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Milford C, Ramlal H, Mofokeng R, Rambally Greener L, Nel A, Smit J, Malherbe M. Self-reported removal and expulsion of the dapivirine vaginal ring: qualitative reports from female ring users and their male partners in the Ring Study (IPM 027). BMC Public Health 2024; 24:1458. [PMID: 38822304 PMCID: PMC11140940 DOI: 10.1186/s12889-024-18795-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 05/08/2024] [Indexed: 06/02/2024] Open
Abstract
BACKGROUND/AIMS The dapivirine vaginal ring is a self-administered, women-initiated, discreet, long-acting HIV-1 prevention option for women. It was found to be safe and effective in healthy HIV-negative women who adhered to product use instructions, and has been approved for use in women aged 18 and older in some African countries. A qualitative study was conducted to explore participants' and their male partners' discussions on accidental/purposeful vaginal ring removals during The Ring Study (IPM 027 clinical trial). METHODS Data were collected via in-depth interviews and focus group discussions with female trial participants and their male partners, from seven research centres in South Africa and Uganda. Data were thematically analysed using NVivo. RESULTS More participants reported purposeful ring removals than accidental expulsions. Various factors influenced purposeful ring removal - including individual (discomfort during use/sex and to clean it), partner (to show them, because of discomfort during sex, to test if partners could feel it, and concerns of harm), organisational (doctor's request), and socio-cultural (rumours about sickness and infertility). Some described their own ring use removal, others discussed why other participants removed their rings. CONCLUSIONS Vaginal ring adherence is critical to improve and support product efficacy. Counselling on vaginal anatomy, vaginal ring insertion and importance of adherence is important to minimise vaginal ring removal. Couples counselling is also important to facilitate support and long-term vaginal ring adherence behaviour. Understanding factors influencing vaginal ring adherence is important for tailoring and targeting messages to support correct and consistent vaginal ring use as it is made available to the public.
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Affiliation(s)
- Cecilia Milford
- Wits MRU (MatCH Research Unit), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Commercial City Building, 40 Dr AB Xuma Street, Durban, 4001, South Africa.
- CAPRISA (Centre for the AIDS Programme of Research in South Africa), University of KwaZulu-Natal, Durban, South Africa.
| | - Hariska Ramlal
- Wits MRU (MatCH Research Unit), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Commercial City Building, 40 Dr AB Xuma Street, Durban, 4001, South Africa
| | - Rorisang Mofokeng
- Wits MRU (MatCH Research Unit), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Commercial City Building, 40 Dr AB Xuma Street, Durban, 4001, South Africa
| | - Letitia Rambally Greener
- Wits MRU (MatCH Research Unit), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Commercial City Building, 40 Dr AB Xuma Street, Durban, 4001, South Africa
| | - Annaléne Nel
- IPM South Africa NPC, an affiliate of The Population Council, Inc., New York, NY, USA
| | - Jennifer Smit
- Wits MRU (MatCH Research Unit), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Commercial City Building, 40 Dr AB Xuma Street, Durban, 4001, South Africa
| | - Mariëtte Malherbe
- IPM South Africa NPC, an affiliate of The Population Council, Inc., New York, NY, USA
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Friedland BA, Mgodi NM, Palanee-Phillips T, Mathur S, Plagianos MG, Bruce IV, Lansiaux M, Murombedzi C, Musara P, Dandadzi A, Reddy K, Ndlovu N, Zulu SK, Shale LR, Zieman B, Haddad LB. Assessing the acceptability of, adherence to and preference for a dual prevention pill (DPP) for HIV and pregnancy prevention compared to oral pre-exposure prophylaxis (PrEP) and oral contraception taken separately: protocols for two randomised, controlled, cross-over studies in South Africa and Zimbabwe. BMJ Open 2024; 14:e075381. [PMID: 38479746 PMCID: PMC10936506 DOI: 10.1136/bmjopen-2023-075381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 02/07/2024] [Indexed: 03/17/2024] Open
Abstract
INTRODUCTION Oral pre-exposure prophylaxis (PrEP) is a highly effective HIV prevention method; however, uptake and persistence have been low among southern African women. A dual prevention pill (DPP) that combines PrEP with oral contraception (OC) may increase PrEP use and better meet women's sexual and reproductive health needs. We will gauge the DPP's acceptability in two cross-over clinical trials. METHODS AND ANALYSIS PC952 (Zimbabwe) and PC953 (South Africa) will compare acceptability, adherence and preference for an over-encapsulated DPP versus PrEP and OCs taken separately. HIV-negative, non-pregnant cisgender females in Johannesburg, South Africa (n=96, 16-40 years) and Harare, Zimbabwe (n=30, 16-24 years) will be randomised 1:1 to the order of regimens-DPP or two separate tablets-each used for three 28-day cycles, followed by a 6-month choice period in South Africa. Monthly clinic visits include HIV and pregnancy testing; safety assessments and risk reduction and adherence counselling. We will assess adherence (monthly) based on tenofovir diphosphate drug levels in dried blood spots and by self-report. We will evaluate acceptability (monthly) and preference (end of cross-over) via computer-assisted self-interviewing and in-depth interviews with a subset of participants. Data collection started in September 2022 and ended in January 2024. ETHICS AND DISSEMINATION PC952 was approved by the Ministry of Health and Child Care, Medical Research Council, Research Council and Medicines Control Authority of Zimbabwe; the Chitungwiza City Health Ethics Committee; and the Joint Research Ethics Committee for the University of Zimbabwe Faculty of Medicine and Health Sciences and Parirenyatwa Group of Hospitals. PC953 was approved by the South African Health Products Regulatory Authority and the University of the Witwatersrand's Human Research Ethics Committee. The Population Council IRB approved both studies. We will disseminate results in open-access journals, clinical trials registries, and at local and international meetings and conferences. TRIAL REGISTRATION NUMBERS NCT04778514, NCT04778527.
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Affiliation(s)
| | - Nyaradzo M Mgodi
- University of Zimbabwe - Clinical Trials Research Centre, Harare, Zimbabwe
| | - Thesla Palanee-Phillips
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Faculty of Health Sciences, School of Public Health, Johannesburg, South Africa
- University of Washington, Department of Epidemiology, School of Public Health, Seattle, Washington, USA
| | | | | | - Irene V Bruce
- Population Council, Center for Biomedical Research, New York, New York, USA
| | - Maud Lansiaux
- Population Council, Center for Biomedical Research, New York, New York, USA
| | | | - Petina Musara
- University of Zimbabwe - Clinical Trials Research Centre, Harare, Zimbabwe
| | - Adlight Dandadzi
- University of Zimbabwe - Clinical Trials Research Centre, Harare, Zimbabwe
| | - Krishnaveni Reddy
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Faculty of Health Sciences, School of Public Health, Johannesburg, South Africa
| | - Nkosiphile Ndlovu
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Faculty of Health Sciences, School of Public Health, Johannesburg, South Africa
| | - Sihle K Zulu
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Faculty of Health Sciences, School of Public Health, Johannesburg, South Africa
| | - Lerato R Shale
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Faculty of Health Sciences, School of Public Health, Johannesburg, South Africa
| | - Brady Zieman
- Population Council, Center for Biomedical Research, New York, New York, USA
| | - Lisa B Haddad
- Population Council, Center for Biomedical Research, New York, New York, USA
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Ismail A, Magni S, Katahoire A, Ayebare F, Siu G, Semitala F, Kyambadde P, Friedland B, Jarrahian C, Kilbourne-Brook M. Exploring user and stakeholder perspectives from South Africa and Uganda to refine microarray patch development for HIV PrEP delivery and as a multipurpose prevention technology. PLoS One 2023; 18:e0290568. [PMID: 37651432 PMCID: PMC10470907 DOI: 10.1371/journal.pone.0290568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 08/11/2023] [Indexed: 09/02/2023] Open
Abstract
BACKGROUND Oral HIV pre-exposure prophylaxis (PrEP) is highly effective, but alternative delivery options are needed to reach more users. Microarray patches (MAPs), a novel drug-delivery system containing micron-scale projections or "microneedles" that deliver drugs via skin, are being developed to deliver long-acting HIV PrEP and as a multipurpose prevention technology to protect from HIV and unintended pregnancy. We explored whether MAP technology could meet user and health system needs in two African countries. METHODS Researchers in South Africa and Uganda conducted 27 focus group discussions, 76 mock-use exercises, and 31 key informant interviews to explore perceptions about MAPs and specific features such as MAP size, duration of protection, delivery indicator, and health system fit. Participants included young women and men from key populations and vulnerable groups at high risk of HIV and/or unintended pregnancy, including adolescent girls and young women; female sex workers and men who have sex with these women; and men who have sex with men. In Uganda, researchers also recruited young women and men from universities and the community as vulnerable groups. Key stakeholders included health care providers, sexual and reproductive health experts, policymakers, and youth activists. Qualitative data were transcribed, translated, coded, and analyzed to explore perspectives and preferences about MAPs. Survey responses after mock-use in Uganda were tabulated to assess satisfaction with MAP features and highlight areas for additional refinement. RESULTS All groups expressed interest in MAP technology, reporting perceived advantages over other methods. Most participants preferred the smallest MAP size for ease of use and discreetness. Some would accept a larger MAP if it provided longer protection. Most preferred a protection duration of 1 to 3 months or longer; others preferred 1-week protection. Upper arm and thigh were the most preferred application sites. Up to 30 minutes of wear time was considered acceptable; some wanted longer to ensure the drug was fully delivered. Self-administration was valued by all groups; most preferred initial training by a provider. CONCLUSIONS Potential users and stakeholders showed strong interest in/acceptance of MAP technology, and their feedback identified key improvements for MAP design. If a MAP containing a high-potency antiretroviral or a MAP containing both an antiretroviral and hormonal contraceptive is developed, these products could improve acceptability/uptake of protection options in sub-Saharan Africa.
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Affiliation(s)
| | - Sarah Magni
- Genesis Analytics, Johannesburg, South Africa
| | - Anne Katahoire
- Child Health and Development Centre, Makerere University, Kampala, Uganda
| | - Florence Ayebare
- Child Health and Development Centre, Makerere University, Kampala, Uganda
| | - Godfrey Siu
- Child Health and Development Centre, Makerere University, Kampala, Uganda
| | | | - Peter Kyambadde
- Department of Internal Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
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Garcia M, Roberts ST, Mayo AJ, Scheckter R, Mansoor LE, Palanee-Phillips T, Reddy K, Naidoo Y, Akello CA, Gaffoor Z, Siva S, Rushwaya C, Hlahla K, Jambaya J, Makoni R, Kachale E, Ndovie M, Zuma J, Montgomery ET. Integrating Gender-Based Violence Screening and Support into the Research Clinic Setting: Experiences from an HIV Prevention Open-Label Extension Trial in Sub-Saharan Africa. AIDS Behav 2023; 27:1277-1286. [PMID: 36178556 PMCID: PMC10036410 DOI: 10.1007/s10461-022-03864-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/11/2022] [Indexed: 11/24/2022]
Abstract
HIV and gender-based violence (GBV) are syndemic in sub-Saharan Africa and provision of support for participants who disclose GBV constitutes part of comprehensive care. Consequently, a process was undertaken to develop, implement, and evaluate standard operating procedures (SOPs) in MTN-025/HOPE, a study of the dapivirine vaginal ring for HIV prevention. The SOP was developed using needs assessment surveys in addition to World Health Organization (WHO) guidelines and other literature. Sites tailored and implemented the SOP through HOPE implementation. At study end, staff reported increased training 32/35 (91.43%); improved confidence (18/26; 69.23%); and improved vicarious trauma prevention onsite (17/28; 60.71%). Leadership reported increased staff competence in GBV response. Obstacles included limited referral organizations and time for follow-up, continued training needs, and cultural norms. Development and implementation of an SOP is a feasible strategy to build a GBV response to improve health systems and support sustained effective use of HIV prevention products.
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Affiliation(s)
- Morgan Garcia
- Global Health Population and Nutrition, FHI 360, Durham, NC, USA.
- Global Health Population and Nutrition, FHI 360, 359 Blackwell St, Ste 200, Durham, NC, 27701, USA.
| | - Sarah T Roberts
- Women's Global Health Imperative (WGHI) RTI International, Berkeley, CA, USA
| | - Ashley J Mayo
- Global Health Population and Nutrition, FHI 360, Durham, NC, USA
| | - Rachel Scheckter
- Global Health Population and Nutrition, FHI 360, Durham, NC, USA
| | - Leila E Mansoor
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
| | - Thesla Palanee-Phillips
- Faculty of Health Sciences, Wits Reproductive Health and HIV Institute (Wits RHI), University of the Witwatersrand, Johannesburg, South Africa
- University of Washington School of Public Health, Seattle, WA, USA
| | - Krishnaveni Reddy
- Faculty of Health Sciences, Wits Reproductive Health and HIV Institute (Wits RHI), University of the Witwatersrand, Johannesburg, South Africa
| | - Yuthika Naidoo
- Faculty of Health Sciences, Wits Reproductive Health and HIV Institute (Wits RHI), University of the Witwatersrand, Johannesburg, South Africa
| | - Carolyne Agwau Akello
- Makerere University-Johns Hopkins University (MU-JHU) Research Collaboration, Kampala, Uganda
| | - Zakir Gaffoor
- HIV Prevention Research Unit (HPRU), South African Medical Research Council (SAMRC), Durban, South Africa
| | - Samantha Siva
- HIV Prevention Research Unit (HPRU), South African Medical Research Council (SAMRC), Durban, South Africa
| | - Chenai Rushwaya
- University of Zimbabwe Clinical Trials Research Centre, Harare, Zimbabwe
| | - Kudzai Hlahla
- University of Zimbabwe Clinical Trials Research Centre, Harare, Zimbabwe
| | - Jane Jambaya
- University of Zimbabwe Clinical Trials Research Centre, Harare, Zimbabwe
| | - Rujeko Makoni
- University of Zimbabwe Clinical Trials Research Centre, Harare, Zimbabwe
| | - Evans Kachale
- College of Medicine - Johns Hopkins Bloomberg School of Public Health, Blantyre, Malawi
| | | | - Jabulisile Zuma
- Desmond Tutu HIV Foundation (DTHF) - Emavundleni Clinical Research Site, Cape Town, South Africa
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Friedland BA, Plagianos M, Savel C, Kallianes V, Martinez C, Begg L, Guthrie KM, Venkatasetty D, Pickett J, Haddad LB. Women Want Choices: Opinions from the Share.Learn.Shape Global Internet Survey About Multipurpose Prevention Technology (MPT) Products in Development. AIDS Behav 2023; 27:2190-2204. [PMID: 36881183 DOI: 10.1007/s10461-022-03951-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/06/2022] [Indexed: 03/08/2023]
Abstract
Women need multipurpose prevention technologies (MPTs) to simultaneously prevent sexually transmitted infections (STIs), including HIV, with or without contraception. User feedback early in product development is critical for maximizing uptake and continuation. Our global online survey (April 2017-December 2018) explored women's opinions about MPT formulations in development (e.g., fast-dissolving vaginal inserts, vaginal films, intravaginal rings, injectables, implants), preferences for long-acting or "on-demand" methods, and interest in a contraceptive MPT versus products for HIV/STI prevention alone. Of the 630 women in our final analysis (mean 30 years old; range 18-49), 68% were monogamous, 79% completed secondary education, 58% had ≥ 1 child, 56% were from sub-Saharan Africa and 82% preferred a cMPT versus HIV/STI prevention alone. There were no clear preferences for any specific product or product type (long-acting, on-demand, daily). No single product will appeal everyone, however, adding contraception is likely to increase uptake of HIV/STI prevention methods for most women.
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Affiliation(s)
- B A Friedland
- Center for Biomedical Research, Population Council, 1230 York Avenue, New York, NY, 10065, USA.
| | - M Plagianos
- Center for Biomedical Research, Population Council, 1230 York Avenue, New York, NY, 10065, USA
| | - C Savel
- Information Technology, Population Council, New York, NY, USA
| | - V Kallianes
- Center for Biomedical Research, Population Council, 1230 York Avenue, New York, NY, 10065, USA
| | - C Martinez
- Borough of Manhattan Community College, New York, NY, USA
| | - L Begg
- Center for Biomedical Research, Population Council, 1230 York Avenue, New York, NY, 10065, USA
| | - K M Guthrie
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, Providence, RI, USA.,Department of Behavioral and Social Sciences, School of Public Health, Brown University, Providence, RI, USA
| | - D Venkatasetty
- Center for Biomedical Research, Population Council, 1230 York Avenue, New York, NY, 10065, USA
| | - J Pickett
- Independent Consultant, Chicago, IL, USA
| | - L B Haddad
- Center for Biomedical Research, Population Council, 1230 York Avenue, New York, NY, 10065, USA
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Mataboge P, Nzenze S, Mthimkhulu N, Mazibuko M, Kutywayo A, Butler V, Naidoo N, Mullick S. Planning for decentralized, simplified prEP: Learnings from potential end users in Ga-Rankuwa, gauteng, South Africa. FRONTIERS IN REPRODUCTIVE HEALTH 2023; 4:1081049. [PMID: 36699142 PMCID: PMC9868940 DOI: 10.3389/frph.2022.1081049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 12/16/2022] [Indexed: 01/12/2023] Open
Abstract
Background In South Africa, youth experience challenges with oral Pre-Exposure Prophylaxis (PrEP) access and uptake. Taking services out of healthcare settings has the potential to increase reach and overcome these challenges. This paper presents young and older people's preferences for decentralized, simplified PrEP service delivery and new long-acting HIV prevention methods, in Ga-Rankuwa, South Africa. Methods Between May and August 2021, both PrEP user and non-user adolescent girls and young women (AGYW), pregnant AGYW, female sex workers, adolescent boys and young men (ABYM), and men who have sex with men (MSM) were recruited to participate in focus group discussions (FDGs) in Ga-Rankuwa, Gauteng. Twenty-two FGDs were conducted. Participants were asked about PrEP uptake, potential acceptability of long-acting HIV prevention products, provision of integrated, simplified, and decentralized services, and digital tools to facilitate access to PrEP and other SRH services. A qualitative approach using inductive thematic analysis was carried out to explore emerging themes on decentralized, simplified delivery and the acceptability of long-acting methods. Results Of the 109 participants included in the study approximately 45% (n = 50) were female, the median age was 23 years ± 5.3. A third (n = 37) were current or previous PrEP users, of which, 59.5% (n = 22) collected PrEP refills from the clinic. Decentralized, simplified service delivery was appealing; health facilities, pharmacies and institutions of learning were preferred as service points for PrEP and SRH services, and recreational spaces preferred for dissemination of health information and engagement. ABYM were more open to having recreational spaces as service points. Long-acting Cabotegravir was preferred over the Dapivirine Vaginal Ring due to concerns around perceived side-effects, efficacy, and comfort. Conclusion Providing long-acting PrEP methods through decentralized, simplified service delivery was appealing to this population. They provided practical locations for decentralized service provision to potentially increase their engagement with and uptake of HIV prevention and SRH services.
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Velloza J, Roche S, Concepcion T, Ortblad KF. Advancing considerations of context in the evaluation and implementation of evidence-based biomedical HIV prevention interventions: a review of recent research. Curr Opin HIV AIDS 2023; 18:1-11. [PMID: 36503876 PMCID: PMC9757852 DOI: 10.1097/coh.0000000000000768] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW A paradigm shift is needed in how we think about biomedical HIV prevention product effectiveness. Often, we expect randomized trial findings to be generalizable across populations and settings where products will be delivered, without consideration of key contextual drivers that could impact effectiveness. Moreover, researchers and policy-makers generally discount products with varied effect sizes across contexts, rather than explicating the drivers of these differences and using them to inform equitable product choice and delivery. We conducted a review of the recent HIV prevention research to advance considerations of context in choices of when, why, and how to implement biomedical HIV prevention products, with a particular focus on daily oral preexposure prophylaxis (PrEP) and the dapivirine vaginal ring (DPV). RECENT FINDINGS Findings across recent studies of PrEP and DPV emphasize that products that do not work well in one context might be highly desirable in another. Key contextual drivers of PrEP and DPV effectiveness, use, and implementation include population, health system, cultural, and historical factors. We recommend conceptualization, measurement, and analysis approaches to fully understand the potential impact of context on prevention product delivery. Execution of these approaches has real-world implications for HIV prevention product choice and could prevent the field from dismissing biomedical HIV prevention products based on trial findings alone. SUMMARY Ending the HIV epidemic will require tailored, person-centered, and equitable approaches to design, implement, and evaluate HIV prevention products which necessitates considerations of context in ongoing research and implementation.
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Affiliation(s)
- Jennifer Velloza
- Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, California
| | - Stephanie Roche
- Fred Hutchinson Cancer Center, Public Health Sciences Division
| | - Tessa Concepcion
- Department of Global Health, University of Washington, Seattle, Washington
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Nkomo S, Makoni W, Shapley-Quinn MK, Luecke E, Mbatsane E, Manenzhe K, Ahmed K, Johnson LM, Mahaka I, van der Straten A. Prospective acceptability of a multipurpose technology (MPT) implant in preclinical development to prevent HIV and unplanned pregnancy: Qualitative insights from women end users and health care providers in South Africa and Zimbabwe. PLoS One 2023; 18:e0285711. [PMID: 37195918 DOI: 10.1371/journal.pone.0285711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 05/01/2023] [Indexed: 05/19/2023] Open
Abstract
BACKGROUND Given the high rates of both HIV and unintended pregnancies in sub-Saharan Africa, the SCHIELD program aims to develop a multipurpose technology implant for HIV and pregnancy prevention. An end-user evaluation was undertaken with young women and health care providers to assess preferences for modifiable implant attributes to improve future adoption and rollout. METHODS Focus group discussions were conducted with potential women end users, and health care providers experienced in implant insertion or removal participated in in-depth interviews. All participants were recruited from Harare, Zimbabwe, or Soshanguve, South Africa. The purposively stratified sampled women were either implant experienced or implant naïve and were categorized into three groups: nulliparous, postpartum, or engaged in transactional sex. Topics covered included duration (six months to three years), biodegradability, removability, and independent rod retrievability (per indication). Data were analyzed using Dedoose software and summarized into emerging themes. RESULTS Participants identified three key areas that could facilitate rollout, uptake, and adherence of an implant for HIV and pregnancy prevention. First, discreetness was the most salient topic and was associated with implant characteristics such as anatomical location, flexibility, and biodegradability. Second, the ability to independently retrieve the HIV or pregnancy prevention component was preferred, as life circumstances may change and was favored by all participants, except for young women in Soshanguve. Third, there is a need for proper counseling, sensitization, provider training, and health campaigns to facilitate rollout of a 2-in-1 implant. CONCLUSIONS A 2-in-1 implant was seen as highly desirable by most young women and health care providers. Participants discussed potential concerns and barriers to uptake of a biodegradable implant with dual HIV prevention and contraceptive properties, identifying key implant attributes that product developers can modify while still in preclinical stages.
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Affiliation(s)
| | | | - Mary Kate Shapley-Quinn
- Women's Global Health Imperative, RTI International, San Jose, California, United States of America
| | - Ellen Luecke
- Women's Global Health Imperative, RTI International, San Jose, California, United States of America
| | | | | | - Khatija Ahmed
- Setshaba Research Centre, Soshanguve, South Africa
- Faculty of Health Sciences, Department of Medical Microbiology, University of Pretoria, Pretoria, South Africa
| | - Leah M Johnson
- RTI International, Research Triangle Park, North Carolina, United States of America
| | | | - Ariane van der Straten
- ASTRA Consulting, Kensington, California, United States of America
- Center for AIDS Prevention Studies, University of California, San Francisco, San Francisco, California, United States of America
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Palmeira-de-Oliveira R, Oliveira AS, Rolo J, Tomás M, Palmeira-de-Oliveira A, Simões S, Martinez-de-Oliveira J. Women's preferences and acceptance for different drug delivery routes and products. Adv Drug Deliv Rev 2022; 182:114133. [PMID: 35104506 DOI: 10.1016/j.addr.2022.114133] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 01/22/2022] [Accepted: 01/26/2022] [Indexed: 12/14/2022]
Abstract
To use or not to use, that is the first decision to take regarding a drug product. This mandatory step for adherence dictates product efficacy. The determinants for such decision do not only rely on the priority of the therapeutic or preventive strategy, but are related to a complex network of perceptions, preferences, personal and cultural backgrounds, and results from previous experiences. Women's preferences for dosage forms and even for drug delivery routes have been mainly studied in the fields of contraception and HIV prevention (and their related multipurpose approaches). Much less attention has been devoted to other therapeutic or preventive strategies. In a time when patient-centred approaches and shared decisions are increasingly valued, considering women's preferences and their main determinants is essential for product development and selection. Such products will be more likely to be chosen and used as intended, increasing efficacy, and reducing the overall costs related with these treatments. This knowledge shall be integrated in early stages of product development. This article reviews the state of the art related with women's preferences and acceptance for different dosage forms and drug delivery routes involved in women's health. The methodologies used for collecting these data and their major drawbacks are discussed. Results obtained from acceptability studies and the main determinants for selection of preventive and treatment drug products are discussed as tools for new developments in the field.
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Affiliation(s)
- Rita Palmeira-de-Oliveira
- CICS-UBI Health Sciences Research Center, Faculty of Health Sciences, University of Beira Interior Av. Infante D. Henrique, Covilhã, Portugal; Labfit-HPRD Health Products Research and Development, Lda, Edifício UBIMEDICAL Estrada Municipal 506, 6200-284 Covilhã, Portugal; CNC - Center for Neuroscience and Cell Biology, Center for Innovative Biomedicine and Biotechnology (CIBB), University of Coimbra, Rua Larga, 3004-504 Coimbra, Portugal; Faculty of Health Sciences, University of Beira Interior, Av. Infante D. Henrique, Covilhã, Portugal.
| | - Ana Sofia Oliveira
- CICS-UBI Health Sciences Research Center, Faculty of Health Sciences, University of Beira Interior Av. Infante D. Henrique, Covilhã, Portugal; Faculty of Health Sciences, University of Beira Interior, Av. Infante D. Henrique, Covilhã, Portugal
| | - Joana Rolo
- CICS-UBI Health Sciences Research Center, Faculty of Health Sciences, University of Beira Interior Av. Infante D. Henrique, Covilhã, Portugal
| | - Mariana Tomás
- CICS-UBI Health Sciences Research Center, Faculty of Health Sciences, University of Beira Interior Av. Infante D. Henrique, Covilhã, Portugal; Faculty of Health Sciences, University of Beira Interior, Av. Infante D. Henrique, Covilhã, Portugal
| | - Ana Palmeira-de-Oliveira
- CICS-UBI Health Sciences Research Center, Faculty of Health Sciences, University of Beira Interior Av. Infante D. Henrique, Covilhã, Portugal; Labfit-HPRD Health Products Research and Development, Lda, Edifício UBIMEDICAL Estrada Municipal 506, 6200-284 Covilhã, Portugal; Faculty of Health Sciences, University of Beira Interior, Av. Infante D. Henrique, Covilhã, Portugal
| | - Sérgio Simões
- CNC - Center for Neuroscience and Cell Biology, Center for Innovative Biomedicine and Biotechnology (CIBB), University of Coimbra, Rua Larga, 3004-504 Coimbra, Portugal; Faculty of Pharmacy, University of Coimbra, Pólo das Ciências da Saúde, Azinhaga de Santa Comba, 3000-548 Coimbra, Portugal
| | - José Martinez-de-Oliveira
- CICS-UBI Health Sciences Research Center, Faculty of Health Sciences, University of Beira Interior Av. Infante D. Henrique, Covilhã, Portugal
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10
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Shapley-Quinn MK, Laborde N, Luecke E, Hoesley C, Salata RA, Johnson S, Nel A, Soto-Torres L, Chen BA, van der Straten A. Acceptability of the Dapivirine Vaginal Ring in Postmenopausal US Women. AIDS Patient Care STDS 2022; 36:97-105. [PMID: 35289688 PMCID: PMC8971982 DOI: 10.1089/apc.2022.0002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
For women in the United States who remain sexually active beyond child-bearing years, susceptibility to HIV infection remains, yet condom use is low. We assessed acceptability of the dapivirine vaginal ring (ring) among 96 postmenopausal US women enrolled in a placebo-controlled multisite phase II trial of the ring, using questionnaires and in-depth interviews. Three quarters of women reported “perfect” adherence (ring never out) over the 3-month trial period. At study exit, the ring was found to be very easy to use by 72%, very comfortable to wear by 65%, and 4% reported it ever interfered with their daily activities. The most common worries among participants at preinitiation had decreased significantly at study exit (e.g., worries about inserting the ring declined from 46% to 6%, discomfort during daily activities from 53% to 3%, ring not staying in place from 48% to 14%, all p < 0.0001). Despite some couples feeling the ring during sex, the ring was perceived as more suitable than condoms for prevention because it was not burdensome to use, did not interfere with erection, and provided (for some) additional vaginal lubrication. The ring is a promising, highly acceptable HIV prevention method that is suitable to the lives of postmenopausal women and their male partners and can provide them with an additional prevention choice. Clinical Trials Registration: NCT02010593.
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Affiliation(s)
| | | | - Ellen Luecke
- Global Public Health Impact Center, RTI International, Berkeley, California, USA
| | - Craig Hoesley
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Robert A. Salata
- University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | | | - Annalene Nel
- International Partnership for Microbicides, Silver Spring, Maryland, USA
| | - Lydia Soto-Torres
- Division of AIDS, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland, USA
| | - Beatrice A. Chen
- University of Pittsburgh/Magee-Womens Research Institute, Pittsburgh, Pennsylvania, USA
| | - Ariane van der Straten
- Department of Medicine, Center for AIDS Prevention Studies, University of California, San Francisco, California, USA
- ASTRA Consulting, Kensington, California, USA
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11
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Garcia M, Luecke E, Mayo AJ, Scheckter R, Ndase P, Kiweewa FM, Kemigisha D, Musara P, Mansoor LE, Singh N, Woeber K, Morar NS, Jeenarain N, Gaffoor Z, Gondwe DK, Makala Y, Fleurs L, Reddy K, Palanee-Phillips T, Baeten JM, van der Straten A, Soto-Torres L, Torjesen K. Impact and experience of participant engagement activities in supporting dapivirine ring use among participants enrolled in the phase III MTN-020/ASPIRE study. BMC Public Health 2021; 21:2041. [PMID: 34749675 PMCID: PMC8576984 DOI: 10.1186/s12889-021-11919-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 09/24/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Low adherence to investigational products can negatively impact study outcomes, limiting the ability to demonstrate efficacy. To continue advancing potential new HIV prevention technologies, efforts are needed to improve adherence among study participants. In MTN-020/ASPIRE, a phase III randomized, double-blind, placebo-controlled study of the dapivirine vaginal ring carried out across 15 sites in sub-Saharan Africa, a multifaceted approach to adherence support was implemented, including a strong focus on participant engagement activities (PEAs). In this manuscript, we describe PEAs and participant attendance, and analyze the potential impact of PEAs on ring use. METHODS All sites implemented PEAs and submitted activity and attendance reports to the study management team throughout the study. Participant demographics were collected via case report forms. Residual dapivirine remaining in the last ring returned by each participant was used to estimate drug released from the ring, which was then adjusted for time participants had the ring to calculate probable use categorized into three levels (low/intermittent/high). Product use was connected to PEA attendance using participant identification numbers. We used multivariate Poisson regression with robust standard errors to explore differences in ring use between PEA attendance groups and reviewed qualitative reports for illustrative quotes highlighting participant experiences with PEAs. RESULTS 2312 of 2629 study participants attended at least one of 389 PEAs conducted across sites. Participant country and partner knowledge of study participation were most strongly associated with PEA attendance (p < 0.005) with age, education, and income status also associated with event attendance (p < 0.05). When controlling for these variables, participants who attended at least one event were more likely to return a last ring showing at least some use (RR = 1.40) than those who never attended an event. There was a stronger correlation between a last returned ring showing use and participant attendance at multiple events (RR = 1.52). CONCLUSIONS Our analysis supports the growing body of work illustrating the importance of meaningfully engaging research participants to achieve study success and aligns with other analyses of adherence support efforts during ASPIRE. While causation between PEA attendance and product use cannot be established, residual drug levels in returned rings strongly correlated with participant attendance at PEAs, and the benefits of incorporating PEAs should be considered when designing future studies of investigational products.
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Affiliation(s)
- Morgan Garcia
- Global Health Population and Nutrition, FHI, Durham, NC, 360, USA.
| | - Ellen Luecke
- Women's Global Health Imperative (WGHI) RTI International, Berkeley, CA, USA; ASTRA Consulting, Kensington, CA, USA
| | - Ashley J Mayo
- Global Health Population and Nutrition, FHI, Durham, NC, 360, USA
| | - Rachel Scheckter
- Global Health Population and Nutrition, FHI, Durham, NC, 360, USA
| | - Patrick Ndase
- Population Services International (PSI), 1120 19th St. NW, Washington, DC, USA
| | - Flavia Matovu Kiweewa
- Makerere University-Johns Hopkins University (MU-JHU) Research Collaboration, Kampala, Uganda
| | - Doreen Kemigisha
- Makerere University-Johns Hopkins University (MU-JHU) Research Collaboration, Kampala, Uganda
| | - Petina Musara
- University of Zimbabwe College of Health Sciences-Clinical Trials Research Centre, Harare, Zimbabwe
| | - Leila E Mansoor
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
| | - Nishanta Singh
- HIV Prevention Research Unit (HPRU), South African Medical Research Council (SAMRC), Durban, South Africa
| | - Kubashni Woeber
- HIV Prevention Research Unit (HPRU), South African Medical Research Council (SAMRC), Durban, South Africa
| | - Neetha S Morar
- HIV Prevention Research Unit (HPRU), South African Medical Research Council (SAMRC), Durban, South Africa
| | - Nitesha Jeenarain
- HIV Prevention Research Unit (HPRU), South African Medical Research Council (SAMRC), Durban, South Africa
| | - Zakir Gaffoor
- HIV Prevention Research Unit (HPRU), South African Medical Research Council (SAMRC), Durban, South Africa
| | - Daniel K Gondwe
- College of Medicine - Johns Hopkins Bloomberg School of Public Health, Blantyre, Malawi
| | - Yvonne Makala
- University of North Carolina Project, Lilongwe, Malawi
| | - Llewellyn Fleurs
- Desmond Tutu HIV Foundation, Emavundleni Clinical Research Site, Cape Town, South Africa
| | - Krishnaveni Reddy
- Wits Reproductive Health and HIV Institute (Wits RHI), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Thesla Palanee-Phillips
- Wits Reproductive Health and HIV Institute (Wits RHI), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Jared M Baeten
- Departments of Global Health, Medicine, and Epidemiology, University of Washington, Seattle, WA, USA
| | - Ariane van der Straten
- Women's Global Health Imperative (WGHI) RTI International, Berkeley, CA, USA; ASTRA Consulting, Kensington, CA, USA.,Center for AIDS Prevention Studies (CAPS), University of California San Francisco, San Francisco, CA, USA
| | - Lydia Soto-Torres
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
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12
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Acceptability of the Dapivirine Vaginal Ring for HIV-1 Prevention and Association with Adherence in a Phase III Trial. AIDS Behav 2021; 25:2430-2440. [PMID: 33713213 PMCID: PMC8222015 DOI: 10.1007/s10461-021-03205-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2021] [Indexed: 12/16/2022]
Abstract
We evaluated the acceptability of the 25 mg dapivirine vaginal ring (DVR) as an HIV prevention intervention and its influence on DVR adherence in the MTN-020/ASPIRE phase III trial. Acceptability measures were captured using ACASI at month 3 and end of product use (median 24 months, IQR 15–30). Monthly returned rings were classified as nonadherent if dapivirine release rate was ≤ 0.9 mg/month. Associations between acceptability measures and nonadherence were estimated using Poisson regression models with robust standard errors. At month 3 (N = 2334), 88% reported DVR was comfortable, 80% were unaware of it during daily activities, and 74% never felt it during sex. At exit, 66% were ‘very likely’ to use DVR in the future. Acceptability was found to differ significantly by country across several measures including wearing the ring during sex, during menses, partner acceptability, impact on sexual pleasure and willingness to use the ring in the future. Risk of nonadherence at month 12 was elevated if DVR was felt during sex at month 3 (aRR 1.67, 95% CI 1.26, 2.23). Risk of nonadherence in the last year of study participation was elevated if, at exit, participants minded wearing during sex (aRR 2.08, 95% CI 1.52, 2.85), during menses (aRR 1.57, 95% CI 1.06, 2.32), reported a problematic change to the vaginal environment (aRR 1.57, 95% CI 1.12, 2.21), and were not “very likely” to use DVR in the future (aRR 1.31, 95% CI 1.02, 1.68). DVR acceptability was overall high yet varied by country. Addressing perceived ring interference with sex, menses, or problematic changes to the vaginal environment in future interventions could help improve adherence, as could embracing sex-positive messaging related to ring use and increased pleasure. Trial Registration ClinicalTrials.gov Identifier: NCT01617096.
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13
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Baker Z, Javanbakht M, Moore J, Brosnan H, Squires K, Bunge K, Zimet G, Mensch B, Soto-Torres L, Kapogiannis B, Levy L, Hoesley C, Reirden D, Gaur A, Mayer K, Futterman D, Gorbach P. Qualitative Study on the Acceptability of and Adherence to a Vaginal Ring for HIV Prophylaxis Among Adolescent Girls. J Acquir Immune Defic Syndr 2021; 87:944-950. [PMID: 33675614 PMCID: PMC8192420 DOI: 10.1097/qai.0000000000002674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 12/30/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This study aims to assess the product-related, relationship-related, and sex-related factors that act as facilitators and barriers to the acceptability of a vaginal ring (VR) for HIV prevention among adolescent girls. DESIGN Qualitative study. METHODS Ninety-six girls aged 15-17 years from 6 urban US sites were enrolled in MTN-023/IPM 030, a 24-week randomized controlled trial, for assessing the safety and acceptability of a dapivirine VR for HIV prevention. At week 24, 21 girls were randomly selected to participate in in-depth interviews. Interviews were transcribed verbatim and data analyzed using a thematic analysis approach. Facilitators and barriers to VR acceptability related to participants' relationships, sexual activity, and characteristics of the VR product were identified. RESULTS Factors related to relationships rarely seemed to act as barriers to VR acceptability; most participants disclosed VR use to sexual partners, and positive reactions from sexual partners, which were common, seemed to facilitate VR acceptability. Emotional and/or physical discomfort surrounding VR use during sex was mentioned occasionally as a barrier to VR acceptability. Product characteristics were most frequently mentioned as barriers to VR acceptability. Many participants reported concerns about the large size of the VR on first impression. Although most found the VR comfortable, some reported pain with VR insertion. Several participants were concerned about VR cleanliness, particularly during menstruation. CONCLUSION Product considerations, specifically size and use during menstruation, were the most commonly reported barriers to VR acceptability in this study. Adolescent girls may require additional counseling to assuage product concerns regarding a VR for HIV prevention.
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Affiliation(s)
- Zoë Baker
- Division of Urology, Children's Hospital Los Angeles, Los Angeles, CA
| | - Marjan Javanbakht
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA
| | - Janell Moore
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA
| | - Hannah Brosnan
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA
| | - Kathleen Squires
- Division of Infectious Diseases, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA
- Global Center of Scientific Affairs, Merck Research Labs, Rahway, NJ
| | - Katherine Bunge
- Department of Obstetrics, Gynecology & Reproductive Services, University of Pittsburgh, Pittsburgh, PA
| | - Gregory Zimet
- Department of Pediatrics, Indiana University, Bloomington, IA
| | | | - Lydia Soto-Torres
- National Institute of Allergy and Infectious Diseases, Division of AIDS, Bethesda, MD
| | - Bill Kapogiannis
- Maternal and Pediatric Infectious Disease Branch, National Institute of Child Health and Human Development, Bethesda, MD
| | | | - Craig Hoesley
- Division of Infectious Diseases, University of Alabama, Birmingham, AL
| | - Daniel Reirden
- Department of Adolescent Medicine, Children's Hospital Colorado, Aurora, CO
| | - Aditya Gaur
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, TN
| | - Kenneth Mayer
- Department of Global Health and Population, Harvard School of Public Health, The Fenway Institute, Boston, MA; and
| | - Donna Futterman
- Department of Pediatrics, Albert Einstein College of Medicine, the Bronx, NY
| | - Pamina Gorbach
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA
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14
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Friedland BA, Mathur S, Haddad LB. The Promise of the Dual Prevention Pill: A Framework for Development and Introduction. FRONTIERS IN REPRODUCTIVE HEALTH 2021; 3. [PMID: 34318291 PMCID: PMC8312733 DOI: 10.3389/frph.2021.682689] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Women of reproductive age need multipurpose prevention technology (MPT) products to address two overlapping health risks: unintended pregnancy and HIV. Currently, condoms are the only available MPT, however male condoms are not within the control of a woman, and the use of female condoms has been limited by low acceptability and cost. Oral pre-exposure prophylaxis (PrEP) is highly effective for HIV prevention, yet uptake and adherence among women have been low to date. Women globally need more options for HIV and pregnancy prevention. Several MPTs for simultaneous HIV and pregnancy prevention are in various stages of development and clinical testing, although most are many years away from market launch. A dual prevention pill (DPP), a daily oral pill combining oral contraceptives and PrEP, both of which are licensed, approved products in many low- and middle-income countries (LMIC), is likely to be the fastest route to getting an MPT product into the hands of women. The DPP is one option that could enhance method choice, particularly for women who are already using oral contraceptives. By leveraging the oral contraceptive market and reaching women currently using condoms or with an unmet need for contraception, the DPP has the potential to increase the uptake of PrEP. The successful rollout of the DPP will require careful consideration of user-, provider-, and product-centered factors during product development and introduction. Early attention to these interrelated factors can help ensure that the DPP has the ideal characteristics for maximum product acceptability, that effective and quality services are designed and implemented, and that users can make informed choices, demand the product, and use it effectively. The proposed framework outlines key considerations for the effective development and introduction of the DPP, which could also facilitate integration models for future MPTs.
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Affiliation(s)
- Barbara A Friedland
- Population Council, Center for Biomedical Research, New York, NY, United States
| | - Sanyukta Mathur
- Population Council, HIV and AIDS Program, Washington, DC, United States
| | - Lisa B Haddad
- Population Council, Center for Biomedical Research, New York, NY, United States
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15
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Men's Sexual Experiences with the Dapivirine Vaginal Ring in Malawi, South Africa, Uganda and Zimbabwe. AIDS Behav 2021; 25:1890-1900. [PMID: 33389318 DOI: 10.1007/s10461-020-03119-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/07/2020] [Indexed: 01/20/2023]
Abstract
The dapivirine vaginal ring has been well-tolerated and shown to prevent HIV in clinical trials. The ring is female initiated, yet endorsement for use is sought from male partners in many relationships. In clinical studies, participants have expressed worries about men detecting rings during vaginal sex, which introduces concerns about product use disclosure, sexual pleasure, penile harm, inter-partner dynamics, and ring removals. This study reports African men's firsthand sexual experiences with the ring. Qualitative data were captured through 11 focus group discussions and one in-depth interview with 54 male partners of ring-users at six research sites in Malawi, South Africa, Uganda and Zimbabwe. Following a semi-structured guide, and using demonstration rings, vulva and penis models, men were asked to discuss the ring's impact on sex and views on male engagement and ring use. Interviews were facilitated by local male social scientists, audio-recorded, translated into English, and analyzed thematically. 22 (41%) of the male partners reported feeling the ring during sex, often attributed to perceived incorrect insertion. Many men described the ring as "scratching" the tip of their penises, and sensations of "prodding" something that "blocked" the vagina and prohibited "full entry". In most cases, feelings dissipated with time or when sexual fluids increased. Less common descriptions included perceiving the vaginal texture, wetness and size as different, which increased pleasure for some, and decreased for others. Over half (59%) never noticed the ring; some attempting and failing to feel it during intercourse. A majority of men reported that the ring did not lead to changes in sexual positions, feelings, frequency or experience of sex, although some were initially afraid that the ring was a "magic snake" or "potion". Male partners expressed strong opinions that ring use was a shared prevention responsibility that men should be engaged in, especially for maintaining trust and open communication in relationships. The ring was noticed by many male partners, particularly during women's initial stages of ring use, although this led to few sexual problems or changes. Nevertheless, results suggest that risk of ring discovery should be discussed with women to mitigate any potential negative reactions or social harm. Strategies to increase male partner engagement will enhance support of this prevention method for women.
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16
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Liu AY, Dominguez Islas C, Gundacker H, Neradilek B, Hoesley C, van der Straten A, Hendrix CW, Beamer M, Jacobson CE, McClure T, Harrell T, Bunge K, Devlin B, Nuttall J, Spence P, Steytler J, Piper JM, Marzinke MA. Phase 1 pharmacokinetics and safety study of extended duration dapivirine vaginal rings in the United States. J Int AIDS Soc 2021; 24:e25747. [PMID: 34118115 PMCID: PMC8196716 DOI: 10.1002/jia2.25747] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 04/27/2021] [Accepted: 04/30/2021] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION Vaginal rings are a promising approach to provide a woman-centred, long-acting HIV prevention strategy. Prior trials of a 25 mg dapivirine (DPV) ring have shown a favourable safety profile and approximately 30% risk reduction of HIV-1 infection. Extended duration rings replaced every three months may encourage user adherence, improve health service efficiency and reduce cost overall. We evaluated safety, pharmacokinetics, adherence and acceptability of two three-month rings with different DPV dosages, compared with the monthly DPV ring. METHODS From December 2017 to October 2018, MTN-036/IPM-047 enrolled 49 HIV-negative participant in Birmingham, Alabama and San Francisco, California into a phase 1, randomized trial comparing two extended duration (three-month) rings (100 or 200 mg DPV) to a monthly 25 mg DPV ring, each used over 13 weeks, with follow-up completed in January 2019. Safety was assessed by recording adverse events (AEs). DPV concentrations were quantified in plasma, cervicovaginal fluid (CVF) and cervical tissue, at nominal timepoints. Geometric mean ratios (GMRs) relative to the comparator ring were estimated from a regression model. RESULTS There were no differences in the proportion of participants with grade ≥2 genitourinary AEs or grade ≥3 AEs in the extended duration versus monthly ring arms (p = 1.0). Plasma and CVF DPV concentrations were higher in the extended duration rings compared to the monthly ring. Plasma GMRs were 1.31 to 1.85 and 1.41 to 1.86 and CVF GMRs were 1.45 to 2.87 and 1.74 to 2.60 for the 100 and 200 mg ring respectively. Cervical tissue concentrations were consistently higher in the 200 mg ring (GMRs 2.36 to 3.97). The majority of participants (82%) were fully adherent (ring inserted at all times, with no product discontinuations/outages) with no differences between the monthly versus three-month rings. Most participants found the ring acceptable (median = 8 on 10-point Likert scale), with a greater proportion of participants reporting high acceptability (9 or 10) in the 25 mg arm (73%) compared with the 100 mg (25%) and 200 mg (44%) arms (p = 0.01 and p = 0.15 respectively). CONCLUSIONS The extended duration DPV rings were well-tolerated and achieved higher DPV concentrations compared with the monthly DPV ring. These findings support further evaluation of three-month DPV rings for HIV prevention.
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Affiliation(s)
- Albert Y Liu
- Bridge HIVSan Francisco Department of Public HealthSan FranciscoCAUSA
- Department of MedicineUniversity of CaliforniaSan FranciscoCAUSA
| | - Clara Dominguez Islas
- Vaccine and Infectious Disease DivisionFred Hutchinson Cancer Research CenterSeattleWAUSA
| | - Holly Gundacker
- Statistical Center for HIV/AIDS Research & PreventionFred Hutchinson Cancer Research CenterSeattleWAUSA
| | - Blazej Neradilek
- Statistical Center for HIV/AIDS Research & PreventionFred Hutchinson Cancer Research CenterSeattleWAUSA
| | | | - Ariane van der Straten
- Department of MedicineUniversity of CaliforniaSan FranciscoCAUSA
- Women’s Global Health Imperative (WGHI)RTI InternationalBerkeleyCAUSA
- ASTRA ConsultingKensingtonCAUSA
| | - Craig W Hendrix
- Division of Clinical PharmacologyDepartment of MedicineJohns Hopkins University School of MedicineBaltimoreMDUSA
| | - May Beamer
- Magee‐Womens Research InstitutePittsburghPAUSA
| | | | | | - Tanya Harrell
- Statistical Center for HIV/AIDS Research & PreventionFred Hutchinson Cancer Research CenterSeattleWAUSA
| | - Katherine Bunge
- Magee‐Womens Research InstitutePittsburghPAUSA
- Department of Obstetrics, Gynecology, and Reproductive SciencesUniversity of PittsburghPittsburghPAUSA
| | - Brid Devlin
- International Partnership for MicrobicidesSilver SpringMDUSA
| | - Jeremy Nuttall
- International Partnership for MicrobicidesSilver SpringMDUSA
| | - Patrick Spence
- International Partnership for MicrobicidesSilver SpringMDUSA
| | - John Steytler
- International Partnership for MicrobicidesSilver SpringMDUSA
| | - Jeanna M Piper
- Division of AIDSNational Institutes of HealthBethesdaMDUSA
| | - Mark A Marzinke
- Division of Clinical PharmacologyDepartment of MedicineJohns Hopkins University School of MedicineBaltimoreMDUSA
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17
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Acceptability of a Tenofovir Disoproxil Fumarate Intravaginal Ring for HIV Pre-Exposure Prophylaxis Among Sexually Active Women. Sex Transm Dis 2021; 47:819-824. [PMID: 33186337 DOI: 10.1097/olq.0000000000001254] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Vaginal ring delivery of antiretroviral drugs may provide protection against acquisition of HIV-1 when used as Pre-Exposure prophylaxis. As part of a randomized placebo-controlled safety trial of a tenofovir disoproxil fumarate (TDF) intravaginal ring (IVR), we assessed product acceptability through surveys of women after continuous ring use. METHODS Sexually active, HIV-negative women were enrolled to investigate the safety and pharmacokinetics of 3 months of continuous TDF IVR use. The study was designed to include 40 US participants randomly assigned (3:1) to a TDF or placebo IVR. Twelve were randomized to TDF and 5 to the placebo group before the study was electively discontinued because of the development of vaginal ulcerations in 8 women in the TDF group. Acceptability data were gathered via self-administered, computer-based questionnaires. RESULTS The average age of the 17 participants was 31 years (range, 18-42 years). Sixteen participants (94%) completed all questions at 2 study visits. When asked about ring likeability after 1 month of ring use, 12 (75%) of 16 reported overall liking the ring, including 6 (75%) of 8 who developed ulcerations. In addition, 10 (83%) of 12 who had their menses during the first month of ring use were not bothered by the ring, and 11 (69%) of 16 stated that the ring was not bothersome with use during sex. CONCLUSIONS Despite unanticipated ulcers, TDF and placebo IVRs were acceptable to some women, even when used with menses and during sex, which is promising for continued development of IVRs for HIV prevention.
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18
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Kabarambi A, Kusemererwa S, Krogstad E, Mayaud P, Seeley J, Mugisha J, Gafos M. The dapivirine vaginal ring from the perspective of married men in Uganda. AJAR-AFRICAN JOURNAL OF AIDS RESEARCH 2021; 20:53-60. [PMID: 33632073 DOI: 10.2989/16085906.2020.1866043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background: Men play a key role in influencing uptake of women's health products, such as female condoms and vaginal microbicides used for family planning and HIV prevention.Method: We explored men's perceptions of the dapivirine vaginal ring (DVR), a vaginal microbicide, in Kalungu District, rural south-western Uganda. In June/July 2018, we conducted in-depth interviews with 10 partners of women participating in the DREAM study, a phase 3B open-label extension trial of the DVR. Data were analysed thematically, drawing on the socio-ecological model theoretical framework.Results: Influencing factors such as individual and interpersonal characteristics, perception of HIV risk, lack of knowledge about the DVR, misconceptions, and product characteristics acting at different levels (individual, societal and organisational) affected men's knowledge, attitudes and perceptions towards the DVR, which in turn impacted on their willingness to allow their partners to use it. Above all, men wanted to be involved in the decision- making process about the use of the DVR. All the men were happy that there was a new HIV prevention option in the pipeline and were not concerned about the degree of effectiveness, saying it was better than nothing.Conclusion: The use of the DVR in an environment where men expect to make decisions about sex on behalf of women may affect its usage and success. Given this context, women may not always be able to independently choose to use it. If the DVR is approved and rolled out, increased sensitisation of men about it will be critical to ensure its uptake.
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Affiliation(s)
- Anita Kabarambi
- Medical Research Council/Uganda Virus Research Institute & London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Sylvia Kusemererwa
- Medical Research Council/Uganda Virus Research Institute & London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Emily Krogstad
- Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, University of Cape Town, South Africa
| | - Philippe Mayaud
- Medical Research Council/Uganda Virus Research Institute & London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda.,London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Janet Seeley
- Medical Research Council/Uganda Virus Research Institute & London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda.,London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Joseph Mugisha
- Medical Research Council/Uganda Virus Research Institute & London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Mitzy Gafos
- London School of Hygiene and Tropical Medicine, London, United Kingdom
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Musara P, Milford C, Shapley-Quinn MK, Weinrib R, Mutero P, Odoom E, Mgodi NM, Chirenje ZM, Hanif H, Clark MR, Smit J, van der Straten A, Montgomery ET. Preferences and Acceptability of Vaginal Delivery Forms for HIV Prevention Among Women, Male Partners and Key Informants in South Africa and Zimbabwe: Qualitative Findings. AIDS Behav 2021; 25:124-138. [PMID: 32588257 DOI: 10.1007/s10461-020-02949-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The attributes of an HIV microbicide may affect its acceptability, uptake and use. Quatro, a clinical study with a qualitative component, was conducted to elicit input from end-users and key informants (KIs) on four different placebo vaginal microbicide delivery forms; fast dissolving insert, ring, film and gel. In-depth interviews and focus group discussions were conducted with young women, their male partners and KIs, to explore acceptability and preferences of the four placebo products, with the intention of improving product attributes, adherence, and consequently, long term effectiveness. None of the four microbicide delivery forms stood well above others as the most preferred. Product attributes; long-action, ease of use, invisibility, female initiated and non-interference during sex were favourable in both countries. Despite preference for the long-action, on-demand products were the most liked by women. Qualitative data from the Quatro study provided rich feedback on specific attributes important to the acceptability of four HIV prevention product platforms currently in development, enabling more informed and guided product development efforts moving forward.
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Affiliation(s)
- Petina Musara
- University of Zimbabwe College of Health Sciences-Clinical Trials Research Centre, 15 Phillips Avenue, Belgravia, Harare, Zimbabwe.
| | - Cecilia Milford
- MRU (MatCH Research Unit), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | | | - Rachel Weinrib
- Women's Global Health Imperative, RTI International, San Francisco, CA, USA
| | - Prisca Mutero
- University of Zimbabwe College of Health Sciences-Clinical Trials Research Centre, 15 Phillips Avenue, Belgravia, Harare, Zimbabwe
| | - Enyonam Odoom
- Women's Global Health Imperative, RTI International, San Francisco, CA, USA
| | - Nyaradzo M Mgodi
- University of Zimbabwe College of Health Sciences-Clinical Trials Research Centre, 15 Phillips Avenue, Belgravia, Harare, Zimbabwe
| | - Zvavahera M Chirenje
- University of Zimbabwe College of Health Sciences-Clinical Trials Research Centre, 15 Phillips Avenue, Belgravia, Harare, Zimbabwe
| | - Homaira Hanif
- Eastern Virginia Medical School, CONRAD, Arlington, VA, USA
| | | | - Jenni Smit
- MRU (MatCH Research Unit), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | - Ariane van der Straten
- Women's Global Health Imperative, RTI International, San Francisco, CA, USA
- Center for AIDS Prevention Studies, University of San Francisco, San Francisco, CA, USA
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Nel A, Malherbe M, van Niekerk N, Beksinska M, Greener R, Smit J, Frezieres R, Walsh T. Performance of Male Condoms When Used With and Without a Silicone Placebo Vaginal Ring-A Randomized, Crossover Trial. J Acquir Immune Defic Syndr 2020; 85:51-57. [PMID: 32452969 PMCID: PMC7417015 DOI: 10.1097/qai.0000000000002397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The dapivirine vaginal ring reduced the risk of HIV infection by approximately 30% in Phase III trials. To ensure higher levels of protection against HIV and sexually transmitted infections, women should be counseled to use condoms when using the vaginal ring. This article evaluates the compatibility of male condoms with a placebo vaginal ring. METHODS This was a 2-period crossover, randomized, noninferiority trial. Couples in 2 sites in the United States were randomized to male condom use, with and without a placebo silicone vaginal ring, and asked to use 4 male condoms in each period. The primary noninferiority end points were total clinical failure and their component failure events (clinical breakage or slippage). Frequencies and percentages were calculated for each failure mode and differences in performance of the 2 periods using the male condom without the ring as reference. Noninferiority was defined using a 3% margin at the 5% significance level. Safety and acceptability were also assessed. RESULTS Seventy couples were enrolled, and 68 completed the trial with a total of 275 male condoms used in each period. Total condom clinical failure rates were 2.2% and 4.0% in the presence and absence of the vaginal ring, respectively, with a difference of -1.9% (95% confidence interval: -5.3% to 1.5%), thereby demonstrating noninferiority when used with the ring. There was no difference in safety between the 2 periods. DISCUSSION Concurrent use of the placebo silicone vaginal ring had no significant effect on male condom functionality or safety outcomes.
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Affiliation(s)
- Annalene Nel
- International Partnership for Microbicides, Silver Spring, MD
| | | | | | - Mags Beksinska
- MRU [Maternal, Adolescent and Child Health Research Unit], Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; and
| | - Ross Greener
- MRU [Maternal, Adolescent and Child Health Research Unit], Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; and
| | - Jennifer Smit
- MRU [Maternal, Adolescent and Child Health Research Unit], Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; and
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The Power of the Shared Experience: MTN-020/ASPIRE Trial Participants' Descriptions of Peer Influence on Acceptability of and Adherence to the Dapivirine Vaginal Ring for HIV Prevention. AIDS Behav 2020; 24:2387-2399. [PMID: 31980993 DOI: 10.1007/s10461-020-02799-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Women are disproportionately at risk of acquiring HIV in East and Southern Africa, despite global declines in incidence. Female-initiated HIV prevention methods, like the dapivirine vaginal ring, are needed to end the HIV epidemic. In-depth interviews and focus groups retrospectively explored peer influence on acceptability of and adherence to the ring during the ASPIRE trial, a phase III placebo-controlled trial. Results were analyzed using an inductive analytic approach. Study participants (peers) of all ages and adherence groups developed important interpersonal connections and reported being more open and honest with each other than with external peers or study staff. Study peers who knew each other prior to joining appeared to have a stronger influence on each other's adherence than peers who met in the study. External peers provided primarily negative input about the ring and study, which sometimes led to ring removals. Peers' influence on each other's behavior in both prosocial and detrimental manners could have repercussions on adherence to a biomedical intervention, and consequently, individual disease risk and clinical trial outcomes. Future ring demonstration and implementation studies could use peer networks to intentionally influence uptake and adherence to the ring.
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Roberts ST, Nair G, Baeten JM, Palanee-Philips T, Schwartz K, Reddy K, Kabwigu S, Matovu Kiweewa F, Govender V, Gaffoor Z, Singh N, Siva S, Naidoo K, Montgomery ET. Impact of Male Partner Involvement on Women's Adherence to the Dapivirine Vaginal Ring During a Phase III HIV Prevention Trial. AIDS Behav 2020; 24:1432-1442. [PMID: 31667678 DOI: 10.1007/s10461-019-02707-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Although vaginal microbicides for HIV prevention are designed to be female-initiated, male partner influence has been identified as one of the most significant factors impacting women's willingness and ability to use them. As a result, research teams have sought to increase male partner involvement by encouraging disclosure of product use to male partners, promoting male partner engagement in the study through attendance at the study clinic, and helping women to garner male partner support for product use. This paper aims to assess the impact of these three elements of male partner involvement on women's adherence to the dapivirine vaginal ring during MTN-020/ASPIRE, a phase III randomized placebo-controlled clinical trial involving 2629 women in Malawi, South Africa, Uganda, and Zimbabwe. During the study, 64-80% of participants reported disclosure of ring use at each quarterly visit, and 13% reported that their partners had attended the study clinic at some point during the study. At study exit, 66% reported that their partner was supportive, 18% unsupportive, and 17% were unsure. After adjusting for age, site and time in study, women were more likely to have low ring adherence if they had an unsupportive male partner (aRR 1.29, 95% CI 1.03-1.62). Neither disclosure nor clinic attendance directly predicted ring adherence, but disclosure increased the probability of having a supportive partner (aRRR 24.17, 95% CI 16.38-35.66) or an unsupportive partner (aRRR 4.10, 95% CI 2.70-6.24), relative to an unknown level of partner support. Women were also more likely to have a supportive partner if their partner had attended the clinic (aRRR 3.77, 95% CI 1.36-10.42). This study suggests that although the vaginal ring is relatively discreet, lack of support from male partners remains a relevant barrier to use. Though both disclosure and clinic attendance may increase partner support, disclosure may also increase partner opposition. Interventions to reduce male partner opposition are needed to maximize the potential impact of the ring and other PrEP products for HIV prevention.
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Affiliation(s)
- Sarah T Roberts
- Women's Global Health Imperative, RTI International, 351 California Street, Ste. 500, San Francisco, CA, 94104, USA.
| | - Gonasagrie Nair
- Desmond Tutu HIV Research Centre, University of Cape Town, Cape Town, South Africa
| | - Jared M Baeten
- Departments of Global Health, Medicine, and Epidemiology, University of Washington, Seattle, WA, USA
| | | | | | - Krishnaveni Reddy
- Wits Reproductive Health and HIV Institute (Wits RHI), Johannesburg, South Africa
| | - Samuel Kabwigu
- Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda
| | - Flavia Matovu Kiweewa
- Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda
| | - Vaneshree Govender
- HIV Prevention Research Unit (HPRU), Medical Research Council (MRC), Durban, South Africa
| | - Zakir Gaffoor
- HIV Prevention Research Unit (HPRU), Medical Research Council (MRC), Durban, South Africa
| | - Nishanta Singh
- HIV Prevention Research Unit (HPRU), Medical Research Council (MRC), Durban, South Africa
| | - Samantha Siva
- HIV Prevention Research Unit (HPRU), Medical Research Council (MRC), Durban, South Africa
| | - Kalendri Naidoo
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa
| | - Elizabeth T Montgomery
- Women's Global Health Imperative, RTI International, 351 California Street, Ste. 500, San Francisco, CA, 94104, USA
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Relationship Type and Use of the Vaginal Ring for HIV-1 Prevention in the MTN 020/ASPIRE Trial. AIDS Behav 2020; 24:866-880. [PMID: 31111297 DOI: 10.1007/s10461-019-02521-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Gender roles and imbalances in sexual power contribute to the heightened HIV-1 risk faced by women in Sub-Saharan Africa. This has led prevention research to focus on the development of female controlled methods. Despite the design of products such as vaginal rings to be used autonomously by women, male partners and women's perceptions of relationships influence HIV prevention choices. To understand the influences that male partners and dyadic dynamics had on the use of the Dapivirine Vaginal Ring in the ASPIRE trial, this analysis of qualitative data explored the types of intimate partner relationships that women engaged in. This paper describes how partners facilitated or challenged women's ring use and how women dealt with these challenges within six different types of relationships characterized by power dynamics and commitment levels. We offer insights into how future use of female-initiated HIV prevention products can be promoted through recognition of different relationship types.
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24
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First Impressions Matter: How Initial Worries Influence Adherence to the Dapivirine Vaginal Ring. J Acquir Immune Defic Syndr 2020; 81:304-310. [PMID: 30844995 DOI: 10.1097/qai.0000000000002028] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND In MTN-020/ASPIRE, a dapivirine vaginal ring effectiveness trial in sub-Saharan Africa, we assessed whether worries about ring use changed over time and were associated with adherence. METHODS Participants (N = 2585) were surveyed at baseline and follow-up about worries regarding daily ring use. First, they answered a question about general worries and then responded to 15 items covering specific worries. From a nested qualitative component (N = 214), we extracted themes related to ring worries and adherence. Seven months into the trial, aggregate adherence data were shared with study sites as part of an intervention that included counseling and social support. Nonadherence was defined as dapivirine plasma levels of ≤95 pg/mL. Mixed-effect logistic regression models were used to assess changes in ring worries and nonadherence from baseline to month 3 and later. RESULTS Worry about wearing the ring decreased from 29% at baseline to 4% at month 3 (P < 0.001), while having a specific worry decreased from 47% to 16% (P < 0.001). Among those enrolled before intervention, 29% with baseline worries were nonadherent at month 3 (95% confidence interval: 19% to 39%) compared to 14% without worries (95% confidence interval: 9% to 19%; P = 0.005); the difference persisted through month 6. There was no difference in nonadherence by baseline worry for those enrolled after intervention (P = 0.40). In the qualitative subset, initial ring anxieties reportedly subsided with self-experimentation and practice and the beneficial influence of the intervention. CONCLUSIONS Although worries may be an initial deterrent to correct ring use, intervening early by leveraging social influences from peers and clinicians should facilitate successful adoption and correct ring use.
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A Mixed-Methods Study Examining Adherence to and Acceptability of Intravaginal Rings for HIV Prevention: Behavioral Results of MTN-027. AIDS Behav 2020; 24:607-616. [PMID: 30877580 DOI: 10.1007/s10461-019-02457-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Intravaginal rings (IVR) containing antiretroviral drugs are a promising method for HIV prevention. We triangulated quantitative and qualitative assessments to evaluate the acceptability of four IVRs used continuously for 28 days as part of a Phase I trial (N = 48 HIV-negative women; ages 18-45). Adherence was high throughout the trial, yet 30% of participants reported involuntary IVR expulsions followed by re-insertion. Most participants (93.6%) felt comfortable with the IVR being inside their body. Participants reported liking the IVR more (36.2%) or the same amount (55.3%) since starting the study. When given the option of choosing between the IVR and/or a male condom for HIV-prevention, most reported preferring the IVR (n = 29, 63.0%), and over a quarter of the sample reported liking them equally (n = 12, 26.1%). We observed no differences in IVR acceptability across the study arms. High adherence and acceptability underscores the promise of an IVR as a female-controlled, sustained mechanism for HIV prevention.
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Vargas SE, Midoun MM, Guillen M, Getz ML, Underhill K, Kuo C, Guthrie KM. A Qualitative Systematic Review of Women's Experiences Using Contraceptive Vaginal Rings: Implications for New Technologies. INTERNATIONAL PERSPECTIVES ON SEXUAL AND REPRODUCTIVE HEALTH 2019; 45:25-34. [PMID: 31592770 DOI: 10.1363/45e7619] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
CONTEXT Vaginal rings are available for contraception and hormone replacement, and are being developed as HIV/STD or multipurpose prevention technologies. A comprehensive understanding of women's expectations of and experiences with rings is urgently needed to inform product development and to optimize ring use. METHODS Three databases (PubMed, Global Health and CINAHL) were searched for English-language, peer-reviewed articles published between January 1996 and November 2017 that reported qualitative data on barriers to and facilitators of use of female-controlled contraceptive methods. Data on study methods, findings and conclusions pertaining to contraceptive rings were extracted, organized and analyzed. RESULTS Twenty-six articles, all published since 2008, met the inclusion criteria. Seven studies focused largely or entirely on rings (and involved current, former or potential users), while the others focused on other contraceptive methods but included ring-specific data. Familiarity with the ring was low, and women commonly had initial concerns about the method-often related to insertion and removal, cleanliness and discomfort with touching their vagina-that were typically overcome over time. Other major themes were issues related to ring use and discontinuation, the importance of ring-related properties and characteristics, and considerations related to sexual partners and health care providers. CONCLUSIONS Qualitative data have the potential to inform ring design and promotion. Future research should further explore women's expectations and experiences with the ring, the value of involving male partners in ring evaluation, and evaluation of interventions to improve patient-provider communication concerning ring choice and use.
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Affiliation(s)
- Sara E Vargas
- Research scientist, Centers for Behavioral and Preventive Medicine, The Miriam Hospital, Providence, RI,
| | - Miriam M Midoun
- Graduate student, Department of Comparative Human Development, University of Chicago
| | - Melissa Guillen
- Project director, Centers for Behavioral and Preventive Medicine, The Miriam Hospital, Providence, RI
| | | | - Kristen Underhill
- Associate professor, Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York
| | - Caroline Kuo
- Associate professor (research), Department of Behavioral and Social Sciences, School of Public Health, Brown University, Providence, RI
| | - Kate M Guthrie
- Senior research scientist, Centers for Behavioral and Preventive Medicine, The Miriam Hospital, Providence, RI
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Vargas SE, Midoun MM, Guillen M, Getz ML, Underhill K, Kuo C, Guthrie KM. A Qualitative Systematic Review of Women's Experiences Using Contraceptive Vaginal Rings: Implications for New Technologies. PERSPECTIVES ON SEXUAL AND REPRODUCTIVE HEALTH 2019; 51:71-80. [PMID: 31108027 PMCID: PMC6662569 DOI: 10.1363/psrh.12103] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Revised: 01/28/2019] [Accepted: 03/26/2019] [Indexed: 06/09/2023]
Abstract
CONTEXT Vaginal rings are available for contraception and hormone replacement, and are being developed as HIV/STD or multipurpose prevention technologies. A comprehensive understanding of women's expectations of and experiences with rings is urgently needed to inform product development and to optimize ring use. METHODS Three databases (PubMed, Global Health and CINAHL) were searched for English-language, peer-reviewed articles published between January 1996 and November 2017 that reported qualitative data on barriers to and facilitators of use of female-controlled contraceptive methods. Data on study methods, findings and conclusions pertaining to contraceptive rings were extracted, organized and analyzed. RESULTS Twenty-six articles, all published since 2008, met the inclusion criteria. Seven studies focused largely or entirely on rings (and involved current, former or potential users), while the others focused on other contraceptive methods but included ring-specific data. Familiarity with the ring was low, and women commonly had initial concerns about the method-often related to insertion and removal, cleanliness and discomfort with touching their vagina-that were typically overcome over time. Other major themes were issues related to ring use and discontinuation, the importance of ring-related properties and characteristics, and considerations related to sexual partners and health care providers. CONCLUSIONS Qualitative data have the potential to inform ring design and promotion. Future research should further explore women's expectations and experiences with the ring, the value of involving male partners in ring evaluation, and evaluation of interventions to improve patient-provider communication concerning ring choice and use.
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Affiliation(s)
- Sara E. Vargas
- Research scientist, Centers for Behavioral and Preventive Medicine, The Miriam Hospital, Providence, RI
| | - Miriam M. Midoun
- Graduate student, Department of Comparative Human Development, University of Chicago
| | - Melissa Guillen
- Project director, Centers for Behavioral and Preventive Medicine, The Miriam Hospital, Providence, RI
| | | | - Kristen Underhill
- Associate professor, Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York
| | - Caroline Kuo
- Associate professor (research), Department of Behavioral and Social Sciences, School of Public Health, Brown University, Providence
| | - Kate M. Guthrie
- Senior research, Centers for Behavioral and Preventive Medicine, The Miriam Hospital, Providence, RI
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Montgomery ET, Beksinska M, Mgodi N, Schwartz J, Weinrib R, Browne EN, Mphili N, Musara P, Jaggernath M, Ju S, Smit J, Chirenje ZM, Doncel GF, van der Straten A. End-user preference for and choice of four vaginally delivered HIV prevention methods among young women in South Africa and Zimbabwe: the Quatro Clinical Crossover Study. J Int AIDS Soc 2019; 22:e25283. [PMID: 31069957 PMCID: PMC6506690 DOI: 10.1002/jia2.25283] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 04/05/2019] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Adherence to HIV prevention methods is a challenge, particularly for young women in Sub-Saharan Africa. End-user research during product development can inform modifiable factors to increase future uptake and adherence. METHODS Preferences for four vaginally inserted placebo HIV prevention methods were assessed among Zimbabwean and South African young women using a crossover clinical design. For each of months 1 to 4, participants were asked to use a pre-coitally inserted film, insert (vaginal tablet) and gel once/week for a month, and a monthly ring in a randomly assigned sequence. Participants subsequently chose one preferred product to use as directed for the final study month. Women ranked the four products from most preferred to least preferred at enrolment and after trying all products. RESULTS A total of 200 women aged 18 to 30 (mean 23) were enrolled; 178 (89%) completed follow-up. At baseline, 41% of participants selected the gel as their most preferred product and 61% selected the ring as least preferred. During the crossover period, most (82% to 85%) self-reported using each product at least once a week, although only half the time with sex. Objective biomarker data confirmed adequate use of all products. After trying each product, rankings changed with the film, ring, insert and gel being selected by 29%, 28%, 26% and 16% respectively. Choice varied significantly by country (p < 0.001): More Zimbabweans chose the film (45%), and more South Africans chose the insert (34%). Among women choosing the ring, 88% reported using it every time with sex. By contrast, self-reported adherence was lower for "on-demand" (coitally associated) products, with 40% to 55% using them every time during sex (p < 0.001). CONCLUSIONS Preferences for these four dosage forms varied before and after use, and both within and across countries - there was no clear favourite - indicating the need for a range of options for end-users The ring's popularity increased the most with use, was the second most preferred delivery system, and per self-report, provided more coverage during sex. These end-user perspectives provide important information to product developers and funding agencies.
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Affiliation(s)
| | - Mags Beksinska
- MRU (MatCH Research Unit)Faculty of Health SciencesUniversity of the WitwatersrandDurbanSouth Africa
| | - Nyaradzo Mgodi
- University of Zimbabwe College of Health Sciences Clinical Trials Research CentreHarareZimbabwe
| | | | - Rachel Weinrib
- Women's Global Health ImperativeRTI InternationalSan FranciscoCAUSA
| | - Erica N Browne
- Women's Global Health ImperativeRTI InternationalSan FranciscoCAUSA
| | - Nonhlanhla Mphili
- MRU (MatCH Research Unit)Faculty of Health SciencesUniversity of the WitwatersrandDurbanSouth Africa
| | - Petina Musara
- University of Zimbabwe College of Health Sciences Clinical Trials Research CentreHarareZimbabwe
| | - Manjeetha Jaggernath
- MRU (MatCH Research Unit)Faculty of Health SciencesUniversity of the WitwatersrandDurbanSouth Africa
| | - Susan Ju
- CONRADEastern Virginia Medical SchoolArlingtonVAUSA
| | - Jenni Smit
- MRU (MatCH Research Unit)Faculty of Health SciencesUniversity of the WitwatersrandDurbanSouth Africa
| | - Z Mike Chirenje
- University of Zimbabwe College of Health Sciences Clinical Trials Research CentreHarareZimbabwe
| | | | - Ariane van der Straten
- Women's Global Health ImperativeRTI InternationalSan FranciscoCAUSA
- Center for AIDS Prevention StudiesDepartment of MedicineUniversity of CaliforniaSan FranciscoCAUSA
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Laborde ND, Leslie J, Krogstad E, Morar N, Mutero P, Etima J, Woodrow K, van der Straten A. Perceptions of the "Fabric" - An exploratory study of a novel multi-purpose technology among women in Sub Saharan Africa. PLoS One 2018; 13:e0204821. [PMID: 30379839 PMCID: PMC6209182 DOI: 10.1371/journal.pone.0204821] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 09/15/2018] [Indexed: 11/18/2022] Open
Abstract
Background HIV and pregnancy prevention are dual health priorities for women, and particularly in sub-Saharan Africa. Drug-eluting fibers offer a dosage form that combines HIV prevention and contraception, but early understanding of end-user perspectives is critical to avoid misalignment between products being developed and preferred product attributes. Methods Focus group discussions (FGDs) were conducted in South Africa, Uganda and Zimbabwe, among 55 women who had used vaginal products in previous trials. Participants were given the opportunity to feel a sample of electrospun nanofiber (the fabric), see how it dissolves, and give feedback on shape, size and other attributes. Women were also asked to compare the fabric to vaginal gel and film. Results Three key themes regarding the acceptability of the fabric emerged: 1) look and feel of the product undissolved vs. undissolved, 2) expected effect on sex, and 3) convenience and ease of use. Upon being presented with the fabric, women were initially distrustful, seeing it as undesirable for vaginal insertion. Women generally approved of the product once they saw it dissolve. However, they stressed the importance of the product not interfering with sex by altering the vaginal environment. Women also reacted favorably to the perceived convenience of the fabric, particularly with regards to storage and transport, perceived ease of insertion and use, and dosing regimen. Conclusion Multipurpose prevention technologies, and nanofibers in particular, should be developed with an eye to minimizing impact on sex while maximizing convenience, and presented in such a way as to emphasize non-abrasiveness and ease of dissolution.
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Affiliation(s)
- Nicole D. Laborde
- Women’s Global Health Imperative, RTI International, San Francisco, CA, United States of America
| | - Jonah Leslie
- Women’s Global Health Imperative, RTI International, San Francisco, CA, United States of America
| | - Emily Krogstad
- Women’s Global Health Imperative, RTI International, San Francisco, CA, United States of America
- Department of Bioengineering, University of Washington, Seattle, WA, United States of America
| | - Neetha Morar
- South Africa Medical Research Council, Durban, South Africa
| | - Prisca Mutero
- UZ-UCSF Collaborative Research Programme, Harare, Zimbabwe
| | - Juliane Etima
- Makerere University-Johns Hopkins University Research Unit, Kampala, Uganda
| | - Kim Woodrow
- Department of Bioengineering, University of Washington, Seattle, WA, United States of America
| | - Ariane van der Straten
- Women’s Global Health Imperative, RTI International, San Francisco, CA, United States of America
- Center for AIDS Prevention Studies, Department of Medicine, University of California San Francisco, San Francisco, CA, United States of America
- * E-mail:
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Marino-Merlo F, Macchi B, Armenia D, Bellocchi MC, Ceccherini-Silberstein F, Mastino A, Grelli S. Focus on recently developed assays for detection of resistance/sensitivity to reverse transcriptase inhibitors. Appl Microbiol Biotechnol 2018; 102:9925-9936. [PMID: 30269214 DOI: 10.1007/s00253-018-9390-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 09/07/2018] [Accepted: 09/09/2018] [Indexed: 12/23/2022]
Abstract
The biology of HIV is rather complex due to high rate of replication, frequent recombination, and introduction of mutations. This gives rise to a number of distinct variants referred as quasispecies. In addition, the latency within reservoir allows the periodic reactivation of virus replication. The rapid replication of HIV allows immune response escape and establishment of resistance to therapy that can be acquired through drug selection and/or transmitted among individuals. This prompted, over the years, the development of a range of assays aimed to determine drug resistance and sensitivity, to be used both in clinical practice and in antiviral research. Reverse transcriptase (RT) inhibitors have an eminent place among the anti-HIV drugs, being constantly present from the beginning until today in the most commonly used antiviral regimens. This mini-review seeks to provide an up-to-date overview of recent efforts in developing even more reliable and simple methods, of both genotypic and phenotypic types, for specifically detecting drug resistance and sensitivity to RT inhibitors.
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Affiliation(s)
| | - Beatrice Macchi
- Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Daniele Armenia
- Department of Experimental Medicine and Surgery, University of Rome "Tor Vergata", Rome, Italy
| | | | | | - Antonio Mastino
- Department of Chemical, Biological, Pharmaceutical, and Environmental Sciences, University of Messina, Via F. Stagno d'Alcontres 31, 98166, Messina, Italy. .,The Institute of Translational Pharmacology, CNR, Rome, Italy.
| | - Sandro Grelli
- Department of Experimental Medicine and Surgery, University of Rome "Tor Vergata", Rome, Italy
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Montgomery ET, Stadler J, Naidoo S, Katz AWK, Laborde N, Garcia M, Reddy K, Mansoor LE, Etima J, Zimba C, Chitukuta M, Soto-Torres L. Reasons for nonadherence to the dapivirine vaginal ring: narrative explanations of objective drug-level results. AIDS 2018; 32:1517-1525. [PMID: 29957723 PMCID: PMC6230508 DOI: 10.1097/qad.0000000000001868] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE(S) MTN-020/ASPIRE trial and IPM-027/Ring Study recently proved the dapivirine vaginal ring was safe and effective with consistent use. To optimize the ring's impact, the barriers and facilitators to ring adherence must be understood and addressed. METHODS Former ASPIRE participants were stratified by age group (18-21; 22-45) and randomly selected at seven sites in Malawi, South Africa, Uganda and Zimbabwe, 12-17 months after trial exit. Using in-depth interviews or focus group discussions, ring use barriers were explored using structured guides and visual tools including individual-level depictions of dapivirine levels detected in plasma and returned rings. RESULTS A total of 187 were enrolled; 37% were 18-21 years when they began ASPIRE. Most (75%) had drug-level results, suggesting inconsistent ring use throughout ASPIRE. Participants viewed themselves as adherent, while simultaneously describing regular instances and reasons for ring removal (e.g. for sex or menses). Less adherent women reported fears that partners would oppose the ring or feel it during sex. High adherers expressed altruistic motivations for ring use. Women of all ages attributed young women's nonadherence to their tendency to be less 'serious' about the future, HIV prevention and the study; motivated predominantly by benefits; more fearful of fertility-related consequences; and to having less relationship control. CONCLUSION When presented with objective adherence data, participants provided reasons for intermittent ring use, while simultaneously portraying themselves as consistent ring users. Further research is needed to understand how women could use the ring in a way that fits into the context of their relationships and their lives while still conferring adequate HIV prophylaxis.
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Affiliation(s)
| | - Jonathan Stadler
- Department of Anthropology and Development Studies, University of Johannesburg, Johannesburg
| | - Sarita Naidoo
- HIV Prevention Research Unit, South African Medical Research Council, Durban, South Africa
| | - Ariana W K Katz
- Women's Global Health Imperative, RTI International, San Francisco, California, USA
| | - Nicole Laborde
- Women's Global Health Imperative, RTI International, San Francisco, California, USA
| | | | - Krishnaveni Reddy
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, School of Clinical Medicine, Johannesburg
| | - Leila E Mansoor
- Centre for the AIDS Programme of Research in South African (CAPRISA), Durban, South Africa
| | - Juliane Etima
- Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda
| | | | - Miria Chitukuta
- University of Zimbabwe College of Health Sciences Clinical Trials Unit (UZCHS-CTU), Harare, Zimbabwe
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