The World Health Organization's Department of Reproductive Health and Research that includes the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), will edit a supplement to BJOG in collaboration with CAMI (Coalition for Advancing Multipurpose Innovations) to be published in September 2014.
Women's health is a global priority and WHO/HRP has a mandate to identify actions to improve access to services and commodities that prevent unintended pregnancies and sexually transmitted infections (STIs). This supplement has been developed to raise awareness on the Multipurpose Prevention Technologies (MPTs)—all of which having the potential to improve the health of women, adolescents and children, and enhance gender equity by ensuring that women have the knowledge, tools and services to protect their sexual and reproductive health and rights.
Sexually active women can be exposed to the risk of unintended pregnancy and STIs, including HIV. An estimated 222 million women in developing countries would like to delay or stop childbearing. Improved access to contraception is estimated potentially to reduce maternal mortality by 30% worldwide. Yearly, 500 million curable STIs (syphilis, gonorrhoea, chlamydia and trichomoniasis) occur worldwide and STIs, including HIV, can result in infertility or cancer or be fatal. STIs, as well as persistent reproductive tract infections such as bacterial vaginosis, can also augment the risk of acquiring and transmitting HIV infection. In addition, multidrug resistance, especially of gonococcal infections, is increasing worldwide and poses a major threat to global STI control.
Condoms, both male and female, are currently the only methods that provide simultaneous protection against unintended pregnancy, STIs and HIV infection, but their use needs to be much higher than current levels if STI rates, in particular HIV incidence, are to decline. The effectiveness of condoms for pregnancy prevention is lower than that of other modern contraceptive methods and family planning providers are reluctant to encourage women to forgo an established contraceptive method in favour of condoms, even if this would have the added advantage of also reducing the risk of STIs, including HIV infection. Condom use, either alone or in addition to another reliable contraceptive method (dual use), has increased substantially over the last 20 years, particularly among unmarried women, but condom use among married couples or stable partnerships has remained at very low rates. In generalised HIV epidemic settings more new HIV infections occur within regular partnerships than during casual or commercial sex. To reduce the rates of infection with HIV or other STIs in regular partnerships it is necessary to make condoms easier or more acceptable to use, or to modify or add to existing contraceptive products so that they also prevent STIs.
An alternative approach focuses on the development of other MPTs that could simultaneously address, but not be limited to, more than one sexual and reproductive health prevention need. Work in this area has been underway since the 1980s, driven by the public health importance of reversing the HIV epidemic. Contraception to prevent unplanned or mistimed pregnancy is well accepted in regular partnerships, but methods to prevent STIs are much less acceptable because they raise questions of infidelity by one or the other partner. Methods that are primarily designed to reduce the risk of unplanned pregnancy yet also have an impact on STI risk may be an effective vehicle for reducing the incidence of STIs, including HIV, in regular partnerships. Increasing the range of methods available will allow women to choose the method best suited to her current circumstances and reproductive health priorities. And greater method choice has been shown to result in improved method uptake and continuation.
These MPTs can include vaccines, contraceptives, microbicides and devices (such as intravaginal rings and diaphragms) that address multiple reproductive health needs, including prevention of unintended pregnancy; STIs, including HIV; and/or prevention of other reproductive tract infections, such as bacterial vaginosis or urinary tract infections. The only approved products are male or female condoms, sometimes with innovative designs and concepts. The product most advanced in clinical testing is 1% tenofovir gel, for which there is evidence for impact against HIV and herpes simplex virus type 2 infections from one trial and a confirmatory Phase III trial is currently underway in South Africa. Work to combine the active ingredient tenofovir with a contraceptive in a vaginal ring delivery system is being pursued by CONRAD (Arlington, VA, USA) and the University of Utah. Several approaches are being pursued by the Population Council including combined gels and ring technologies. The International Partnership for Microbicides has recently launched an HIV prevention trial of its novel dapivirine-releasing vaginal ring, and has started preclinical work to combine this with the contraceptive progestin levonorgestrel. With the recent success of the oral pre-exposure prophylaxis HIV prevention trials, a co-formulated combined oral contraceptive with the antiretrovirals tenofovir and emtricitabine can be envisaged. Long-acting injectable antiretrovirals for treatment of HIV infection are in the early phases of development, but could also be envisaged in the long term, in combination with an injectable progestin contraceptive.
The development of safe and effective MPTs is now technically feasible and numerous agencies around the world are conducting research and are at various stages of product development. Importantly, MPTs would increase efficiencies for end-users, donors and providers, by providing simultaneous protection against multiple health risks while also meeting a life course approach to the sexual and reproductive health needs and goals of women.