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The urgent need for a vaginal microbicide in the prevention of HIV transmission.

A vaginal microbicide under the control of the woman that directly slows the transmission of human immunodeficiency virus (HIV) and reduces its cofactor in transmission sexually transmitted disease (STD) without damage to the epithelium of the reproductive tract of either partner is a priority in the prevention and control of acquired immunodeficiency syndrome (AIDS). Weir and colleagues have reported on a reduction in cervical gonorrhea among Cameroon sex workers who use nonoxynol-9. Feldblum and Weir have described a protective effect of nonoxynol-9 against HIV. A US study found that women who used spermicides or a diaphragm had a lower STD reinfection rate than those whose partners used a condom; this suggests compliance may be more important than effectiveness in slowing transmission. Although Rosenberg and colleagues demonstrated in a 1987 study of Thai sex workers that nonoxynol-9 in a vaginal sponge slowed the transmission of gonorrhea and chlamydia the results of a similar Kenyan study indicated an increased risk of genital ulcers and HIV transmission with its use. Ten times as much nonoxynol-9 was used in the Kenyan study as was used in the Cameroon study. Frequent repeated high doses of the spermicide is associated with the damage seen in the Kenyan study. In the Cameroon study 303 sex workers were counseled to use suppositories containing 100 mg of nonoxynol-9 and to ask their partners to use condoms during every sex act. Results were self-reported (both condoms spermicide or none). Few cases of gonorrhea occurred in the group that used both methods consistently. Gramicidin is 1000 times as effective as nonoxynol-9 against HIV in experiments in vitro. Others include chlorhexidine benzylkonium chloride gossypol and dextran sulfate; these have regulatory approval for use in humans. It is time that more research is undertaken in this area or that policy is made based on what is already known about the efficacy and safety of a drug when it is not given in toxic doses.