Rwanda Vaginal Microbiota Restoration Study

Study Overview
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Brief Summary
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A pilot randomized controlled clinical trial of intermittent use of two different vaginal lactobacilli-containing probiotics, and oral metronidazole, to prevent bacterial vaginosis recurrence.

Detailed Description
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This is a pilot study to prepare for larger clinical trials. Sixty-eight HIV-negative, non-pregnant, sexually active women aged 18-45 with bacterial vaginosis (BV, by modified Amsel criteria and/or Nugent score) and/or Trichomonas vaginalis (TV, on wet mount or by culture) will be treated using oral metronidazole for 7 days. After successful treatment, and when they are free of vaginal candidiasis, other curable sexually transmitted infections (STIs) and urinary tract infection (UTI)), they will be randomised to 4 different vaginal microbiome (VMB) maintenance interventions (17 per group) within 3 days of completing oral metronidazole treatment: 1) Behavioral 'vaginal practices cessation and safer sex' counselling only (control); 2) Behavioral counselling plus 500mg metronidazole pills twice per week for two months; 3) Behavioral counselling plus Ecologic Femi vaginal capsule, once per day for 5 days immediately after oral metronidazole treatment followed by thrice weekly, for two months; 4) Group 4: Behavioral counselling plus Gynophilus vaginal tablet, once every 4 days for two months. Vaginal probiotic use may be ceased temporarily during menstruation. Participants will be asked to adhere to the interventions for 2 months, and VMB assessments will take place before (screening and enrolment visits), during (Day 7, Month 1 and Month 2 visits), and after the interventions (Month 6 visit).

Official Title
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Preparing for a Clinical Trial of Interventions to Maintain Normal Vaginal Microbiota for Preventing Adverse Reproductive Health Outcomes in Africa

Conditions
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Bacterial Vaginosis

Intervention / Treatment
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* Biological: Vaginal multiple lactobacilli-containing probiotic for prevention of BV recurrence
* Drug: Prophylactic use of metronidazole pills (500 mg)
* Biological: Vaginal Lcr35-containing probiotic for prevention of BV recurrence


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Sexually active, defined as having had sex at least twice in the two weeks prior to screening At high risk of HIV/STIs/BV, defined as having had more than one sexual partner in the last 12 months OR having been treated for an STI and/or BV in the last 12 months Successfully treated for BV (modified Amsel criteria) or TV (wet mount), and free of STIs, symptomatic vaginal candidiasis and UTI at enrollment Currently in good physical and mental health as judged by a study physician Willing and able to adhere to study procedures and provide written informed consent. Exclusion Criteria: Pregnant HIV positive Clinician-observed genital ulcers, condylomata, or other genital abnormalities at screening or enrollment Underwent a gynaecological surgery/invasive procedure in the 3 months prior to screening History of significant urogenital prolapse, undiagnosed vaginal bleeding, urine or faecal incontinence, or blood clotting disorders Allergic to metronidazole or any other components of the study drugs Not willing to stop use of other oral or vaginal probiotics from the screening visit until the end of study participation Participating in another health intervention study For any other reason potentially interfering with participant safety or protocol adherence as judged by the Principal Investigator

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 45 Years

Sexes Eligible for Study
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Female

Accepts Healthy Volunteers
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No

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: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| No Intervention: Group 1<br>Negative control group: After initial treatment for BV/TV, no intervention. | |
| Other: Group 2<br>Positive control group: After initial treatment for BV/TV, metronidazole pills (500 mg) twice per week for 2 months. | Drug: Prophylactic use of metronidazole pills (500 mg)<br>* Prophylactic use of metronidazole pills to prevent BV recurrence after metronidazole treatment for BV or TV<br>* Other names: Tricozole;|
| Active Comparator: Group 3<br>After initial treatment for BV/TV, Ecologic Femi+ vaginal capsule (a vaginal probiotic) once per day for 5 days immediately after the initial treatment followed by thrice weekly for two months. | Biological: Vaginal multiple lactobacilli-containing probiotic for prevention of BV recurrence<br>* Vaginal probiotic to restore the vaginal microbiome and prevent BV recurrence after metronidazole treatment for BV or TV<br>* Other names: Ecologic Femi+ vaginal capsule;|
| Active Comparator: Group 4<br>After initial treatment for BV/TV, Gynophilus LP vaginal tablet (a vaginal probiotic) once every 4 days for two months. | Biological: Vaginal Lcr35-containing probiotic for prevention of BV recurrence<br>* Vaginal probiotic to restore the vaginal microbiome and prevent BV recurrence after metronidazole treatment for BV or TV<br>* Other names: Gynophilus LP vaginal tablet;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Bacterial Vaginosis (BV) Incidence by Modified Amsel Criteria | Modified Amsel criteria positive is at least 2 of 3 of the following positive: clue cells, vaginal pH, whiff test. Modified intent-to-treat (ITT) analyses (women with Nugent 7-10 at enrollment excluded), using person-years (PY) at risk as denominator of each incidence rate. | 2 months (intervention period) | 
| Bacterial Vaginosis (BV) Incidence by Nugent Scoring (Nugent 7-10) | The Nugent score is a scale from 0-10 based on visualisation of three different bacterial morphotypes on a Gram stained slide, but in the incidence rates, the variable was used as a binary variable: BV present (Nugent score 7-10) or absent (Nugent score 0-6). Modified intent-to-treat (ITT) analyses (women with Nugent 7-10 at enrollment excluded), using person-years (PY) at risk as the denominator for each incidence rate. | 2 months (intervention period) | 
| Trichomonas Vaginalis (TV) Incidence by Culture | A swab was inoculated into an InPouch culture pouch, specifically designed for TV growth. The pouch was checked daily for five days to detect growth. The results was positive when growth detected and negative when no growth detected on the fifth day. Intent-to-treat (ITT) analyses, using person-years (PY) at risk as the denominator for each incidence rate. | 2 months (intervention period) | 
| Vaginal Candidiasis Incidence by Wet Mount Microscopy | A wet mount is a smear of vaginal fluid on a microscopy slide, which is examined under a microscope. Yeasts are visible without staining. The definition of vaginal candidiasis was any yeast visible on the wet mount. Symptomatic vaginal candidiasis was considered a safety outcome because treatment of bacterial vaginosis often results in vaginal candidiasis. Intent-to-treat (ITT) analysis with person-years (PY) at risk as the denominator of all incidence rates. | 6 months: 2 months intervention period plus 4 months after intervention cessation | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Vaginal Microbiota Composition by Illumina HiSeq Sequencing: Lactobacillus Genus Concentration | The vaginal microbiota sequencing results are exploratory and full data can be found in a manuscript on the BioRxiv preprint server. The most important outcome is the concentration of Lactobacillus genus in vaginal samples taken at the end of the intervention period (M2 visit). | 2 months (intervention period) |