Multipurpose Prevention Technologies Interview

NCTCFP: Dr. Haddad, tell us a bit about what led you to the work you do with multipurpose prevention technologies, or MPTs.

DR. HADDAD: I am an OB/Gyn and I trained in Boston, then moved down to Atlanta where I completed a complex family planning fellowship at Emory. During my fellowship, I started doing some global health work in Malawi with the integration of family planning within HIV settings. A lot of the work that I started building upon was at the intersections between reproductive infectious diseases and contraception. So, recognizing overlapping burdens, unmet need, and, on the clinical side, many challenges with providing comprehensive care for these intersecting conditions, I focused primarily on family planning while also doing quite a bit of work in HIV care settings.

A lot of my research grew from that clinical work and also grew in the areas of translational research related to reproductive infectious diseases and contraception. About two and a half years ago, I moved over to Population Council, where I became their medical director, and I started working more on the product development side. This was, and is, exciting because as a researcher, I can recognize the gaps that exist, but I wanted to go beyond just identification into working to find solutions to address them.

NCTCFP: The HIV/sexually transmitted infection (STI) syndemics and the unmet need for effective and accessible contraceptive methods continue to pose significant health risks for people worldwide. Can you give us a brief overview of the public health rationale for the interest in and the evolution of the development of MPTs over the last decade or so?

DR. HADDAD: There are several things, I think, that multi-purpose prevention technologies have an opportunity to address. First is motivation for use and self-perception of risk. STI and HIV prevention and perceived risk may not always align with actual risk, so people may feel stigmatized or feel low self-perception of risk, and not use prevention methods. This actually puts them at risk. Coupling [STI and HIV prevention] with something that they may feel concerned about, like pregnancy, may enhance the use of these prevention technologies. That's the public health benefit of reducing the risks of sexually transmitted infections that have overlapping burdens.

The issues of stigma alone….in some relationships, couples may struggle with communication around the prevention of STIs and HIV. There are issues of trust where concerns about pregnancy may not be as stigmatized, and so, being able to integrate prevention that some people may actually be very concerned about but may not be comfortable integrating into their relationship would then be facilitated.

My hope is by integration, it also opens opportunities for expanding outlets for distribution as well. So, for instance, where contraception is very medicalized, there's a way to enhance wider distribution by making it about broader prevention. Prevention now gets normalized as part of routine counseling, and it's just an added benefit. I like to use the example of when I buy toothpaste - I may be looking for something to prevent cavities, but I will pick up the toothpaste that whitens my teeth, freshens breath, and prevents gingivitis, even if those are not my perceived issues. If I’m just going to do the same thing every day, I may as well get the additional benefits.

That’s where I see the largest public health benefit occurring. We all do it - go for the extras - I buy the milk with additional omega 3 and vitamin D, I mean, even if you're not concerned about it, you want to get that extra benefit. So that's where I see an opportunity to normalize broader prevention. It’s a problem….we make sexual and reproductive health something that you have to whisper about. I hope MPTs offer an opportunity to recognize that these issues affect all persons, so opening that avenue for greater use, acceptability, and access is key.

NCTCFP: What MPT products are already available and what can we expect in the near future? What is the estimated uptake for the products globally and in the US?

DR. HADDAD: So currently - and this goes nicely with Condom Awareness Month - the only available MPTs are condoms. We know condoms have great benefits, but condoms have not fully addressed the problem. I think there are a lot of challenges with common use and questions about how far condoms have come. There are several MPTs in development right now, and at multiple stages in development.

The one that is probably closest to market is the dual prevention pill. The reason this is closest to market is that combines two approved products - oral HIV pre-exposure prophylaxis, or PrEP, and an existing hormonal contraceptive pill. By leveraging these two approved products, the regulatory burden is not as large, so it has a faster route to market.

That's only one of the MPTs under development, and that will address the needs of people who feel comfortable using a pill every day and feel comfortable with hormonal contraception and something to address HIV risk. But it isn't covering all the other sexually transmitted infections. I think you're not going to find one method that's going to address everything. But we need to offer opportunities for enough options to address the issues that are common in different communities and the concerns of different groups of people. Bottom line - why wouldn’t I want to protect myself from additional things if I’m not having to do any additional work?

NCTCFP: We recently talked with people from Evofem about their FDA-approved contraceptive gel, Phexxi®. They say they are collecting data now to submit an STI prevention indication for their product.  Can you comment on this?

DR. HADDAD: Yes, I can. I do believe that through reducing the pH in the vagina, not only can you achieve contraception, there's also likely prevention of other sexually transmitted infections as well, including bacterial STIs and I think this is one opportunity. Now, again I think people want choices. We all want options, and what we've learned from the contraceptive field is, there is no one size that fits all. People are looking for different things, and different people feel comfortable integrating different things into their sexual life. Using a gel before sex and with each sexual act is good, and it is a great option for people who feel comfortable with that, and who maybe don't want a systemic method, or feel that they aren't necessarily needing that spontaneity. That situation - an ‘on-demand’ method - may not address everybody's needs though.

My goal and my hopes are that there would be the same diversity of choice for MPTs as there is for contraceptive methods - a variety to meet the needs of individuals in many different situations.

I do want to highlight that an additional burden for MPTS is showing effectiveness for multiple indications is challenging -  a regulatory burden. It would be nice if there was a streamlined regulatory process that could enhance the ability to get those approvals for more products that have more than one indication.

I [also] want to highlight the funding challenges. Another issue is polarization of funding streams, so HIV funding is separate from family planning funding, and there's very little funding for sexually transmitted infections. That additionally complicates the research and development of MPTs. Unfortunately, it's not a major priority area for large pharmaceutical companies, and so it's often some of the smaller more mission-driven organizations that are driving this work.

NCTCFP: What is the estimated uptake for the products globally and in the US?

DR. HADDAD: What we know from multiple surveys is that people are interested in using a method that not only prevents pregnancy or prevents HIV but permits multiple indications. There are several studies in different settings that all present that hypothetical question of which product you would want to use, and overwhelmingly people indicate they want would want to use MPTs. At this time, though, this is with people responding to questions about hypothetical products. So we don't have the data on the real-world market use. And we know there are multiple reasons that people choose a product. For instance, people don't just look at efficacy as the only driving force for why they would use a method. They look at multiple attributes, including ease of use, privacy, side effects, and other characteristics.

NCTCFP: Where can people find more information and get updates about MPTs? What are some good resources?

DR. HADDAD: I recommend the Initiative for Multipurpose Prevention Technologies, or IMPT (theimpt.org).  They are an unbiased organization committed to advancing products that simultaneously prevent HIV, other STIs, and/or unintended pregnancy. Then there are other organizations interested in MPT research and development, like the Population Council (www.popcouncil.org).

NCTCFP: Thank you so much, Dr. Haddad, for sharing all of this great information about multipurpose prevention technologies with us!