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Eakle R, Bourne A, Jarrett C, Stadler J, Larson H. Motivations and barriers to uptake and use of female-initiated, biomedical HIV prevention products in sub-Saharan Africa: an adapted meta-ethnography. BMC Public Health 2017; 17:968. [PMID: 29258455 PMCID: PMC5738143 DOI: 10.1186/s12889-017-4959-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 11/29/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Women bear a disproportionate burden of HIV throughout the world prompting extensive research into HIV prevention products for women which has met with varied success. With an aim of informing future policy and programming, this review examines the barriers and motivations to the uptake and use of female initiated products in sub-Saharan countries. METHODS We conducted a systematic review as an adapted meta-ethnography of qualitative data focused on actual use of products. After deduplication, 10,581 and 3861 papers in the first and second round respectively were screened. Following the PRISMA guidance, 22 papers were selected and synthesized using Malpass's definitions of first, second, and third order constructs. First order constructs, consisting of participant data published in the selected papers, were extracted and categorised by second and third order constructs for analysis. A weight of evidence review was conducted to compare and assess quality across the papers. RESULTS The 22 papers selected span 11 studies in 13 countries. We derived 23 s order constructs that were translated into seven overarching third order constructs: Sexual Satisfaction, Trust, Empowerment and Control, Personal Well-being, Product use in the social-cultural environment, Practical Considerations, Risk Reduction, and Perceptions of Efficacy. Relationships and trust were seen to be as or more important for product use as efficacy. These constructs reveal an inherent inter-relationality where decision making around HIV prevention uptake and use cannot be binary or mono-faceted, but rather conducted on multiple levels. We developed a framework illustrating the central and proximal natures of constructs as they relate to the decision-making process surrounding the use of prevention products. CONCLUSIONS Health systems, structural, and individual level HIV prevention interventions for women should adopt a holistic approach. Interventions should attend to the ways in which HIV prevention products can serve to reduce the likelihood of HIV transmission, as well as help to protect partnerships, enhance sexual pleasure, and take into account woman's roles in the social environment. Stigma, as well as sexuality, is likely to continue to influence product uptake and use and should be prominently taken into account in large-scale interventions. TRIAL REGISTRATION Not applicable.
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Affiliation(s)
- Robyn Eakle
- Wits Reproductive Health & HIV Institute, University of the Witwatersrand, Hillbrow Health Precinct, 22 Esselen Street, Hillbrow, Johannesburg, 2001, South Africa.
- Department of Social and Environmental Health Research, Sigma Research, London School of Hygiene and Tropical Medicine, London, UK.
| | - Adam Bourne
- Australian Research Centre in Sex, Health & Society, La Trobe University, Melbourne, Australia
| | - Caitlin Jarrett
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
- Swiss Tropical and Public Health Institute (Swiss TPH), Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Jonathan Stadler
- Wits Reproductive Health & HIV Institute, University of the Witwatersrand, Hillbrow Health Precinct, 22 Esselen Street, Hillbrow, Johannesburg, 2001, South Africa
- Department of Anthropology and Development Studies, University of Johannesburg, Johannesburg, South Africa
| | - Heidi Larson
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
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O'Cathain A, Hoddinott P, Lewin S, Thomas KJ, Young B, Adamson J, Jansen YJ, Mills N, Moore G, Donovan JL. Maximising the impact of qualitative research in feasibility studies for randomised controlled trials: guidance for researchers. Pilot Feasibility Stud 2015; 1:32. [PMID: 27965810 PMCID: PMC5154038 DOI: 10.1186/s40814-015-0026-y] [Citation(s) in RCA: 222] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Accepted: 08/13/2015] [Indexed: 01/02/2023] Open
Abstract
Feasibility studies are increasingly undertaken in preparation for randomised controlled trials in order to explore uncertainties and enable trialists to optimise the intervention or the conduct of the trial. Qualitative research can be used to examine and address key uncertainties prior to a full trial. We present guidance that researchers, research funders and reviewers may wish to consider when assessing or undertaking qualitative research within feasibility studies for randomised controlled trials. The guidance consists of 16 items within five domains: research questions, data collection, analysis, teamwork and reporting. Appropriate and well conducted qualitative research can make an important contribution to feasibility studies for randomised controlled trials. This guidance may help researchers to consider the full range of contributions that qualitative research can make in relation to their particular trial. The guidance may also help researchers and others to reflect on the utility of such qualitative research in practice, so that trial teams can decide when and how best to use these approaches in future studies.
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Affiliation(s)
- Alicia O'Cathain
- Medical Care Research Unit, School of Health and Related Research, University of Sheffield, Regent Street, Sheffield, S1 4DA UK
| | - Pat Hoddinott
- Primary Care, Nursing Midwifery and Allied Health Professionals Research Unit, University of Stirling, Stirling, FK9 4LA Scotland UK
| | - Simon Lewin
- Global Health Unit, Norwegian Knowledge Centre for the Health Services, Oslo, Norway ; Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Kate J Thomas
- Medical Care Research Unit, School of Health and Related Research, University of Sheffield, Regent Street, Sheffield, S1 4DA UK
| | - Bridget Young
- Institute of Psychology, Health and Society, University of Liverpool, Waterhouse Building, Block B, Brownlow Street, Liverpool, L69 3GL UK
| | - Joy Adamson
- Department of Health Sciences, University of York, Seebohm Rowntree Building, Heslington, York, YO10 5DD UK
| | - Yvonne Jfm Jansen
- Behavioural and Societal Sciences, Work, Health & Care, Schoemakerstraat 97 (Gebouw A), Delft, 2628 VK Netherlands
| | - Nicola Mills
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS UK
| | - Graham Moore
- Centre for the Development and Evaluation of Complex Interventions for Public Health Improvement, Cardiff University, Cardiff, CF10 3XQ UK
| | - Jenny L Donovan
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS UK
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The implications of post-coital intravaginal cleansing for the introduction of vaginal microbicides in South Africa. AIDS Behav 2014; 18:297-310. [PMID: 24337726 PMCID: PMC3905171 DOI: 10.1007/s10461-013-0676-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Post-coital intravaginal cleansing (IVC) could counteract the protective effect of a vaginal microbicide. IVC less than 1 h after sex is discouraged in most microbicide trials. During a microbicide trial in KwaZulu-Natal, we collected quantitative data on post-coital IVC. We discussed IVC during in-depth-interviews (IDIs) and focus-group discussions (FGDs) with women enrolled in the trial, and during FGDs with community members. Nearly one-third (336/1,143) of women reported IVC less than an hour after sex. In multivariate analysis, post-coital IVC was associated with younger age, larger household size, greater sexual activity, consistent gel use, and clinic of enrolment. During IDIs and FGDs, respondents described post-coital IVC as a common hygiene practice motivated by the need to remove semen, vaginal fluids and sweat, although this practice may be amenable to change in the context of microbicide use. We need to consider strategies for influencing post-coital IVC practices in future microbicide trials and delivery programmes.
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Crosby RA, Ricks J, Young A. Condom migration resulting from circumcision, microbicides and vaccines: brief review and methodological considerations. Sex Health 2012; 9:96-102. [PMID: 22348637 DOI: 10.1071/sh11091] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2011] [Accepted: 09/13/2011] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To provide an updated review of condom migration as a means of highlighting methodological issues for future studies of this behavioural issue. METHODS Electronic searches of PubMed, MEDLINE and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases were carried out in October 2010 and updated in January 2011 for English-language articles published from 1994 onward. RESULTS Evidence addressing condom migration from microbicides and vaccines is vastly underdeveloped, simply because these products are still experimental. In contrast, the more advanced evidence regarding male circumcision is hopeful because it suggests that migration may not be an overwhelming issue. Nonetheless, the entire body of empirical evidence on this question could be substantially expanded and improved. CONCLUSION Until stronger evidence suggests that condom migration is unlikely, it is important to be mindful of the potential for condom migration to occur in response to biomedical interventions (circumcision, microbicides and vaccines).
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Affiliation(s)
- Richard A Crosby
- College of Public Health, University of Kentucky, 111 Washington Avenue, Lexington, KY 40536-0003, USA.
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Kacanek D, Dennis A, Sahin-Hodoglugil NN, Montgomery ET, Morar N, Mtetwa S, Nkala B, Phillip J, Watadzaushe C, van der Straten A. A qualitative study of obstacles to diaphragm and condom use in an HIV prevention trial in sub-Saharan Africa. AIDS EDUCATION AND PREVENTION : OFFICIAL PUBLICATION OF THE INTERNATIONAL SOCIETY FOR AIDS EDUCATION 2012; 24:54-67. [PMID: 22339145 DOI: 10.1521/aeap.2012.24.1.54] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Consistent condom use and the substitution of condoms with potential HIV prevention methods of lower or unknown effectiveness are important concerns in the development of new prevention technologies. This qualitative study explored obstacles to consistent condom use with the diaphragm in MIRA, an HIV prevention trial in South Africa and Zimbabwe. We conducted 26 focus group discussions (FGDs) with 206 women and 7 FGDs and 10 in-depth interviews with 41 male partners of intervention-arm women. The belief that the diaphragm/gel prevented HIV, women's difficulties negotiating condom use, and men's unawareness that using the products together was recommended were obstacles to consistent condom use with the diaphragm/gel. Concerns about protection from HIV and pregnancy, recognition that the diaphragm was not yet proven to prevent HIV or sexually transmitted infections, and the trial context were facilitators. Understanding selective study product use in HIV prevention trials may inform improved adherence counseling and male involvement strategies.
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Affiliation(s)
- Deborah Kacanek
- Department of Biostatistics, Harvard School of Public Health, Boston, MA 02115, USA.
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Turner AN, Feldblum P, Hoke TH. Condom use and sexually transmitted infections among Malagasy sex workers. Int J STD AIDS 2011; 22:552-7. [DOI: 10.1258/ijsa.2011.010311] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
We evaluated whether use of a short- or longer-term recall period for condom use was superior for assessing risk of acquisition of incident sexually transmitted infection (STI). Female sex workers ( n = 1000) in Madagascar took part in a randomized trial comparing counselling strategies for male and female condom promotion. We explored associations between women's self-reported condom use with clients and non-paying partners and incident STI, examining both short-term recall (last sex act) and longer-term recall (over the past month and year). Self-reported condom use was generally not associated with reduced STI risk, whether measured at the last act or over longer time periods; with clients or non-paying partners; and through unadjusted and adjusted modelling. No condom use measure (short versus longer time periods, with one or both partner types) was strongly predictive of STI, suggesting poor validity.
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Affiliation(s)
- A N Turner
- Division of Infectious Diseases, Department of Internal Medicine, The Ohio State University, Columbus, OH
| | - P Feldblum
- Family Health International, Durham, NC, USA
| | - T H Hoke
- Family Health International, Durham, NC, USA
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Penman-Aguilar A, Legardy-Williams J, Turner AN, Rabozakandriana TOO, Williams D, Razafindravoavy S, Behets F, Van Damme K, Jamieson DJ. Effect of treatment assignment on intravaginal cleansing in a randomized study of the diaphragm with candidate microbicide. J Womens Health (Larchmt) 2011; 20:187-95. [PMID: 21314445 DOI: 10.1089/jwh.2010.2143] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Intravaginal cleansing may predispose women to adverse health outcomes and may interfere with the effectiveness and safety of female-initiated methods for preventing sexually transmitted infections (STIs). In a 4-week randomized study of 192 Malagasy sex workers, we evaluated associations between self-reported intravaginal cleansing and randomization assignment: diaphragm with viscous candidate microbicide gel (Acidform™, TOPCAD, Chicago, IL, licensed to Instead, Coppell, TX), diaphragm with placebo hydroxyethylcellulose gel (HEC, ReProtect LLC, Baltimore, MD), Acidform alone, or HEC alone. METHODS Women were counseled to avoid intravaginal cleansing and were blinded to gel assignment. We evaluated changes in self-reported intravaginal cleansing across the study and assessed the effects of treatment assignment and covariates on frequent (more than once daily) intravaginal cleansing. Significant predictors in domain-specific models were evaluated in an all-domain multiple regression model. RESULTS The proportion of women reporting intravaginal cleansing decreased from baseline (97%) to week 1 (82%) (p < 0.001). Self-reported frequent intravaginal cleansing decreased from baseline (87% to 56%) during the same time period (p < 0.001). In adjusted analyses, the Acidform-diaphragm group had 60% lower odds of frequent intravaginal cleansing during the study (odds ratio [OR] 0.4, 95% confidence interval [CI] 0.2-0.8) compared to the control group (HEC only). HEC-diaphragm and Acidform only users did not differ from controls. Living on the coast of Madagascar, not cohabiting, frequent intravaginal cleansing at enrollment, and high coital frequency predicted frequent intravaginal cleansing during follow-up. CONCLUSIONS Gel characteristics and the diaphragm's presence likely influenced women's cleansing. Viscous gel delivered by a cervical barrier (such as a diaphragm) may minimize the likelihood of frequent intravaginal cleansing.
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Affiliation(s)
- Ana Penman-Aguilar
- Women's Health and Fertility Branch, Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia 30341, USA.
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Behavioral considerations for engaging youth in HIV clinical research. J Acquir Immune Defic Syndr 2010; 54 Suppl 1:S25-30. [PMID: 20571420 DOI: 10.1097/qai.0b013e3181e15c22] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
From both scientific and ethical perspectives, it is important that youth be enrolled in biomedical HIV prevention clinical trials. At the same time, adolescents, as minors, are considered a vulnerable population requiring particular attention to the reduction of potential harm associated with participation in such trials. In this article, we review the evidence supporting enrollment of youth in HIV clinical trials, including data on HIV infection rates, sexual behavior, and cognitive, psychosocial, and neurophysiological development. Next, we address the potential risks associated with clinical trial participation, with a focus on the concept of preventive misconception, the tendencies to (1) overestimate the probability of assignment to the experimental condition, as opposed to the placebo, and (2) assume that the experimental intervention is efficacious. Finally, we discuss targeted interventions to reduce preventive misconception and the importance of developing and testing adolescent-friendly risk-reduction interventions that are tailored to the structure and time frame of a biomedical HIV prevention clinical trial. The very issues that make inclusion of youth in HIV prevention clinical trials necessary also demand that particularly intensive efforts be made to protect participating minors from the harm that could accrue from a clinical trial.
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Vaginal practices and associations with barrier methods and gel use among Sub-Saharan African women enrolled in an HIV prevention trial. AIDS Behav 2010; 14:590-9. [PMID: 20352318 PMCID: PMC2865639 DOI: 10.1007/s10461-010-9690-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Vaginal practices may interfere with the use and/or the effectiveness of female-initiated prevention methods. We investigated whether vaginal practices differed by randomization group in a phase III trial of the diaphragm with lubricant gel (MIRA) in Sub-Saharan Africa (n = 4925), and if they were associated with consistent use of study methods. At baseline, vaginal practices were commonly reported: vaginal washing (82.77%), wiping (56.47%) and insertion of dry or absorbent materials (20.58%). All three practices decreased during the trial. However, women in the intervention group were significantly more likely to report washing or wiping during follow-up compared to those in the control group. Additionally, washing, wiping, and insertion, were all independently and inversely associated with consistent diaphragm and gel use and with condom use as well, regardless of study arm. A better understanding of the socio-cultural context in which these practices are embedded could improve educational strategies to address these potentially modifiable behaviors, and may benefit future HIV prevention interventions of vaginal methods.
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Adherence to diaphragm use for infection prevention: a prospective study of female sex workers in Kenya. Infect Dis Obstet Gynecol 2010; 2009:420196. [PMID: 20224648 PMCID: PMC2833308 DOI: 10.1155/2009/420196] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2009] [Revised: 11/16/2009] [Accepted: 12/21/2009] [Indexed: 11/23/2022] Open
Abstract
Objective. To assess adherence to and acceptability of the diaphragm among 140 female sex workers in Kenya in a 6-month prospective study. Methods. At baseline and bimonthly visits, participants were interviewed on diaphragm knowledge, attitude, and practices. We used principal component analysis and logistic regression to identify predictors of consistent use. Results. At 50% of 386 bimonthly visits, women reported consistently using a diaphragm with all partners during the preceding 2 weeks. Consistent use was significantly higher at the 6-month than the 2-month visit. Women reported less covert use with “helping” (regular sex partners to whom she could go for help or support) than with “other” partners. Perceptions that diaphragms are easier to use than condoms and that their lack of coital interruption is important were associated with consistent diaphragm use with both partner types. Partner support of diaphragm use is correlated with consistent use with “helping” partners only while higher parity, consistent condom use, and perceived lack of need of condoms as a benefit of diaphragms were associated with consistent use with “other” partners. Conclusions. Diaphragm acceptance among female sex workers in Nairobi was high. Future studies should distinguish between partner types when evaluating diaphragm adherence.
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van der Straten A, Sahin-Hodoglugil N, Clouse K, Mtetwa S, Chirenje MZ. Feasibility and potential acceptability of three cervical barriers among vulnerable young women in Zimbabwe. JOURNAL OF FAMILY PLANNING AND REPRODUCTIVE HEALTH CARE 2010; 36:13-9. [DOI: 10.1783/147118910790290966] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Montgomery ET, Blanchard K, Cheng H, Chipato T, de Bruyn G, Ramjee G, Padian N, van der Straten A. Diaphragm and lubricant gel acceptance, skills and patterns of use among women in an effectiveness trial in Southern Africa. EUR J CONTRACEP REPR 2009; 14:410-9. [DOI: 10.3109/13625180903215430] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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The use of the diaphragm instead of condoms in a phase III diaphragm trial. AIDS Behav 2009; 13:564-72. [PMID: 19085099 DOI: 10.1007/s10461-008-9504-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2008] [Accepted: 11/28/2008] [Indexed: 10/21/2022]
Abstract
The MIRA trial assessed whether providing diaphragm, lubricant gel, and condoms (intervention) compared with condoms alone (control) could reduce HIV incidence among 5,039 Southern African women. Compared with the control group, the cumulative proportion of last sex acts protected by any method was higher in the intervention group (OR = 1.33; 95% CI 1.18, 1.49); however, only 36.3% of last sex acts were protected by both a male condom and a diaphragm, whereas 36.6% were protected by a diaphragm only. Product substitution (ever deciding to use a diaphragm instead of a condom in the previous 3 months) was reported at every visit by 22.4%, at some visits by 60.7%, and at none of the visits by 16.8% of these women. Women at greater risk for infection through their own or their partner's behavior or who believed the diaphragm protected against HIV were more likely to report product substitution at every visit.
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Patterns and Predictors of Adherence to Diaphragm Use in a Phase III Trial in Sub-Saharan Africa: A Trajectory Analysis. J Acquir Immune Defic Syndr 2009; 50:419-26. [DOI: 10.1097/qai.0b013e3181958511] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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The diaphragm and lubricant gel for prevention of cervical sexually transmitted infections: results of a randomized controlled trial. PLoS One 2008; 3:e3488. [PMID: 18941533 PMCID: PMC2567030 DOI: 10.1371/journal.pone.0003488] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2008] [Accepted: 09/17/2008] [Indexed: 11/29/2022] Open
Abstract
Background We evaluated the effectiveness of the Ortho All-Flex Diaphragm, lubricant gel (Replens®) and condoms compared to condoms alone on the incidence of chlamydial and gonococcal infections in an open-label randomized controlled trial among women at risk of HIV/STI infections. Methods We randomized 5045 sexually-active women at three sites in Southern Africa. Participants who tested positive for curable STIs were treated prior to enrollment as per local guidelines. Women were followed quarterly and tested for Chlamydia trachomatis (CT) or Neisseria gonorrhoeae (GC) infection by nucleic-acid amplification testing (Roche Amplicor®) using first-catch urine specimens. STIs detected at follow-up visits were treated. We compared the incidence of first infection after randomization between study arms in both intent-to-treat (ITT) and per-protocol populations. Findings Baseline demographic, behavioral and clinical characteristics were balanced across study arms. Nearly 80% of participants were under 35 years of age. Median follow-up time was 21 months and the retention rate was over 93%. There were 471 first chlamydia infections, 247 in the intervention arm and 224 in the control arm with an overall incidence of 6.2/100 woman-years (wy) (relative hazard (RH) 1.11, 95% Confidence Interval (CI): 0.93–1.33; p = 0.25) and 192 first gonococcal infections, 95 in the intervention arm and 97 in the control arm with an overall incidence of 2.4/100wy (RH 0.98, 95%CI: 0.74–1.30; p = 0.90). Per protocol results indicated that when diaphragm adherence was defined as “always use” since the last visit, there was a significant reduction in the incidence of GC infection among women randomized to the intervention arm (RH 0.61, 95%CI: 0.41–0.91, P = 0.02). Interpretation There was no difference by study arm in the rate of acquisition of CT or GC. However, our per-protocol results suggest that consistent use of the diaphragm may reduce acquisition of GC. Trial Registration ClinicalTrials.gov NCT00121459 [NCT00121459]
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