The importance of discreet use of the diaphragm to Zimbabwean women and their partners

Understanding the experiences of married Southern African women in protecting themselves from HIV/AIDS: a systematic review and meta-synthesis

Background: Whilst marriage has been repeatedly identified in the literature as an HIV risk factor amongst Southern African women, not much is known about women's perception of their role, experiences and strategies used to address HIV risks in the context of a marriage. Aims: The aim of the study was to synthesise perceptions, experiences and strategies of married Southern African women in the prevention of HIV. Methods: A systematic review of qualitative studies was conducted. Three electronic databases (Medline, Cinahl and PsycINFO) were systematically searched to identify relevant literature. The meta-synthesis process followed Sandelowski and Barroso's [2007. Handbook for Synthesizing Qualitative Research. Springer Publishing Company] recommendations. Results: Of 7 609 papers, 15 were included in the review. The quality of the included studies was variable. In the final synthesis stage, three broad analytic themes emerged: contextual background, cues to preventive behaviour, and HIV prevention strategies. Implications: Findings were used to develop a conceptual framework for studying HIV/AIDS prevention experiences of married Southern African women.

The Potential of Pre-Exposure Prophylaxis for Women in Violent Relationships

HIV and intimate partner violence (IPV) are significant intersecting threats to women's health. Women in violent relationships have few feasible HIV risk reduction options as traditional prevention methods are largely dependent on a partner's cooperation. The purpose of this review is to explore potential benefits and drawbacks of pre-exposure prophylaxis (PrEP) use among women in the United States experiencing IPV. Advantages of PrEP use in this population include the potential for covert or autonomous use, coital independence, dual protection against sexual and injection risk, and facilitated connections to social services. A number of barriers, however, may interfere with the effective use of PrEP, including partner resistance, cost, frequent medical visits, gendered norms regarding sexuality, and stigma. To realize its potential for women in violent relationships, it will be necessary to incorporate PrEP into behavioral and structural interventions that encourage uptake, facilitate adherence, ensure women's safety, and challenge existing gender norms.

High acceptability of a vaginal ring intended as a microbicide delivery method for HIV prevention in African women

Vaginal rings (VRs) are new methods for continuous delivery of microbicides. This is the first study to quantitatively and qualitatively explore the acceptability of rings in Africa: 157 HIV-negative, sexually active women aged 18-35 used a placebo silicone elastomer ring for 12 weeks. They completed product acceptability questionnaires every 4 weeks. We conducted 6 exit focus group discussions with a subset of 48 women and 19 in-depth interviews with male partners. Retention in the study was high (97 %). Initial insertion at the clinic was successful on first attempt for 81 % of participants. Most women were comfortable using the ring, and very few (≤2 %) could feel it during daily activities or had ring-related physical or emotional problems. In the qualitative interviews many participants reported that they initially had concerns about using the ring. However, only a minority of women actually reported concerns with the ring during the study. The most frequent concern was that the ring would get lost inside the body (20 %), and this was significantly correlated with study site, frequently thinking about the ring and reporting that the ring was not very easy to remove. Qualitative data suggest that informants grew to like the ring because it felt securely placed, was unnoticeable during daily activities, and felt "normal" during sex. The ring appeared to be highly acceptable for women and men. Initial concerns with this novel method suggest a need for enhanced product counseling when VRs are introduced.

Sharing the trousers: gender roles and relationships in an HIV-prevention trial in Zimbabwe

Male and female gender roles and inequalities are important in contributing to the disproportionate burden of HIV experienced by women in sub-Saharan Africa. Within the context of an HIV prevention trial, we aimed to describe and understand male partner influence on women's use of HIV-prevention methods. Our presumption was not that regressive gender norms prevailed - rather, that a wide range of gendered attitudes and dynamics would be expressed among couples. Data from 16 focus groups with Zimbabwean female trial participants and their male partners and 4 in-depth couples interviews were collected, and form the basis of the analysis. Findings offer descriptions of how couples have adapted techniques for negotiating modern household economies and sexual decision-making in a manner that both preserves traditional gender roles, while accommodating women's entrance into new domains such as the workforce or an HIV-prevention trial. Women's agency to introduce novel female-initiated-method use into her intimate relationships is described. Men and women's accounts of method introduction and use suggest different perceptions about the locus of sexual decision making. The study provides unique insight into a gendered context that is dynamic yet sensitive to change, which in turn can provide useful information to more appropriately guide HIV-prevention activities in this setting.

A qualitative study of obstacles to diaphragm and condom use in an HIV prevention trial in sub-Saharan Africa

Consistent condom use and the substitution of condoms with potential HIV prevention methods of lower or unknown effectiveness are important concerns in the development of new prevention technologies. This qualitative study explored obstacles to consistent condom use with the diaphragm in MIRA, an HIV prevention trial in South Africa and Zimbabwe. We conducted 26 focus group discussions (FGDs) with 206 women and 7 FGDs and 10 in-depth interviews with 41 male partners of intervention-arm women. The belief that the diaphragm/gel prevented HIV, women's difficulties negotiating condom use, and men's unawareness that using the products together was recommended were obstacles to consistent condom use with the diaphragm/gel. Concerns about protection from HIV and pregnancy, recognition that the diaphragm was not yet proven to prevent HIV or sexually transmitted infections, and the trial context were facilitators. Understanding selective study product use in HIV prevention trials may inform improved adherence counseling and male involvement strategies.

Moving beyond safe sex to women-controlled safe sex: a concept analysis

AIM

This paper is a report of a conceptual analysis of women-controlled safe sex.

BACKGROUND

Women bear disproportionate burdens from sexually related health compromising outcomes. Imbalanced societal gender and power positions contribute to high morbidities. The expression, women-controlled safe sex, aims to empower women to gain control of their sexual lives. Few researchers focus on contextualized socio-cultural definitions of sexual safety among women.

DATA SOURCES

The sample included scientific literature from Scopus, CINAHL, PubMed, PsychINFO and Sociological Abstracts. Papers were published 2000-2010.

REVIEW METHODS

Critical analyses of literature about women-controlled safe sex were performed in May 2011 using Rodgers' evolutionary concept analysis methods. The search focused on social and cultural influences on sexual practices aimed at increasing women's control over their sexual safety.

RESULTS

The analysis uncovered five attributes of women-controlled safe sex: technology; access to choices; women at-risk; 'condom migration' panic; and communication. Three antecedents included: male partner influence; body awareness; and self-efficacy. Consequences were categorized as positive or negative. Nine surrogate terms included: empowerment; gender power; female-controlled sexual barrier method; microbicides; diaphragm; sexual negotiation and communication; female condom; women-initiated disease transmission prevention; and spermicides. Finally, a consensus definition was identified: a socio-culturally influenced multi-level process for initiating sexual safety by women deemed at-risk for sexually related dangers, usually sexually transmitted infections and/or HIV/AIDS.

CONCLUSION

This concept analysis described current significance, uses, and applications of women-controlled safe sex in the scientific literature. The authors clarified its limited nature and conclude that additional conceptual refinement in nursing is necessary to influence women's health.

The importance of male partner involvement for women's acceptability and adherence to female-initiated HIV prevention methods in Zimbabwe

Enlisting male partner involvement is perceived as an important component of women’s successful uptake of female-initiated HIV prevention methods. We conducted a longitudinal study among a cohort of 955 Zimbabwean women participating in a clinical trial of the effectiveness of a female-initiated HIV prevention method (the diaphragm and lubricant gel) to: (a) describe the extent to which women involved their male partners in the decision to use the study products, and (b) measure the effect perceived male partner support had on their acceptability and consistent use of these methods. Reported levels of male partner involvement in discussions and decisions regarding: joining the study, study activities, the outcome of HIV/STI test results, and product use were very high. In multivariate analyses, regular disclosure of study product use and partner approval for the diaphragm and gel were significantly associated with women’s acceptability and consistent use of the products; an essential component for determining efficacy of investigational prevention methods. These results support the need for more sophisticated measurement of how couples interact to make decisions that impact study participation and investigational product use as well as more rigorous adaptations and evaluations of existing strategies to involve male partners in female-initiated HIV prevention trials.

A lifetime of low-risk behaviors among HIV-positive Latinas in Los Angeles

The objective is to assess the differences in lifetime and current transmission risk behaviors of HIV-positive and HIV-negative Latinas. In 2005-2006, 214 HIV-positive Latinas were recruited from systems of care and 111 HIV-negative Latina-matched controls were interviewed in Los Angeles, CA regarding lifetime and recent sexual and drug-taking risk behaviors. Multivariate OLS regression and logistic regression models were used to assess differences in lifetime and current transmission risk. There was no significant difference between the two groups with respect to lifetime exposure through injection drug use. HIV-positive Latinas reported significantly more lifetime sexual partners than HIV-negative Latinas. Rates of current sexual activity were not significantly different across the two groups. HIV-positive Latinas were less likely to report recent unprotected sex relative to HIV-negative Latinas. In Los Angeles, HIV-positive and HIV-negative Latinas were very similar with respect to transmission risk. The challenges these findings pose to prevention efforts that target Latinas and suggestions for new interventions are discussed.

Adherence to diaphragm use for infection prevention: a prospective study of female sex workers in Kenya

Objective. To assess adherence to and acceptability of the diaphragm among 140 female sex workers in Kenya in a 6-month prospective study. Methods. At baseline and bimonthly visits, participants were interviewed on diaphragm knowledge, attitude, and practices. We used principal component analysis and logistic regression to identify predictors of consistent use. Results. At 50% of 386 bimonthly visits, women reported consistently using a diaphragm with all partners during the preceding 2 weeks. Consistent use was significantly higher at the 6-month than the 2-month visit. Women reported less covert use with “helping” (regular sex partners to whom she could go for help or support) than with “other” partners. Perceptions that diaphragms are easier to use than condoms and that their lack of coital interruption is important were associated with consistent diaphragm use with both partner types. Partner support of diaphragm use is correlated with consistent use with “helping” partners only while higher parity, consistent condom use, and perceived lack of need of condoms as a benefit of diaphragms were associated with consistent use with “other” partners. Conclusions. Diaphragm acceptance among female sex workers in Nairobi was high. Future studies should distinguish between partner types when evaluating diaphragm adherence.

Degrees of disclosure: a study of women's covert use of the diaphragm in an HIV prevention trial in sub-Saharan Africa

In sub-Saharan Africa more women are infected with HIV/AIDS than men and new prevention methods are urgently needed. One major attribute of female-initiated HIV prevention methods is that they can be used covertly, without a male partner's knowledge. Using mixed methods, we explored the predictors and dimensions of covert use of the diaphragm in a randomized controlled trial that tested its effectiveness for HIV prevention. The Methods for Improving Reproductive Health in Africa (MIRA) trial was conducted in Zimbabwe and South Africa, and data collection took place between September 2003 and January 2007. This study is a secondary analysis of quantitative and qualitative data from participants randomized to the intervention group, and their male partners. It includes survey data from 2316 women (mean age=28.3), 14 focus group discussions (FGD) conducted with 104 women, and 7 FGD and 10 in-depth interviews with 37 male partners. The median follow-up for trial participation was 21 months (range: 12-24). At their final visit, approximately 9% of women had never disclosed to their primary partners that they were using the diaphragm (covert use). In multivariate analysis, predictors of covert use included being older, not co-habiting with the partner, having a partner who did not use condoms, and being from South Africa. Qualitative analysis revealed that covert use was not dichotomous, but ranged along a continuum, which we categorized into five levels (i.e. full disclosure; mostly open use; occasional covert use; mostly covert use; and completely covert use). We discuss the critical role of the option of covert use for many women in the context of an HIV prevention trial, as well as gender power dynamics which may influence women's decisions about disclosure.

The use of the diaphragm instead of condoms in a phase III diaphragm trial

The MIRA trial assessed whether providing diaphragm, lubricant gel, and condoms (intervention) compared with condoms alone (control) could reduce HIV incidence among 5,039 Southern African women. Compared with the control group, the cumulative proportion of last sex acts protected by any method was higher in the intervention group (OR = 1.33; 95% CI 1.18, 1.49); however, only 36.3% of last sex acts were protected by both a male condom and a diaphragm, whereas 36.6% were protected by a diaphragm only. Product substitution (ever deciding to use a diaphragm instead of a condom in the previous 3 months) was reported at every visit by 22.4%, at some visits by 60.7%, and at none of the visits by 16.8% of these women. Women at greater risk for infection through their own or their partner's behavior or who believed the diaphragm protected against HIV were more likely to report product substitution at every visit.

HIV prevention: What have we learned from community experiences in concentrated epidemics?

Drawing on lessons learned from community experiences in concentrated epidemics, this paper explores three imperatives in the effort to reduce the sexual transmission of HIV: combat prevention fatigue, diversify HIV testing and combat stigma and discrimination. The paper argues for a non-judgmental harm reduction approach to the prevention of sexual transmission of HIV that takes into account the interpretation of risk by diverse individuals and communities in the era of antiretroviral therapy. This approach requires greater attention to increasing access to opportunities to know one's serostatus, especially among key populations at greater risk. Novel approaches to diversifying HIV testing approaches at community level are needed. Finally, the paper makes a plea for bold measures to combat stigma and discrimination, which continues to represent a formidable barrier for access to services for affected populations and may contribute to HIV-related risk behaviours. A "triple therapy" approach to address stigma and discrimination is discussed, which includes greater acceptance of people living with HIV and AIDS (PLWHA), improving relevant laws and policies, and involving prevention users- working with people rather than for people-.Note: this paper corresponds to the plenary talk of Bruno Spire at the XVIIth World AIDS Conference, August 8th, Mexico city: http://www.kaisernetwork.org/health_cast/player.cfm?id=4383.

Female condom uptake and acceptability in Zimbabwe

As the first phase of a two-phase prospective cohort study to assess the acceptability of the diaphragm as a potential HIV/STI prevention method, we conducted a 2-month prospective study and examined the effect of a male and female condom intervention on female condom (FC) use among 379 sexually active women in Harare, Zimbabwe. Reported use of FC increased from 1.1% at baseline to 70.6% at 2-month follow-up. Predictors of FC uptake immediately following the intervention included interest in using FC, liking FC better than male condoms, and believing one could use them more consistently than male condoms. Women reported 28.8% of sex acts protected by FC in the 2 weeks prior to last study visit. Though FC may not be the preferred method for the majority of women, with access, proper education, and promotion they may be a valuable option for some Zimbabwean women.

Diaphragm and lubricant gel for prevention of HIV acquisition in southern African women: a randomised controlled trial

BACKGROUND

Female-controlled methods of HIV prevention are urgently needed. We assessed the effect of provision of latex diaphragm, lubricant gel, and condoms (intervention), compared with condoms alone (control) on HIV seroincidence in women in South Africa and Zimbabwe.

METHODS

We did an open-label, randomised controlled trial in HIV-negative, sexually active women recruited from clinics and community-based organisations, who were followed up quarterly for 12-24 months (median 21 months). All participants received an HIV prevention package consisting of pre-test and post-test counselling about HIV and sexually transmitted infections, testing, treatment of curable sexually transmitted infections, and intensive risk-reduction counselling. The primary outcome was incident HIV infection. This study is registered with ClinicalTrials.gov, number NCT00121459.

FINDINGS

Overall HIV incidence was 4.0% per 100 woman-years: 4.1% in the intervention group (n=2472) and 3.9% in the control group (n=2476), corresponding to a relative hazard of 1.05 (95% CI 0.84-1.32, intention-to-treat analysis). The proportion of women using condoms was significantly lower in the intervention than in the control group (54%vs 85% of visits, p<0.0001). The proportions of participants who reported adverse events (60% [1523] vs 61% [1529]) and serious adverse events (5% [130] vs 4% [101]) were similar between the two groups.

INTERPRETATION

We observed no added protective benefit against HIV infection when the diaphragm and lubricant gel were provided in addition to condoms and a comprehensive HIV prevention package. Our observation that lower condom use in women provided with diaphragms did not result in increased infection merits further research. Although the intervention seemed safe, our findings do not support addition of the diaphragm to current HIV prevention strategies.