Over the past four decades, the world has made substantial
gains in the effort to prevent unplanned pregnancies and reduce the risk of
sexually transmitted infections (STIs), including HIV, and other reproductive
tract infections (RTIs). Yet, STIs and RTIs still cause a heavy health burden,
especially in developing countries, and there is an equally urgent unmet need
To date, prevention
strategies have focused largely on single indications, namely, the prevention
of unplanned pregnancy, prevention of STIs or prevention of RTIs. This approach
does not adequately recognize the intrinsic link between unplanned pregnancy
and STIs: a woman at risk of an unplanned pregnancy is often simultaneously at
risk for an STI, including HIV, or other RTI. Thus, there is a critical need
for multipurpose prevention technologies that will allow people to avoid more
than one adverse health outcome.
technologies were the focus of Advancing Prevention Technologies for Sexual and
Reproductive Health, an international symposium held in Berkeley, CA, in March
2009. For 2 days, more than 150 participants from developing and industrialized
countries discussed and debated the opportunities and challenges for advancing
technologies that address multiple sexual and reproductive health (SRH) needs.
The symposium proceedings draw from those presentations and the subsequent
discussions.2 This editorial seeks to convey the key points of these
discussions and engage health care professionals in the effort to fulfill the
potential that these technologies might offer.
universal health need
Unplanned pregnancy and STIs
typically affect the most disadvantaged groups — especially young women,
adolescents and the poor — the hardest. But women from all socioeconomic groups
face challenges to their SRH.7,8,9,10,11
- More than 120 million couples have an unmet need for
- An estimated 80 million women experience an unplanned
pregnancy (45 million of which end in abortion).
- More than half a million women die from complications
associated with pregnancy, childbirth and the postpartum period.
- Roughly 340 million people acquire new gonorrhea,
syphilis, chlamydia or trichomonas infections.
In addition, untold numbers
of individuals acquire chronic infections with the herpes simplex virus (HSV)
and human papillomavirus (HPV), which is the primary cause of cervical cancer.12
Millions of women are
vulnerable to several of these adverse outcomes, yet many women are only able
to access or afford prevention for a single intervention, such as contraception
or treatment for an STI. At the same time, many providers struggle to ensure
that their clients have access to all prevention methods that meet their
It is time to address SRH
prevention in a more holistic way and to develop prevention tools that address
multiple health risks; are acceptable, affordable, accessible and easy to use;
and can meet individuals’ varying health needs and reproductive intentions.
Such interventions could have a dramatic effect on the health and well-being of
millions of women and their families.
technologies for SRH could include vaccines, microbicides and devices [such as
intravaginal rings (IVRs), diaphragms and condoms] that provide protection from
unplanned pregnancy; STIs including HIV; and/or other common RTIs. As the
report from the Berkeley symposium explains, “Providing people with suitable
protection is a continuing challenge, especially in settings where access to
health services is limited, and the availability of technologies that address
more than one indication would be a significant improvement in terms of
efficiency and convenience. The provider would be able to stock, supply, and
advise on a more compact range of products, and the user would need to
purchase, understand, store, and use fewer products. A further advantage is
that users would be protected automatically against more than one indication
even if they had obtained the product with regard to a single perceived risk”.2
While such technologies will benefit both men and women, women will gain the
most, as they are more vulnerable to these risks for both physiological and
Some multipurpose prevention
technologies already exist, but they are woefully underutilized. Male and
female condoms, for instance, prevent both unplanned pregnancy and STIs. Male
condoms are not always used consistently. While the launch of the UNFPA Global
Female Condom Initiative in 2005 has significantly increased access to female
condoms, this woman-controlled prevention method has nonetheless been slow to
achieve widespread distribution or user acceptance and more must be done to
increase its demand and access.13
Extensive experience with
existing prevention methods — condoms, diaphragms, IVRs, hormonal methods and
vaccines — and recent advances in the development of microbicides and oral
pre-exposure prophylaxis with antiretroviral drugs have laid a solid foundation
for the development of new prevention technologies for multiple SRH risks.
Several of these technologies, such as more user-friendly female condoms and
diaphragms, are in the late stages of clinical testing. The PATH Women’s
Condom, for example, has gone through several clinical studies and is entering
a regulatory study for its approval in China and the US. A new generation of
microbicides, including products based on antiretroviral drugs, continues to
hold promise despite the failure of some of the earlier products to protect,
including the polyanion PRO 2000 (http://www.mdp.mrc.ac.uk).
Momentum is building. The
National Institutes of Health, US Agency for International Development, the
Ministry of Health of China and other donors are currently supporting efforts
to advance multipurpose prevention strategies, including preclinical research,
effectiveness trials and pre- and postintroduction studies on a range of
potential multipurpose prevention products, both coitally dependent and long
Collaborations between different organizations and research
disciplines, such as behavioral scientists, immunologists, engineers,
epidemiologists, drug developers, clinicians, and advocates, are evolving and
helping to advance some exciting novel SRH prevention approaches.14, 15,
Research efforts include semisolid gels, gel capsules, films,
IVRs, sponges, compound-releasing intrauterine systems, diaphragms, and male
and female condoms with and without spermicidal or anti-infective agents.
Listed here are some of the various entities which are currently pursuing this
work: CONRAD, Family Health International, International Partnership for
Microbicides, Ministry of Health of China, PATH, the Population Council, Queens
University of Belfast, University of Witwatersrand, University of Alabama,
University of California Berkeley, University of California San Francisco,
University of Utah, biotech companies (e.g., ReProtect, Mapp Biopharmaceutical,
Inc., and Osel, Inc.) and others. The CONRAD program, for example, has
dedicated a major portion of its portfolio to combined approaches.2
The Population Council, PATH, International Partnership for Microbicides,
University of Utah and CONRAD are working on multipurpose IVRs and diaphragms
which would be impregnated with contraceptives and anti-STI microbicides.2,18
Other technologies in development include probiotics that prevent bacterial and
urinary infections and could be modified to serve as drug-delivery systems.19,20
Multipurpose vaccines are also in development and the discovery of
potentially suitable antigens for several STI pathogens is progressing,
including chlamydia, HIV, HSV, gonorrhea and trichomonas.
For each of the
technologies, the challenge will be to ensure that their production and
deployment can be sufficiently cost-effective for widespread use in developing
countries with minimal health care infrastructure. The Berkeley symposium gave
voice to many promising ideas and a shared belief that multipurpose
technologies can and should be developed. It is, of course, recognized that
these technologies will not by themselves achieve all the desired goals and
that they will need to be introduced with care, and their deployment preceded
and accompanied by well-designed educational programs.
The effort to develop
multipurpose prevention technologies and bring them to populations in need will
encounter many complex challenges. The work will require technical innovation,
scientific persistence, significant human and technical resources, and,
crucially, political will. Given the rapid evolution of relevant technologies
and an increasingly focused effort, these challenges can be overcome. With
sufficient funding, new tools such as these could become the building blocks
for cost-effective prevention efforts. When combined with more effective
programming of existing prevention technologies, women and communities will
benefit from improved health.
will be required to bring multipurpose prevention technologies within reach.
Researchers, funders, product developers, engineers, microbiologists,
behavioral scientists, advocates and others must work together to maximize
their technical expertise, community involvement and political will. In
addition, these stakeholders must promote cross-disciplinary communication and
collaboration, ensuring that parallel development tracks interact at strategic
Health professionals can
contribute their expertise and voice toward this effort in multiple ways. For
example, they can:
- Educate clients about the intrinsic link between STIs
and unplanned pregnancies and the need for simultaneous prevention.
- Clinicians can educate
their clients about the need to prevent STIs and unplanned pregnancy and
encourage clients to use existing combined methods to increase their
levels of protection, such as male or female condoms for STI/HIV
prevention combined with hormonal methods and IUDs, since these are the
most effective contraceptive options now available.
- Seek opportunities to facilitate cross-disciplinary
- Researchers can explore
opportunities to collaborate with researchers in different fields that
can complement their work. They can also participate in conferences and
learn about relevant work outside their particular research area.
- Clinicians can find
ways to help researchers recruit participants into clinical trials of new
prevention products and participate in product acceptability research.
Data on these topics are needed in diverse geographic regions in the US
and internationally as well as in communities with diverse social and
- Advocate for increased support for multipurpose
- All health care
professionals can educate donors and funders about the need for intensive,
multidisciplinary research aimed at providing affordable and acceptable
multipurpose prevention technologies.
- Professionals can also
educate legislators and policymakers about the importance of multipurpose
- They can inform other
stakeholders — professional societies, organizations and coalitions;
reproductive health and HIV organizations; and health advocacy groups —
about the need for greater investment in multipurpose prevention
technologies for SRH
- All supporters can
spread the word within their professional networks by presenting on this
topic and submitting articles to these networks’ newsletters and related
This is a pivotal time for
reproductive health professionals. We have the opportunity to identify and
prioritize opportunities to achieve a significant health impact in
industrialized as well as in developing countries by accelerating the
development of multipurpose prevention technologies. Together, we can address
this need and improve the health and well-being of women and their families
around the world.
- Guttmacher Institute and United Nations Population Fund
(UNFPA). Adding It Up: The Benefits of Investing in Sexual and Reproductive
Health Care. New York: AGI. Available at: http://www.guttmacher.org/pubs/addingitup.pdf.
- Stone A. Symposium Report: Advancing Prevention
Technologies for Sexual and Reproductive Health. Available at: http://www.cami-health.com/APT2009/PDFs/report-aug09.pdf.
- Cates W, Steiner MJ. Dual protection against unplanned
pregnancy and sexually transmitted infections: what is the best
contraceptive approach?. Sex Transm Dis. 2002;29:168–174.
- International Planned Parenthood Federation, University
of California San Francisco, Joint United Nations Program on HIV/AIDS,
UNFPA, World Health Organization. Sexual & reproductive health and
HIV. Linkages: evidence review and recommendations. Available online at: http://data.unaids.org/pub/Agenda/2009/2009_linkages_evidence_review_en.pdf.
- Wilcher R, Petruney T, Reynolds HW, Cates W. From
effectiveness to impact: contraception as an HIV prevention intervention. Sex
Transm Infect. 2008;84(Suppl 2):ii54–ii60.
- Feldblum PJ, Nasution MD, Hoke TH, et al. Pregnancy
among sex workers participating in a condom intervention trial highlights
the need for dural protection. Contraception. 2007;76:105–110.
- Allsworth JE, Lewis VA, Peipert JF. Viral sexually
transmitted infections and bacterial vaginosis: 2001–2004 National Health
and Nutrition Examination Survey data. Sex Transm Dis.
- Frost JJ, Singh S, Finer LB. US women’s one-year
contraceptive use patterns, 2004. Perspect Sex Reprod Health.
- Glasier A, Gulmezoglu AM, Schmid GP, Moreno CG, Van
Look PFA. Sexual and reproductive health: a matter of life and death. Lancet.
- CDC. HIV/AIDS Surveillance Report 2003; (Vol. 15).
Atlanta: US Department of Health and Human Services, CDC; 2005.
- The World Bank and International Monetary Fund. Global
Monitoring Report 2009: A Development Emergency. 2009; Washington DC.
- Bosch FX, de Sanjosé S. The epidemiology of human
papillomavirus infection and cervical cancer. Dis Markers.
- UNFPA. Empowering women to protect themselves:
promoting the female condom in Zimbabwe. Available at: http://www.unfpa.org/public/cache/offonce/News/pid/3913;jsessionid=4FBD9DA8AD4EFB9F069224AC0EEB0670.
- Verguet S, Young Holt B, Szeri A. Reframing behavioral
acceptability of microbicide gel vehicles in conjunction with biophysical
constraints. Presented at the 2009 Advancing Prevention Technologies for
Sexual and Reproductive Health Symposium, Berkeley California. Available
- Morrow K, Fava J, Rosen R, Kiser P, Katz D. Linking
biophysical functions to user perceptions and acceptability in preclinical
product development. Presented at the 2009 Advancing Prevention
Technologies for Sexual and Reproductive Health Symposium, Berkeley
California. Available at: http://www.cami-health.com/APT2009/posters.html.
- Arntzen C, Herbst-Kralovetz M, Mason H, Tacket C,
Khanna N, Zeitlin L, Whaley K The vaccine and microbicide alliance.
Presented at the 2009 Advancing Prevention Technologies for Sexual and
Reproductive Health Symposium, Berkeley California. Available at: http://www.cami-health.com/APT2009/posters.html.
- Alliance for Microbicide Development. HIV/STI
Prevention Research and Development: October 2009 Pipeline Update of
Microbicide and PrEP Candidates. Silver Spring, MD. Available at: http://www.microbicide.org/uploads/3/1/2/1/3121935/microbicide_pipeline_update_1_oct_2009.pdf.
- Nath A, Sitruk-Ware R. Novel non-oral hormonal
contraceptive methods for women. Exp Rev Obstet Gynecol.
- Bolton M, van der Straten A, Cohen CR. Probiotics:
potential to prevent HIV and sexually transmitted infections in women. Sex
Transm Dis. 2008;35:214–225.
- Liu X, Lagenaur LA, Simpson DA, et al. Engineered
vaginal lactobacillus strain for mucosal delivery of the human
immunodeficiency virus inhibitor cyanovirin-N. Antimicrob Agents