TY - JOUR
AU - Waller, Donald
AB - Abstract Current modern contraceptives rely heavily on the use of hormones. These birth control drug products, including pills, patches, injections, and IUDS, have been extremely beneficial to millions of women and their families over the past 50 years. But a surprisingly high number of women abandon such modern methods, many because they cannot tolerate the side effects and others because they have medical issues for which hormonal methods are contraindicated. In addition, modern hormonal methods are simply not available to many women. The extent of this problem is steadily becoming more apparent. We present the case for developing simple nonhormonal vaginal products that women can use when needed, ideal products that are multipurpose and offer both contraception and sexually transmitted disease protection. Gel-based vaginal products are particularly well suited for this purpose. Gels are easy to use, highly acceptable to many women, and can be safely formulated to enhance natural vaginal defenses against infection. However, the development of a new chemical entity for this application faces significant technical and regulatory hurdles. These challenges and our solutions are described for polyphenylene carboxymethylene (PPCM), a novel topical drug in a vaginal gel nearing human clinical trials. We have advanced PPCM from benchtop to IND-enabling studies and provide a brief description of the complex development process. We also describe a simple lab assay which can be used as a biomarker for contraceptive activity to enable pharmacodynamic studies in vaginal contraceptive development, both preclinically and in early human clinical trials. Introduction More pregnancy prevention methods are needed Around 40% of pregnancies worldwide are unintended and 45% of pregnancies in the USA continue to be unplanned—higher than in other industrialized countries [1, 2]. This persists in spite of the development of highly effective contraceptives. The long-acting reversible contraceptives (LARCs) have been particularly successful and are likely responsible for recent reductions in unplanned pregnancies among teens [1]. Oral contraceptives continue to be the most popular reversible method. Yet, overall contraceptive use has not significantly increased [3]. Use of these hormonal drug and device products is limited by health concerns and side effects, availability, costs, and access to medical services [4–6]. In the USA, at least 19 million women who depend on publicly funded contraception services live in contraceptive “deserts.” These are countries that lack accessible health centers which provide a complete range of contraceptive services [7]. Even more distressing is the “condom migration” that occurs with hormonal contraceptive users. They can be less likely to use condoms compared with women who use other contraceptive methods and may be more susceptible to sexually transmitted infections (STIs) [8–10]. Additionally, many U.S. women who previously used hormonal birth control methods are now at risk of pregnancy because they use nothing, primarily because of dissatisfaction with or distrust of hormones [5, 11]. The situation may be even more worrisome in developing countries. A recent comprehensive survey of 36 low- and middle-income countries found that the use of long-acting modern methods remains consistently low. Among women with an unintended pregnancy who last used a long-acting modern method, 40% had discontinued the modern method because of side effects [12]. Not only do many women distrust hormonal birth control methods, but also some women believe that any hormonal method may have postfertilization activity and is actually an abortifacient [13]. This concern about health risks associated with hormonal contraceptives is shared by many family planning professionals. Interactions with other drugs, effects of obesity, and chronic disease conditions are all of concern [14]. Recently, an increased breast cancer risk has been linked to hormonal contraception [15]. While the risk is presumably small, it contributes to women’s concerns. The need for more contraceptive product choices is an accepted reality [16]. When a greater variety of contraceptives are made available, more women use contraception. This has been shown globally: in countries where only a single method is made available, only about 10% of women will practice contraception. This increases linearly up to 70% contraceptive use when six methods are available [17]. Obviously, no single method is equally acceptable to all women. Method acceptability varies with partner and family relationships, age, personal preferences, cultural influences, as well as perceived safety and efficacy [16]. Many women may prefer a nonhormonal method that can be easily accessed only when needed and is not absorbed into the body [2, 18, 19]. Yet, with the exception of detergent spermicides, nearly all woman-controlled contraceptives available today depend on continuous systemic hormonal activity or intrauterine devices. STI prevention for women is lacking Women who engage in intercourse may be at significant risk for both an unplanned pregnancy and an STI. Ideally, a preventive method will provide dual protection and be woman-controlled. The worldwide incidence and prevalence of STIs are growing [20–23]. In the USA, the reported incidence rates of chlamydia and gonorrhea have grown dramatically, and one in six adults has genital herpes [20, 22]. Drug resistant strains of gonorrhea are continuing to appear, both globally and in the USA, foreshadowing a time when many people may struggle to find a cure [24]. Clearly, the field of reproductive health needs more solutions to help turn the tide of increasing STIs and unplanned pregnancies. We must develop a variety of multipurpose prevention technologies (MPTs) drug products to provide comprehensive protection from both unwanted pregnancy and a range of STIs. This may be particularly important for young women who may be more anxious about accidental pregnancy than acquiring an STI [25–29]. Ideally, this broader protection would be provided by a single multipurpose MPT product [30]. Materials and methods Ethics approval and consent to participate The sperm study was conducted in accordance with principles for human experimentation as defined in the Declaration of Helsinki and International Conference on Harmonization Good Clinical Practice guidelines and approved by the relevant institutional review boards. Informed consent was obtained from all participants. Animal studies declaration All animal studies were conducted following recommendations for optimal animal welfare with the approval of the Office of Laboratory Animal Welfare, in AALAC approved facilities. Multipurpose prevention technologies MPTs are an innovative class of products that deliver various combinations of human immunodeficiency virus (HIV) prevention, other STI prevention, and contraception. While not labeled as MPTs, some older vaginal products were potential MPTs. Early, in vitro and limited clinical studies suggested that the spermicide nonoxynol-9 (N-9) might offer some STI protection as well as contraception. In fact, significant protection against both chlamydia and gonorrhea infections was demonstrated in women who used a vaginal sponge impregnated with N-9 [31]. Unfortunately, the cytotoxic effects of N-9 and potential to facilitate HIV infection have discouraged use and further development [32, 33]. The female condom, which could potentially be an effective MPT, has had very limited acceptance [34, 35]. Current development In the last decade, this unmet need for woman-controlled dual protection has become more widely recognized and has evolved into an active pipeline for the development of MPTs [26, 28, 29, 36–39]. The intravaginal ring (IVR) is a promising MPT in active clinical development. IVRs offer sustained drug release, which avoids some of the compliance issues of coitally dependent use, but they are not a panacea. Acceptability may be limited by cost, user distrust of hormonal contraception, menstrual irregularities, poor fit leading to expulsions, and difficulty with insertion and removal [40–42]. In addition, user dissatisfaction can cause many women to remove the ring and lose protection [43]. Male partner resistance can also be a barrier to successful IVR use, particularly for women who suffer from power inequities in sexual relationships [40, 41]. Several new coitally dependent methods are under development as well, including gels, films, and tablets [30]. However, such as IVRs, nearly all these vaginal products depend on hormonal contraceptive action. In addition, the STI component of these MPTs has focused on HIV prevention, primarily by the use of a vaginal microbicide, with relatively little attention to other important STIs. While the extreme morbidity and mortality linked with HIV is widely feared, other STIs—particularly HSV, Neisseria gonorrhoeae (Ng), and Chlamydia trachomatis (Ct)—pose a greater infection risk to many women and their partners, particularly young women in the developed world [44, 45]. While treatable and sometimes curable, they can also cause significant disease, permanent infertility, and can occasionally be fatal. Efforts to develop vaginal microbicides have essentially ignored these important infections. Vaccine development for all STIs is ongoing, but except for Human Papilloma Virus and Hepatitis B, effective vaccination for other STIs is not imminent [25]. A shift in emphasis from HIV protection to broader STI protection with focus on gonorrhea and chlamydia infections is long overdue, ideally in combination with effective contraception. Barriers to MPT development Why are not more companies working on new vaginal MPTs? Simply put, the fastest path to introducing a new contraceptive is to make incremental changes to existing drug products. Highly effective LARC’s and contraceptive pills are available and widely used. Small changes to existing methods, primarily hormone-based methods and condoms, require minimal clinical trials and have a clear regulatory pathway, which reduces the time and cost required to supply a well-established market. This is more attractive to drug companies. All coitally dependent methods face much greater development challenges. Efficacy rates are difficult to assess—primarily because many women find it difficult to adhere to a method that must be used consistently and correctly with every act of intercourse. Recent clinical trials have highlighted this problem. In the case of HIV microbicide trials, the actual effectiveness has been significantly underestimated due to multiple factors, including pervasive adherence issues, inaccurate reporting by study subjects or frequent nonuse, as well as HIV acquisition via anal intercourse or intravenous drug use [46–48]. In a recent hormonal contraceptive study, misreporting occurred in 27% of participants who had used but would not admit to using backup contraception [49]. In retrospect, these difficulties are not unexpected, given the challenges faced by the women enrolled in these HIV prevention trials: “Imagine getting a group of largely poor women in a developing country, whose role is still largely to marry, submit uncomplainingly to sex and support their family, to agree to squeeze goo every day for a year (or every time they think hubby is going to want sex) into their vaginas, do it despite the disapproval of conservative moms and suspicious spouses, report regularly to a clinic for checkups, and answer impertinent questionnaires about their sex lives to researchers, when they’ve been told that half of them are getting a placebo anyway.” … … Gus Cairns [50] In spite of these frustrations, subsequent data analysis has uncovered some important protective effects against both HIV and HSV in women who demonstrated the highest compliance [51–53]. Simply enrolling women in contraceptive trials is equally problematic. Like HIV prevention trials, contraceptive testing requires large numbers of participants who must participate for 6–12 months. In addition, participants are being asked to risk becoming pregnant. This is not a small issue. Women who become pregnant are forced to choose either termination or carrying the pregnancy to term. Since highly reliable birth control methods are available to them, it is reasonable to assume that many women in these trials are willing to accept a pregnancy and they may not be highly motivated to use the assigned method. This may be particularly true for women who are planning to increase their family size [54, 55]. This attitude was confirmed by a recent online survey we conducted asking 504 heterosexual women if they would be willing to try a new contraceptive gel and how they would feel if they got pregnant. Sixty percent of nonmothers responded that it would be a serious problem or even “disastrous.” In contrast, only 35% of the mothers were as concerned. In addition to imperfect use and misreporting, the frequency of intercourse, age, fertility, methodological problems, and even investigator bias—all contribute to the inaccuracy of effectiveness measurements [56]. An additional problem is that even with “perfect use,” nonsystemic vaginal products are likely to have inherent method failures. Unlike vaginal methods that release systemically absorbable contraceptive substances, the effectiveness of products that act only in the vagina (gels, films, foams, and suppositories) depend on their ability to coat vaginal/cervical tissues immediately after application and mix with genital secretions postcoitally. Vaginal anatomy is highly variable [57], and it is unlikely that any vaginally applied product will always provide perfect coverage and/or achieve complete inactivation of the sperm. All these uncertainties contribute to the wide variation in effectiveness rates that have been reported for vaginal spermicides [58, 59]. Even though women who are reliable users of coitally dependent contraceptive methods can expect a higher effectiveness than is reported in most clinical studies, efficacy will always be lower compared with methods that offer continuous protection. But efficacy is only one determinant of contraceptive choice, and women may reject highly effective methods because of other concerns [59]. Interestingly, a low-efficacy method may be chosen even by women who do not ever want to become pregnant. A recent U.S. study of women at risk of pregnancy found that a low-efficacy method was chosen by 20 % who “never in the future” want to become pregnant, by 27% who wish to “delay pregnancy,” and by 29% who are “not sure” [60]. Development of novel coitally dependent products has also been hampered by the lack of established preclinical and clinical protocols. Work on vaginal HIV prevention products has spawned a plethora of recommendations for preclinical testing and many of these are applicable to any vaginal product [61]. This has resulted in a constantly changing regulatory environment, which complicates the development path even more [36, 62, 63]. Lack of a reliable animal model for contraception has added to the difficulty. Size, shape, secretions, pH, reproductive cycle, and microbiome of commonly available animal models are poorly matched to the human vagina [64, 65]. Consequently, formulations designed to take advantage of the natural protective barriers and function of the human vagina cannot be adequately studied in current animal models. Vaginal contraceptive studies are also limited by the lack of established biomarkers for spermicidal activity [61]. Such biomarkers could be used to verify activity and proper formulation development both preclinically and in early Phase I human testing, before engaging in additional long-term and difficult efficacy trials where women are at risk for pregnancy. Traditionally, sperm activity has been measured by observing the numbers of progressive motile sperm. This has assumed that such sperm have fertilization potential. The actual methodology is labor-intensive and requires a ready supply of mature, healthy sperm, along with skilled microscopy, all of which is time sensitive. In clinical trials with women not at risk of pregnancy, cervical mucus must be collected soon after coitus and immediately examined microscopically (Sims-Huhner test) [66, 67]. Not only is such postcoital testing labor-intensive and time-sensitive for the experimental subjects, the laboratory and the investigator, but it also has poor reproducibility [66]. This contrasts with microbicide development work for STI pathogens which have well established precise in vitro assays for activity on samples that can be easily obtained from the vaginal vault, transported, stored, and processed with fewer time constraints [68]. Such anti-infective efficacy can also be assessed with numerous validated animal models [69]. The family planning community inadvertently discourages coitally dependent MPT development and has an innate bias in favor of hormonal-based contraceptives. Because they are not coitally dependent, these methods are more effective and much easier to use. But easier for the woman or for the physician/provider? The provider can simply write a prescription or give an injection or implant a device, and most adherence uncertainties are avoided. But for many women, these drugs and devices are unacceptable, and efficacy is only one determinant of contraceptive choice. Highly effective contraceptive methods may be rejected because of other concerns. Hormone-based methods require medical services that are at best inconvenient, have unpleasant side-effects, are expensive, or may not even be available. Furthermore, some women do not want continuous protection. Not all women are in a steady relationship or have infrequent intercourse, and thus are not willing to use long-acting drug products. The availability of a method that can be used only when needed is an important option for many women [2, 18, 19]. Another difficulty for developers is that the market for a vaginal contraceptive is difficult to gauge since few comparable products are currently on the market, whereas the market for a new hormonal contraceptive or new IUD is easily estimated. Yet, we know that women will use vaginal products. Women in developed economies already know and use vaginal drug products and lubricants. Nearly 29 million units of personal lubricants—valued at over $1 billion—were sold in America last year through retail outlets, not including online and boutique sales [70]. Twenty-seven million units of OTC vaginal yeast treatment products were sold in 2018 through retail outlets [71]. Proper formulation, which includes aesthetics as a key criterion, and consumer marketing are critical and effective driving forces for adoption of a vaginal product. An MPT dual purpose vaginal product is expected to have greater acceptability and compliance compared with a single purpose vaginal contraceptive or microbicide. It will be an attractive option for women who are not only concerned about their STI risks but are even more concerned about pregnancy prevention [25–29, 39]. Furthermore, women who seek contraception in addition to STI protection are likely to have greater support from partners, family, and community [72–77]. All of these factors will improve compliance both in clinical trials and more importantly, use in the real world. The case for vaginal gels Vaginal gels can be engineered to maintain, improve, and take advantage of natural protective mechanisms while providing a versatile vehicle for active contraceptive and anti-STI activity [78]. Natural protection from pathogens is primarily due to a hostile fluid environment maintained by a healthy microbiome and mucus. A Lactobacilli dominant microbiome produces an acidic environment that is very effective in killing and inactivating most STI pathogens, including both viruses and bacteria as well as inactivating spermatozoa [79]. Secreted mucus is an important contributor to prevent both disease and pregnancy. Vaginal epithelial cells provide a transudate to the vaginal vault environment, whereas the mucus layer is derived from the cervical secretions, which varies during the reproductive cycle. Mucus can act as a barrier to spermatozoa ascending the reproductive tract and pathogens accessing tissues. Semen deposition neutralizes and dilutes this protective vaginal environment. A vaginal gel can help counteract these effects by maintaining both the acidity and the viscosity of vaginal fluids [80, 81]. Natural vaginal fluids also provide lubricity, reducing vaginal abrasions and tears from intercourse, which can readily provide a portal of entry for pathogens. Vaginal gels can amplify this property with a formulation that enhances the sexual experience for both partners while reducing susceptibility to STIs, as well as help overcome adherence issues [82]. Gels also have the advantage that they can be designed to optimize coating of the entire vaginal epithelium. This can minimize the potential for reduced efficacy due to the large variation in shape and sizes of the vagina. Gels can also be formulated to maximize mucoadhesion to ensure that the gel is retained at the most critical time—during and after sexual intercourse. Gels may be active immediately upon insertion into the vagina and are slowly expelled after intercourse by natural vaginal secretions [83]. In contrast, long-acting methods generally release active ingredient(s) slowly and must be inserted well ahead of intercourse. They must provide sustained release to maintain effective drug levels and may create as yet unknown negative side effects with extended exposure. Multiple acceptability surveys of preferred vaginal formulations have found support for odorless and colorless gel products and can be an important guide to the development of new vaginal gel products [84]. Recent studies have provided important information regarding user preferences for the physical and aesthetic properties of gel formulations and can be used to guide MPT formulation composition [85, 86]. Development of a candidate MPT—polyphenylene carboxymethylene gel Polyphenylene carboxymethylene is contraceptive and microbicidal Polyphenylene carboxymethylene (PPCM sodium salt) was originally developed as a potential MPT by the TOPCAD research group at Rush University. PPCM is an anionic mandelic acid condensation polymer that may provide excellent MPT protection [87–92]. It differs from other polyanion candidate products in several important ways. First, PPCM is not sulfated/sulfonated and thus is structurally distinct from Pro 2000, PSS (polystyrene sulfonate), Carragard, and CS (cellulose sulfate). Unlike these sulfated/sulfonated polyanions, PPCM does not lose effectiveness in the presence of seminal plasma [93–96]. Unlike N-9 and CS, PPCM does not damage epithelial surfaces [97]. Finally, in contrast to the other sulfated/sulfonated polyanions, PPCM does not reduce levels of SLPI, an important regulator of innate immunity that may protect the host from excessive/dysregulated inflammation typical of infectious diseases [98–100]. These factors may have contributed to the clinical failures of these polyanions in Phase III microbicide trials. PPCM is active against multiple sexually transmitted pathogens—both viral and bacterial. Extensive preclinical testing has demonstrated that PPCM is active against HIV-1, HSV-1, HSV-2, papilloma virus, ebola virus, Ng, and Ct [89, 90, 92, 93, 101, 102]. PPCM, like other polyanions, prevents viral infection by binding to the viral envelope to prevent attachment to heparan sulfate (or similar) receptors on the host cell [103]. Glycosaminoglycans such as heparan sulfate are believed to be important for host cell attachment and infectivity of many other STI pathogens as well, including Ng and Ct [104–107]. Since these receptors are thought to be highly conserved, the development of pathogen resistance to PPCM is unlikely [105, 107, 108]. This is particularly important for future Ng prevention technology, where rapid and continuous evolution of antibiotic resistance is a major challenge [109]. PPCM is also innovative because, unlike most currently available spermicides, it has a noncytotoxic contraceptive mechanism. PPCM causes a premature loss of the sperm acrosome (PAL), a critical organelle required for successful sperm–oocyte interaction. This contraceptive activity may be caused by induction of PAL through dysregulation of Ca2+ signaling [87, 88, 110]. The same mechanism may be partly responsible for the multiple activities of this contraceptive microbicide. Infection of target cells by HSV and HIV is associated with Ca2+ signaling in the target cells [88, 111]. In addition to causing PAL, PPCM inhibits hyaluronidase and acrosin, the acrosomal enzymes needed for fertilization. Inhibitors of these enzymes are contraceptive in the rabbit model [112, 113]. Interestingly, PPCM has little or no effect on human spermatozoa motility [92]. PPCM is an effective contraceptive in the rabbit model. Fertilization of oocytes was reduced by >90% when spermatozoa were preincubated with 5 mg/mL PPCM before artificial insemination. A 4% PPCM gel completely prevented conception when placed vaginally before artificial insemination [92]. Synthesis and characterization PPCM is a polyanion with an average (Mw) molecular weight = 3500–5000 (Figure 1). Figure 1 Open in new tabDownload slide Molecular formula: C8H6O2Na(C8H5O2Na)nC8H6O2Na. Figure 1 Open in new tabDownload slide Molecular formula: C8H6O2Na(C8H5O2Na)nC8H6O2Na. As a polymer drug, PPCM faces a complex regulatory strategy as it does not fit into either of the two main molecular categories of drugs, namely small molecules and biologics. PPCM was first licensed with a lab scale synthetic method after early preclinical studies indicated anti-infective and contraceptive activity against HIV, HSV, Ng, Ct, papilloma virus, trichomoniasis, and spermatozoa [92]. However, no analytical methods had been developed and the detailed molecular structure was in question. Consequently, the analytical methods used to characterize the molecular structure were developed de novo. The molecular structure was finally determined using 900-mHz NMR. All analytical methods were developed and validated for the measurement of the stability, quantity, identity, and purity of PPCM. A bioassay to determine systemic absorption, requested by FDA, was developed using LC-MS/MS techniques and validated in rat and rabbit plasma and vaginal tissue with an LLOQ of 5 ng/mL. The scale up and commercial production of PPCM have also been challenging. To our knowledge, there are only two approved soluble, active polymer drugs: Copaxone (Glatiramer) and Voluven (hydroxyethyl starch) [114]. Thus, few CROs who support drug startups have had any experience with a new, active polymer drug (as opposed to excipients) and polymer producers are often not qualified to produce these drugs or not familiar with drug quality requirements. The manufacturing method for the API was optimized including the development of quality assurance procedures. The manufacturer successfully passed a QA audit, and a quality contract was executed. A production batch of API was produced under cGMP and put on a stability program under ICH guidelines. At T = 12 months, PPCM remains within specifications and is stable. Two forced degradation studies, including one performed according to the FDA and ICH guidelines, demonstrated that PPCM degrades simply to shorter oligomers with no other detectable break down products. PPCM in aqueous solution showed degradation under high oxidation (3% hydrogen peroxide, 7 days, 13.3% degradation) and slight degradation at low pH (1 N HCl, 6 days, 0.1% degradation). PPCM is extremely stable under ambient storage conditions and in aqueous solution. Laboratory produced batches from 2002 to 2008 were also analyzed and found to be stable. Table 1 includes our current specifications for PPCM. Table 1 Selected Specifications of Batch BPR-18-12-B1-19 PPCM sodium salt Property . Specification . Test results . Test method . Appearance White to off-white powder Pass Visual Identification IR spectrum Conforms to structure Pass FTIR pH (5% in water) FIO 7.13 PPC107 Mw range 3500–5000 3835 HPLC-GPC with SEC Polydispersity (Mw/Mn) <1.70 1.40 HPLC-GPC with SEC Purity HPLC—ion exchange (IEX) Target—95–105% AUC 99% HPLC-IEX HPLC—impurities by RRT Report results <LOQ (0.05%) WPT/2068-182 Property . Specification . Test results . Test method . Appearance White to off-white powder Pass Visual Identification IR spectrum Conforms to structure Pass FTIR pH (5% in water) FIO 7.13 PPC107 Mw range 3500–5000 3835 HPLC-GPC with SEC Polydispersity (Mw/Mn) <1.70 1.40 HPLC-GPC with SEC Purity HPLC—ion exchange (IEX) Target—95–105% AUC 99% HPLC-IEX HPLC—impurities by RRT Report results <LOQ (0.05%) WPT/2068-182 Open in new tab Table 1 Selected Specifications of Batch BPR-18-12-B1-19 PPCM sodium salt Property . Specification . Test results . Test method . Appearance White to off-white powder Pass Visual Identification IR spectrum Conforms to structure Pass FTIR pH (5% in water) FIO 7.13 PPC107 Mw range 3500–5000 3835 HPLC-GPC with SEC Polydispersity (Mw/Mn) <1.70 1.40 HPLC-GPC with SEC Purity HPLC—ion exchange (IEX) Target—95–105% AUC 99% HPLC-IEX HPLC—impurities by RRT Report results <LOQ (0.05%) WPT/2068-182 Property . Specification . Test results . Test method . Appearance White to off-white powder Pass Visual Identification IR spectrum Conforms to structure Pass FTIR pH (5% in water) FIO 7.13 PPC107 Mw range 3500–5000 3835 HPLC-GPC with SEC Polydispersity (Mw/Mn) <1.70 1.40 HPLC-GPC with SEC Purity HPLC—ion exchange (IEX) Target—95–105% AUC 99% HPLC-IEX HPLC—impurities by RRT Report results <LOQ (0.05%) WPT/2068-182 Open in new tab Formulation development The challenge is to develop a formulation that maximizes the inactivation of spermatozoa in the complex milieu of the vaginal environment, with special attention to vaginal pH, secretions, cervical mucus barrier, microbiome, semen composition, and shear/mixing action during coital activity. A variety of novel mucoadhesive formulations with 4% PPCM Na Salt were developed based on optimum viscosity, pH, rheological characteristics, and osmolality. The effects of dilution on characteristics were considered as well; the gel should be miscible with vaginal secretions, cervical mucus, and seminal fluid without leaking out during intercourse. To assess this, a progressive 8-h in vitro study of PPCM gel release into both simulated vaginal fluid and simulated semen was conducted. A wide variety of excipients were considered based on literature assessments for specific properties to enhance the formulations with desired mucoadhesive and releasing characteristics, including HPMC (K4M, K100 or E50), Xanthan and/or Guar Gum, Carbopol 940, chitosan, Poloxamers. HEC (Natrasol 250 HR), and Na CMC. Six different 4% PPCM sodium salt formulations were prepared: altering methods of preparation as needed based on compatibility and solubility data. Both Carbopol/Polycarbophil and Xanthan gum/HPMC formulations showed better mucoadhesive strength compared with the marketed product Gynol II with an acceptable pH profile. Our final formulation is comprised of deionized water, PPCM sodium salt (4% w/w), HPMC K100, xanthan gum NF, glycerin, methyl paraben, propyl paraben, and pH adjusters (lactic acid and sodium hydroxide, as needed). The resulting gel, at T = 3 months under controlled stability (25 °C/60% RH), has a viscosity of 3.97 × 107 mPa-s, a pH of 5.4. The osmolality (1020 mOsm/kg) is below the WHO maximum acceptable level for vaginal lubricants [115] and is also below the level shown to cause epithelial disruption in a 3D model [116]. Osmolality would be further reduced in the presence of genital secretions after vaginal application. Optimized formulations were manufactured under GLP to conduct a stability study as per ICH guidelines and to provide test articles for GLP toxicology studies. Specifically, gels at 0, 1, 4, and 10% concentrations were held at 25 °C/60% RH and 40 °C/75% RH for 6 months. Samples were analyzed for appearance, viscosity, pH, and assay at 1, 3, and 6 months. Preclinical toxicology testing Table 2 lists results of the preclinical toxicology IND-enabling studies required by the FDA for a new chemical entity, which is intended for contraception and disease mitigation. Table 2 Comparison of sperm inactivation by PPCM measured by both an HBA and AS Completed . Genotoxicity . Study description . Study results . GLP Reverse Bacterial Mutation Assay (AMES), Bioreliance Five strains Salmonella and Escherichia coli plated w/PPCM up to 5000 μg/mL; evaluated for toxicity and mutations PPCM was nontoxic to selected strains. PPCM is not mutagenic in AMES assay GLP Rat Lymphoma Assay, Bioreliance PPCM solution of 1.95–500 μg/mL plated with L5178/TK+/− mouse lymphoma cells w/or w/o S9 metabolic stimulator PPCM is not mutagenic GLP Rat Micronucleus Assay, Bioreliance Male SD rats, 25, 50, 100, and 200 mg/kg, 10 mL/kg IV, once. Groups harvested 24 and 48 h No significant increase in the incidence of micronuclei at either time point. No significant reduction in %PCE compared to control; indicates PPCM is not cytotoxic Safety toxicology Non-GLP acute oral toxicity rats MB research 12 M/F Sprague Dawley rats dosed with either 1000 or 2000 mg/kg PPCM A single dose of either 1000 or 2000 mg/kg had no observed toxicological effect Non-GLP acute IV toxicity rats—MB research 6 M/F Sprague Dawley rats dosed w/single injection 10, 50, or 100 mg/kg PPCM in water solution No toxicological effects seen at 10 mg/kg. Some distress observed at 50 and 100 mg/kg on day 1. No distress days 2–14. No deaths occurred Non-GLP 3-day Labial Irritation—rabbits—Sinclair Research 24F New Zealand Whites; 0.2 mL of either vehicle control, 4, 10, or 30% PPCM gel applied to labia; scored pre- and postdose PPCM-gel was well tolerated with concentrations up to 300 mg/mL Non-GLP tissue distribution/route of excretion of 14C-PPCM––SRI Intl. Vaginal application of 0.4 and 4% 14C-PPCM with sampling of blood at 1, 4, 8, and 24 h On average, about 1–2% of the total radioactive dose was in the blood for the 4.0% group, and <1% for the 0.4% group at each time point GLP 28-day vaginal/labial/penile irritation in rabbits w/PK Tk and 14-day recovery Saline, 1, 4, and 10% plus vehicle control doses 1.0 mL 28 consecutive days. 2 animals/grp allowed to recover for 14 days prior to sacrifice. Pk samples collected @ 6 times day 1 and day 28. Bioassay by LC/MS-MS and data analyzed Necropsy and histopathology No clinical symptoms in either males or females. No test article-related early deaths; no notable test article-related clinical observations; no changes in body weight, food consumption, clinical chemistry, hematology, coagulation, or urinalysis parameters; and no gross pathology findings or organ weight differences in males or females. Low drug concentrations were detected in plasma of both males and females. No penile irritation and only mild to moderate vaginal irritation was observed in a dose dependent manner. Systemic NOAEL = 10% and vaginal NOAEL = 4% Non-GLP DRF Oral SD rats A dose range finding study w/7-day repeat dose (8M/8F) Sprague Dawley rats at 1000 and 2000 mg/kg. A single bioassay sample taken 24-h post final dose No mortality during this study. There were no PPCM sodium salt-related clinical observations, changes in body weight, coagulation parameters, or gross pathology findings GLP 28-day oral toxicity in SD rats w/Pk Tk and 14-day recovery PPCM aqueous solution. Doses of 500, 1000, and 2000 mg/Kg plus control group. 15M and 15F per group, with 5/gp recovering for 14 days. Bioassay samples pulled 6 times Day 1, Day 28, and Day 42 Ongoing Completed . Genotoxicity . Study description . Study results . GLP Reverse Bacterial Mutation Assay (AMES), Bioreliance Five strains Salmonella and Escherichia coli plated w/PPCM up to 5000 μg/mL; evaluated for toxicity and mutations PPCM was nontoxic to selected strains. PPCM is not mutagenic in AMES assay GLP Rat Lymphoma Assay, Bioreliance PPCM solution of 1.95–500 μg/mL plated with L5178/TK+/− mouse lymphoma cells w/or w/o S9 metabolic stimulator PPCM is not mutagenic GLP Rat Micronucleus Assay, Bioreliance Male SD rats, 25, 50, 100, and 200 mg/kg, 10 mL/kg IV, once. Groups harvested 24 and 48 h No significant increase in the incidence of micronuclei at either time point. No significant reduction in %PCE compared to control; indicates PPCM is not cytotoxic Safety toxicology Non-GLP acute oral toxicity rats MB research 12 M/F Sprague Dawley rats dosed with either 1000 or 2000 mg/kg PPCM A single dose of either 1000 or 2000 mg/kg had no observed toxicological effect Non-GLP acute IV toxicity rats—MB research 6 M/F Sprague Dawley rats dosed w/single injection 10, 50, or 100 mg/kg PPCM in water solution No toxicological effects seen at 10 mg/kg. Some distress observed at 50 and 100 mg/kg on day 1. No distress days 2–14. No deaths occurred Non-GLP 3-day Labial Irritation—rabbits—Sinclair Research 24F New Zealand Whites; 0.2 mL of either vehicle control, 4, 10, or 30% PPCM gel applied to labia; scored pre- and postdose PPCM-gel was well tolerated with concentrations up to 300 mg/mL Non-GLP tissue distribution/route of excretion of 14C-PPCM––SRI Intl. Vaginal application of 0.4 and 4% 14C-PPCM with sampling of blood at 1, 4, 8, and 24 h On average, about 1–2% of the total radioactive dose was in the blood for the 4.0% group, and <1% for the 0.4% group at each time point GLP 28-day vaginal/labial/penile irritation in rabbits w/PK Tk and 14-day recovery Saline, 1, 4, and 10% plus vehicle control doses 1.0 mL 28 consecutive days. 2 animals/grp allowed to recover for 14 days prior to sacrifice. Pk samples collected @ 6 times day 1 and day 28. Bioassay by LC/MS-MS and data analyzed Necropsy and histopathology No clinical symptoms in either males or females. No test article-related early deaths; no notable test article-related clinical observations; no changes in body weight, food consumption, clinical chemistry, hematology, coagulation, or urinalysis parameters; and no gross pathology findings or organ weight differences in males or females. Low drug concentrations were detected in plasma of both males and females. No penile irritation and only mild to moderate vaginal irritation was observed in a dose dependent manner. Systemic NOAEL = 10% and vaginal NOAEL = 4% Non-GLP DRF Oral SD rats A dose range finding study w/7-day repeat dose (8M/8F) Sprague Dawley rats at 1000 and 2000 mg/kg. A single bioassay sample taken 24-h post final dose No mortality during this study. There were no PPCM sodium salt-related clinical observations, changes in body weight, coagulation parameters, or gross pathology findings GLP 28-day oral toxicity in SD rats w/Pk Tk and 14-day recovery PPCM aqueous solution. Doses of 500, 1000, and 2000 mg/Kg plus control group. 15M and 15F per group, with 5/gp recovering for 14 days. Bioassay samples pulled 6 times Day 1, Day 28, and Day 42 Ongoing Open in new tab Table 2 Comparison of sperm inactivation by PPCM measured by both an HBA and AS Completed . Genotoxicity . Study description . Study results . GLP Reverse Bacterial Mutation Assay (AMES), Bioreliance Five strains Salmonella and Escherichia coli plated w/PPCM up to 5000 μg/mL; evaluated for toxicity and mutations PPCM was nontoxic to selected strains. PPCM is not mutagenic in AMES assay GLP Rat Lymphoma Assay, Bioreliance PPCM solution of 1.95–500 μg/mL plated with L5178/TK+/− mouse lymphoma cells w/or w/o S9 metabolic stimulator PPCM is not mutagenic GLP Rat Micronucleus Assay, Bioreliance Male SD rats, 25, 50, 100, and 200 mg/kg, 10 mL/kg IV, once. Groups harvested 24 and 48 h No significant increase in the incidence of micronuclei at either time point. No significant reduction in %PCE compared to control; indicates PPCM is not cytotoxic Safety toxicology Non-GLP acute oral toxicity rats MB research 12 M/F Sprague Dawley rats dosed with either 1000 or 2000 mg/kg PPCM A single dose of either 1000 or 2000 mg/kg had no observed toxicological effect Non-GLP acute IV toxicity rats—MB research 6 M/F Sprague Dawley rats dosed w/single injection 10, 50, or 100 mg/kg PPCM in water solution No toxicological effects seen at 10 mg/kg. Some distress observed at 50 and 100 mg/kg on day 1. No distress days 2–14. No deaths occurred Non-GLP 3-day Labial Irritation—rabbits—Sinclair Research 24F New Zealand Whites; 0.2 mL of either vehicle control, 4, 10, or 30% PPCM gel applied to labia; scored pre- and postdose PPCM-gel was well tolerated with concentrations up to 300 mg/mL Non-GLP tissue distribution/route of excretion of 14C-PPCM––SRI Intl. Vaginal application of 0.4 and 4% 14C-PPCM with sampling of blood at 1, 4, 8, and 24 h On average, about 1–2% of the total radioactive dose was in the blood for the 4.0% group, and <1% for the 0.4% group at each time point GLP 28-day vaginal/labial/penile irritation in rabbits w/PK Tk and 14-day recovery Saline, 1, 4, and 10% plus vehicle control doses 1.0 mL 28 consecutive days. 2 animals/grp allowed to recover for 14 days prior to sacrifice. Pk samples collected @ 6 times day 1 and day 28. Bioassay by LC/MS-MS and data analyzed Necropsy and histopathology No clinical symptoms in either males or females. No test article-related early deaths; no notable test article-related clinical observations; no changes in body weight, food consumption, clinical chemistry, hematology, coagulation, or urinalysis parameters; and no gross pathology findings or organ weight differences in males or females. Low drug concentrations were detected in plasma of both males and females. No penile irritation and only mild to moderate vaginal irritation was observed in a dose dependent manner. Systemic NOAEL = 10% and vaginal NOAEL = 4% Non-GLP DRF Oral SD rats A dose range finding study w/7-day repeat dose (8M/8F) Sprague Dawley rats at 1000 and 2000 mg/kg. A single bioassay sample taken 24-h post final dose No mortality during this study. There were no PPCM sodium salt-related clinical observations, changes in body weight, coagulation parameters, or gross pathology findings GLP 28-day oral toxicity in SD rats w/Pk Tk and 14-day recovery PPCM aqueous solution. Doses of 500, 1000, and 2000 mg/Kg plus control group. 15M and 15F per group, with 5/gp recovering for 14 days. Bioassay samples pulled 6 times Day 1, Day 28, and Day 42 Ongoing Completed . Genotoxicity . Study description . Study results . GLP Reverse Bacterial Mutation Assay (AMES), Bioreliance Five strains Salmonella and Escherichia coli plated w/PPCM up to 5000 μg/mL; evaluated for toxicity and mutations PPCM was nontoxic to selected strains. PPCM is not mutagenic in AMES assay GLP Rat Lymphoma Assay, Bioreliance PPCM solution of 1.95–500 μg/mL plated with L5178/TK+/− mouse lymphoma cells w/or w/o S9 metabolic stimulator PPCM is not mutagenic GLP Rat Micronucleus Assay, Bioreliance Male SD rats, 25, 50, 100, and 200 mg/kg, 10 mL/kg IV, once. Groups harvested 24 and 48 h No significant increase in the incidence of micronuclei at either time point. No significant reduction in %PCE compared to control; indicates PPCM is not cytotoxic Safety toxicology Non-GLP acute oral toxicity rats MB research 12 M/F Sprague Dawley rats dosed with either 1000 or 2000 mg/kg PPCM A single dose of either 1000 or 2000 mg/kg had no observed toxicological effect Non-GLP acute IV toxicity rats—MB research 6 M/F Sprague Dawley rats dosed w/single injection 10, 50, or 100 mg/kg PPCM in water solution No toxicological effects seen at 10 mg/kg. Some distress observed at 50 and 100 mg/kg on day 1. No distress days 2–14. No deaths occurred Non-GLP 3-day Labial Irritation—rabbits—Sinclair Research 24F New Zealand Whites; 0.2 mL of either vehicle control, 4, 10, or 30% PPCM gel applied to labia; scored pre- and postdose PPCM-gel was well tolerated with concentrations up to 300 mg/mL Non-GLP tissue distribution/route of excretion of 14C-PPCM––SRI Intl. Vaginal application of 0.4 and 4% 14C-PPCM with sampling of blood at 1, 4, 8, and 24 h On average, about 1–2% of the total radioactive dose was in the blood for the 4.0% group, and <1% for the 0.4% group at each time point GLP 28-day vaginal/labial/penile irritation in rabbits w/PK Tk and 14-day recovery Saline, 1, 4, and 10% plus vehicle control doses 1.0 mL 28 consecutive days. 2 animals/grp allowed to recover for 14 days prior to sacrifice. Pk samples collected @ 6 times day 1 and day 28. Bioassay by LC/MS-MS and data analyzed Necropsy and histopathology No clinical symptoms in either males or females. No test article-related early deaths; no notable test article-related clinical observations; no changes in body weight, food consumption, clinical chemistry, hematology, coagulation, or urinalysis parameters; and no gross pathology findings or organ weight differences in males or females. Low drug concentrations were detected in plasma of both males and females. No penile irritation and only mild to moderate vaginal irritation was observed in a dose dependent manner. Systemic NOAEL = 10% and vaginal NOAEL = 4% Non-GLP DRF Oral SD rats A dose range finding study w/7-day repeat dose (8M/8F) Sprague Dawley rats at 1000 and 2000 mg/kg. A single bioassay sample taken 24-h post final dose No mortality during this study. There were no PPCM sodium salt-related clinical observations, changes in body weight, coagulation parameters, or gross pathology findings GLP 28-day oral toxicity in SD rats w/Pk Tk and 14-day recovery PPCM aqueous solution. Doses of 500, 1000, and 2000 mg/Kg plus control group. 15M and 15F per group, with 5/gp recovering for 14 days. Bioassay samples pulled 6 times Day 1, Day 28, and Day 42 Ongoing Open in new tab Development of a biomarker for PPCM contraceptive activity Since PPCM does not directly affect motility, postcoital testing for sperm motility cannot be used to assess sperm inactivation. Early work on PPCM identified PAL as a likely mechanism of action, and an acrosome staining (AS) method has been used to assess acrosomal loss as a surrogate marker of sperm inactivation. But like postcoital testing for motility, this method is technician-dependent, tedious, and complicated [92]. A more convenient measure of sperm activity would be useful for in vitro preclinical studies and could potentially serve as a biomarker to assess the contraceptive effectiveness of PPCM in the vagina. Both the contraceptive and anti-infective actions of a nonsystemic vaginal product occur in the vaginal vault and may be limited by uneven distribution and leakage. In addition, fluids from the vagina, cervix, or seminal fluid contain complex proteins and other substances that may reduce effectiveness when mixed with a vaginal product [96, 117–119]. A better biomarker for sperm activity could help us learn more about these effects in early clinical testing of ex vivo vaginal samples as well as in preclinical studies. This in turn can guide the design of subsequent proof of concept clinical testing. We can make better decisions about subsequent clinical trial design if PPCM gel efficacy can be determined without risk of pregnancy. An inexpensive, user-friendly, commercially available hyaluronan binding assay (HBA) may be such a biomarker. Hyaluronan Binding Assay (HBA) is a validated test to assess the functional examination of human sperm. Only mature sperm are able to bind to the hyaluronan contained in the zona pellucida of the mature oocyte, which is the initial step in fertilization. Thus, anything which prevents this binding step will prevent fertilization [120]. Multiple studies demonstrate that the fraction of motile sperm that bind to the hyaluronan substrate in the HBA is directly correlated with numerous parameters of sperm health—including greater progressive motility, lower DNA fragmentation, reduced sperm agglutination, normal overall morphology, as well as an intact acrosome [121–124]. The HBA has been extensively evaluated in the context of assisted reproductive technology and has been used to isolate and select healthy sperm for in vitro fertilization [125, 126]. Sperm—either washed or in neat semen—are placed on the slide, and the ratio of bound to unbound sperm is easily determined microscopically. Since HBA reliably identifies the fraction of mature healthy sperm with fertilization potential in a washed sperm or semen sample, the assay will also measure reduction in the fraction of healthy sperm due to inactivation by a contraceptive. We have conducted preliminary studies in vitro using HBA to assess PPCM contraceptive effectiveness (MS in preparation). HBA binding was validated against PAL sperm inactivation measured with AS [127]. Sperm incubated with increasing concentrations of PPCM exhibited a linear decrease in the fraction of viable sperm, measured by both HBA and AS. While the EC50 ~ 0.1 μg/mL with both methods, HBA detected inactivation of a much larger fraction of the total sperm population compared with the AS technique. Up to 80% of the total sperm were inactivated (unbound) shown by HBA after exposure to PPCM. This contrasts with about 25% inactivated by PAL and identified by AR staining. The superior sensitivity of HBA is also seen with the positive control (ionophore) (Figure 2). Figure 2 Open in new tabDownload slide Comparison of sperm inactivation by PPCM measured by both an HBA and AS. Washed human sperm (20 million/mL) were resuspended in Biggers, Whitter, and Whittingham (BWW), divided into aliquots and incubated with increasing concentrations of PPCM for 15 min. Additional aliquots were incubated in BWW medium without PPCM (negative control) or with Ca++ ionophore A23187 (positive control). Mature, intact sperm bind to hyaluronan (HBA). The “% Unbound to Hyaluronan” represents the fraction of sperm inactivated by PPCM and unable to bind. Mature, intact sperm have an intact acrosome, which is identified by AS. Thus, “% Acrosome Reaction” represents the inactivated sperm with premature acrosome caused by PPCM. Both assays demonstrate dose-dependent increase in sperm inactivation (contraceptive activity) after exposure to PPCM. However, the HBA shows a greater effect and accounts for an 80% reduction, whereas AR shows maximal reduction of only 27%. Bars represent the mean ± SEM, n = 4–6/treatment group. #P < 0.01 PPCM at 100, 10, 1.0, and 0.1 vs. no PPCM in the HBA assay. *P < 0.01 PPCM at 100, 10, 1.0, and 0.1 ug/mL vs. no PPCM in the acrosome reaction assay. Figure 2 Open in new tabDownload slide Comparison of sperm inactivation by PPCM measured by both an HBA and AS. Washed human sperm (20 million/mL) were resuspended in Biggers, Whitter, and Whittingham (BWW), divided into aliquots and incubated with increasing concentrations of PPCM for 15 min. Additional aliquots were incubated in BWW medium without PPCM (negative control) or with Ca++ ionophore A23187 (positive control). Mature, intact sperm bind to hyaluronan (HBA). The “% Unbound to Hyaluronan” represents the fraction of sperm inactivated by PPCM and unable to bind. Mature, intact sperm have an intact acrosome, which is identified by AS. Thus, “% Acrosome Reaction” represents the inactivated sperm with premature acrosome caused by PPCM. Both assays demonstrate dose-dependent increase in sperm inactivation (contraceptive activity) after exposure to PPCM. However, the HBA shows a greater effect and accounts for an 80% reduction, whereas AR shows maximal reduction of only 27%. Bars represent the mean ± SEM, n = 4–6/treatment group. #P < 0.01 PPCM at 100, 10, 1.0, and 0.1 vs. no PPCM in the HBA assay. *P < 0.01 PPCM at 100, 10, 1.0, and 0.1 ug/mL vs. no PPCM in the acrosome reaction assay. HBA may be suitable for measuring the contraceptive effectiveness of other vaginal products preclinically for studies that assess sperm maturity and viability. It may prove to be particularly useful for early phase clinical trials to assess spermicidal activity in the vagina before and after application of a vaginal contraceptive product—both pre- and postcoitally. Thus, HBA may provide relevant data for human sperm inactivation potential of PPCM and lead to the validation of an important assay to assess additional PPCM formulations or other sperm inactivating compounds in the human vaginal milieu. Summary There is clearly a need for an MPT that provides both STI protection and a nonhormonal contraceptive choice. Development of an MPT that is woman-controlled, administered vaginally, not systemically absorbed, and available OTC without medical services will be an important choice for dual protection. This is particularly true for women who want an “on-demand” method, who need only episodic protection, women who cannot tolerate side effects of systemic and/or hormone-based products, or for whom the medical services needed to obtain these methods are simply not available. A gel formulation is a logical candidate for vaginal application. We describe the development of a candidate MPT product utilizing PPCM, a novel polyanion with noncytotoxic contraceptive and anti-infective activity. The formulation is designed to maximize the inactivation of spermatozoa in the complex vaginal milieu. Development of novel nonhormonal coitally dependent contraceptive drug products is particularly difficult and faces resistance from several quarters. However, the undertaking is worthwhile given the millions of women who would benefit from these new products. Conference Presentation: This work was presented in part at the 2019 NICHD Contraception Development Meeting October 3-6, Houston TX. Acknowledgements We thank G. Prins, W. Birch, L. Birch, K. Feathergill, and C. DeJonge for participating in the evaluation of the HBA biomarker. Conflict of Interest The authors have declared that no conflict of interest exists. References 1. Finer L , Zolna M. Declines in unintended pregnancy in the United States, 2008–2011 . N Engl J Med 2016 ; 374 : 843 – 852 . Google Scholar Crossref Search ADS PubMed WorldCat 2. Sedgh G , Ashford L, Rubina Hussain. Unmet Need for Contraception in Developing Countries: Examining Women’s Reasons for Not Using a Method (Report) . New York : Guttmacher Institute ; 2016 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 3. CDC . Key Statistics from the National Survey of Family Growth—C Listing . National Center for Health Statistics . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 4. Castle S , Askew I. Contraception discontinuations: Reasons, challenges, and solutions. Population Council 2015 Report . Family Planning ; 2020 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 5. Moreau C , Cleland K, Trussell J. Contraceptive discontinuation attributed to method dissatisfaction in the United States . Contraception 2007 ; 76 : 267 – 272 . Google Scholar Crossref Search ADS PubMed WorldCat 6. Janiak E , Clark J, Bartz D, Langer A, Gottleib B. Barriers and pathways to providing long-acting reversible contraceptives in Massachusetts community health centers: A qualitative exploration . Perspect Sex Reprod Health 2018 ; 50 ( 3 ): 111 – 118 . Google Scholar Crossref Search ADS PubMed WorldCat 7. Decide Power to Birth Control Access. Secondary birth control access . https://powertodecide.org/what-we-do/access/birth-control-access. 8. Steiner R , Liddon N, Swartzendruber AL, Rasberry CN, Sales JM. Long-acting reversible contraception and condom use among female US high school students. Implications for sexually transmitted infection prevention . JAMA Ped 2016 ; 170 : 428 – 434 . Google Scholar Crossref Search ADS WorldCat 9. O'Leary A . Are dual-method messages undermining STI/HIV prevention? Infect Dis Obstet Gyn 2011 ; 2010 : 691210 . Google Scholar OpenURL Placeholder Text WorldCat 10. Gallo M , Warner L, Gallo MF, Warner L, Jamieson DJ, Steiner MJ. Do women using long-acting reversible contraception reduce condom use? A novel study design incorporating semen biomarkers . Infect Dis Obstet Gyn 2011 ; 107140 . Google Scholar OpenURL Placeholder Text WorldCat 11. Nelson A , Cohen S, Galitsky A, Hathaway M, Kappus D, Kerolous M, Patel K, Dominguez L. Women's perceptions and treatment patterns related to contraception: Results of a survey of US women . Contraception 2018 ; 97 : 267 – 273 . Google Scholar Crossref Search ADS WorldCat 12. Bellizzi S , Mannava P, Nagai M, Sobel HL. Reasons for discontinuation of contraception among women with a current unintended pregnancy in 36 low and middle-income countries . Contraception 2020 ; 101 : 26 – 33 . Google Scholar Crossref Search ADS PubMed WorldCat 13. Dreweke J . Contraception is not abortion: The strategic campaign of antiabortion groups to persuade the public otherwise . Guttmacher Policy Review 2014 ; 17 : 14 – 20 . Google Scholar OpenURL Placeholder Text WorldCat 14. FDA Center for Drug Evaluation and Research . Drug Interactions with Hormonal Contraceptives: Public Health and Drug Development Implications, Public Meeting ; 2015 . 15. March L , Skovlund C, Hannaford PC, Iverson L, Fielding S, Lidegaard ∅. Contemporary hormonal contraception and the risk of breast cancer . N Engl J Med 2017 ; 377 : 2228 – 2239 . Google Scholar Crossref Search ADS PubMed WorldCat 16. Kavanaugh M , Jerman J. Contraceptive method use in the United States: Trends and characteristics between 2008, 2012 and 2014 . Contraception 2017 ; 97 : 14 – 21 . Google Scholar Crossref Search ADS PubMed WorldCat 17. Ross J , Stover J. Use of modern contraception increases when more methods become available: Analysis of evidence from 1982–2009 . Glob Health: Sci Pract 2013 ; 1 : 203 – 212 . Google Scholar Crossref Search ADS PubMed WorldCat 18. Bradley S , Schwandt H, Kahn S. Levels, Trends, and Reasons for Contraceptive Discontinuation. USAID:DHS Analytical Studies No. 20 . Calverton, MD : ICF International ; 2009 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 19. Lee J , Jezewski M. Attitudes toward oral contraceptive use among women of reproductive age: A systematic review . Adv Nurs Sci 2007 ; 30 : E85 – E103 . Google Scholar Crossref Search ADS WorldCat 20. Looker K , Magaret A, Turner KME, Vicerman P, Gottlieb SL, Newman LM. Global estimates of prevalent and incident herpes simplex virus type 2 infections in 2012 . PLoS ONE 2015 ; 10 ( 1 ): 1 – 23 . Google Scholar Crossref Search ADS WorldCat 21. WHO . Sexually Transmitted Infections (STIs) . Fact Sheet ; 2016 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 22. Bradley H , Markowitz L. Seroprevalence of herpes simplex virus types 1 and 2—United States, 1999–2010 . J Infect Dis 2014 ; 209 : 325 – 333 . Google Scholar Crossref Search ADS PubMed WorldCat 23. CDC . 2016 Sexually Transmitted Diseases Surveillance. Fact Sheet 2015. Reported STDs in the United States ; 2016 . 24. Wi T , Lahra MM, Ndowa F, Bala M, Dillon JR, Ramon- Pardo P, Eremin S, Bolan G, Unemo M. Antimicrobial resistance in Neisseria gonorrhoeae: Global surveillance and a call for international collaborative action . Plos Medicine 2017 ; 14 : 1 – 11 . Google Scholar Crossref Search ADS WorldCat 25. Quaife M , Terri-Prestholt F, Vickerman P. The promise of multipurpose pregnancy, STI, and HIV prevention . Lancet 2017 ; 17 : 21 – 22 . Google Scholar Crossref Search ADS PubMed WorldCat 26. Friend D . An update on multipurpose prevention technologies for the . Expert Opin Drug Deliv 2016 ; 13 : 533 – 545 . Google Scholar Crossref Search ADS PubMed WorldCat 27. Hallet V . Experimental vaginal ring fights HIV, but will women wear it? Sexual Behavior HIV/AIDS (Health) ; 2016 . www.npr.org . 28. Lusti-Narasimhan M , Merialdia M, Holt B. Multipurpose prevention technologies: Maximising positive synergies . BJOG 2014 ; 121 ( Suppl. 5 ): 251 ; Guest Editorial . Google Scholar Crossref Search ADS PubMed WorldCat 29. Romano J , Van Damme L, Hillier S. The future of multipurpose prevention technology product strategies: Understandingthe market in parallel with product development . BJOG 2014 ; 121 : 15 – 18 . Google Scholar Crossref Search ADS PubMed WorldCat 30. CAMI . MPT Product Development Database. IMPT for Reproductive Health Current . CA, USA : Public Health Institute ; 2020. http://mpts101.org/mpt-database. Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 31. Rosenberg M , Rojanapithayakorn W, Feldblum PJ, Higgins JE. Effect of the contraceptive sponge on chlamydial infection, gonorrhea, and candidiasis. A Comparative Clinical Trial . JAMA 1987 ; 257 : 2308 – 2312 . Google Scholar Crossref Search ADS PubMed WorldCat 32. Hillier S , Moench T, Shattock R, Black R, Reichelderfer P, Veronese F. In vitro and in vivo: The story of nonoxynol 9 . J Acquir Immune Defic Syndr 2005 ; 39 : 1 – 8 . Google Scholar Crossref Search ADS PubMed WorldCat 33. Richardson B . Nonoxynol-9 as a vaginal Microbicide for prevention of sexually transmitted infections . JAMA 2002 ; 287 : 1171 – 1172 . Google Scholar Crossref Search ADS PubMed WorldCat 34. Ezire O , Oluigbo O, Archibong V, Ifeanyi O, Anyanti J. Barriers to repeated use of female condom among women and men of reproductive age in Nigeria . J AIDS HIV Res 2013 ; 5 : 206 – 213 . Google Scholar OpenURL Placeholder Text WorldCat 35. Guerra F , Simbayi L. Prevalence of knowledge and use of the female condom in South Africa . AIDS Behav 2014 ; 18 : 146 – 158 . Google Scholar Crossref Search ADS PubMed WorldCat 36. Fernandez-Romero J , Deal C, Herold BC, Schiller J, Patton D, Zydowsky T, Romano J, Petro CD, Narasimhan M. Multipurpose prevention technologies: The future of HIV and STI protection . Trends Microbiol 2015 ; 23 : 429 – 436 . Google Scholar Crossref Search ADS PubMed WorldCat 37. Hughes L , Griffith R, Aitken RJ. The search for a topical dual action spermicide/microbicide . Curr Med Chem 2007 ; 14 : 775 – 786 . Google Scholar Crossref Search ADS PubMed WorldCat 38. Thurman A , Clark M, Doncel GF. Multipurpose prevention technologies: Biomedical tools to prevent HIV-1, HSV-2, and unintended pregnancies . Infect Dis Obstet Gyn 2011 ; 2011 : 1 – 10 . Google Scholar Crossref Search ADS WorldCat 39. Hynes J , Sheth A, Lathrop E, Sales JM, Haddad LB. Preferred product attributes of potential multipurpose prevention Technologies for Unintended Pregnancy and Sexually Transmitted Infections or HIV among U.S. women . J Women's Health 2019 ; 28 : 665 – 672 . Google Scholar Crossref Search ADS WorldCat 40. Baeten J , Palanee-Phillips T, Brown E, Schwartz K, Soto-Torres L, Govender V, Mgodi N, Kiweewa FM, Nair G, Mhlanga F, Siva S, Bekker LG et al. . Use of a vaginal ring containing Dapivirine for HIV-1 prevention in women . NEJM 2016 ; 375 : 2121 – 2132 . Google Scholar Crossref Search ADS PubMed WorldCat 41. Guthrie K , Vargas S, Shaw J, Rosen K, van den Berg J, Kiser P, Buckheit K, Bregman D, Thompson L, Jensen K, Johnson T et al. . The promise of Intravaginal rings for prevention: User perceptions of biomechanical properties and implications for prevention product development . Plos One 2015 ; 10 ( 12 ): e0145642 . Google Scholar Crossref Search ADS PubMed WorldCat 42. NIAID NIH . Women Report Vaginal Ring for Preventing HIV had Little Effect on Sexual Intercourse. Violence and Social Harm were Associated with Low Adherence . 2016 : 18 . 43. Stifani B , Plagianos M, Vieira C, Merkatz RB. Factors associated with non-adherence to instructions for using the Nestorone/ethinyl estradiol contraceptive vaginal ring . Contraception 2018 ; 97 : 415 – 421 . Google Scholar Crossref Search ADS PubMed WorldCat 44. Forhan S , Gottlieb S, Sternberg MR, Xu F, Datta SD, McQuillan GM, Berman SM, Markowitz LE. Prevalence of sexually transmitted infections among female adolescents aged 14 to 19 in the United States . Pediatrics 2009 ; 124 : 1505 – 1512 . Google Scholar Crossref Search ADS PubMed WorldCat 45. CDC . 2015 sexually transmitted diseases treatment guidelines. Genital HSV Infections ; 2015 . 46. Masse B , Boily M, Dimitrov D, Desai K. Efficacy dilution in randomized placebo-controlled vaginal microbicide trials . Emerg Themes Epidemiol 2009 ; 6 ( 5 ): 1742 – 7622 . Google Scholar OpenURL Placeholder Text WorldCat 47. Turner A , De Kock A, Meehan-Ritter A, Blanchard K, Sebola MH, Hoosen AA, Coetzee N, Ellertson C. Many vaginal microbicide trial participants acknowledged they had misreported sensitive sexual behavior in face-to-face interviews . J Clin Epidemiol 2009 ; 62 : 759 – 765 . Google Scholar Crossref Search ADS PubMed WorldCat 48. Notario-Pérez F , Caro R, Veiga-Ochoa MD. Historical development of vaginal microbicides to prevent sexual transmission of HIV in women: From past failures to future hopes . Drug Des Dev Ther 2017 ; 11 : 1767 – 1787 . Google Scholar Crossref Search ADS WorldCat 49. Achilles S , Mhlanga F, Musara P, Poloyac S, Chirenje Z, Hillier S et al. . Misreporting of contraceptive hormone use in clinical research participants . Contraception 2018 ; 97 : 346 – 353 . Google Scholar Crossref Search ADS PubMed WorldCat 50. Cairns G. Postcard From Delhi: The View From the Microbicide 2008 Conference. POZ and AIDS Meds; News—Special Report ; 2008 . 51. Marrazzo J , Rabe L, Kelly C, Livant E, Chirenje M, Richardson B, Dai J, Piper J, Hillier S, the VOICE Study Team. Association of tenofovir (TFV) detection with reduced risk of herpes simplex virus type-2 (HSV-2) acquisition in the VOICE (MTN 003) study . AIDS Res Human Retrovir 2014 ; 30 : A31 – A31 . Google Scholar Crossref Search ADS WorldCat 52. Rees H , Delaney-Moretlwe S, Lombard C, Baron D, Panchia R, Myer L, Schwartz J, Doncel G, Gray G FACTS 001 Phase III Trial of Pericoital Tenofovir 1% Gel for HIV Prevention in Women CROI . Seattle Washington ; 2015 : (Abstract Number 26LB) . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 53. Abdool Karim Q , Abdool Karim S, Frohlich A, Grobler A, Baxter C, Mansoor L, Kharsany A, Sibeko S, Mlisana K, Omar Z, Gengiah T, Maarschalk S et al. . Effectiveness and safety of tenofovir gel, an antiretroviral microbicide, for the prevention of HIV infection in women . Science 2010 ; 329 : 1168 – 1174 . Google Scholar Crossref Search ADS PubMed WorldCat 54. Edelman DA , North BB. Parity and the effectiveness of the today contraceptive sponge . Adv Contracept 1987 ; 3 : 327 – 333 . Google Scholar Crossref Search ADS PubMed WorldCat 55. Crawford T , Boyer R. Parity and the expected consequences of childbearing . Popul Environ 1984 ; 58 : 234 – 245 . Google Scholar Crossref Search ADS WorldCat 56. Trussell J . Understanding contraceptive failure . Best Pract Res Clin Obstet Gynaecol 2009 ; 23 : 199 – 209 . Google Scholar Crossref Search ADS PubMed WorldCat 57. Barnhart T , Izquierdo A, Pretorius ES, Shera DM, Shabbout M, Shaunik A. Baseline dimensions of the human vagina . Hum Reprod 2006 ; 21 ( 6 ): 1618 – 22 . Google Scholar Crossref Search ADS PubMed WorldCat 58. Grimes DA , Lopez LM, Raymond EG, Halpern V, Nanda K, Schulz KF. Spermicide used alone for contraception . Cochrane Database Syst Rev 2013 ; 12 . Google Scholar OpenURL Placeholder Text WorldCat 59. Raymond E , Trussell J, Weaver MA, Reeves MF. Estimating contraceptive efficacy: The case of spermicide . Contraception 2013 ; 87 : 134 – 137 . Google Scholar Crossref Search ADS PubMed WorldCat 60. Wolgemuth T , Judge-Golden C, Callegari L, Zhao X, Mor M, Borrero S. Associations between pregnancy intention, attitudes, and contraceptive use among women veterans in the ECUUN study . Womens Health Issues 2018 ; 28 : 480 – 487 . Google Scholar Crossref Search ADS PubMed WorldCat 61. Mauck CK . Biomarkers for evaluating vaginal Microbicides and contraceptives: Discovery and early validation . Sex Transm Dis 2009 ; 36 : S73 – S75 . Google Scholar Crossref Search ADS PubMed WorldCat 62. Brady M , Park H. What Regulatory Guidance Exists for Multipurpose Prevention Technologies (MPTs)? A Review of Key Guidance Documents and Their Applicability to MPTs . Washington, DC : Population Council ; 2011 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 63. Stone A . Regulatory Issues in Microbicide Development/Alan Stone . World Health Organization : World Health Organization ; 2010 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 64. Castle PE , Hoen TE, Whaley KJ, Cone RA. Contraceptive testing of vaginal agents in rabbits . Contraception 1998 ; 58 : 51 – 60 . Google Scholar Crossref Search ADS PubMed WorldCat 65. Liechty E . Animal models of contraception: Utility and limitations . Open Access J Contracept 2015 ; 6 : 27 – 35 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 66. Glatstein IZ , Best CL, Palumbo A, Sleeper LA, Friedman AJ, Hornstein MD. The reproducibility of the postcoital test: A prospective study . Obstet Gynecol 1995 ; 85 : 396 – 400 . Google Scholar Crossref Search ADS PubMed WorldCat 67. Mauck C , Baker JM, Barr SP, Johanson W, Archer DF. A phase I study of Femcap@ used with and without spermlclde—Postcoital testing . Contraception 1997 ; 56 : 111 – 115 . Google Scholar Crossref Search ADS PubMed WorldCat 68. Keller MJ , Herold BC. Understanding basic mechanisms and optimizing assays to evaluate the efficacy of vaginal Microbicides . Sex Transm Dis 2009 ; 36 ( 3 ): S92 - S95 . Google Scholar Crossref Search ADS PubMed WorldCat 69. Veazey R , Shattock R, Klasse PJ, Moore JP. Animal models for microbicide studies . Curr HIV Res 2012 ; 10 : 79 – 87 . Google Scholar Crossref Search ADS PubMed WorldCat 70. Anon . Over-the-counter Women's health . Drugstore News 2015 . OpenURL Placeholder Text WorldCat 71. Anon . OTC Sales in Volume (Units). Secondary OTC Sales in Volume (units) . https://chpa.org/SalesVolume.aspx. 72. Brothers J , Hotton A, Hosek SG, Harper GW, Fernandez MI. Young women living with HIV: Outcomes from a targeted secondary prevention empowerment pilot trial . AIDS Patient Care STDs 2016 ; 30 : 229 – 235 . doi: 10.1089/apc.2015.0294published . Google Scholar Crossref Search ADS PubMed WorldCat 73. Gayle-Campbell K . Analyzing the relationship between women's decisions to use contraception and their partners' perceptions of preventative behavior . Univ of Central Florida ; 2015 : 1990 – 2015 . Master's Thesis . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 74. Lanham M , Wilcher R, Montgomery ET, Pool R, Schuler S, Lenzi R, Friedland B. Engaging male partners in women’s microbicide use: Evidence from clinical trials and implications for future research and microbicide introduction . AIDS Res Hum Retrovir 2014 ; 30 : A9 . Google Scholar Crossref Search ADS WorldCat 75. Louw C , Masilo N, Villiers M, Nel A, Isaacs M et al. . Community engagement in a volatile community post-marikana for a phase III microbicide ring trial . AIDS Res Hum Retrovir 2014 ; 30 : A27 . Google Scholar Crossref Search ADS WorldCat 76. Nakyanzi T , Kabwigu S, Kemigisha D, Nanziri SC, Ndawula P, Nanyonga S, Etima J, Kiweewa FM, White R, Noguchi L, Nakabiito C. Why women at high risk for HIV-1 infection did not join the VOICE study in Uganda: A qualitative community study . AIDS Res Human Retrovir 2014 ; 30 : A26 – A27 . Google Scholar Crossref Search ADS WorldCat 77. Reddy K , Ramchuram P, Maseko N, Vuma A. Strategies to improve male involvement and partner support in the ASPIRE trial: The Hillbrow experience . AIDS Res Human Retrovir 2014 ; 30 : A9 – A10 . Google Scholar Crossref Search ADS WorldCat 78. das Neves J , Bahia MF. Gels as vaginal drug delivery systems . Int J Pharm 2006 ; 318 : 1 – 14 . Google Scholar Crossref Search ADS PubMed WorldCat 79. Jespers V , van de Wiggert J, Cools P, Verhelst R, Verstraelen H, Delany-Moretlwe S, Mwaura M, Ndayisaba GF, Mandaliya K, Menten J, Hardy L, Crucitti T et al. . The significance of lactobacillus crispatus and L. vaginalis for vaginal health and the negative effect of recent sex: A cross-sectional descriptive study across groups of African women . BMC Infect Dis 2015 ; 15 ( 115 ): 14 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 80. Keller M , Carpenter C, Lo Y, Einstein MH, Liu C, Fredricks DN, Herold BC. Phase I randomized safety study of twice daily dosing of acidform vaginal gel: Candidate antimicrobial contraceptive . PLoS One 2012 ; 7 : e46901 . Google Scholar Crossref Search ADS PubMed WorldCat 81. Ferguson LM , Rohan LC. The importance of the vaginal delivery route for antiretrovirals in HIV prevention . Ther Deliv 2011 ; 2 ( 1 ): 1535 – 50 . Google Scholar Crossref Search ADS PubMed WorldCat 82. Hoffman S , Morrow K, Mantell JE, Rosen RK, Carballo-Diéguez A, Gai R. Covert use, vaginal lubrication, and sexual pleasure: A qualitative study of urban U.S. women in a vaginal Microbicide clinical trial . Arch Sex Behav 2010 ; 39 : 748 – 760 . Google Scholar Crossref Search ADS PubMed WorldCat 83. Viega MD , Ruiz-Caru R, Martín-Illana A, Notario-Pérez F, Cazorla-Luna R. Polymer Gels in Vaginal Drug Delivery Systems , 1st ed. Springer ; 2018 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 84. Morrow K , Fava JL, Rosen RK, Vargas S, Barroso C, Christensen AL, Woodsong C, Severy L. Willingness to use microbicides is affected by the importance of product characteristics, use parameters, and protective properties . J Acquir Immune Defic Syndr 2007 ; 45 : 93 – 101 . Google Scholar Crossref Search ADS PubMed WorldCat 85. Guthrie K , Rosen R, Vargas SE, Guillen M, Steger AL, Getz ML, Smith KA, Ramirez JJ, Kojic EM. User input in iterative design for prevention product development: Leveraging interdisciplinary methods to optimize effectiveness . Drug Deliv Transl Res 2017 ; 7 : 761 – 770 . Google Scholar Crossref Search ADS PubMed WorldCat 86. Guthrie K , Dunsiger S, Vargas SE, Fava JL, Shaw JG, Rosen RK, Kiser PF, Kojic EM, Friend DR, Katz DF. Perceptibility and the “choice experience”: User sensory perceptions and experiences inform vaginal prevention product . AIDS Res Hum Retrovir 2016 ; 32 : 1022 – 1031 . Google Scholar Crossref Search ADS PubMed WorldCat 87. Anderson RA , Brown D, Jackson EM, Feathergill KA, Bremer JW, Morack R, Rawlins RG. Feasibility of repurposing the polyanionic microbicide, PPCM, for prophylaxis against HIV transmission during ART . Obstet Gynecol 2011 ; 2011 : 13 (Article ID 524365) . Google Scholar OpenURL Placeholder Text WorldCat 88. Anderson RA , Feathergill KA, Waller DP, Zaneveld LJ. SAMMA induces premature human acrosomal loss by Ca2+ signaling dysregulation . J. Androl. 2006 ; 27 : 568 – 577 . Google Scholar Crossref Search ADS PubMed WorldCat 89. Cheshenko N , Keller M, MasCasullo V, Jarvis A, Cheng H, John M, Li JH, Hogarty K, Anderson R, Waller D, Zaneveld L, Profy T et al. . Candidate topical mcrobicides bind herpes simplex virus glycoprotein B and prevent viral entry and cell-to-cell spread . Antimicrob Agents Chemother 2004 ; 48 : 2025 – 2036 . Google Scholar Crossref Search ADS PubMed WorldCat 90. Herold BC , Scordi-Bello I, Cheshenko N, Marcellino D, Dzuzelewski M, Francois F, Morin R, Mas Casullo V, Anderson RA, Chany C 2nd, Waller DP, Zaneveld LJD et al. . Mandelic acid condensation polymer: Novel candidate microbicide for prevention of human immunodeficiency virus and herpes simplex virus entry . J Virol 2002 ; 76 : 11236 – 11244 . Google Scholar Crossref Search ADS PubMed WorldCat 91. Keller MJ , Klotman ME, Herold BC. Rigorous pre-clinical evaluation of topical microbicides to prevent transmission of human immunodeficiency virus . J Antimicrob Chemoth 2003 ; 51 : 1099 – 1102 . Google Scholar Crossref Search ADS WorldCat 92. Zaneveld L , Anderson R, Diao XH, Waller DP, Chany C, Feathergill KA, Doncel G, Cooper MD, Herold BC. Use of mandelic acid condensation polymer (SAMMA), a new antimicrobial contraceptive agent, for vaginal prophylaxis . Fertil Steril 2002 ; 78 : 1107 – 1115 . Google Scholar Crossref Search ADS PubMed WorldCat 93. Mesquita P , Wilson S, Manlow P, Fischetti L, Keller MJ, Herold BC, Shattock R. Candidate microbicide PPCM blocks human immunodeficiency virus type 1 infection in cell and tissue cultures and prevents genital herpes in a murine model . J Virol 2008 ; 82 : 6576 – 6584 . Google Scholar Crossref Search ADS PubMed WorldCat 94. Neurath R , Strick N, Li Y. Role of seminal plasma in the anti-HIV-1 activity of candidate microbicides . BMC Infect Dis 2006 ; 6 : 150 . Google Scholar Crossref Search ADS PubMed WorldCat 95. Patel S , Hazrati E, Cheshenko N, Galen B, Yang H, Guzman E, Wang R, Herold BC, Keller MJ. Seminal plasma reduces the effectiveness of topical polyanionic microbicides . J Infect Dis 2007 ; 196 (9): 1294 – 402 . Google Scholar Crossref Search ADS WorldCat 96. Tan S , Lu L, Liu J, Oksov Y, Lu H, Jiang S, Liu S. Polyanionic candidate microbicides accelerate the formation of semen-derived amyloid fibrils to enhance HIV-1 infection . Plos One 2013 ; 8 : 1 – 14 . Google Scholar Crossref Search ADS WorldCat 97. Mesquita P , Cheshenko N, Wilson S, Mahtre M, Guzman E, Fakioglu E, Keller MJ, Herold BC. Disruption of tight junctions by cellulose sulfate facilitates HIV infection: Model of microbicide safety . J Infect Dis 2009 ; 200 : 599 – 608 . Google Scholar Crossref Search ADS PubMed WorldCat 98. Doumas S , Kolokotronis A, Stefanopoulos P. Anti-inflammatory and antimicrobial roles of secretory leukocyte protease inhibitor . Infect Immun 2005 ; 73 : 1271 – 1274 . Google Scholar Crossref Search ADS PubMed WorldCat 99. Majchrzak-Gorecka M , Majewski P, Grygier B, Murzyn K, Cichy J. Secretory leukocyte protease inhibitor (SLPI), a multifunctional protein in the host defense response . Cytokine Growth Factor Rev 2016 ; 28 : 79 – 93 . Google Scholar Crossref Search ADS PubMed WorldCat 100. McNeely T , Shugars D, Rosendahl M, Tucker C, Eisenberg SP, Wahl SM. Inhibition of human immunodeficiency virus type 1 infectivity by secretory leukocyte protease inhibitor occurs prior to viral reverse transcription . Blood 1997 ; 90 : 1141 – 1149 . Google Scholar Crossref Search ADS PubMed WorldCat 101. Escaffre O , Juelicha T, Freiberg A. Polyphenylene carboxymethylene (PPCM) in vitro antiviral efficacy against Ebola virus in the context of a sexually transmitted infection . Antivir Res 2019 ; 170 : 10 . Google Scholar Crossref Search ADS WorldCat 102. Chang T , Teleshova N, Rapista A, Paluch M, Anderson RA, Waller DP, Zaneveld LJD, Granelli- Piperno A, Klotman M. SAMMA, a mandelic acid condensation polymer, inhibits dendritic cell-mediated HIV transmission . FEBS J 2007 ; 581 : 4596 – 4602 . Google Scholar Crossref Search ADS WorldCat 103. Scordi-Bello I , Mosoian A, He C, Chen Y, Cheng Y, Jarvis G, Keller MJ, Hogarty K, Waller DP, Profy AT, Herold BC, Klotman M. Candidate sulfonated and sulfated topical microbicides: Comparison of anti-human immunodeficiency virus activities and mechanisms of action . Antimicrob Agents Chemother 2005 ; 49 : 3607 – 3615 . Google Scholar Crossref Search ADS PubMed WorldCat 104. Edwards J , Apicella M. The molecular mechanisms used by Neisseria gonorrhoeae to initiate infection differ between men and women . Clin Microbiol Rev 2004 ; 17 : 965 – 981 . Google Scholar Crossref Search ADS PubMed WorldCat 105. Park P , Reizes O, Bernfield M. Cell surface heparan sulfate proteoglycans: Selective regulators of ligand-receptor encounters . J Biol Chem 2000 ; 275 : 29923 – 29926 . Google Scholar Crossref Search ADS PubMed WorldCat 106. Rosmarin D , Carettec J, Olive AJ, Starnbach MN, Brummelkamp TR, Ploegh HL. Attachment of chlamydia trachomatis L2 to host cells requires sulfation . PNAS 2012 ; 109 : 10059 – 10064 . Google Scholar Crossref Search ADS PubMed WorldCat 107. Shieh M , WuDunn D, Montgomery RI, Esko JD, Spear PG. Cell surface receptors for herpes simplex virus are heparan sulfate proteoglycans . J Cell Biol 1992 ; 116 : 1273 – 1281 . Google Scholar Crossref Search ADS PubMed WorldCat 108. Lopes C , Dietrich C, Nader HB. Specific structural features of syndecans and heparan sulfate chains are needed for cell signaling . Braz J Med Biol Res 2006 ; 39 : 157 – 167 . Google Scholar Crossref Search ADS PubMed WorldCat 109. Wi T , Lahra M, Ndowa F, Bala M, Dillon JR, Ramon- Pardo P, Eremin SR, Bolan G, Unemo M. Antimicrobial resistance in Neisseria gonorrhoeae: Global surveillance and a call for international collaborative action . PloS Med 2017 ; 14 : 11 . Google Scholar Crossref Search ADS WorldCat 110. Anderson RA , Feathergill KA, Chany CJ, Jain S, Krunic A. Nitric oxide–dependent human acrosomal loss induced by PPCM (SAMMA) and by nitric oxide donors occurs by independent pathways: Basis for synthesis of an improved contraceptive Microbicide . J Androl 2009 ; 30 : 168 – 182 . Google Scholar Crossref Search ADS PubMed WorldCat 111. Cheshenko N , Del Rosario B, Woda C, Marcellino D, Satlin L, Herold BC. Herpes simplex virus triggers activation of calcium-signaling pathways . J Cell Biol 2003 ; 163 : 283 – 293 . Google Scholar Crossref Search ADS PubMed WorldCat 112. Joyce C , Zaneveld L. Vaginal contraceptive activity of hyaluronidase and cyclooxygenase (prostaglandin synthetase) inhibitors in the rabbit . Fertil Steril 1985 ; 44 : 426 – 428 . Google Scholar Crossref Search ADS PubMed WorldCat 113. Kaminski J , Nuzzo N, Bauer L, Waller DP, Zaneveld LJ. Vaginalcontraceptive activity of aryl 4-guanidinobenzoates (acrosin inhibitors) in rabbits . Contraception 1985 ; 31 : 183 – 189 . Google Scholar Crossref Search ADS WorldCat 114. Connor EF , Lees I, Maclean D. Polymers as drugs—Advances in therapeutic applications of polymer binding agents . J Polym Sci 2017 ; 55 : 3146 – 3157 . Google Scholar Crossref Search ADS WorldCat 115. Cunha A , Machado R, Palmeira-de-Oliveira A, Martinez-de-Oliveira J, das Neves J, Palmeira-de-Oliveira R. Characterization of commercially available vaginal lubricants: A safety perspective . Pharmaceutics 2014 ; 6 : 530 – 542 . Google Scholar Crossref Search ADS PubMed WorldCat 116. Ayehuniea S , Wang Y, Landry T, Bogojevic S, Cone RA. Hyperosmolal vaginal lubricants markedly reduce epithelial barrier properties in a three-dimensional vaginal epithelium model . Toxicol Rep 2018 ; 5 : 134 – 140 . Google Scholar Crossref Search ADS PubMed WorldCat 117. Keller MJ , Guzman E, Hazrati E, Kasowitz A, Cheshenko N, Wallenstein S, Cole A, Cole AM, Profy AT, Wira CR, Hogarty K, Herold BC. PRO 2000 elicits a decline in genital tract immune mediators without compromising intrinsic antimicrobial activity . Aids 2007 ; 21 : 467 – 476 . Google Scholar Crossref Search ADS PubMed WorldCat 118. Herold B , Mesquita P, Madan RP, Keller MJ. Female genital tract secretions and semen impact the development of microbicides for the prevention of HIV and other sexually transmitted infections . Am J Reprod Immunol 2011 ; 65 : 325 – 333 . Google Scholar Crossref Search ADS PubMed WorldCat 119. Rocker A , Roan N, Yadav JK, Fändrich M, Münch J. Structure, function and antagonism of semen amyloids . Chem Commun 2018 ; 54 : 7557 – 7569 . Google Scholar Crossref Search ADS WorldCat 120. Huszar G , Ozenci CC, Cayli S, Zavaczki Z, Hansch E, Vigue L. Hyaluronic acid binding by human sperm indicates cellular maturity, viability, and unreacted acrosomal status . Fertil Steril 2003 ; 79 : 1616 – 1624 . Google Scholar Crossref Search ADS PubMed WorldCat 121. Huszar G , Ozkavukcu S, Jakab A, Celik-Ozenci C, Sati GL, Cayli S. Hyaluronic acid binding ability of human sperm reflects cellular maturity and fertilizing potential: Selection of sperm for intracytoplasmic sperm injection . Curr Opin Obstet Gynecol 2006 ; 18 : 260 – 267 . Google Scholar Crossref Search ADS PubMed WorldCat 122. Szucsa M , Osvatha P. Hyaluronan bound mature sperm count (HB-MaSC) is a more informative indicator of fertility than conventional sperm parameters: Correlations with body mass index (BMI) . Reprod Biol 2019 ; 19 : 38 – 44 . Google Scholar Crossref Search ADS PubMed WorldCat 123. Tarozzi N . Sperm–hyaluronan-binding assay: Clinical value in conventional IVF under Italian law . Reprod Biomed Online 2009 ; 19 : 35 – 43 . Google Scholar Crossref Search ADS PubMed WorldCat 124. Ye H , Huang G, Gao Y, Liu D. Relationship between human sperm-hyaluronan binding assay and fertilization rate in conventional in vitro fertilization . Hum Reprod 2006 ; 21 : 1545 – 1550 . Google Scholar Crossref Search ADS PubMed WorldCat 125. Breznik B , Kovacic B, Vlaisavljević V. Are sperm DNA fragmentation, hyperactivation, and hyaluronan-binding ability predictive for fertilization and embryo development in in vitro fertilization and intracytoplasmic sperm injection? Fertil Steril 2013 ; 99 : 1233 – 1241 . Google Scholar Crossref Search ADS PubMed WorldCat 126. Fen C , Lee S, Lim MN, Yu SL. Relationship between sperm hyaluronan-binding assay (HBA) scoreson embryo development, fertilisation, and pregnancy rate in patients undergoing intra-cytoplasmic sperm injection (ICSI) . Proc Singapore Healthc 2013 ; 22 : 120 – 124 . Google Scholar Crossref Search ADS WorldCat 127. De Jonge C , Mack SR, Zaneveld LJ. Synchronous assay for human sperm capacitation and the acrosome reaction . J Androl 1989 ; 10 : 232 – 239 . Google Scholar Crossref Search ADS PubMed WorldCat Author notes Grant Support: This work was supported by the National Institutes of Health under grants R42 AI069659 (M.W.), R43/44 AI084225 (M.W.) and R44 HD092206-01 (M.W.). Equal contribution was made by Mary Weitzel and Barbara North. © The Author(s) 2020. Published by Oxford University Press on behalf of Society for the Study of Reproduction. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com © The Author(s) 2020. Published by Oxford University Press on behalf of Society for the Study of Reproduction.
TI - Development of multipurpose technologies products for pregnancy and STI prevention: update on polyphenylene carboxymethylene MPT gel development
JF - Biology of Reproduction
DO - 10.1093/biolre/ioaa087
DA - 2020-08-04
UR - https://www.deepdyve.com/lp/oxford-university-press/development-of-multipurpose-technologies-products-for-pregnancy-and-0DIsRka0Qt
SP - 299
EP - 309
VL - 103
IS - 2
DP - DeepDyve
ER -