Beyond the Condom: A New Approach to Sexual Health
WHY YOU SHOULD CARE
Because a new class of products might give women more options than condoms to prevent both pregnancy and sexually transmitted infections.
The rubbers may finally be hitting the road.
The male condom is king when it comes to effective sexual protection. Used correctly, it prevents sexually transmitted infections (STIs) and pregnancy alike. But there’s a big problem, especially for women in the developing world: Men often refuse to wear them. Women in the highest-risk populations don’t always have the capacity to successfully negotiate condom use.
That’s why a new generation of so-called multipurpose prevention technologies (MPTs) could spark a revolution. They would prevent pregnancy and STIs, and be largely in the control of women. MPTs could take various forms: a diaphragm sold together with an HIV prevention gel, an intravaginal ring that releases both pregnancy-preventing hormones and HIV-blocking drugs, and more.
The lubricant Amphora creates an acidic environment in the vagina that kills sperm, as well as vaginosis- and gonorrhea-causing bacteria.
MPTs could put women’s health into their hands. “Women in the highest-risk populations don’t always have the capacity to successfully negotiate [condom] use with their partner,” says Joseph Romano, scientific adviser to the Coalition Advancing Multipurpose Innovations (CAMI). The implications could be huge. STI rates could fall, and women, untied from their wombs, might choose to have fewer children. That could dampen population growth and ramp up women’s participation in the economy and even school enrollment rates.
Since most MPTs are still at an early stage of development, it’s unclear when they’ll hit the market. When they do, they probably won’t completely replace currently available condoms or birth control, which work just fine for some women. “When [condoms] are used properly and consistently, they are very efficacious,” wrote Manjula Lusti-Narasimhan, a scientist in the Department of Reproductive Health and Research at the World Health Organization, in an email.
Unplanned births are often associated with higher infant mortality, illness, abandonment and other negative outcomes. Women are also at risk; more than half of unintended pregnancies result in abortion — but nearly half of all abortions aren’t performed safely, especially in developing countries.
But with 86 million unintended pregnancies in 2008 and an estimated 2.5 million new HIV cases worldwide in 2011, few can argue against the need for MPTs. Researchers currently aim to develop them primarily for developing countries in South Asia and sub-Saharan Africa, hotbeds of the AIDS epidemic.
MPT strategies could come in three varieties. The simplest would be a single product, like a shot or pill containing both pregnancy-preventing hormones and an STI prevention drug. Co-packaged MPTs are just what they sound like: contraceptives and STI prevention products sold together, like an HIV-preventing gel bundled with an intravaginal ring that releases contraceptives, like the NuvaRing. MPTs could also be co-administered — the pill taken with Truvada, for example — a more flexible option for women who want to get pregnant but still protect themselves from HIV.
There are currently about 25 MPTs in the pipeline. Evofem Inc.’s personal lubricant, Amphora, creates an acidic environment in the vagina, shown to kill sperm, as well as vaginosis- and gonorrhea-causing bacteria. The company announced the completion of a phase 3 trial to test its efficacy as a contraceptive in June. Gilead Science, Inc.’s Tenofovir vaginal gel for preventing HIV and herpes is in phase 3 trials, and nonprofit organization CONRAD has begun a phase 1 trial to test an intravaginal ring designed to continually deliver Tenofovir and the contraceptive levonorgestrel for 90 days.
Romano is most excited about the possibility of an implant that releases a steady dose of pregnancy-preventing hormones and an HIV prevention drug. HIV prevention drugs exist — the FDA approved Truvada in 2012 — but figuring out how to load two to three years’ worth of the drug into a tiny device is no small feat. “It’s much further down the line,” he says.
There’s a humanitarian need but also a potentially lucrative market for these products, too.
— Bethany Young Holt
Since researchers are designing MPTs primarily for high-risk countries in the developing world, they’ll likely be low-cost and rolled out to women in these regions first, and later modified to meet the needs of women elsewhere. But CAMI executive director Bethany Young Holt hopes that MPTs will be simultaneously introduced to lower-priority regions, too. “Condom negotiation … is a universal issue,” she says. “It’s going on with college students in the [San Francisco] Bay Area. There’s a humanitarian need but also a potentially lucrative market for these products, too.”
But why has it taken so long? One answer is that HIV/STI prevention and reproductive health have existed for years as distinct research disciplines with separate funding streams. In recent years, however, their products have started to overlap. For example, an intravaginal ring for HIV prevention has shown promise in monkeys — and works much like the NuvaRing, except it releases drugs designed to block viral infection instead of pregnancy-preventing hormones. “The two fields support each other,” Romano says. As a result, family planning and HIV experts at the National Institutes of Health, USAID, the Gates Foundation and other organizations have begun exchanging data and technical expertise.
But MPT approaches don’t end with pregnancy and STIs. Implantable devices could deliver drugs for cancer plus other diseases simultaneously. Holt says some researchers have begun applying MPT platforms to prevent Ebola, as well as other diseases. “Long-acting drug delivery goes beyond MPTs,” Romano says. “There are challenging populations like [children] or the elderly, where it’s difficult to get people using the drug.” Disrupting the condom space might very well be the first step toward medicine’s much-needed shake-up.