Learning from women about HIV risk, HIV testing behaviors, and prevention practices in Mpumalanga, South Africa: A descriptive study to inform microbicides introduction

The provision of any new prevention product in clinical trial settings is often vastly different from implementation in “real life” public sector settings. In addition, use of antiretrovirals (ARV), such as tenofovir gel, for pre-exposure prophylaxis requires regular HIV testing to ensure users are uninfected before initiating and continuing product use. Therefore, before any ARV-based prevention product can be introduced to women, information is needed on HIV testing practices, how best to integrate products into existing primary health care systems, and women’s risk perception and health-seeking behaviors. The Population Council, in partnership with Solutions IPPT, conducted a study to learn more about women’s experiences in routine primary health care centers in Mpumalanga, South Africa to inform microbicides introduction. This report discusses the issues explored in the study: service seeking, constellation of services, HIV testing behavior, self-assessment of risk, and interest in tenofovir gel

Does size matter? A randomized controlled trial to assess the impact of external diameter on adherence to 3 different intravaginal rings among 24 US couples

Background: Intravaginal rings (IVRs) are being developed as multipurpose prevention technologies (MPTs) for simultaneous HIV and pregnancy prevention. However, no empirical data exists to support the current 54-58mm size as ideal. Understanding the impact of IVR size on adherence is critical for developing a product that can be used correctly and consistently. Methods: We conducted a randomized, open-label, 3-way crossover trial comparing adherence, preference, and acceptability of 3 non-medicated silicone IVRs of differing external diameters: 46mm, 56mm and 66mm. 24 couples in Atlanta, GA and Bronx, NY were randomized to the sequence of IVR use, used each continuously for ~30 days. The primary objective was to compare ring adherence, defined as never having the IVR out of the vagina for \u3e 30 minutes in 24h. Women reported occurrence and duration of expulsions and removals via daily text. We summarized the proportion of days the IVR was removed, expelled, or out all day, and the proportion of women adherent to each IVR. We used mixed methods logistic regression models with random intercepts (per participant) to compare the probability of each event happening per day of IVR use, per IVR. Results: 23/24 couples completed the study. 78%, 75% and 59% of participants were adherent to the IVRs of diameter 46mm, 56mm and 66mm respectively (Table 1). The 46mm and 66mm IVR performed similarly, with more expulsions and 24h outages for the 66mm IVR. When adjusting for size and sequence, women had \u3e 15 times the odds of the 66mm IVR being out all day versus the 56mm IVR (15.7, 95% CI: 3.4, 72.6). Conclusions: External diameter of these non-medicated IVRs had a significant impact on frequency of removal and expulsion. Product developers should prioritize IVRs in the range of 46mm-56mm

Baseline Predictors of High Adherence to a Coitally Dependent Microbicide Gel Based on an Objective Marker of Use : Findings from the Carraguard Phase 3 Trial

A randomized, placebo-controlled, efficacy trial of Carraguard was unable to demonstrate a reduction in women's risk of HIV infection, which may have been due, in part, to low adherence (gel used in 42 % of vaginal sex acts, on average). A secondary analysis was undertaken to understand baseline factors associated with high adherence (gel used in aeyen85 % of sex acts). Women who reported aeyen1 vaginal sex act, returned aeyen1 opened applicator, and had aeyen1 conclusive post-enrollment HIV test (N = 5990) were included. Adherence was estimated as the ratio of average weekly applicator insertions (based on a dye stain assay indicating vaginal insertion)/average weekly sex acts (by self-report). Multivariate logistic regression modeling indicated that coital frequency, site, contraception, and partner age difference had a significant impact on adherence. Women reporting > 1 and aecurrency sign2 vaginal sex acts per week, on average, were half as likely to be adherent as those reporting 1 vaginal sex act per week or less [adjusted odds ratio (AOR): 0.48; 95 % CI 0.38-0.61]; women from the Western Cape had one-third the odds of being adherent compared to women from KZN (AOR: 0.31; 95 % CI 0.23-0.41); compared to women using injectable contraception, women using any other or no method were more likely to be adherent (AOR: 1.30; 95 % CI 1.04-1.63); and women who had a larger age gap from their partners were more likely to be adherent (AOR: 1.03; 95 % CI 1.01-1.05; p = 0.001). Despite low adherence, overall, 13 % of participants achieved nearly perfect adherence, indicating a potential niche for a coitally dependent microbicide. More research is needed on the impact of sexual patterns and HIV risk perception on product acceptability and adherence to improve counseling in ongoing trials and when products are eventually introduced.Peer reviewe

Factors associated with non-adherence to instructions for using the Nestorone®/ethinyl estradiol contraceptive vaginal ring

Objectives: We sought to identify factors associated with non-adherence to instructions for using a novel contraceptive providing 1-year of protection. Study design: Data from a multi-country Phase 3 trial of the Nestorone® (segesterone acetate)/ethinyl estradiol (NES/EE) CVR were analyzed. Participants were instructed to use the CVR over 13 cycles and follow a 21/7 regimen. Their reports of CVR removals\u3e2 h outside scheduled removal periods served as a proxy for non-adherence. We used multivariate logistic regression to determine factors associated with such use. Results: Of 905 participants, 120 (13%) reported CVR removals\u3e2 h. Removals for washing (OR 3.96, 95%CI 2.50–6.27) or sexual intercourse (OR 3.19, 95%CI 2.03–4.99), and finding CVR insertion difficult (OR 2.80, 95%CI 1.36–5.80) were factors associated with removals\u3e2 h. Lower educational attainment also predicted ring removal \u3e 2 h (OR 3.23, 95%CI 1.55–6.75). Women residing in Europe or Australia were less likely to remove the ring for \u3e 2 h compared with women in the US (OR 0.44, 95%CI 0.24–0.83 and OR 0.13, 95%CI 0.02–0.98, respectively). Participants who reported removals \u3e 2 h were more likely to discontinue CVR use (OR 1.93, 95%CI 1.24–2.95), report dissatisfaction (OR 2.20, 95%CI 1.32–3.69), and become pregnant during the study (OR 4.07, 95%CI 1.58–10.50). Conclusions: Removing the CVR for washing and before intercourse are factors associated with non-adherence to ring use. These are important topics for counseling women who are considering or using vaginal rings, including the NES/EE CVR. Implications: Findings from this study may be useful in guiding counseling for current and prospective vaginal ring users. Anticipatory guidance should focus on how the ring feels in the vagina and during sex. Asking about ring removals may help identify women who are at increased risk for having an unplanned pregnancy

Estradiol inhibits HIV-1BaL infection and induces CFL1 expression in peripheral blood mononuclear cells and endocervical mucosa

An inhibitory effect of estradiol (E2) on HIV-1 infection was suggested by several reports. We previously identified increased gene expression of actin-binding protein cofilin 1 (CFL1) in endocervix in the E2-dominated proliferative phase of the menstrual cycle. Actin cytoskeleton has an integral role in establishing and spreading HIV-1 infection. Herein, we studied in vitro effects of E2 on HIV-1 infection and on CFL1 expression to gain insight into the mechanism of HIV-1 inhibition by E2. E2 dose-dependently inhibited HIV-1BaL infection in peripheral blood mononuclear cells (PBMCs) and endocervix. In PBMCs and endocervix, E2 increased protein expression of total CFL1 and phosphorylated CFL1 (pCFL1) and pCFL1/CFL1 ratios. LIMKi3, a LIM kinase 1 and 2 inhibitor, abrogated the phenotype and restored infection in both PBMCs and endocervix; inhibited E2-induced expression of total CFL1, pCFL1; and decreased pCFL1/CFL1 ratios. Knockdown of CFL1 in PBMCs also abrogated the phenotype and partially restored infection. Additional analysis of soluble mediators revealed decreased concentrations of pro-inflammatory chemokines CXCL10 and CCL5 in infected tissues incubated with E2. Our results suggest a link between E2-mediated anti-HIV-1 activity and expression of CFL1 in PBMCs and endocervical mucosa. The data support exploration of cytoskeletal signaling pathway targets for the development of prevention strategies against HIV-1

Factors predicting improper use of a woman-controlled long-acting reversible contraceptive: Results from the acceptability study of a novel contraceptive vaginal ring

Objectives: Improper contraceptive use accounts for a large proportion of unintended pregnancies. We sought predictors of improper use of an investigational 1-year, reusable contraceptive vaginal ring that is woman controlled

Risk factors for and outcomes of ring expulsions with a one year contraceptive vaginal system

Background: The FDA-approved, segesterone acetate/ethinyl estradiol, ring-shaped contraceptive vaginal system, known was Annovera (Sever Pharma Solutions/QPharma, Malmö, Sweden inserted and removed under a woman’s control for a 21 day in/7 day out regimen for up to 13 cycles of use. Objectives: We aimed to describe patterns of ring expulsion over time, identify potential predictors of expulsion and evaluate the impact of expulsions on method discontinuation and pregnancy risk. Study Design: Using data from 2064 participants in two multinational Phase 3 clinical trials of this contraceptive vaginal system we examined data from participants’ daily diaries for documentation of complete ring expulsion. We modeled the odds of reported expulsions over time, adjusting for background and demographic characteristics, using mixed-effects logistic regression models with random intercepts. We compared probability of continuation between those who did and did not report expulsions in the first cycle of use using survival analysis and hazards modeling. To determine if expulsions during the first cycle of use affected risk of pregnancy, we calculated Pearl Indices. Results: Most participants (75%) never experienced any expulsions during any cycle of use, with 91-97% not experiencing an expulsion during any one cycle. The incidence of expulsion was highest in Cycle 1 (9%). The odds of experiencing expulsions decreased by half in cycles 2-8 3 vs cycle 1 (0.48 95% CI 0.40-0.58) and in in cycles 9-13 expulsions were about a third that in cycle 1 (0.32 95% CI 0.26-0.41). Of those who did experience expulsions, most (62-84%) experienced ≤2 expulsions per cycle. Participants from study sites in Latin America vs U.S. had higher odds of not experiencing an expulsion (OR 1.95, 95% CI 1.45-2.63). Women with more education had higher odds of experiencing an expulsion. Notably, parity, age and BMI were not associated with expulsion. Participants who did experience any expulsions in Cycle 1 were more likely to discontinue early hazards ratio 1.28, 95% CI (1.14, 1.43) compared to participants who had an expulsion. The Pearl Index for participants who had expulsions during Cycle 1 was 3.99 (95% CI: 1.29-9.31), higher than among participants who reported no expulsions (PI 2.39, 95% CI: 1.61-3.41) but the overlapping confidence intervals indicate there is not sufficient evidence to demonstrate an association between expulsions and pregnancy risk. Conclusions: Expulsions were infrequent overall, decreased with subsequent cycles of use and were not associated with BMI or parity. Early discontinuation of product use was higher among participants who experienced an expulsion during Cycle 1. While it is unclear whether pregnancy risk is associated with expulsions, early recognition of expulsions among users may identify those at higher risk for discontinuation and may highlight, where enhanced anticipatory counselling and guidance may be advantageous

Acceptability of the Nestorone®/ethinyl estradiol contraceptive vaginal ring: Development of a model; implications for introduction

Objectives: Develop and test a theoretical acceptability model for the Nestorone®/ethinyl estradiol contraceptive vaginal ring (CVR); explore whether domains of use within the model predict satisfaction, method adherence and CVR continuation. Study Design: Four domains of use were considered relative to outcome markers of acceptability, that is, method satisfaction, adherence and continuation. A questionnaire to evaluate subjects\u27 experiences relative to the domains, their satisfaction (Likert scale) and adherence to instructions for use was developed and administered to 1036 women enrolled in a 13-cycle Phase 3 trial. Method continuation was documented from the trial database. Stepwise logistic regression (LR) analysis was conducted and odds ratios (ORs) calculated to assess associations of satisfaction with questions from the four domains. Fisher\u27s Exact Test was used to determine the association of satisfaction with outcome measures. Results: A final acceptability model was developed based on the following determinants of CVR satisfaction: ease of use, side effects, expulsions/feeling the CVR and sexual activity including physical effects during intercourse. Satisfaction was high (89%) and related to higher method adherence [OR, 2.6 (1.3, 5.2)] and continuation [OR, 5.5 (3.5, 8.4)]. According to the LR analysis, attributes of CVR use representing items from the four domains—finding it easy to remove, not complaining of side effects, not feeling the CVR while wearing it and experiencing no change or an increase in sexual pleasure and/or frequency—were associated with higher odds of satisfaction. Conclusion: Hypothesized domains of CVR use were related to satisfaction, which was associated with adherence and continuation. Results provide a scientific basis for introduction and future research. Implications Statement: Acceptability research is important when introducing a new method of contraception and determining whether it can be a successful option in meeting the reproductive health needs of women and men. This study was designed to test a conceptual model of acceptability and identify factors associated with successful use of a new contraceptive delivery modality. Original research was conducted for this publication

\u3ci\u3eEx vivo\u3c/i\u3e colonic tissue susceptibility to HIV-1 in cisgender men and women

The biology of HIV-1 acquisition through unprotected receptive anal intercourse is understudied. Considering that sex hormones are implicated in intestinal physiology, pathology, and HIV acquisition and pathogenesis, we explored links between sex hormones, ex vivo HIV-1BaL infection of colonic mucosa, and candidate biomarkers of susceptibility to HIV-1 (CD4+ T cell frequencies and immune mediators) in cisgender women and men. No consistent significant associations between sex hormone concentrations and ex vivo tissue infection with HIV- 1BaL were detected. In men, serum estradiol (E2) concentrations were positively associated with tissue proinflammatory mediators (IL17A, GM-CSF, IFNγ, TNFα, and MIG/CXCL9) and serum testosterone concentrations were negatively associated with frequencies of activated CD4+ T cells (CD4+CCR5+, CD4+HLADR+, and CD4+CD38+HLA-DR+). In women, the only significant interactions were positive associations between progesterone (P4)/E2 ratios and tissue ILRA concentrations and between P4/E2 ratios and frequencies of tissue CD4+α4β7high+ T cells. The study did not reveal relationships between biological sex or phase of the menstrual cycle and ex vivo tissue HIV-1BaL infection and tissue immune mediators. A comparison of CD4+ T cell frequencies between study groups revealed a higher frequency of tissue CD4+α4β7high+ T cells in women versus men. In contrast, higher frequencies of tissue CD4+CD103+ T cells were detected in men versus women in the follicular phase of the menstrual cycle. Overall, the study identified associations between systemic sex hormone concentrations, biological sex, and tissue candidate biomarkers of susceptibility to HIV-1. The significance of these results for tissue susceptibility to HIV-1 and early HIV-1 pathogenesis warrants further investigation