Salad! Fruit salad! Vegetable salad! You know, the type that come with all the goodness served in one bowl. Or those that you get to choose the combinations that sate your palate’s desire? Sometimes I’m perfectly okay with slicing a succulent cucumber and sprinkling it with some creamy garlic vinaigrette. When I want to outdo myself, I love taking my time to make a good chopped salad, and I will add a variety of nuts and seeds to make it richer. The result is a yummy bowl named Chef Eve’s Saturday Special. My neighbor calls it “The rabbit diet”. Some of my friends would rather have the nuts and leave the “leaves” alone; others think I need prayers for some of my food choices. My mother tells me I need to eat “real” food more often. Well, we all have diverse tastes, and different food preferences. This salad combo works perfectly for me. No burned fingers, and most importantly no scrubbing burnt cooking pots afterwards.

And salad, my dear friends is what exactly I think about when someone mentions Multipurpose Prevention Technologies (MPTs). These are products in development that would simultaneously address multiple sexual and reproductive health needs, including prevention of unintended pregnancy; prevention of sexually transmitted infections (STIs), including HIV, and/or prevention of other reproductive tract infections (RTIs), such as bacterial vaginosis or urinary tract infections. 

Several MPT formulations were presented at the recent HIV Research for Prevention or “R4P” conference in Cape Town (October 27-31, 2014). The ones discussed in Cape Town combine contraceptive and microbicide approaches to prevent pregnancy, HIV—and, in some cases, other STIs like herpes—into one product. How can this not be exciting to anyone? While these products do not exist yet, the idea is a great one: You pop a pill, and voila! You hit the freeway. 

Not really, but it could be liberating to have a prevention tool that allowed you not worry about pregnancy or HIV. 

Daily oral PrEP using tenofovir is already an option women could use—and lots of women talked about it in Cape Town—as a way to take control over HIV prevention and stop worrying about our husband or boyfriend having a “mpango wa kando” (Swahili slang name for multiple sexual partners). 

In the future, an MPT injection might be developed that would let you get a tiny unpainful jab (at least that’s what I hope it will be; no one likes needles!), and for one, or two or three months or more, you need not think about pregnancy, or HIV, or herpes. And then there are those of us who would want to have a baby but then would not want to have an infection. Well, guess what? MPTs could  have our backs covered too.  There is research into MPTs that will prevent HIV and STIs but allow for pregnancy. Just like salad, if you don’t like nuts, we can make you a garden “combo” or we can just slice up the cucumber; there are many options! The choice is yours. Dr. Nelly Mugo, a researcher at KEMRI likes to say “The same thing does not work for the same woman all the time.” I agree, whole heartedly. Some days, I don’t even want to see my best combo salad. Some days I just want a giant mug of the over-priced pumpkin spice latte! If only we had Starbucks in Kenya!

Let’s just pause for a minute, and do the math. No, not advanced calculus, just big numbers and percentages. Statistics show that globally, approximately 35.3 million people are living with HIV. Sub-Saharan Africa remains most severely affected, accounting for 71% of the people living with HIV worldwide. More than half of them are women. Approximately 40% (80 million annually) of all pregnancies are unintended. 80 million! That’s about twice the population of my lovely country Kenya! This is a mind-boggling number. More than three-quarters of these pregnancies occur among women with an unmet need for contraception living in low-resource countries. It is estimated that approximately half of all unintended pregnancies end in illegal abortions likely occurring under unsafe conditions, leading to maternal deaths, and either temporary or permanent disabilities among millions of women. The WHO maps provide an over view of the global SRH burden. In the MPT session this morning, the maps were dubbed as “the warm colored maps” showing large regions of unmet SRH needs, and seems that the brighter the colors the higher the prevalence of HIV/STI or unmet family planning needs or the more deaths they indicate. How sad. Some of those colors are really fancy. I hope they do maintain those lovely colors when MPTs will be out in the market doing what they were developed to do, and then the colors can show the decline in HIV, decline in maternal health, decline in unintended pregnancy. Decline. Decline. Decline.  Am a dreamer. And all dreams are valid. Ask Lupita Nyong’o.

Now, imagine the possibility product that would reserve this numbers! I am looking forward to that day. It is so exciting to know that developers, scientists, social behavioral scientist and market researchers are all burning midnight oil in a collaborative effort to ensure successful development and delivery of MPTs. To suit our diverse SRH needs, MPTs are being developed in diverse formulations. For instance a single sized diaphragm is being evaluated in South Africa as a reusable delivery of a microbicide gel that could reduce the risk of HIV. The diaphragm is already a contraceptive that prevents unwanted pregnancy. It also presents an option for non-hormonal barrier contraception. With an anti-HIV gel, it could be a one-two punch. 

There several other MPTs under development including intravaginal rings that combine contraceptive hormone with ARVs for HIV and HSV2 prevention; and multipurpose injectables. These different formulations provide many options for women and could also allow women to use a product without necessarily negotiating with their sex partners. The need to have HIV prevention options that do not require negotiation with a partner,was emphasized in one of the lunch time session at the Advocate’s Corner. At HIV R4P. One of the participants expressed concerns that all options currently available need some form of negotiation, and if one is not negotiating one is wondering if their partner is “wearing their ARVs”. Such are the issues that make me think MPTs could not have come at a better time. 

Even though MPT are still at the very early stages of development, a lot of progress has been made so far. But even as stakeholders continue with the development process, there are a number of unanswered questions that need to be addressed; do we know if MPTs will be effective? Do we know what women want? Do women know what they want? When these products will be found to work how will they be provided to those who need it? Will the MPTs be easily assessable when available? Will the women afford the products? How do we address issues around provider attitude? Will we be able to manufacture them? These are just a few of the many questions that need answers.  As Prof Elizabeth Bukusi said in Cape Town, the process is like navigating your way on a very muddy road, one is never really sure if they will get to the end, but there is always hope that you will get there, “and if you can’t take the road, take the boat” she said. We need to think about where we have come from so far, where we are at with the epidemics, and find a way to get us to where we are going.

For more information on MPTs, make sure to check out:

• AVAC’s Multipurpose Technologies Page
• HIV R4P Webcast on Multipurpose Prevention Technologies
• Webinar: “What do women want in MPTs?”

Multipurpose Prevention Technologies (MPTs) are a fast-growing area in women’s sexual and reproductive health. On November 12, AVAC and CAMI Health co-hosted a webinar: MPT Acceptability in Uganda, Nigeria and South Africa.

Webinar Materials

• Flash Animation
• PDF Slides
• Additional Q&A

The webinar summarized methods and key findings from the market research study conducted by Ipsos Healthcare, with support from the Bill & Melinda Gates Foundation, to assess the acceptability of multipurpose options among women in Uganda, Nigeria and South Africa.

The webinar discussed:

• What women in Uganda, Nigeria and South Africa shared about sexual behavior, contraceptives and HIV prevention needs—and how this information will be used to shape the MPT agenda.
  What the research found about the acceptability of four potential MPTs (injectables, implants, intra-vaginal film, intra-vaginal ring).
• Jeff Lucas and Moushira El-Sahn from Ipsos Healthcare summarized methods and key findings from the market research data, and Bethany Young-Holt from CAMI Health moderated the discussion.

This call was one of the latest updates in the MPT field. Here are some other resources of note:

• Two weeks ago, the journal BJOG: An international Journal of Obstetrics and Gynaecology published a suite of articles (all open access) on the future of “multipurpose” options that would provide both contraception and protection against HIV and/or other sexually transmitted infections. It is a strong series of updates related to the science and policy of new product development and an excellent overview of the state of play of this critical area of work.
• Ipsos presented an initial stage of this work last April as part of AVAC’s Research & Reality series of webinars, several of which highlighted key issues around women and the HIV prevention agenda. The archived slides and recordings are available online.
• Multiple MPT products are in the pipeline. See AVAC’s infographic, MPT Products in the Pipeline: Selected Highlights, that summarizes which MPTs are further along in testing for both sustained-release and on-demand products.

This week a new issue of the journal BJOG: An international Journal of Obstetrics and Gynaecology published a suite of articles (all open access) on the future of “multipurpose” options that would provide both contraception and protection against HIV and/or other sexually transmitted infections. It is a strong series of updates related to the science and policy of new product development and an excellent overview of the state of play of this critical area of work.

For decades, advocates working on both HIV prevention and sexual and reproductive health have spoken about the need for strategies that multiple issues, multiple needs. This is true for all people—our bodies require many types of care and treatment, and the more places we have to go to get what we need, the more likely it is that something… doesn’t get taken care of. It is particularly true for women, who have urgent needs for HIV prevention and contraception that is safe, effective and discrete. HIV positive women have similar needs—that extend to HIV treatment that works with their contraception.

The contributions include one from Helen Rees, leader of the Wits Reproductive Health and HIV Institute and long-time women’s health advocate Anna Forbes on “Policy implications for multipurpose prevention technologies service delivery“. AVAC Executive Director contributed a piece, “Condoms: the multipurpose prevention technologies that already exist“. The full volume is also available.

A blog post on the issues quotes Heather Boonstra, Director of Public Policy at the Guttmacher Institute, Washington, DC, USA, and lead author of the review paper:

“The evidence strongly indicates that providing women with effective new tools to simultaneously prevent unwanted pregnancy as well as STIs and HIV is essential. However, just developing these methods is not enough. They need to be designed and marketed in a way that meets the needs and respects the rights of women and their partners. Ultimately, MPTs will only be viable options if women actually use them.

“To succeed, MPTs must adequately address concerns that cause many women to reject other modern contraceptive methods, taking into account women’s perceptions of risk for unintended pregnancy, HIV and other STIs. Any successful strategy must also acknowledge that women’s needs change over time, and a suite of MPT options may be needed to provide women with choices.”