“People around the world have mysterious notions about the vagina,” Sharon Hillier told a group of journalists and advocates today. Hillier, one of five co-chairs of HIV R4P, the first global conference devoted to biomedical HIV prevention research, is here to explain her work, which she sums up as making vaginas much more resistant to HIV.
First she has to clear up those mysterious notions. People think vaginas are dirty, she noted; they are not, she added, they are cleaner than your mouth.
“It is an ecosystem,” she said, “a beautiful one.” So one challenge is keeping it that way, or as she puts it, “make it better and don’t screw it up.”
To that end she describes herself as a “vaginal ecologist.” She has been immersed over the last couple of decades in the search for a vaginal microbicide, or as she prefers to put it, “a product designed to prevent or reduce the sexual transmission of HIV and other sexually transmitted diseases when inserted in the beautiful ecosystem.”
She is also interested in the eventual development of what are now called, with increasing frequency, as they seem increasingly feasible, “multi-purpose technologies,” products that can protect against HIV, other STIs and unintended pregnancy — a product, she says, she would want for her own daughter, although she is not a fan of the term (“Who wants to put a multi-purpose technology in your woo-woo?” she asks rhetorically).
But first she goes back to the days when it was hoped that the spermicide nonoxynol-9 could protect against HIV before it was discovered that the detergent in it “degraded the beautiful clear mucosa.” The research road of clinical trials in the search for a suitable microbicide since has been circuitous, leading to both disappointing dead ends (the Pro 2000 vaginal gel, for example, which showed promising results in a small trial that didn’t hold up in a larger one), a view of a destination, with the CAPRISA trial which showed an antiretroviral-based microbicide offered some protection against HIV, and obstacles — the VOICE (for Vaginal and Oral Interventions to Control the Epidemic) — which showed that an effective product is useless if it does not meet the needs of the women it is intended for, and which, Hillier says, “changed the way we do business.”
But the quest continues, she said, because developing microbicides — in different forms, to be used on different schedules, and for vaginal and rectal use — is important to controlling the epidemic. Receptive sex partners are highly vulnerable to HIV, she noted — vaginal transmission twice as likely as transmission through penile membranes, and transmission through anal membranes 20 times likelier than through vaginal tissues. Worldwide, data indicates that 92 percent of couples don’t use condoms.
Now, confirmatory research of the CAPRISA results is continuing, the ASPIRE trial of an antiretroviral loaded vaginal ring was launched in 2012 and is expected to produce results in late 2015 or early 2016, the Ring Study of another antiretroviral vaginal ring is expected to yield results by late 2016, and early stage trials have begun on a potential rectal microbicide product.
Pressed, Hillier was willing to say a vaginal microbicide could have approval by 2019.
The search won’t be over, though, said Hillier, who is looking forward to the development of a film that can dissolve in the vagina and disburse an effective microbicide, as well as to multi-purpose technologies — whatever their name might be. She knows more obstacles lie ahead, and tells how men have objected to the ring, saying they could feel it, when evidence suggests that is impossible. (“It’s just an interesting thing about who owns the vagina,” she noted.)
“If you can maximize choices, you can optimize effectiveness,” Hillier said. “We don’t want to develop another thing that’s like the condom — that works but nobody wants it.”
Stay tuned for updates through the week on microbicide research and more.