbicide

BACKGROUND AND OBJECTIVES

Methods of HIV and STD prevention, which can be controlled by the receptive partner, are a high priority for research and development. Studies on the safety of Nonoxynol-9 (N-9) on the vaginal mucosa have yielded conflicting results. No Phase I study has evaluated the effect of N-9 on the rectal mucosa.

GOALS

To assess the safety of 52.5 mg of N-9 in a 1.5-g gel when applied one to four applicators per day to the rectum and penis.

STUDY DESIGN

The study included 25 HIV-negative and 10 HIV-positive, monogamous gay male couples in which each partner was exclusively insertive or receptive while using N-9 gel. Each participant served as his own control during placebo gel use compared to during N-9 gel use. Receptive partners underwent anoscopic examination after 1 week of placebo use and after 2, 5, and 6 weeks of N-9 gel use, with rectal biopsies obtained after 1 week of placebo use and after 5 and 6 weeks of N-9 gel use. Insertive partners had safety monitoring after 1 week of placebo use and after 2, 5, and 6 weeks of N-9.

RESULTS

No rectal ulcers were detected; superficial rectal erosions were noted in two HIV-negative participants. Abnormal or slightly abnormal histologic abnormalities of rectal biopsies were detected in 31 (89%) receptive participants after N-9 gel use compared to 24 (69%) participants after 1 week of placebo gel use. Meatal ulceration, not caused by herpes simplex virus, was detected in one HIV-negative participant.

CONCLUSION

Low-dose N-9 gel was not associated with macroscopic rectal and penile epithelial disruption or inflammation, but histologic abnormalities were commonly observed during N-9 gel as well as during placebo gel use.

Bile salts: natural detergents for the prevention of sexually transmitted diseases

The development of new, safe, topical microbicides for intravaginal use for the prevention of sexually transmitted diseases is imperative. Previous studies have suggested that bile salts may inhibit human immunodeficiency virus infection; however, their activities against other sexually transmitted pathogens have not been reported. To further explore the potential role of bile salts in preventing sexually transmitted diseases, we examined the in vitro activities and cytotoxicities of select bile salts against Chlamydia trachomatis, herpes simplex virus (types 1 and 2), Neisseria gonorrhoeae, and human immunodeficiency virus in comparison to those of nonoxynol-9 and benzalkonium chloride using both primary cells and cell lines derived from the human female genital tract. We found that taurolithocholic acid 3-sulfate and a combination of glycocholic acid and taurolithocholic acid 3-sulfate showed excellent activity against all of the pathogens assayed. Moreover, taurolithocholic acid 3-sulfate alone or in combination was less cytotoxic than nonoxynol-9 and benzalkonium chloride. Thus, taurolithocholic acid 3-sulfate alone or in combination warrants further evaluation as a candidate topical microbicidal agent.

Concanavalin A-immobilized polystyrene nanospheres capture HIV-1 virions and gp120: potential approach towards prevention of viral transmission

To establish an effective tool for the prevention of HIV-1 transmission, lectin-immobilized polystyrene nanospheres were synthesized and examined for their HIV-1 capture activity. When concanavalin A (Con A) was immobilized on the surface of polystyrene nanospheres (400 nm in diameter) with poly(methacrylic acid) branches and incubated with HIV-1 suspension at room temperature for 60 min, the nanospheres (Con A-NSs) achieved a >3.3 log and a 2.2 log reduction of viral infectivity in HIV-1 (IIIB strain) suspension at a concentration of 2 and 0.5 mg/ml, respectively. Meanwhile, Con A-free nanospheres, which were not immobilized with Con A, achieved only a 0.29 log reduction at 0.5 mg/ ml. Con A-NSs (2 mg/ml) could also reduce the gp120 level of III(B) and HE strains to <7.1% and 5.5% of each control, respectively. The combination of Con A-NS treatment followed by filtration with a microporous membrane efficiently removed virion-free gp120 as well as infectious viral particles from HIV-1 suspension. Electron microscopic examination demonstrated that HIV-1 virions were trapped on the surface of Con A-NSs. Thus, Con A-NSs can capture HIV-1 virions and gp120 with high affinity, and may have potential as an effective tool for the prevention of HIV-1 transmission.

The protective effect of condoms and nonoxynol-9 against HIV infection

OBJECTIVES

Whether or not spermicides can reduce the risk of human immunodeficiency virus (HIV) transmission remains an important question for the control of heterosexual HIV transmission. The authors provide estimates from a reanalysis of one of the few observational studies on the efficacy of condoms and spermicides, used separately and together, per vaginal contact.

METHODS

In this reanalysis, three different models were used to assess the efficacy of spermicides and condoms: linear (Pearl index), exponential (maximum likelihood), and monotonic (marginal likelihood).

RESULTS

Reported use of barrier methods among 27,432 contacts was as follows: condoms plus nonoxynol-9, 39%; condoms alone, 25%; nonoxynol-9 alone, 24%; and unprotected, 11%. Under all three models, the results indicate a strong protective effect for spermicidal suppositories. The Pearl index indicated that spermicide alone is apparently efficacious, but the efficacy per contact cannot be quantified with this approach. Maximum likelihood estimates for the efficacy of nonoxynol-9 alone and condoms (with or without nonoxynol-9) were 100% (95% confidence interval [CI95] = 43%, 100%) and 92% (95% CI95 = 79%, 100%), respectively.

CONCLUSIONS

The data from this observational study suggest that spermicides may be efficacious in reducing the risk of HIV transmission.

Do spermicides containing nonoxynol-9 prevent sexually transmitted infections? A meta-analysis

BACKGROUND AND OBJECTIVES

There are conflicting opinions on whether to recommend spermicides containing nonoxynol-9 for prevention of sexually transmitted diseases, including human immunodeficiency virus (HIV).

GOAL

To systematically review and summarize the medical literature on the effect of spermicides containing nonoxynol-9 on prevention of gonorrhea, chlamydial infection, and HIV.

STUDY DESIGN

Meta-analysis. Potential articles were identified through computerized literature searches. Articles were included if the design was clinical trial, cohort, case-control, or cross-sectional; original outcome data were presented for gonorrhea, chlamydial infection, or HIV; and spermicides containing nonoxynol-9 were used separately from other barrier methods. Study characteristics including design, population, spermicide dose, and delivery method were abstracted. Relative risks (RR) and 95% confidence intervals (CI) were determined from information published in the study or from study authors. Summary risk estimates were computed for clinical trials.

RESULTS

Twelve eligible articles were identified, including six clinical trials and six observational studies. Eleven articles evaluated gonorrhea; each found a reduced risk of infection with spermicide use. Among six clinical trials, the summary RR was 0.62 (95% CI, 0.49-0.78). The five articles evaluating chlamydial infection also found significant reduction among spermicide users, with the four clinical trials having a summary RR of 0.75 (95% CI, 0.62-0.91). The degree of spermicidal protection against gonorrhea and chlamydial infection did not differ materially among studies with different study designs or spermicidal preparations (i.e., sponge, gel, suppository, or film). Three studies evaluated degree of protection according to consistency of use and found stronger protection with more consistent use. The two studies on spermicidal prevention of HIV had contrasting results: An observational study found a significant protective effect (RR = 0.1), whereas a clinical trial found a nonsignificantly increased risk (RR = 1.7).

CONCLUSIONS

Nonoxynol-9-containing spermicides have an appreciable protective effect against both gonorrhea and chlamydial infection, and wider use of spermicides might substantially reduce the incidence of these diseases. However, insufficient data exist to judge their effect on HIV transmission, and more research on the effect of nonoxynol-9 on HIV transmission is urgently needed to make evidence-based clinical decisions and public health recommendations in the future.

Sulfated carbohydrate compounds prevent microbial adherence by sexually transmitted disease pathogens

Heparan sulfate (HS) serves as a receptor for adherence of herpes simplex viruses, Chlamydia trachomatis, Neisseria gonorrhoeae, and, indirectly, human immunodeficiency virus. Using primary human culture systems, we identified sulfated carbohydrate compounds that resemble HS and competitively inhibit infection by these pathogens. These compounds are candidates for intravaginal formulations for the prevention of sexually transmitted diseases.

Safety of a nonoxynol-9 vaginal gel in Kenyan prostitutes. A randomized clinical trial

OBJECTIVE

To evaluate the safety and toxicity of once-daily administration of Advantage-24 (Columbia Research Laboratories, Inc., Rockville Centre, NY), a vaginal gel containing 52.5 mg of nonoxynol-9 (N-9), including the effects of this gel on the vaginal and cervical epithelium.

STUDY DESIGN

Randomized, placebo-controlled, double-blind crossover trial, with a 2-week product application period and a 2-week washout period.

METHODS

Female sex workers in Mombasa, Kenya were randomized to one of two sequences, N-9 followed by placebo, or vice versa. Women were instructed to apply one applicator of N-9 or placebo gel vaginally once each day. During each of the two product periods, subjects were evaluated by questionnaire and physical examination, including colposcopy, after 7 and 14 days of product use. The primary outcome was genital epithelial disruption.

RESULTS

Sixty subjects were randomized, of whom 52 (87%) had complete follow-up. There were four episodes of epithelial disruption, three of which occurred during the placebo period and one during the N-9 period. The estimated risk of epithelial disruption associated with N-9 use was 0.33 (95% confidence interval, 0.03-3.26). There was no increased frequency of other, nondisruptive epithelial lesions during N-9 use.

CONCLUSIONS

No genital epithelial toxicity of N-9 vaginal gel was observed. This safety profile suggests that this N-9 product is appropriate for evaluation for human immunodeficiency virus type 1 prevention in a phase III efficacy trial.

Use of spermicide and impact of prophylactic condom use among sex workers in Santa Fe de Bogota, Colombia

BACKGROUND AND OBJECTIVES

Condom use is one of the most important preventive measures sex workers can take to reduce the risk of becoming infected with a sexually transmitted disease. However, a client may refuse to use a condom when requested. Some sexually transmitted disease prevention programs are recommending that sex workers use spermicide as an alternative prophylaxis when a condom is refused, yet little is known about the effect of this recommendation on prophylactic condom use.

GOAL

To determine if using spermicide, either in conjunction with condoms or as a backup, influenced overall condom use among a group of sex workers at high risk of sexually transmitted diseases in Santa Fe de Bogota, Colombia.

STUDY DESIGN

Participants were assigned randomly to one of three condom use groups: use of condoms only (Condoms Only), use of condoms and spermicides concurrently (Condom and Spermicide), or use of spermicide when condoms were refused (Spermicide as a Backup). A total of 199 sex workers entered the study and were asked to return for follow-up every 2 weeks for a period of 12 weeks.

RESULTS

Women assigned to the Spermicide as a Backup group used a condom for an average of 78.1% of their reported acts of intercourse, compared with an average of 94.5% in the Condom Only and 92.3% in the Condom and Spermicide groups. However, women in the Spermicide as a Backup group used a condom or spermicide for an average of 96.9% of their acts of intercourse. Condoms were used for every intercourse act by less than 5% of the women in the Spermicide as a Backup groups, compared with 50.7% in the Condom Only group and 41.2% in the Condom and Spermicide group (P 0.001). When condoms were not used, client refusal was the primary reason reported. The incidence of sexually transmitted diseases and other urogenital inflammations in all groups was lower than expected.

CONCLUSIONS

Among Colombian sex workers, condom use declined substantially when women were instructed to use spermicides if they were unable to persuade their partner to use a condom. However, these same women usually used the study spermicide as an alternate prophylaxis.

HIV, STD and their current impact on reproductive health: the need for control of sexually transmitted diseases

STD and HIV are the second most important cause of Disability Adjusted Life Years lost in women in the developing world. Reasons for this are multiple, and include their higher vulnerability for STD and HIV, poor health care seeking behavior and lack of accessible and acceptable services. There is considerable synergism between family welfare services and STD programs: complications and sequelae of STD affect the reproductive tract and child health and survival; reproductive and child health and survival are the focus of family welfare programs. Family welfare services are thus well positioned to incorporate STD and HIV prevention and control measures. This is feasible, although practical and logistical problems need to be addressed. Where indicated, pilot integration projects can assess the cost-effectiveness and outcome of such programs.

Spermicide acceptability among patients at a sexually transmitted disease clinic in Zambia

OBJECTIVE

This study assessed the acceptability of three nonoxynol-9 spermicides among persons attending a sexually transmitted disease clinic in Lusaka, Zambia.

METHODS

Spermicidal foam, suppositories, and foaming tablets were evaluated. Women (n = 114) and men (n = 150) attending an sexually transmitted disease clinic were enrolled. After each participant used two products, each for 2 weeks, consistency of use and acceptability were evaluated.

RESULTS

At admission, most women (74%) and men (58%) were not using any family planning method. Moreover, most women (85%) and men (98%) had at least one sexually transmitted disease or genital infection. During the study, the proportion of coital episodes protected by spermicide use was high, yet loss to follow-up and discontinuation were also substantial. Discontinuation was frequently unrelated to acceptability. Women and men rated all three products positively along several acceptability parameters. Foam was the least desirable delivery system due to excess messiness.

CONCLUSIONS

The results of this study suggest that it is feasible to distribute spermicides to women and men at increased risk for sexually transmitted disease and that the products will be used. Further research should be done among different populations and include other spermicidal delivery mechanisms.

Effectiveness of the non-spermicidal fit-free diaphragm

Standard instructions for diaphragm use call for an individually sized latex diaphragm, used in conjunction with spermicide jelly. However, some investigators have reported that the diaphragm can be effective without a spermicide. A non-randomized trial designed to measure the contraceptive effectiveness of the diaphragm used without spermicide was conducted. A total of 110 self-selected women were enrolled to use a non-spermicide fit-free (60mm) diaphragm for a period of one year. They were advised to wear the diaphragm continuously, removing it once each day for washing but not within six hours after intercourse. Product-related problems related to insertion, retention and removal were few at both the 6- and 12-month follow-up visits, most commonly odor. The 12-month life table accidental pregnancy rate during typical use was 24.1 per 100 women (29.5 per 100 women without female barrier experience and 17.9 per 100 women with barrier experience). Over 85% of the women who returned for follow-up visits reported using the diaphragm during every act of intercourse. Until better data refute the traditional recommendations, users should be advised to add spermicide to fitted latex diaphragms.

Nonoxynol-9 use, genital ulcers, and HIV infection in a cohort of sex workers

OBJECTIVES

To measure the associations between use of nonoxynol-9 (N-9) and incidence of genital ulcers, and incident ulcers and HIV seroconversion.

METHODS

In a study of barrier contraceptive use and HIV infection, 273 female sex workers used condoms and 100 mg N-9 suppositories, and recorded sexual activity on coital logs. Genital ulcers were diagnosed clinically at monthly clinic visits. HIV infection was diagnosed by ELISA and Western blot. We calculated ulcer incidence rates by level of N-9 use. A nested matched case-control analysis assessed the effect of ulcers on HIV acquisition.

RESULTS

More frequent N-9 use was not associated with genital ulcers and may have been protective against the lesions. Ulceration was not a strong risk factor for HIV acquisition in this study (odds ratio 1.1; 95% confidence interval 0.3-3.5).

CONCLUSIONS

Frequent use of N-9 can cause genital irritation and ulceration. Ulcers, in turn, may be risk factors for HIV acquisition. This study, however, did not find an association between N-9 use and ulcers, nor between ulcers and HIV. There is probably a threshold of N-9 use frequency or dose below which the risk of ulceration is minimal. Ulcers due to infectious causes may have been prevented by N-9 use in this cohort.