Time for multiple prevention technologies (MPTs) is now

The call to end AIDS at the recently concluded XIX International AIDS Conference (AIDS 2012) warrants us to act upon a range of AIDS related interventions. One of these is around preventing HIV transmission. "We have to address the needs, challenges and opportunities for development of multiple prevention technologies (MPTs) that would provide simultaneous protection against HIV, other sexually transmitted infections (STIs) and unintended pregnancies" said Dr Helen Rees, Executive Director, Wits Reproductive Health and HIV Institute, University of the Witwatersrand, South Africa, who was co-chairing the "New Products, New Paradigms:Combination Products for Women" satellite session at AIDS 2012. This session was co-convened by the Population Council and Coalition Advancing Multipurpose Innovations (CAMI), along with AVAC - Global Advocacy for HIV Prevention, CONRAD, USAID, and WHO.

Dr Rees had echoed what Dr Badri Saxena, President, Microbicides Society of India (MSI), said to Citizen News Service (CNS) before AIDS 2012 opened in US. According to him, "There is not one preventive product for HIV. There have to be several tools available - microbicides, vaccines and, in some cases, male circumcision, among others. And there has to be better use of existing methods like the male and female condoms. When there was a big epidemic of HIV/AIDS in the 1980’s America turned the tide by effective use of barrier preventive products like condoms and safer sex practices. For countries like India, Africa and China our healthcare delivery systems have to be energised. We have to improve the implementation/ effectiveness of existing technologies, and then work for newer technologies. This requires training of manpower, more public participation and safe sexual practices and behaviour. In India non HIV Sexually Transmitted Infections (STI), like Human Papilloma Virus (HPV) and cervical cancer are a big problem with an estimated 3 million people suffering from them every year. These people are at-risk for HIV, so better control of such infections is more essential to prevent HIV in the country. New technologies are welcome because no one method suits all, and it is for men and women who are most at risk to choose."

Multiple prevention technologies for sexual and reproductive health, also called combination or dual technologies, include vaccines, microbicides and devices like intravaginal rings, diaphragms, and are designed to address multiple sexual and reproductive health needs, including prevention of unintended pregnancies, sexually transmitted diseases including HIV, and other reproductive track infections (RTI). MPTs are some of the most innovative health products under development to simultaneously prevent unintended pregnancies and sexually transmitted infections including HIV. MPTs that are safe, acceptable, affordable and easily available can improve health across the world.

Promising innovations include multipurpose vaccines and gels, easier to use vaginal rings and single sized diaphragms that may provide simultaneous protection against unintended pregnancy and infection and have a major impact on the health of women and their families. New microbicide gels can lead to declines in HIV and STIs while contraceptive technologies appropriate for dual use can increase the positive global health impacts of family planning. The pipeline of MPT products currently relies on combining anti retroviral (ARV) drugs and hormonal contraceptives. At present one ARV, tenovofir has proof of concept as a topical agent and another, dapivirine, will enter clinical efficacy testing in rings in 2012. 

Women worldwide bear the social, health and economic burden of unintended pregnancies and STIs which are great public health challenges. Unprotected sex puts women at simultaneous risk of HIV, other STIs and unintended pregnancy—all of which can impose heavy burdens on mortality and morbidity. MPTs integrating contraception and prevention of HIV/other STIs would address these combined risks and, with improved uptake, enhance public health impact. Effective, safe and affordable MPTs would save lives and money, and improve the health of women and their families worldwide.
According to the WHO, every day over 1000 women die from preventable causes related to pregnancy and childbirth (358,000 annually) with 99% of these deaths occuring in developing countries. Also, 215 million women experience the unmet need of family planning as they lack access to information and services and/or support of their partners and communities. This not only leads to population growth, but also compromises women's health and economic prospects. There are 86 million unintended pregnancies and 4 million newborn deaths worldwide annually, and 16.8 million women are living with HIV. For women in their reproductive years (15-49) HIV/AIDS was the leading cause of death and disease worldwide in 2009. Women are 5 times more likely to get sexually transmitted infections than men. Each day about 500,000 young people, mostly women, contract a sexually transmitted infection. 

Africa and South Asia are the two regions hit hardest by high rates of fertility, HIV and HPV, all of which contribute to an unacceptable high percentage of women’s deaths in this region. 

Different global regions have different reproductive health needs and public health priorities, so priorities for MPT research and development will also differ. So we need to identify MPT products with highest potential for public health impact. Emerging MPTs include drug combinations, drug and device combinations, bacterial therapeutics, multivalent vaccines and nano particles. Key attributes of these devices should be: storage at high temperatures; long shelf life;  concealable presentation;  no life style effects; easy access in low resource settings. There is variability in needs/priorities across different regions. In sub Saharan Africa it is HIV and pregnancy with STI emphasis on HSV2, BV, TV and HPV. In India it is pregnancy and HIV. IN China it is HIV/STI.

So the path to an ideal MPT is not linear as there are many challenges to overcome - regional differences, unique product specific regulatory considerations, hormonal contraception and HIV relationship, trial designs to test efficacy without placebo control, and above all resources (money, trial capacity, participants, development partnerships).

Today’s technologies are not meeting the health needs of women. Current prevention methods for any major risk are limited, nonexistent or partner dependent and also there are many constraints on access to and use of available methods. Most available methods address single indications. there is an urgent need to bring together researchers, healthcare providers, policy makers, health care providers, policy makers, advocates, product developers and donors to develop MPTs to protect women against unintended pregnancies, STIs and RTIs. Technologies that can simultaneously address multiple sexual and reproductive health and rights (SRHR) needs will go a long way in helping women. Such products can help policymakers meet multiple health and development goals. 

The consequences of unsafe sex are among the greatest public health challenges of our times. Women and their families risk unintended pregnancies, as well as HIV and other infections, leading to maternal mortality, low rates of child survival and a poor quality of life. While their needs may vary according to where they live and their stage of life, all women could benefit by improved prevention methods for reproductive health. MPTs, though still in the development stages, can empower women and decrease maternal mortality, improve child survival and health, enable women to get better education and improve the economic opportunities for women.

Shobha Shukla - CNS
(The author is the Managing Editor of Citizen News Service (CNS). She is a J2J Fellow of National Press Foundation (NPF) USA. She has worked earlier with State Planning Institute, UP and taught physics at India's prestigious Loreto Convent. She also authored a book on childhood TB (2012), co-authored a book (translated in three languages) "Voices from the field on childhood pneumonia" and a report on Hepatitis C and HIV treatment access issues in 2011. Email: shobha@citizen-news.org, website: http://www.citizen-news.org) 

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