Estrogen, Probiotics and Vaginal Health to Prevent HIV Infection in ACB Women

Study Overview
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Brief Summary
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This study will enrol African, Caribbean and Black (ACB) women who are known to have a more diverse vaginal microbiome, higher rates of bacterial vaginosis with lower numbers of protective lactobacilli, and are at increased risk for HIV. The investigators will evaluate the safety, feasibility, effect on the vaginal bacterial microbiome and changes in local immune and inflammatory responses with the administration of vaginal estrogen alone, vaginal estrogen in combination with oral or vaginally administered probiotics, or vaginal probiotics alone.

Detailed Description
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Women are at increased risk of HIV acquisition compared with men. A number of biological factors are associated with increased risk, many of which likely enhance risk by increasing inflammation in the female genital tract. Susceptibility to infections and immune responses in the female genital tract are regulated by hormones: progesterone increases inflammation and HIV susceptibility and estrogen decreases inflammation and enhances colonization with Lactobacilli. A Lactobacillus dominant vaginal microbiome is associated with increased protection against HIV, while a polymicrobial vaginal flora, as seen in bacterial vaginosis, is associated with increased risk. About 40% of ACB women have a polymicrobial flora. The goal of this study is to establish a Lactobacillus dominant vaginal microbiome in ACB women, that will be associated with decreased inflammation and decreased susceptibility to HIV, by administering a low level of intravaginal estrogen to increase colonization with Lactobacilli together with a Lactobacillus-containing probiotic.

Official Title
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Improving Vaginal Health to Decrease Biological Risk of HIV-1 Infection in Canadian African, Caribbean and Black (ACB) Women: Estrogen and Probiotic Treatment for Vaginal Health

Conditions
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HIV-1-infection, Bacterial Vaginoses

Intervention / Treatment
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* Drug: Estring Vaginal Ring
* Other: RepHresh Pro-B


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: African, Caribbean, Black Pre-menopausal women in good general health, as determined by the investigator Uterus and cervix present Negative pregnancy test Currently practicing barrier or non-hormonal forms of contraception, and planning to continue, for the duration of the study (barrier contraceptive, abstinence) Willing to undergo a pelvic exam by a female nurse/female doctor Willing to abstain from vaginal intercourse for 48 hours prior to sampling, over the entire course of the study Able to understand, comply and consent to protocol requirements and instructions Able to attend scheduled study visits and complete required investigations Exclusion Criteria: Currently lactating Pregnant: suspected, current or in the last 12 months Irregular menstrual cycle (less than 6 periods in a year) not related to contraceptive use, pregnancy or breastfeeding Post-menopausal Hormonal Contraceptive use or other hormonal treatment in the past 3 months Current Intra-Uterine Device (IUD) use Positive test result for Gonorrhea and/or Chlamydia Clinically obvious genital ulceration/lesions Symptomatic vaginal yeast infection or clinically significant vaginal discharge HIV-positive Any clinically significant abnormality on screening safety blood tests, that in the opinion of the investigator would preclude enrolment. Diagnosed blood clotting disorder Any genital tract procedure (e.g. biopsy) within the past 6 months Use of oral probiotic supplement, oral antibiotics or oral steroids within the past 30 days Current use of any vaginal products (except tampons) such as spermicides, microbicides, douching or drying products, antifungals, or steroids. Known intolerance of Lactobacillus-containing probiotic supplements Undiagnosed abnormal genital bleeding Known, suspected, or history of breast cancer Known or suspected estrogen-dependent malignant neoplasia (e.g. endometrial cancer) Currently taking immunosuppressive drugs Known or suspected hypersensitivity to any component of the Estring or RepHresh Pro-B products Diagnosis of endometrial hyperplasia Known liver dysfunction or disease; as long as liver function tests have failed to return to normal Active or past history of arterial thromboembolic disease (e.g. stroke, myocardial infarction, coronary heart disease) Partial or complete loss of vision due to ophthalmic vascular disease Porphyria Concomitant medication which in the opinion of the investigator may be associated with a significant drug interaction with the estrogen in Estring. The conditions below are grounds for exclusion based on the opinion of the investigator: Risk factors for estrogen dependent tumours, e.g. first degree heredity for breast cancer Diabetes mellitus with or without vascular involvement Migraine or (severe) headache Epilepsy A history of, or risk factors for, thromboembolic disorders Systemic lupus erythematosus Otosclerosis Cholelithiasis Leiomyoma (uterine fibroids) Endometriosis A history of endometrial hyperplasia Hypertension Asthma Diagnosed anemia

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 49 Years

Sexes Eligible for Study
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Female

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Prevention
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Estring alone<br>Participants will be given a single packet containing one Estring vaginal ring. Participants will begin using the vaginal ring on day 0 and keep it in place until day 30. Estring should not be removed during the one-month study intervention. | Drug: Estring Vaginal Ring<br>* Estradiol vaginal ring, containing 2mg estradiol designed for slow release over 30 days<br>* Other names: 17 beta-estradiol;|
| Active Comparator: Estring and vaginal RepHresh Pro-B<br>Participants will be given a single packet containing one Estring vaginal ring. Participants will begin using the vaginal ring on day 0 and keep it in place until day 30. Estring should not be removed during the one-month study intervention. Participants will also be instructed to insert one RepHresh Pro-B capsule vaginally twice daily, morning and night, until day 30 | Drug: Estring Vaginal Ring<br>* Estradiol vaginal ring, containing 2mg estradiol designed for slow release over 30 days<br>* Other names: 17 beta-estradiol;Other: RepHresh Pro-B<br>* Probiotic supplement containing 2.5 billion CFU of Lactobacilli reuteri RC-14 and Lactobacilli rhamnosus GR-1, administered vaginally or orally<br>|
| Active Comparator: Estring and oral RepHresh Pro-B<br>Participants will be given a single packet containing one Estring vaginal ring. Participants will begin using the vaginal ring on day 0 and keep it in place until day 30. Estring should not be removed during the one-month study intervention. Participants will be instructed to take one RepHresh Pro-B capsule orally twice daily until day 30. | Drug: Estring Vaginal Ring<br>* Estradiol vaginal ring, containing 2mg estradiol designed for slow release over 30 days<br>* Other names: 17 beta-estradiol;Other: RepHresh Pro-B<br>* Probiotic supplement containing 2.5 billion CFU of Lactobacilli reuteri RC-14 and Lactobacilli rhamnosus GR-1, administered vaginally or orally<br>|
| Active Comparator: Vaginal RepHresh Pro-B<br>Participants will be given a 30 days supply of RepHresh Pro-B and instructed to insert one capsule vaginally twice daily until day 30. | Other: RepHresh Pro-B<br>* Probiotic supplement containing 2.5 billion CFU of Lactobacilli reuteri RC-14 and Lactobacilli rhamnosus GR-1, administered vaginally or orally<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Refusal rate | Number of eligible participants approached who do not consent to be enrolled | 12 months | 
| Participant retention rate | Number of participants who complete the study as proportion of total number of participants enrolled | 12 months | 
| Incidence of treatment emergent adverse events | The incidence of adverse events, including serious adverse events, their severity and their relationship to study intervention assessed by reviewing case report forms and participant diaries. | 2 months | 
| Rate of adherence | Adherence will be measured by calculating the total probiotic used/total dispensed and for Estring by total days used/total time period | 30 days | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Changes in proportion of Lactobacillus species in the vaginal microbiota | Aliquots of cervico-vaginal lavage (CVL) fluids will undergo microbiome analysis using a modified Illumina sequencing method for bacterial community profiling of 16S rRNA to measure changes from baseline at follow-up sampling. | 30 days | 
| Change in innate inflammatory cytokine/chemokine levels | Changes from baseline in levels of cytokine/chemokines will be measured in CVL by a 22-plex multiplex assay at 2 and 4 weeks | 30 days | 
| Changes in number of HIV target cells in the genital tract | Changes from baseline in level of HIV susceptible CD4+ T cells will be quantified using a lab developed HIV pseudovirus assay at 2 and 4 weeks. | 30 days |