28 June 2002 keralamonitor.com

Nonoxynol-9 ineffective in preventing HIV infection

Spermicides containing nonoxynol-9 do not protect against HIV infection
and may even increase the risk of HIV infection in women using these
products frequently, according to a WHO report released today. The report
also advises women at high risk of HIV infection against using nonoxynol-9
spermicides for contraception.

The report contains the recommendations of a meeting of experts convened
by the World Health Organization (WHO) Department of Reproductive Health
and Research (RHR) and the CONRAD Program* based in the Eastern Virginia
Medical School. The experts also concluded that spermicides containing
nonoxynol-9 do not protect against two other common sexually transmitted
infections - cervical gonorrhoea and chlamydia.

Nonoxynol-9 is present in most spermicides on the market today. It has
been used over the past half-century in a wide range of spermicidal
products-vaginal gels, creams, foams, suppositories, sponges, and films,
used alone or with other contraceptive devices, such the diaphragm. While
it had been hoped that these products might reduce the risk of sexually
transmitted infections, including HIV infection, they have primarily been
used as methods of contraception. Estimated numbers of women of
reproductive age using spermicides vary from country to country, from less
than 1% in Asia to nearly 17% in some Latin American countries.

"Nonoxynol-9 clearly does not prevent HIV infection and may even favour
infection if used frequently. There is an urgent need to develop a
microbicide which can substantially reduce the transmission of sexually
transmitted infections, including HIV, and which can be used by women,"
says Dr Tomris Türmen, Executive Director of Family and Community Health
(FCH) at WHO.

In the 1970s and 1980s, laboratory tests showed that nonoxynol-9 could
inactivate the organisms that cause gonorrhoea, chlamydial infections, and
other sexually transmitted infections, as well as HIV. These findings
fuelled hopes that it could be used not only for contraceptive but also
for microbicidal purposes. Clinical trials conducted to date do not
support these hopes.

On the contrary, two studies mentioned in the report point to an increased
risk of sexually transmitted infections, including HIV infection, in women
using nonoxynol-9 products. A possible reason, suggested by the findings
of other studies, is that nonoxynol-9 can disrupt the epithelium, or wall,
of the vagina, thereby potentially facilitating invasion by an infective
organism.

The frequency of this epithelial disruption seems to depend on the
intensity of use of the product-from 18% of women using the product every
other day to 53% using it four times a day, in one study. "Women who have
multiple daily acts of intercourse should be advised to choose another
method of contraception," the experts concluded. However, they added, for
women who do not use spermicides frequently and who are not at a high risk
of HIV infection, spermicides that contain low doses of nonoxynol-9 are
"probably safe".

Dr Henry Gabelnick, Director of CONRAD, emphasied that, "The failure of
nonoxynol-9 to provide protection against HIV and other sexually
transmitted infections (STIs) should not lead to the conclusion that
microbicides are not possible but should instead accelerate research to
find safe and effective products."

Scientists are working on some 60 promising compounds, of which 11 have
reached the clinical testing stage, but lack of funds is slowing progress.
Although the potential market is large-an estimated 340 million cases of
curable reproductive tract infections occur each year-most cases are in
resource-poor developing countries.

Regarding the use of spermicides for contraception, the report concluded
that, when used alone, nonoxynol-9 is only moderately effective for
pregnancy prevention but better than no contraceptive method at all.
"Although far less effective than the pill or intrauterine devices or
injectable or implantable contraceptives, nonoxynol-9 spermicides offer
some advantages," according to Dr Tim Farley, of the Department of
Reproductive Health and Research in FCH "They are readily accessible as
over-the-counter products, available just about everywhere in the world
and they are under the woman's control."

Nonoxynol-9 is sometimes added to male condoms as a lubricant. The
experts found no evidence that nonoxynol-9-lubricated condoms provided any
more protection against pregnancy or sexually transmitted infections than
condoms lubricated with silicone, used as a lubricant for the majority of
condoms available in developing countries. Since nonoxynol-9 may cause
some adverse effects, the experts recommended that such condoms should no
longer be promoted, but noted that "it is better to use a
nonoxynol-9-lubricated condom than no condom."

Nonoxynol-9 is also present in many lubricants used by people engaging in
anal intercourse. Some users may be under the impression that it can also
protect against HIV infection. The evidence reviewed by the experts is
particularly disturbing in this regard. Studies in mice and in human
subjects "revealed significant sloughing of sheets of [rectal]
epithelium", the report says, suggesting that an "increased risk of
infection soon after the application of products containing nonoxynol-9
seems quite likely".

While spermicides containing nonoxynol-9 remain a contraceptive option for
women at low risk of HIV Infection, they are substantially less effective
in preventing pregnancy than most other methods. Women at risk of HIV
infection who want contraception should be informed that consistent and
correct condom use is highly effective for pregnancy prevention and
prevention of sexually transmitted infections, including HIV Infection.

* The CONRAD Program is a non-governmental organization administered
through the Eastern Virginia Medical School in the United States. Its
mission is the development of new technology for fertility regulation and
prevention of sexually transmitted infections that is appropriate for
developing countries.