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Ngure K, Browne EN, Reddy K, Friedland BA, van der Straten A, Palanee-Phillips T, Nakalega R, Gati B, Kalule HN, Siziba B, Soto-Torres L, Nair G, Garcia M, Celum C, Roberts ST. Correlates of Adherence to Oral and Vaginal Pre-exposure Prophylaxis (PrEP) Among Adolescent Girls and Young Women (AGYW) Participating in the MTN-034/REACH Trial. AIDS Behav 2024:10.1007/s10461-024-04382-3. [PMID: 38852114 DOI: 10.1007/s10461-024-04382-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/15/2024] [Indexed: 06/10/2024]
Abstract
We evaluated correlates of adherence to PrEP, including daily oral tenofovir disoproxil fumarate in combination emtricitabine (oral FTC/TDF) and the monthly dapivirine ring (ring)among adolescent girls and young women (AGYW) in the MTN-034/REACH study. We enrolled 247 AGYW aged 16-21 years in South Africa, Uganda and Zimbabwe (ClinicalTrials.gov: NCT03074786). Participants were randomized to the order of oral FTC/TDF or ring use for 6 months each in a crossover period, followed by a 6-month choice period. We assessed potential adherence correlates-individual, interpersonal, community, study, and product-related factors-quarterly via self-report. We measured biomarkers of adherence monthly; high adherence was defined as > 4 mg dapivirine released from returned rings or intracellular tenofovir diphosphate levels ≥ 700 fmol/punch from dried blood spots (DBS). We tested associations between correlates and objective measures of high adherence using generalized estimating equations. High adherence to oral FTC/TDF was significantly associated with having an older primary partner (p = 0.04), not having exchanged sex in the past 3 months (p = 0.02), and rating oral FTC/TDF as highly acceptable (p = 0.003). High ring adherence was significantly associated with unstable housing (p = 0.01), disclosing ring use to a male family member (p = 0.01), and noting a social benefit from study participation (p = 0.03). All associations were moderate, corresponding to about 6%-10% difference in the proportion with high adherence. In our multinational study, correlates of adherence among African AGYW differed for oral FTC/TDF and the ring, highlighting the benefit of offering multiple PrEP options.
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Affiliation(s)
- Kenneth Ngure
- School of Public Health, Jomo Kenyatta University of Agriculture and Technology, Box 19704-00202, Nairobi, Kenya.
- Department of Global Health, University of Washington, Seattle, USA.
| | - Erica N Browne
- Women's Global Health Imperative (WGHI), RTI International, Berkeley, CA, USA
| | - Krishnaveni Reddy
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Ariane van der Straten
- Department of Medicine, Center for AIDS Prevention Studies, University of California, San Francisco, USA
- ASTRA Consulting, Kensington, CA, USA
| | - Thesla Palanee-Phillips
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Rita Nakalega
- Makerere University - Johns Hopkins University Research Collaboration, Kampala, Uganda
| | - Brenda Gati
- Makerere University - Johns Hopkins University Research Collaboration, Kampala, Uganda
| | - Hadijah N Kalule
- Makerere University - Johns Hopkins University Research Collaboration, Kampala, Uganda
| | - Bekezela Siziba
- University of Zimbabwe Clinical Trials Research Centre, Harare, Zimbabwe
| | - Lydia Soto-Torres
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD, USA
| | | | | | - Connie Celum
- Department of Global Health, University of Washington, Seattle, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Sarah T Roberts
- Women's Global Health Imperative (WGHI), RTI International, Berkeley, CA, USA
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Beauchamp G, Hosek S, Donnell D, Chan KCG, Anderson PL, Dye BJ, Mgodi N, Bekker LG, Delany-Moretlwe S, Celum C. The Effect of Disclosure of PrEP Use on Adherence Among African Young Women in an Open-Label PrEP Study: Findings from HPTN 082. AIDS Behav 2024; 28:1512-1521. [PMID: 37768427 PMCID: PMC11069481 DOI: 10.1007/s10461-023-04175-0] [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] [Accepted: 09/09/2023] [Indexed: 09/29/2023]
Abstract
To develop effective PrEP adherence interventions, it is important to understand the interplay between disclosure of pre-exposure prophalxis (PrEP) use, social support, and PrEP adherence. We leveraged the HPTN 082 study conducted among 451 adolescent girls and young women (AGYW) (ages 16 to 25 years, 2016 to 2019) in South Africa and Zimbabwe. Among the 349 who had month three disclosure and PrEP adherence data, 60% (n = 206) felt supported by adults, and 89% (n = 309) disclosed PrEP use to at least one person. PrEP disclosure was not associated with increased adherence, measured by intracellular tenofovir-diphosphate concentrations in dried blood spots. Women who reported having supportive adults, and disclosed to their parents, had higher adherence at 6 months with an increase of 177 fmol/punch (95% CI 12 to 343, t = 2.11, p = 0.04). PrEP interventions that help AGYW identify supportive relationships and effectively communicate the benefits of PrEP may improve PrEP adherence.Clinicaltrials.gov ID number: NCT02732730.
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Affiliation(s)
- Geetha Beauchamp
- Department of Health Systems and Population Health, University of Washington, Seattle, WA, USA.
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, 1100 Fairview Ave. N., Mail Stop M2-C200, Seattle, WA, 98109, USA.
| | - Sybil Hosek
- Department of Psychiatry, Stroger Hospital of Cook County, Chicago, IL, USA
| | - Deborah Donnell
- Department of Health Systems and Population Health, University of Washington, Seattle, WA, USA
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, 1100 Fairview Ave. N., Mail Stop M2-C200, Seattle, WA, 98109, USA
| | - Kwun C G Chan
- Department of Health Systems and Population Health, University of Washington, Seattle, WA, USA
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Peter L Anderson
- Department of Pharmaceutical Sciences, University of Colorado-Anschutz Medical Campus, Aurora, CO, USA
| | | | - Nyaradzo Mgodi
- University of Zimbabwe Clinical Trials Research Centre, Harare, Zimbabwe
| | - Linda-Gail Bekker
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Sinead Delany-Moretlwe
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Connie Celum
- Departments of Global Health, Medicine, and Epidemiology, University of Washington, Seattle, WA, USA
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Agot K, Onyango J, Perry B, Molokwu N, Taylor J, Ngoje D, Corneli A. How men influence young women taking PrEP: perspectives from young women, male partners, and male peers in Siaya county, Western Kenya. BMC Womens Health 2024; 24:218. [PMID: 38570779 PMCID: PMC10993511 DOI: 10.1186/s12905-024-03044-9] [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: 11/15/2023] [Accepted: 03/24/2024] [Indexed: 04/05/2024] Open
Abstract
BACKGROUND Daily oral pre-exposure prophylaxis (PrEP) is an effective HIV prevention option for those who are most vulnerable to HIV infection, especially young women (YW). Objection by or lack of support from male sexual partners has been shown to impact YW's ability to take PrEP consistently. We explored the views of YW, and male partners and male peers of YW in Siaya County, Western Kenya, to illustrate how men influence, and can support, YW in using PrEP. METHODS We used Photovoice to capture the views of YW ages 18-24 who were currently or previously enrolled in the DREAMS program and with current or previous experience taking PrEP. We also captured the views of YW's sexual partners and male peers. The YW completed eight photo assignments that focused on identifying factors influencing their PrEP use, and male participants completed four photo assignments focused on identifying ways men support or hinder YW's PrEP use. Photographs were presented and discussed in same- and mixed-gender groups using the SHOWeD method. YW also participated in in-depth interviews. The analysis focused on identifying themes that described men's influence on YW's PrEP adherence and persistence. RESULTS Among YW, a restricting male influence on PrEP use emerged in the majority of photo assignments such that YW's photographs and discussions revealed that men were more often viewed as barriers than supporters. YW perceived that they had little autonomy over their sexual lives and choice to use PrEP. YW's PrEP use was perceived to be hindered by stigmatizing community narratives that influenced men's support of PrEP use among women. Male participants suggested that men would support YW's PrEP use if PrEP was better promoted in the community and if men were more knowledgeable about its benefits. CONCLUSIONS A lack of support from male partners and peers and stigmatizing community narratives influence YW's PrEP use. Community-based programs should include education about PrEP specifically for male partners and peers of YW to positively influence PrEP use among YW.
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Affiliation(s)
- Kawango Agot
- Impact Research and Development Organization, Mito Jura Road, off Kisumu-Kakamega Highway, Kisumu, 9171 - 40141, Kenya.
| | - Jacob Onyango
- Impact Research and Development Organization, Mito Jura Road, off Kisumu-Kakamega Highway, Kisumu, 9171 - 40141, Kenya
| | - Brian Perry
- Department of Population Health Sciences, Duke University, Durham, NC, USA
| | - Nneka Molokwu
- Department of Population Health Sciences, Duke University, Durham, NC, USA
| | - Jamilah Taylor
- Department of Population Health Sciences, Duke University, Durham, NC, USA
| | - Duncan Ngoje
- Impact Research and Development Organization, Mito Jura Road, off Kisumu-Kakamega Highway, Kisumu, 9171 - 40141, Kenya
| | - Amy Corneli
- Department of Population Health Sciences, Duke University, Durham, NC, USA
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
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Hartmann M, Nyblade L, Otticha S, Marton T, Agot K, Roberts ST. The development of a conceptual framework on PrEP stigma among adolescent girls and young women in sub-Saharan Africa. J Int AIDS Soc 2024; 27:e26213. [PMID: 38379129 PMCID: PMC10879468 DOI: 10.1002/jia2.26213] [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: 06/01/2023] [Accepted: 01/17/2024] [Indexed: 02/22/2024] Open
Abstract
INTRODUCTION Stigma is a well-known barrier to HIV testing and treatment and is an emerging barrier to pre-exposure prophylaxis (PrEP) use. To guide future research, measurement and interventions, we developed a conceptual framework for PrEP stigma among adolescent girls and young women (AGYW) in sub-Saharan Africa, a priority population for PrEP. METHODS A literature review, expert consultations and focus group discussions (FGDs) were conducted to adapt the Health Stigma and Discrimination Framework, describing the stigmatization process nested within the socio-ecological framework. We reviewed all articles on PrEP stigma and on HIV, contraceptive or sexuality stigma among AGYW from 2009 to 2019. Expert consultations were conducted with 10 stigma or PrEP researchers and two Kenyan youth advisory boards to revise the framework. Finally, FGDs were conducted with AGYW PrEP users (4 FGDs; n = 20) and key influencers (14 FGDs; n = 72) in Kenya with the help of a Youth Research Team who aided in FGD conduct and results interpretation. Results from each phase were reviewed and the framework was updated to incorporate new and divergent findings. This was validated against an updated literature search from 2020 to 2023. RESULTS The conceptual framework identifies potential drivers, facilitators and manifestations of PrEP stigma, its outcomes and health impacts, and relevant intersecting stigmas. The main findings include: (1) PrEP stigma is driven by HIV, gender and sexuality stigmas, and low PrEP community awareness. (2) Stigma is facilitated by factors at multiple levels: policy (e.g. targeting of PrEP to high-risk populations), health systems (e.g. youth-friendly service availability), community (e.g. social capital) and individual (e.g. empowerment). (3) Similar to other stigmas, manifestations include labelling, violence and shame. (4) PrEP stigma results in decreased access to and acceptability of PrEP, limited social support and community resistance, which can impact mental health and decrease PrEP uptake and adherence. (5) Stigma may engender resilience by motivating AGYW to think of PrEP as an exercise in personal agency. CONCLUSIONS Our PrEP stigma conceptual framework highlights potential intervention targets at multiple levels in the stigmatization process. Its adoption would enable researchers to develop standardized measures and compare stigma across timepoints and populations as well as design and evaluate interventions.
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Affiliation(s)
- Miriam Hartmann
- Women's Global Health ImperativeRTI InternationalBerkeleyCaliforniaUSA
- Department of Global Public HealthKarolinska InstitutetStockholmSweden
| | - Laura Nyblade
- Women's Global Health ImperativeRTI InternationalBerkeleyCaliforniaUSA
| | | | - Tozoe Marton
- Women's Global Health ImperativeRTI InternationalBerkeleyCaliforniaUSA
| | - Kawango Agot
- Impact Research Development OrganizationKisumuKenya
| | - Sarah T. Roberts
- Women's Global Health ImperativeRTI InternationalBerkeleyCaliforniaUSA
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Roberts ST, Hartmann M, Minnis AM, Otticha SO, Browne EN, Montgomery ET, Agot K. Breaking down relationship barriers to increase PrEP uptake and adherence among adolescent girls and young women in Kenya: safety and preliminary effectiveness results from a pilot cluster-randomized trial. J Int AIDS Soc 2023; 26:e26198. [PMID: 38123866 PMCID: PMC10733161 DOI: 10.1002/jia2.26198] [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: 03/20/2023] [Accepted: 11/28/2023] [Indexed: 12/23/2023] Open
Abstract
INTRODUCTION Oral pre-exposure prophylaxis (PrEP) has the potential to reduce HIV acquisition among adolescent girls and young women (AGYW) in sub-Saharan Africa, a priority population for epidemic control. However, intimate partner violence (IPV) and low relationship power can create significant challenges to PrEP use. The Tu'Washindi intervention aimed to increase PrEP use by addressing relationship- and violence-related barriers among AGYW enrolled in the DREAMS Initiative in Siaya County, Kenya. METHODS Our multi-level, community-based intervention was piloted in a cluster-randomized controlled trial conducted at six DREAMS sites from April to December 2019 (NCT03938818). Three intervention components were delivered over 6 months: an eight-session empowerment-based support club, community sensitization targeted towards male partners and a couples' PrEP education event. Participants were ages 17-24, HIV negative and either eligible for, or already taking, PrEP. Over 6 months of follow-up, we assessed IPV (months 3 and 6) and PrEP uptake and continuation (month 6) through interviewer-administered questionnaires; PrEP adherence was assessed with Wisepill electronic monitoring devices. These outcomes were compared using adjusted Poisson and negative binomial regression models. RESULTS We enrolled 103 AGYW with median age of 22 years (IQR 20-23); one-third were currently taking PrEP and 45% reported IPV in the past 3 months. Retention was 97% at month 6. Compared to the control arm, intervention arm participants were more likely to initiate PrEP, if not already using it at enrolment (52% vs. 24%, aRR 2.28, 95% CI 1.19-4.38, p = 0.01), and those taking PrEP had more days with device openings (25% of days vs. 13%, aRR 1.94, 95% CI 1.16-3.25, p = 0.01). Twenty percent of participants reported IPV during follow-up. There were trends towards fewer IPV events (aIRR 0.66, 95% CI 0.27-1.62, p = 0.37) and fewer events resulting in injury (aIRR 0.21, 95% CI 0.04-1.02, p = 0.05) in the intervention versus control arm. CONCLUSIONS Tu'Washindi shows promise in promoting PrEP uptake and adherence among AGYW without concomitant increases in IPV; however, adherence was still suboptimal. Further research is needed to determine whether these gains translate to increases in the proportion of AGYW with protective levels of PrEP adherence and to evaluate the potential for the intervention to reduce IPV risk.
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Affiliation(s)
- Sarah T. Roberts
- Women's Global Health ImperativeRTI InternationalBerkeleyCaliforniaUSA
| | - Miriam Hartmann
- Women's Global Health ImperativeRTI InternationalBerkeleyCaliforniaUSA
| | | | | | - Erica N. Browne
- Women's Global Health ImperativeRTI InternationalBerkeleyCaliforniaUSA
| | | | - Kawango Agot
- Impact Research and Development OrganizationKisumuKenya
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Young AM, Saidi F, Phanga T, Tseka J, Bula A, Mmodzi P, Pearce LD, Maman S, Golin CE, Mutale W, Chi BH, Hill LM. Male partners' support and influence on pregnant women's oral PrEP use and adherence in Malawi. FRONTIERS IN REPRODUCTIVE HEALTH 2023; 5:1206075. [PMID: 37614700 PMCID: PMC10442580 DOI: 10.3389/frph.2023.1206075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 07/24/2023] [Indexed: 08/25/2023] Open
Abstract
Introduction Daily oral pre-exposure prophylaxis (PrEP) is a safe and effective HIV prevention method for pregnant and postpartum women, but adherence barriers exist. Understanding the role of male partners in supporting PrEP use may inform strategies to support PrEP adherence among pregnant and breastfeeding women. Methods To understand male partners' involvement in women's use of PrEP, we conducted in-depth interviews with pregnant women in Lilongwe, Malawi who had recently decided to use PrEP (n = 30) and their male partners (n = 20) in the context of a PrEP adherence trial. Women were purposively recruited to ensure variation in their partners' HIV status. Interviews were conducted in Chichewa using a semistructured guide. We followed a thematic approach to analyze the interview data. Results Most male partners were receptive to women using PrEP during pregnancy because it eased their fears of the woman and baby acquiring HIV. Men often played a key role in women's PrEP adherence by providing daily reminders and encouragement to adhere to their medication. The majority of women appreciated this support from the men as it lessened the burden of remembering to take their medications daily on their own and aided their adherence. However, several women who lacked male partner support spoke of wanting their partners to be more involved. Many men living with HIV found the mutual support beneficial for their antiretroviral therapy adherence, while men without HIV or with status unknown appreciated knowing that the family was protected. While most men were open to women continuing PrEP beyond the current study, some would only support it if women were still at risk for acquiring HIV. Conclusion In this study, male partners were strongly motivated to support the PrEP adherence of their female partners as a way of ensuring that the pregnant women and unborn babies were protected against HIV. Promoting disclosure and tangible support that arises organically among men may be helpful, but programs to enhance this support and identify ways to support women who do not receive support from their partners or do not wish to disclose their PrEP use to partners may be needed.
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Affiliation(s)
- Alinda M Young
- Department of Maternal and Child Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Women's Global Health Imperative at RTI International, Berkeley, CA, United States
| | - Friday Saidi
- UNC Project-Malawi, Lilongwe, Malawi
- Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | | | | | | | | | - Lisa D Pearce
- Department of Sociology, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Suzanne Maman
- Department of Health Behavior, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Carol E Golin
- Department of Health Behavior, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Wilbroad Mutale
- Department of Health Policy, University of Zambia School of Public Health, Lusaka, Zambia
| | - Benjamin H Chi
- Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Lauren M Hill
- Department of Health Behavior, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
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Hartmann M, Roberts ST, Triplett N, Tenza S, Maboa O, Mampuru L, Mayisela N, Mbewe D, Tolley EE, Reddy K, Palanee-Phillips T, Montgomery ET. Development of a relationship counselling website to identify and mitigate risk of intimate partner violence in the context of women's PrEP use. PLOS DIGITAL HEALTH 2023; 2:e0000329. [PMID: 37578954 PMCID: PMC10424861 DOI: 10.1371/journal.pdig.0000329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 07/18/2023] [Indexed: 08/16/2023]
Abstract
Discreet, accessible interventions are urgently needed to mitigate the risk of intimate-partner violence (IPV) and other relationship barriers that women encounter to using HIV prevention methods such as pre-exposure prophylaxis (PrEP). We adapted a counsellor-administered intervention, CHARISMA, into a mobile-optimized website to enhance accessibility and reduce human resources required for HIV prevention and relationship counseling. Using human-centered design and participatory methods, CHARISMA was adapted through workshops with former CHARISMA in-person intervention participants (n = 14; ages 18-45) and web development 'sprints' combined with cognitive interviews (n = 24). 'CHARISMA mobile' was then beta-tested with 81 women naïve to the in-person intervention. In beta-testing, participants used a 'think aloud' process to provide feedback on ease of use and rated design, functionality, comprehension, confidentiality, safety, and usefulness on a scale of 1 to 5 via a survey. Data were conducted in four rounds, interspersed with rapid assessment according to go/no-go criteria, and website adaptations. The updated website was pilot tested for 'real-world' feasibility and acceptability among 159 women using their own smartphones at a location of their choice. Feedback was measured via surveys and website analytics. Workshops and cognitive interviews generated insights on technology use, contextual adaptations, and confidentiality, which were integrated into the beta version. The beta version met all 'go' criteria and was further adapted for pilot testing. In pilot testing, users found the website was useful (mean rating 4.54 out of 5), safe (4.5 out of 5), and had few concerns about confidentiality (1.75, representing low concern). On average, users rated the website more than 4 stars out of 5. Beta and pilot-testing suggested the smartphone-optimized website was well-accepted, relevant, engaging, feasible to administer, discreet and safe. Results contributed to a refined website, suitable for adaptations to other contexts and further evaluation where outcomes related to PrEP use and relationships should be assessed.
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Affiliation(s)
- Miriam Hartmann
- Women’s Global Health Imperative, RTI International, Berkeley, California, United States of America
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Sarah T. Roberts
- Women’s Global Health Imperative, RTI International, Berkeley, California, United States of America
| | - Noah Triplett
- Women’s Global Health Imperative, RTI International, Berkeley, California, United States of America
| | - Siyanda Tenza
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Onthatile Maboa
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Lydia Mampuru
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Nonkululeko Mayisela
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Dorica Mbewe
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Krishnaveni Reddy
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Thesla Palanee-Phillips
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- University of Washington, Department of Epidemiology; School of Public Health, Seattle, United States of America
| | - Elizabeth T. Montgomery
- Women’s Global Health Imperative, RTI International, Berkeley, California, United States of America
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McLellan-Lemal E, Deaton SR, Betts JE, Ondenge K, Mudhune V, O'Connor SM, Nyagol B, Thurman AR, Doncel GF, Allen SA, Heffron R, Mugo NR. Acceptability of an intravaginal ring for simultaneously preventing HIV infection and pregnancy: Qualitative findings of the Kisumu Combined Ring Study, 2019. Contemp Clin Trials 2022; 122:106935. [PMID: 36162740 DOI: 10.1016/j.cct.2022.106935] [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: 07/31/2021] [Revised: 04/06/2022] [Accepted: 09/20/2022] [Indexed: 01/27/2023]
Abstract
Multipurpose prevention technology intravaginal rings (MPT IVRs) may offer a promising solution for addressing women's multiple sexual and reproductive health needs. We describe MPT IVR acceptability perspectives and examine user experiences of 25 cisgender women aged 18-34 years enrolled in a phase IIa randomized, partially blinded, placebo-controlled evaluation of tenofovir-based IVRs with and without contraceptive co-formulation. All took part in an individual, audio-recorded, semi-structured qualitative interview. A thematic analysis of transcribed interviews was completed in MaxQDA. Participants shared little to no knowledge of or experience with IVRs prior to joining the study. Four MPT IVR themes were identified: physical well-being, method reliability, personal management, and societal endorsement. Commonly cited of concern, but less described as being experienced, were physical discomforts (e.g., painful insertion/removal; inability to carry out daily activities/chores; foreign body sensation; expulsion; sexual interference, or debilitating side effects). Uncertainty regarding efficacy influenced perspectives about intended prevention benefits. Personal choices in managing reproduction and sexual behaviors had to be congruent with sociocultural values and norms for acceptance beyond the individual user level. Participants viewed broader community acceptance as likely to be mixed given community opposition to the use of modern family planning methods. They also shared concerns that IVR use could lead to infertility, especially among nulliparous women, or that it would encourage premarital sex or high-risk sexual behaviors among adolescent and young women. While a MPT IVR may not be suitable for all women, first-hand testimonials could help influence collective receptivity. Additional community acceptability research is needed. Clinical Trial Registration The study is registered at http://ClinicalTrials.gov under the identifier NCT03762382.
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Affiliation(s)
- Eleanor McLellan-Lemal
- Centers for Disease Control and Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Division of HIV/AIDS Prevention, Atlanta, GA, USA
| | | | | | - Ken Ondenge
- Kenya Medical Research Institute, Center for Global Health Research, Kisumu, Kenya
| | - Victor Mudhune
- Kenya Medical Research Institute, Center for Global Health Research, Kisumu, Kenya
| | - Siobhan M O'Connor
- Centers for Disease Control and Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Division of HIV/AIDS Prevention, Atlanta, GA, USA
| | - Beatrice Nyagol
- Kenya Medical Research Institute, Center for Global Health Research, Kisumu, Kenya
| | | | | | - Shannon A Allen
- United States Agency for International Development, Washington, DC, USA
| | - Renee Heffron
- University of Washington, Department of Global Health, International Clinical Research Center, Seattle, WA, USA
| | - Nelly R Mugo
- University of Washington, Department of Global Health, International Clinical Research Center, Seattle, WA, USA; Kenya Medical Research Institute, Center for Clinical Research, Nairobi, Kenya
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Couples' Preferences for "2 in 1" Multipurpose Prevention Technologies to Prevent Both HIV and Pregnancy: Results of a Discrete Choice Experiment in Uganda and Zimbabwe. AIDS Behav 2022; 26:3848-3861. [PMID: 35674885 PMCID: PMC9175528 DOI: 10.1007/s10461-022-03713-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
End-user input early in biomedical product development may optimize design to support high uptake and adherence. We interviewed 400 couples (800 total participants) in Uganda and Zimbabwe to assess their preferences for multipurpose prevention technologies (MPTs) for HIV and pregnancy prevention. Using a discrete choice experiment, couples made a series of choices between hypothetical MPTs, including oral tablets and vaginal rings, inserts, and films and completed an interviewer-administered questionnaire assessing sociodemographic and behavioral measures. Most couples preferred presented MPTs over male condoms. Couples’ MPT choices in both countries were influenced most by the combination of product form and dosing frequency, with monthly dosing preferred over daily. Analysis highlighted differences by country as to which side effects were most important: Ugandan couples placed greater importance on effects on the vaginal environment during sex, whereas Zimbabwean couples placed more importance on changes to menstruation and other side effects (headache, cramps). Couples’ preferences signaled an openness to new product forms and more frequent dosing if preferred characteristics of other attributes were achieved.
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Montgomery ET, Roberts ST, Reddy K, Tolley E, Hartmann M, Wilson E, Mathebula F, Wagner LD, Zissette S, Lanham M, Wilcher R, Baeten JM, Palanee-Phillips T. Integration of a Relationship-focused Counseling Intervention with Delivery of the Dapivirine Ring for HIV Prevention to Women in Johannesburg: Results of the CHARISMA Pilot Study. AIDS Behav 2022; 26:752-763. [PMID: 34546473 PMCID: PMC8840958 DOI: 10.1007/s10461-021-03434-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/10/2021] [Indexed: 12/21/2022]
Abstract
Biomedical, female-initiated HIV prevention methods can help reduce disproportionately high HIV rates among women in sub-Saharan Africa, but male partner resistance and intimate partner violence (IPV) may impact ability to ensure effective use. To support consistent use of the dapivirine vaginal ring (VR), we pilot-tested the impact of the CHARISMA relationship counseling intervention ("CHARISMA") with women enrolled in the multi-site open-label Microbicide Trials Network (MTN) 025/HOPE trial at the Wits Reproductive Health and HIV Research Institute (Wits RHI) site in Johannesburg, South Africa. Lay counselors used a 42-item tool with five subscales to assess relationships and IPV and provide tailored counseling at enrolment, followed by a booster counselling session at Month 1 and follow-up checks at Months 3 and 6. We evaluated potential impact by examining self-reported ring disclosure to partners, partner clinic attendance, self-reported incident social harms (SH) and IPV, and biomarkers of ring adherence at Wits RHI. We subsequently compared these outcomes at three comparator HOPE study sites using multivariable regression models. Comparator study sites were purposively selected as those most similar to Wits RHI for baseline characteristics identified a priori. At Wits RHI, 95 of 96 (99%) HOPE participants enrolled into the CHARISMA pilot study. Mean age was 30, 36.8% lived with a partner, and 85.3% received their partner's financial support. During the six months of pilot study follow-up, participants reported: ring use disclosure to partners at 72.7% visits; 4.3% partners attending the research clinic; one partner-related SH; and 9.5% experienced incident IPV. The mean level of dapivirine released from returned used rings was 3.4 mg (SD 1.56), suggesting moderate adherence. Participants in the CHARISMA pilot had high background prevalence and incidence of IPV but were nevertheless able to adhere to ring use, and some male partners came to the research clinic. In adjusted regression models, compared to Wits RHI, partner clinic attendance was lower at all comparator sites; and significantly so at Site A (aRR 0.12, 95% CI 0.00-0.98). Sites B and C had lower levels of dapivirine released (suggesting lower adherence), but this difference was not significant. Site B women were more likely to report ring disclosure to partners at FU visits (aRR 1.12, 95% CI 1.00-1.25). IPV reported during follow-up was significantly lower at Site B (aRR 0.20, 95% CI 0.04-0.98, p = 0.047). CHARISMA taught women skills to decide on levels of ring-use disclosure to partners or others; therefore it is difficult to interpret differences in ring disclosure to partners with other sites. Similarly, CHARISMA heightened participants' awareness of abuse, possibly increasing IPV reports. Testing CHARISMA under fully-powered controlled conditions will improve understanding of its impact on women's relationships and ability to use female-initiated HIV prevention methods.
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Affiliation(s)
| | - Sarah T Roberts
- Women's Global Health Imperative, RTI International, Berkeley, CA, USA
| | - Krishnaveni Reddy
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Miriam Hartmann
- Women's Global Health Imperative, RTI International, Berkeley, CA, USA
| | - Ellen Wilson
- Women's Global Health Imperative, RTI International, Berkeley, CA, USA
| | - Florence Mathebula
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - L Danielle Wagner
- Women's Global Health Imperative, RTI International, Berkeley, CA, USA
| | | | | | | | - Jared M Baeten
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Thesla Palanee-Phillips
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
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11
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Evidence for use of a healthy relationships assessment tool in the CHARISMA pilot study. PLoS One 2022; 16:e0261526. [PMID: 34972141 PMCID: PMC8719706 DOI: 10.1371/journal.pone.0261526] [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] [Received: 04/16/2021] [Accepted: 12/03/2021] [Indexed: 12/01/2022] Open
Abstract
Introduction The CHARISMA intervention, nested within the MTN-025/HOPE vaginal ring trial in Johannesburg, South Africa, seeks to facilitate women’s use of HIV prevention products by promoting partner dialogue and mitigating intimate partner violence (IPV). We developed “HEART”, a lay counselor-administered relationship assessment tool, for the CHARISMA pilot. The five-scale tool assesses participants’ endorsement of Traditional Values (TV), her HIV Prevention Readiness (HPR) and levels of partner support (PS), abuse and control (PAC), and resistance to HIV prevention (PR), guiding decisions about which of three counselling modules to offer (partner communication/A; ring disclosure/B; and IPV prevention/C). Methods We correlated baseline scores on HEART subscales with a) independent measures of relationship stability, disclosure and IPV to assess construct validity, and b) with specific modules offered to determine how HEART was used in the pilot. We examined changes in HEART scores at three and six months. Finally, we ran separate growth models for each subscale to examine changes in scores, accounting for partnership changes and counseling module(s) received. Results Baseline HEART scores correlated as predicted among subscales and with other measures. Reliabilities for four subscales were 0.75 or higher. Women who disclosed study participation and ring use scored higher on PS and lower on PR. Women experiencing IPV scored lower on PS, and higher on PAC and PR. During the pilot, 82% of women received one and 17% received two or more modules; over half received the IPV module. Women with higher PAC and PR scores were more likely to receive the IPV than the communication or disclosure modules. Over time, the TV, PAC and PR scores decreased, and PS score increased. Receiving the IPV module was associated with a decreased PAC score. Conclusions These data offer preliminary evidence for HEART construct and predictive validity and support its further evaluation to guide implementation and monitor the impact of the CHARISMA intervention in a randomized controlled evaluation.
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Weitzel M, North BB, Waller D. Development of multipurpose technologies products for pregnancy and STI prevention: update on polyphenylene carboxymethylene MPT gel development†. Biol Reprod 2021; 103:299-309. [PMID: 32469052 PMCID: PMC7401404 DOI: 10.1093/biolre/ioaa087] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 05/18/2020] [Accepted: 05/27/2020] [Indexed: 01/06/2023] Open
Abstract
Current modern contraceptives rely heavily on the use of hormones. These birth control drug products, including pills, patches, injections, and IUDS, have been extremely beneficial to millions of women and their families over the past 50 years. But a surprisingly high number of women abandon such modern methods, many because they cannot tolerate the side effects and others because they have medical issues for which hormonal methods are contraindicated. In addition, modern hormonal methods are simply not available to many women. The extent of this problem is steadily becoming more apparent. We present the case for developing simple nonhormonal vaginal products that women can use when needed, ideal products that are multipurpose and offer both contraception and sexually transmitted disease protection. Gel-based vaginal products are particularly well suited for this purpose. Gels are easy to use, highly acceptable to many women, and can be safely formulated to enhance natural vaginal defenses against infection. However, the development of a new chemical entity for this application faces significant technical and regulatory hurdles. These challenges and our solutions are described for polyphenylene carboxymethylene (PPCM), a novel topical drug in a vaginal gel nearing human clinical trials. We have advanced PPCM from benchtop to IND-enabling studies and provide a brief description of the complex development process. We also describe a simple lab assay which can be used as a biomarker for contraceptive activity to enable pharmacodynamic studies in vaginal contraceptive development, both preclinically and in early human clinical trials.
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Affiliation(s)
| | | | - Donald Waller
- Yaso Therapeutics Inc, Scottsdale, AZ, USA.,College of Pharmacy, University of Illinois, Chicago, IL, USA
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Hartmann M, Otticha S, Agot K, Minnis AM, Montgomery ET, Roberts ST. Tu'Washindi na PrEP: Working With Young Women and Service Providers to Design an Intervention for PrEP Uptake and Adherence in the Context of Gender-Based Violence. AIDS EDUCATION AND PREVENTION : OFFICIAL PUBLICATION OF THE INTERNATIONAL SOCIETY FOR AIDS EDUCATION 2021; 33:103-119. [PMID: 33821679 PMCID: PMC8384060 DOI: 10.1521/aeap.2021.33.2.103] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/19/2023]
Abstract
HIV pre-exposure prophylaxis (PrEP) reduces HIV acquisition among adolescent girls and young women (AGYW). Existing evidence suggests that uptake and adherence are low among AGYW and that relationship factors such as gender-based violence (GBV) are important barriers. Through a community-based participatory research (CBPR) process, a youth advisory board (YAB), service providers (SP), and a study team developed the Tu'Washindi na PrEP intervention to support AGYW PrEP use in the context of GBV. The YAB also guided the formative research and interpretation of results. The authors pretested the intervention with SP, AGYW and their partners, and community change agents, and then developed guides for AGYW support clubs, community-based male sensitization sessions, and couples-based events that included formulation of story lines for dramatized PrEP negotiation and information dissemination skills. Stakeholder engagement led to an intervention responsive to AGYW's needs for PrEP support in the context of their relationships, which was evaluated through a 6-month pilot community randomized controlled trial.
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Affiliation(s)
- Miriam Hartmann
- Women's Global Health Imperative, RTI International, Berkeley, California
| | | | - Kawango Agot
- Impact Research Development Organization, Kisumu, Kenya
| | - Alexandra M Minnis
- Women's Global Health Imperative, RTI International, Berkeley, California
| | | | - Sarah T Roberts
- Women's Global Health Imperative, RTI International, Berkeley, California
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14
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Acceptability and feasibility of the CHARISMA counseling intervention to support women's use of pre-exposure prophylaxis: results of a pilot study. BMC WOMENS HEALTH 2021; 21:126. [PMID: 33766006 PMCID: PMC7992829 DOI: 10.1186/s12905-021-01262-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 03/11/2021] [Indexed: 12/31/2022]
Abstract
Background Women may need or seek male partner approval to safely and consistently use oral antiretroviral pre-exposure prophylaxis (PrEP) or vaginal microbicides. We developed CHARISMA, a counseling intervention to support women’s relationships and their ability to consistently use HIV prevention products. Methods In a pilot study with 95 female participants in Johannesburg, South Africa, lay counselors implemented CHARISMA, assessing participants’ relationship(s) with their male partner(s) and barriers or facilitators to HIV prevention method use, and then providing tailored, interactive counseling. We conducted study participant surveys and clinic staff interviews to evaluate CHARISMA’s feasibility and acceptability. Results The CHARISMA pilot study indicates that a two-session relationship counseling intervention with 6-month follow-up to support women’s ability to safely and effectively use vaginal microbicides was generally acceptable and feasible. Most participants thought CHARISMA was relevant, helpful, and about the right length, and that it had a positive impact on their relationships with their partners and their product use. Staff estimated that the intervention took 1.5–2 h to implement at enrollment and 45 min to an hour for the month 1 visit. They thought that overall CHARISMA was generally feasible to implement. Conclusions Findings from this study suggest several lessons learned that may be relevant to others developing interventions supporting women’s use of oral PrEP or vaginal microbicides. The use of lay counselors instead of nurses to deliver counseling appeared to be successful, but the counselors experienced significant stress from hearing about participants’ traumatic experiences and required emotional support to avoid burnout. Although staff and participants felt that having multiple intervention sessions over time was valuable, a similar level of intensity may not be feasible in other settings. Further research is needed to determine an intervention delivery mode and follow-up period that optimally balances participant needs and clinic resources. Male engagement was a challenge, as it has been in previous studies of vaginal microbicides. Alternative strategies to reach men that do not require them to come to the clinic or rely on their female partners may be more effective. Supplementary Information The online version contains supplementary material available at 10.1186/s12905-021-01262-z.
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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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16
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Scorgie F, Khoza N, Baron D, Lees S, Harvey S, Ramskin L, Stangl A, Colombini M, Mashauri E, Delany-Moretlwe S. Disclosure of PrEP use by young women in South Africa and Tanzania: qualitative findings from a demonstration project. CULTURE, HEALTH & SEXUALITY 2021; 23:257-272. [PMID: 32129720 DOI: 10.1080/13691058.2019.1703041] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
Investigating how young women disclose oral pre-exposure prophylaxis (PrEP) use is important given evidence that disclosure is associated with higher adherence. We report qualitative results on PrEP disclosure among young women in South Africa and Tanzania who participated in a PrEP demonstration project (EMPOWER). In total, 81 in-depth interviews were conducted with 39 young women aged 16-24 years-25 from Johannesburg and 14 from Mwanza-at approximately 3, 6 and/or 9 months post-enrolment. Analysis of data was thematic and inductive. Most Johannesburg participants were students in the inner-city; in Mwanza, all worked in recreational venues, occasionally engaging in sexual transactions with customers. A continuum of approaches was evident. Partner disclosure was common in Johannesburg but less so in Mwanza, where many partners were feared as judgemental and potentially violent. In both sites, participants commonly disclosed to family to secure support, and to friends and work colleagues to advocate about PrEP and encourage uptake among at-risk peers. Adherence clubs appeared helpful in building participants' skills and confidence to disclose, particularly in gender-inequitable sexual relationships. PrEP counselling for young women should focus on strengthening communication skills and helping develop strategies for safe disclosure.
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Affiliation(s)
- Fiona Scorgie
- Wits RHI (Wits Reproductive Health and HIV Institute), University of the Witwatersrand, Faculty of Health Sciences, Johannesburg, South Africa
| | - Nomhle Khoza
- Wits RHI (Wits Reproductive Health and HIV Institute), University of the Witwatersrand, Faculty of Health Sciences, Johannesburg, South Africa
| | - Deborah Baron
- Wits RHI (Wits Reproductive Health and HIV Institute), University of the Witwatersrand, Faculty of Health Sciences, Johannesburg, South Africa
| | - Shelley Lees
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine (LSHTM), London, United Kingdom
| | - Sheila Harvey
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine (LSHTM), London, United Kingdom
- Mwanza Intervention Trials Unit (MITU), National Institute for Medical Research, Mwanza, Tanzania
| | - Lethabo Ramskin
- Wits RHI (Wits Reproductive Health and HIV Institute), University of the Witwatersrand, Faculty of Health Sciences, Johannesburg, South Africa
| | - Anne Stangl
- International Center for Research on Women (ICRW), Washington, DC, USA
| | - Manuela Colombini
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine (LSHTM), London, United Kingdom
| | - Emma Mashauri
- Mwanza Intervention Trials Unit (MITU), National Institute for Medical Research, Mwanza, Tanzania
| | - Sinead Delany-Moretlwe
- Wits RHI (Wits Reproductive Health and HIV Institute), University of the Witwatersrand, Faculty of Health Sciences, Johannesburg, South Africa
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17
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Tolley EE, Zissette S, Martinez A, Palanee-Phillips T, Mathebula F, Tenza S, Hartmann M, Montgomery ET. Development and initial validation of a simple tool to screen for partner support or opposition to HIV prevention product use. PLoS One 2020; 15:e0242881. [PMID: 33351805 PMCID: PMC7755213 DOI: 10.1371/journal.pone.0242881] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 11/10/2020] [Indexed: 11/25/2022] Open
Abstract
In HIV prevention trials, male partners have influenced women’s ability to adhere to investigational products, including antiretroviral (ARV) containing vaginal rings. Validated scales can be useful tools to systematically measure complex constructs, such as those related to male partner engagement. Although multiple scales exist to assess physical, psychological and sexual violence within intimate relationships, fewer scales focus on supportive behaviors within these relationships. Our intervention involved development of a Healthy Relationship Assessment Tool (HEART) that assessed both positive and negative aspects of male partner involvement in women’s HIV prevention. We identified and refined 127 potential items, representing intimate partner violence, agency and social support. A structured survey, including potential items and other sociodemographic and behavioral variables was administered to former microbicide trial and non-trial participants. We conducted an exploratory factor analysis (EFA) to identify a reduced set of constructs and items to screen women who might experience social harms or benefits from vaginal ring use. We examined associations between constructs and with other survey variables to assess content and construct validity. In a subset of 10 women who participated in the survey and qualitative interviews, we used qualitative data to predict survey scores. We retained five constructs with theoretical relevance and good-to-strong reliability for the tool, including: Traditional Values; Partner Support; Partner Abuse & Control; Partner Resistance to HIV Prevention; and HIV Prevention Readiness. Predicted associations between HEART constructs, and correspondence between participants’ qualitative data and HEART scores were generally correct, while those between constructs and other sociodemographic variables were more mixed. Initial validation of the HEART tool was promising. The tool will be used during the CHARISMA pilot study at the Johannesburg MTN 025/HOPE site and validated as part of a randomized controlled trial of CHARISMA within a PrEP demonstration project. Beyond clinical trial settings, HEART could assist PrEP or antiretroviral treatment (ART) providers with an easy-to-administer tool to identify risk and tailor risk reduction, empowerment and adherence counseling for microbicides, PrEP or ART related services.
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Affiliation(s)
- Elizabeth E. Tolley
- Behavioral, Epidemiological & Clinical Sciences, FHI 360, Durham, North Carolina, United States of America
- * E-mail:
| | - Seth Zissette
- Behavioral, Epidemiological & Clinical Sciences, FHI 360, Durham, North Carolina, United States of America
- Notre Dame University, South Bend, Indiana, United States of America
| | - Andres Martinez
- Behavioral, Epidemiological & Clinical Sciences, FHI 360, Durham, North Carolina, United States of America
| | - Thesla Palanee-Phillips
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Florence Mathebula
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Siyanda Tenza
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Miriam Hartmann
- Women’s Global Health Imperative, RTI International, San Francisco Project Office, California, United States of America
| | - Elizabeth T. Montgomery
- Women’s Global Health Imperative, RTI International, San Francisco Project Office, California, United States of America
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18
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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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19
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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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The Invisible Product: Preferences for Sustained-Release, Long-Acting Pre-exposure Prophylaxis to HIV Among South African Youth. J Acquir Immune Defic Syndr 2019; 80:542-550. [PMID: 30865050 DOI: 10.1097/qai.0000000000001960] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Long-acting injectable and implantable approaches aim to overcome some of the documented challenges with uptake and adherence to current HIV prevention methods. Youth are a key end-user population for these methods. We used qualitative methods to examine product attributes and preferences for current and future long-acting HIV prevention approaches. METHODS Ninety-five South African youth aged 18-24 years, of whom 62 were female and 33 male, completed 50 interviews and 6 focus groups. We purposively selected for previous product experience, including oral pre-exposure prophylaxis, injectable pre-exposure prophylaxis, or the vaginal ring, to ensure participants' opinions were rooted in actual experience. RESULTS Irrespective of previous method-use experience, gender, or sexual orientation, the majority expressed a preference for prevention methods formulated as injectables or implants. Several mentioned that their top priority in any product was efficacy, and for some, this overrode other concerns; for example, even if they feared pain, an implant or an injectable would be used if fully protective. Although efficacy was a top priority, there was also a clear desire across all subgroups for a product that would not interfere with sex, would stay in the system to provide protection, and that caused minimal burden, or was not apparent to others, and these characteristics were most salient for long-acting methods. CONCLUSIONS Narrative explanations for preferences converged thematically around different dimensions of "invisibility" including invisibility to oneself, one's partner and household members, and community members. End-user preferences can be used to inform product development of long-acting HIV prevention approaches formulated as injections or implants to optimize adherence and impact.
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Abstract
OBJECTIVES Assessment of safety is an integral part of real-time monitoring in clinical trials. In HIV prevention research, safety of investigational products and trial participation has been expanded to include monitoring for 'social harms', generally defined as negative consequences of trial participation that may manifest in social, psychological, or physical ways. Further research on social harms within HIV prevention research is needed to understand the potential safety risks for women and advance the implementation of prevention methods in real-world contexts. METHODS Secondary analysis of quantitative data from three randomized, double-blind, placebo-controlled trials of microbicide candidates in sub-Saharan Africa was conducted. Additionally, we assessed data from two prospective cohort studies that included participants who became HIV-positive or pregnant during parent trials. RESULTS Social harms reporting was low across the largest and most recent microbicide studies. Social harm incidence per 100 person-years ranged from 1.10 (95% CI 0.78-1.52) to 3.25 (95% CI 2.83-3.74) in the phased trials. Reporting differed by dosing mechanism (e.g. vaginal gel, oral tablet, ring) and study, most likely as a function of measurement differences. Social harms were most frequently associated with male partners, rather than, for example, experiences of stigma in the community. CONCLUSION Measurement and screening for social harms is an important component of conducting ethical research of novel HIV prevention methods. To date, social harm incidence reported in microbicide trials has been relatively low (<4% per 100 person-years), and the majority have been partner-related events. However, any incidence of social harm within the context of HIV prevention is important to capture and understand for the safety of individuals, and for the successful impact of prevention methods in a real-world context.
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Impact of Partner-Related Social Harms on Women's Adherence to the Dapivirine Vaginal Ring During a Phase III Trial. J Acquir Immune Defic Syndr 2019; 79:580-589. [PMID: 30239426 PMCID: PMC6231955 DOI: 10.1097/qai.0000000000001866] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Background: Long-acting female-initiated methods such as the dapivirine ring may give women greater agency in HIV-1 prevention. However, social harms, defined as nonmedical adverse consequences of study participation or dapivirine ring use, may reduce product adherence and consequently HIV-1 protection. Methods: We assessed whether experiencing social harms from male partners was associated with lower adherence to the dapivirine ring in the MTN-020/ASPIRE trial. Reports of social harms were solicited quarterly. Low adherence was defined by plasma dapivirine levels ≤95 pg/mL or residual dapivirine levels in returned rings >23.5 mg. Results: Among 2629 women enrolled in ASPIRE, 85 (3.2%) reported 87 social harms during a median follow-up of 1.6 years. Women were significantly more likely to have low adherence, measured by plasma dapivirine levels, at visits with a social harm in the past month than at visits where no social harm was reported (adjusted risk ratio 2.53, 95% confidence interval: 1.37 to 4.66, P = 0.003). There was no association for social harms reported ≥1 month prior, suggesting an acute, short-term effect. Women were significantly more likely to not return a ring at visits with a social harm reported (adjusted risk ratio 24.70, 95% confidence interval: 18.57 to 32.85, P < 0.001). In rings that were returned, social harms were not associated with residual dapivirine levels. Conclusions: Although social harms were uncommon (<5% of women with >1 year of use), participants reporting social harms by male partners had lower adherence to the dapivirine ring. Strategies to mitigate nonadherence to product use related to social harms should be evaluated in future studies of female-controlled HIV-1 prevention options.
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Hartmann M, Lanham M, Palanee-Phillips T, Mathebula F, Tolley EE, Peacock D, Pascoe L, Zissette S, Roberts ST, Wagner D, Wilson E, Ayub A, Wilcher R, Montgomery ET. Generating CHARISMA: Development of an Intervention to Help Women Build Agency and Safety in Their Relationships While Using PrEP for HIV Prevention. AIDS EDUCATION AND PREVENTION : OFFICIAL PUBLICATION OF THE INTERNATIONAL SOCIETY FOR AIDS EDUCATION 2019; 31:433-451. [PMID: 31550193 PMCID: PMC7082989 DOI: 10.1521/aeap.2019.31.5.433] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
This article describes the development of the Community Health clinic model for Agency in Relationships and Safer Microbicide Adherence intervention (CHARISMA), an intervention designed to address the ways in which gender norms and power differentials within relationships affect women's ability to safely and consistently use HIV pre-exposure prophylaxis (PrEP). CHARISMA development involved three main activities: (1) a literature review to identify appropriate evidence-based relationship dynamic scales and interventions; (2) the analysis of primary and secondary data collected from completed PrEP studies, surveys and cognitive interviews with PrEP-experienced and naïve women, and in-depth interviews with former vaginal ring trial participants and male partners; and (3) the conduct of workshops to test and refine key intervention activities prior to pilot testing. These steps are described along with the final clinic and community-based intervention, which was tested for feasibility, acceptability, and preliminary effectiveness in Johannesburg, South Africa.
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Affiliation(s)
- Miriam Hartmann
- Women's Global Health Imperative, RTI International, San Francisco, California
| | | | | | | | | | - Dean Peacock
- Sonke Gender Justice, Johannesburg, South Africa
| | - Laura Pascoe
- Sonke Gender Justice, Johannesburg, South Africa
| | | | - Sarah T Roberts
- Women's Global Health Imperative, RTI International, San Francisco, California
| | - Danielle Wagner
- Women's Global Health Imperative, RTI International, San Francisco, California
| | - Ellen Wilson
- Women's Global Health Imperative, RTI International, San Francisco, California
| | - Asha Ayub
- Women's Global Health Imperative, RTI International, San Francisco, California
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Scorgie F, Stadler J, Baron D, Ju S, Ikaneng T, Mabude Z, Makgopa S, Malefo MA, Manenzhe KN, Mazibuko T, Ntjana H, Nkala B, Palanee-Phillips T, Gray G, Rees H, Delany-Moretlwe S. "It Was Not My Aim to Sleep There": The Impact of Timing and Location of Sex on Adherence to Coitally-Dependent HIV Pre-exposure Prophylaxis. AIDS Behav 2018; 22:3692-3704. [PMID: 29909589 DOI: 10.1007/s10461-018-2195-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
The FACTS 001 trial found that vaginal pre- and post-coital application of 1% tenofovir gel did not prevent HIV-1 infection amongst young South African women. The trial included a multi-faceted approach to adherence support and collected objective and self-reported adherence measures. Using qualitative data collected from a random sub-set of FACTS 001 participants (135 in-depth interviews at product discontinuation and 13 focus group discussions at dissemination of trial results), we explore the importance of 'place' and 'timing' in shaping acts of sexual intimacy and product adherence. Demographically, this qualitative sub-sample is similar to the trial cohort of predominantly young, unemployed women living with parents or other family members. Sexual intimacy was largely unpredictable and happened across multiple locations in which women had limited privacy, autonomy, or control over the timing of sex. This made adherence to the dosing strategy challenging. Findings may inform the development of future event-driven pre-exposure prophylaxis regimens or products.
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Affiliation(s)
- Fiona Scorgie
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Corner Esselen and Klein Street, Hillbrow, Johannesburg, 2001, South Africa.
| | - Jonathan Stadler
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Corner Esselen and Klein Street, Hillbrow, Johannesburg, 2001, South Africa
| | - Deborah Baron
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Corner Esselen and Klein Street, Hillbrow, Johannesburg, 2001, South Africa
| | - Susan Ju
- CONRAD, 1911 North Fort Myer Drive, Arlington, VA, USA
| | - Tshepiso Ikaneng
- MEDUNSA Clinical Research Unit (MeCRU), Ga-Rankuwa, North West Province, South Africa
| | - Zonke Mabude
- MatCH Research Unit, Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | | | | | | | - Hilda Ntjana
- The Desmond Tutu HIV Foundation, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Busi Nkala
- Perinatal HIV Research Unit (PHRU), University of the Witwatersrand, Chris Hani Baragwanath Hospital, Soweto, South Africa
| | - Thesla Palanee-Phillips
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Corner Esselen and Klein Street, Hillbrow, Johannesburg, 2001, South Africa
| | - Glenda Gray
- South African Medical Research Council, Cape Town, South Africa
| | - Helen Rees
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Corner Esselen and Klein Street, Hillbrow, Johannesburg, 2001, South Africa
| | - Sinead Delany-Moretlwe
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Corner Esselen and Klein Street, Hillbrow, Johannesburg, 2001, South Africa
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Krogstad EA, Atujuna M, Montgomery ET, Minnis A, Ndwayana S, Malapane T, Shapley‐Quinn MK, Manenzhe K, Bekker L, van der Straten A. Perspectives of South African youth in the development of an implant for HIV prevention. J Int AIDS Soc 2018; 21:e25170. [PMID: 30152004 PMCID: PMC6111144 DOI: 10.1002/jia2.25170] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 07/13/2018] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Implants are a new dosage form in development for HIV pre-exposure prophylaxis (PrEP) with potential for high adherence given that they are provider-administered and are intended for long-acting protection. Integrating end-user preference into early stage product development may further overcome challenges with future product uptake and adherence. Hence, we sought to optimize the design of a PrEP implant in early-stage development by gathering opinions about implant attributes from potential end-users in South Africa. METHODS We conducted 14 focus group discussions (FGDs) with young women and men aged 18 to 24 in Cape Town and Soshanguve, South Africa, inviting participants into discussion as co-designers. FGDs were homogenous by gender and previous implant experience. During FGDs, we showed prototype devices and followed a semi-structured guide with questions on history of contraceptive implant use, preferences for physical characteristics of an implant, implant biodegradability, insertion process, participant-driven ideas for implant design, and social adoption considerations. FGDs were facilitated in English, isiXhosa, Tswana, isiZulu, or Tsonga, audio-recorded, transcribed into English, and qualitatively coded and analysed. RESULTS In this qualitative sample of 105 youth (68 women and 37 men), 58 participants were from Soshanguve and 47 from Cape Town, and 23% had previously used contraceptive implants. Participants expressed preferences for several implant design features; specifically, longer duration (≥6 months) was more important to most participants than the size or number of devices implanted. A majority preferred a flexible versus stiff implant to minimize palpability, thereby increasing discreetness and comfort. Nearly all participants favoured a biodegradable implant to avoid removal and thus reduce clinic visits. Concerns about the implant centred on its possible side effects and the "plastic" look of the prototype displayed for demonstration. CONCLUSIONS This study offers preliminary insights into an implant for HIV prevention that provides long-lasting protection may be well received among young South Africans. Additionally, flexibility, discreetness, and biodegradability may increase acceptability of the implant. Such end-user feedback is being incorporated into current implant designs in the hope of creating an effective long-acting PrEP product that is likely to achieve high uptake and adherence in target populations.
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Affiliation(s)
- Emily A Krogstad
- Desmond Tutu HIV CentreUniversity of Cape TownCape TownSouth Africa
- RTI InternationalWomen's Global Health ImperativeSan FranciscoCaliforniaUSA
| | | | | | - Alexandra Minnis
- RTI InternationalWomen's Global Health ImperativeSan FranciscoCaliforniaUSA
| | - Sheily Ndwayana
- Desmond Tutu HIV CentreUniversity of Cape TownCape TownSouth Africa
| | | | | | | | | | - Ariane van der Straten
- RTI InternationalWomen's Global Health ImperativeSan FranciscoCaliforniaUSA
- Center for AIDS Prevention StudiesUniversity of California – San FranciscoSan FranciscoCaliforniaUSA
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Abstract
Sexual intercourse (vaginal and anal) is the predominant mode of human immunodeficiency virus (HIV) transmission. Topical microbicides used in an on-demand format (i.e., immediately before or after sex) can be part of an effective tool kit utilized to prevent sexual transmission of HIV. The effectiveness of prevention products is positively correlated with adherence, which is likely to depend on user acceptability of the product. The development of an efficacious and acceptable product is therefore paramount for the success of an on-demand product. Acceptability of on-demand products (e.g., gels, films, and tablets) and their attributes is influenced by a multitude of user-specific factors that span behavioral, lifestyle, socio-economic, and cultural aspects. In addition, physicochemical properties of the drug, anatomical and physiological aspects of anorectal and vaginal compartments, issues relating to large-scale production, and cost can impact product development. These factors together with user preferences determine the design space of an effective, acceptable, and feasible on-demand product. In this review, we summarize the interacting factors that together determine product choice and its target product profile.
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Affiliation(s)
- Sravan Kumar Patel
- School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, 15213, USA.,Magee-Womens Research Institute, Pittsburgh, PA, 15213, USA
| | - Lisa Cencia Rohan
- School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, 15213, USA. .,Magee-Womens Research Institute, Pittsburgh, PA, 15213, USA.
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Laborde ND, Pleasants E, Reddy K, Atujuna M, Nakyanzi T, Chitukuta M, Naidoo S, Palanee-Phillips T, Baeten JM, Montgomery ET. Impact of the Dapivirine Vaginal Ring on Sexual Experiences and Intimate Partnerships of Women in an HIV Prevention Clinical Trial: Managing Ring Detection and Hot Sex. AIDS Behav 2018; 22:437-446. [PMID: 29151197 PMCID: PMC5866044 DOI: 10.1007/s10461-017-1977-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Vaginally-inserted HIV prevention methods have been reported to impact the sexual experience for women and their partners, and hence impacts acceptability of and adherence to the method. We analyzed in-depth interviews and focus group discussions about participants' sexual experiences while wearing the ring, collected during the MTN-020/ASPIRE phase 3 safety and effectiveness trial of a dapivirine vaginal ring for HIV prevention in Malawi, South Africa, Uganda, and Zimbabwe. Most women reported that partners did not feel the ring during sex, however, women felt they had to manage their partners' interaction with or reaction to the ring. In maintaining positive relationships, women were concerned about partners' discovering ring use and about ensuring that partners had a good sexual experience with them. Finally women were concerned about how they themselves experienced sex with the ring. Some found that the ring made the vaginal environment more desirable for their partners and themselves.
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Affiliation(s)
- Nicole D Laborde
- Women's Global Health Imperative, RTI International, 351 California St. Ste. 500, San Francisco, CA, 94104, USA.
| | - Elizabeth Pleasants
- Women's Global Health Imperative, RTI International, 351 California St. Ste. 500, San Francisco, CA, 94104, USA
| | - Krishnaveni Reddy
- Wits Reproductive Health, HIV Institute (WRHI), Johannesburg, South Africa
| | | | - Teopista Nakyanzi
- Makerere University-Johns Hopkins University Research Unit, Kampala, Uganda
| | | | - Sarita Naidoo
- HIV Prevention Research Unit, South Africa Medical Research Council, Durban, South Africa
| | | | | | - Elizabeth T Montgomery
- Women's Global Health Imperative, RTI International, 351 California St. Ste. 500, San Francisco, CA, 94104, USA
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Dunn J, Zhang Q, Weeks MR, Li J, Liao S, Li F. Indigenous HIV Prevention Beliefs and Practices Among Low-Earning Chinese Sex Workers as Context for Introducing Female Condoms and Other Novel Prevention Options. QUALITATIVE HEALTH RESEARCH 2017; 27:1302-1315. [PMID: 27811288 PMCID: PMC5440208 DOI: 10.1177/1049732316673980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
New interventions to reduce HIV and sexually transmitted infections (STI) among female sex workers are introduced into the context of women's existing prevention beliefs and practices. These indigenous practices affected implementation of our program to introduce female condoms to women in sex-work establishments in southern China. We used ethnographic field observations and in-depth interviews to document common prevention methods women reported using to protect themselves before and during intervention implementation. Individual, sex-work establishment, and other contextual factors, including sources of information and social and economic pressures to use or reject prevention options, shaped their perceptions and selection of these methods and affected adoption of female condoms as an additional tool. Efforts to improve uptake of effective prevention methods among low-income sex workers require attention to the context and spectrum of women's HIV/STI prevention practices when introducing innovations such as female condoms, microbicides, pre-exposure prophylaxis pills, and others, as they become available.
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Affiliation(s)
- Jennifer Dunn
- 1 Institute for Community Research, Hartford, Connecticut, USA
| | | | | | - Jianghong Li
- 1 Institute for Community Research, Hartford, Connecticut, USA
| | - Susu Liao
- 3 Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Fei Li
- 3 Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
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Intimate Partner Violence and Adherence to HIV Pre-exposure Prophylaxis (PrEP) in African Women in HIV Serodiscordant Relationships: A Prospective Cohort Study. J Acquir Immune Defic Syndr 2017; 73:313-322. [PMID: 27243900 PMCID: PMC5065369 DOI: 10.1097/qai.0000000000001093] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Background: Intimate partner violence (IPV) is associated with higher HIV incidence, reduced condom use, and poor adherence to antiretroviral therapy and other medications. IPV may also affect adherence to pre-exposure prophylaxis (PrEP). Methods: We analyzed data from 1785 HIV-uninfected women enrolled in a clinical trial of PrEP among African HIV serodiscordant couples. Experience of verbal, physical, or economic IPV was assessed at monthly visits by face-to-face interviews. Low PrEP adherence was defined as clinic-based pill count coverage <80% or plasma tenofovir levels <40 ng/mL. The association between IPV and low adherence was analyzed using generalized estimating equations, adjusting for potential confounders. In-depth interview transcripts were examined to explain how IPV could impact adherence. Results: Sixteen percent of women reported IPV during a median of 34.8 months of follow-up (interquartile range 27.0–35.0). Overall, 7% of visits had pill count coverage <80%, and 32% had plasma tenofovir <40 ng/mL. Women reporting IPV in the past 3 months had increased risk of low adherence by pill count (adjusted risk ratio 1.49, 95% confidence interval: 1.17 to 1.89) and by plasma tenofovir (adjusted risk ratio 1.51, 95% confidence interval: 1.06 to 2.15). Verbal, economic, and physical IPV were all associated with low adherence. However, the impact of IPV diminished and was not statistically significant 3 months after the reported exposure. In qualitative interviews, women identified several ways in which IPV affected adherence, including stress and forgetting, leaving home without pills, and partners throwing pills away. Conclusions: Women who reported recent IPV in the Partners PrEP Study were at increased risk of low PrEP adherence. Strategies to mitigate PrEP nonadherence in the context of IPV should be evaluated.
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Mweemba O, Dixey R, Bond V, White A. The influence of social constructs of hegemonic masculinity and sexual behaviour on acceptability of vaginal microbicides in Zambia. Glob Public Health 2017; 13:931-943. [PMID: 28604240 DOI: 10.1080/17441692.2017.1337800] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Vaginal microbicides are heralded as a woman's HIV prevention method. This study, conducted in a microbicide clinical trial setting in Zambia, explored how the social construction of masculinity and sexual behaviour influenced the acceptability of vaginal microbicides. The data were generated from 18 In-depth Interviews and 8 Focus Group Discussions. The data were analysed thematically. The study found that hegemonic masculinity influenced the use of vaginal microbicides positively and negatively, in multiple ways including: decision to initiate gel use, autonomous use of the gel, and consistent use of the gel. Men were seen as heads of households and decision-makers who approved their partners' intentions to initiate gel use. Autonomous gel use by women was not supported because it challenged men's dominant position in sexual matters and at a family level. The socially accepted notion that men engaged in multiple sexual relationships also influenced women's decision to use the gel. Sustained gel use depended on the perceived effect of the gel on men's sexual desires, sexual performance, fertility, and sexual behaviour. This study suggests that acceptability of microbicides partially lies within the realm of men, with use constrained and dictated by cultural constructs and practice of masculinity and gender.
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Affiliation(s)
- Oliver Mweemba
- a Department of Public Health , University of Zambia , Lusaka , Zambia
| | - Rachael Dixey
- b Centre for Health Promotion Research, Leeds Beckett University , Leeds , UK
| | - Virginia Bond
- c Department of Global Health and Development , London School of Hygiene and Tropical Medicine , London , UK.,d ZAMBART Project , University of Zambia , Lusaka , Zambia
| | - Alan White
- e Centre for Men's Health, Leeds Beckett University , Leeds , UK
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Abstract
BACKGROUND The MTN-020/ASPIRE trial evaluated the safety and effectiveness of the dapivirine vaginal ring for prevention of HIV-1 infection among African women. A nested qualitative component was conducted at six of 15 study sites in Uganda, Malawi, Zimbabwe and South Africa to evaluate acceptability of and adherence to the ring. METHOD Qualitative study participants (n = 214) were interviewed with one of three modalities: single in-depth interview, up to three serial interviews or an exit Focus Group Discussion. Using semistructured guides administered in local languages, 280 interviews were audio-recorded, transcribed, translated, coded and analyzed. RESULTS We identified three key findings: first, despite initial fears about the ring's appearance and potential side effects, participants grew to like it and developed a sense of ownership of the ring once they had used it. Second, uptake and sustained adherence challenges were generally overcome with staff and peer support. Participants developed gradual familiarity with ring use through trial progression, and most reported that it was easy to use and integrate into their lives. Using the ring in ASPIRE was akin to joining a team and contributing to a broader, communal good. Third, the actual or perceived dynamics of participants' male partner relationship(s) were the most consistently described influence (which ranged from positive to negative) on participants' acceptability and use of the ring. CONCLUSION It is critical that demonstration projects address challenges during the early adoption stages of ring diffusion to help achieve its potential public health impact as an effective, long-acting, female-initiated HIV prevention option addressing women's disproportionate HIV burden.
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Pinchoff J, Boyer CB, Mutombo N, Chowdhuri RN, Ngo TD. Why don't urban youth in Zambia use condoms? The influence of gender and marriage on non-use of male condoms among young adults. PLoS One 2017; 12:e0172062. [PMID: 28333963 PMCID: PMC5363807 DOI: 10.1371/journal.pone.0172062] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 01/30/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Zambia experiences high unmet need for family planning and high rates of HIV, particularly among youth. While male condoms are widely available and 95% of adults have heard of them, self-reported use in the past 12 months is low among young adults (45%). This study describes factors associated with non-use of male condoms among urban young adults in Zambia. METHODS A household cross-sectional survey in four urban districts was conducted from November 2015 to January 2016 among sexually active young adults ages 18-24 years. A random walk strategy was implemented in urban areas; eligible, enrolled participants were administered a survey on household characteristics, health access, and knowledge, attitudes and practices related to contraception. Relative risk regression models were built to determine factors associated with the decision to not use a male condom (non-use) at most recent sexual intercourse. RESULTS A total of 2,388 individuals were interviewed; 69% were female, 35% were married, and average lifetime sex partners was 3.45 (SD±6.15). Non-use of male condoms was 59% at most recent sexual intercourse. In a multivariate model, women were more likely to report non-use of a male condom compared with men (aRR = 1.24 [95% CI: 1.11, 1.38]), married individuals were more likely to report non-use compared with unmarried individuals (aRR = 1.59 [1.46, 1.73]), and those residing in the highest poverty wards were more likely to report non-use compared with those in the lowest poverty wards (aRR = 1.31 [1.16, 1.48]). Those with more negative perceptions of male condom use were 6% more likely to report non-use (aRR = 1.06 [1.03, 1.09]). Discussion regarding contraception with a partner decreased non-use 13% (aRR = 0.87 [0.80, 0.95]) and agreement regarding male condom use with a partner decreased non-use 16% (aRR = 0.84 [0.77, 0.91)]). DISCUSSION Non-use of male condoms is high among young, married adults, particularly women, who may be interested in contraception for family planning but remain at risk of STI infection. Effective marketing strategy of dual protection methods to this population is critical.
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Affiliation(s)
- Jessie Pinchoff
- Research Department, Innovations for Poverty Action, New Haven, Connecticut, United States of America
| | - Christopher B. Boyer
- Research Department, Innovations for Poverty Action, New Haven, Connecticut, United States of America
| | | | | | - Thoai D. Ngo
- Poverty, Gender and Youth Program, Population Council, One Dag Hammarskjold Plaza, New York, New York, United States of America
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Social Context of Adherence in an Open-Label 1 % Tenofovir Gel Trial: Gender Dynamics and Disclosure in KwaZulu-Natal, South Africa. AIDS Behav 2016; 20:2682-2691. [PMID: 26945585 PMCID: PMC5069327 DOI: 10.1007/s10461-016-1339-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
CAPRISA 008, an open-label extension study of tenofovir gel with coitally-related dosing, provided an opportunity to explore the relationship between product adherence and gender dynamics in a context where women knew they were receiving an active product with evidence of HIV prevention effectiveness. Interviews with 63 CAPRISA 008 participants and 13 male partners in KwaZulu-Natal, South Africa, highlighted that the process of negotiating gel use was determined in part by relationship dynamics including the duration of the relationship, the living situation, an evaluation of the relationship (e.g., partner intimacy and relationship expectations) and culturally-defined steps for formalizing the relationship. While disclosure facilitated adherence for many, others reported using the gel effectively with no disclosure, and in some situations disclosure was a barrier to adherence. Women should be supported in their choice about what to disclose and have opportunity to use this and similar products without their partners’ knowledge or acquiescence.
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Minnis AM, van der Straten A, Salee P, Hendrix CW. Pre-exposure Prophylaxis Adherence Measured by Plasma Drug Level in MTN-001: Comparison Between Vaginal Gel and Oral Tablets in Two Geographic Regions. AIDS Behav 2016; 20:1541-8. [PMID: 25969178 DOI: 10.1007/s10461-015-1081-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Despite strong evidence that daily oral pre-exposure prophylaxis (PrEP) reduces HIV risk, effectiveness across studies has varied. Inconsistent adherence constitutes one explanation. Efforts to examine adherence are limited when they rely on self-reported measures. We examined recent adherence as measured by plasma tenofovir (TFV) concentration in participants of MTN-001, a phase 2 cross-over trial comparing oral tablet and vaginal gel formulations of TFV among 144 HIV-uninfected women at sites in the United States (U.S.) and sub-Saharan Africa (SSA). Adherence to daily product use was higher in the U.S. than in the SSA sites. Within region, however, adherence was similar between products. In the U.S., gel adherence was higher among married women, and lower among women using male condoms and injectable contraceptives. At the SSA sites, gel adherence was lower for younger women. Inconsistent adherence points to challenges in use of daily PrEP, even during a trial of short duration.
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Optimizing HIV prevention for women: a review of evidence from microbicide studies and considerations for gender-sensitive microbicide introduction. J Int AIDS Soc 2015; 18:20536. [PMID: 26700845 PMCID: PMC4689151 DOI: 10.7448/ias.18.1.20536] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 10/23/2015] [Accepted: 11/13/2015] [Indexed: 11/12/2022] Open
Abstract
Introduction Microbicides were conceptualized as a product that could give women increased agency over HIV prevention. However, gender-related norms and inequalities that place women and girls at risk of acquiring HIV are also likely to affect their ability to use microbicides. Understanding how gendered norms and inequalities may pose obstacles to women's microbicide use is important to inform product design, microbicide trial implementation and eventually microbicide and other antiretroviral-based prevention programmes. We reviewed published vaginal microbicide studies to identify gender-related factors that are likely to affect microbicide acceptability, access and adherence. We make recommendations on product design, trial implementation, positioning, marketing and delivery of microbicides in a way that takes into account the gender-related norms and inequalities identified in the review. Methods We conducted PubMed searches for microbicide studies published in journals between 2000 and 2013. Search terms included trial names (e.g. “MDP301”), microbicide product names (e.g. “BufferGel”), researchers’ names (e.g. “van der Straten”) and other relevant terms (e.g. “microbicide”). We included microbicide clinical trials; surrogate studies in which a vaginal gel, ring or diaphragm was used without an active ingredient; and hypothetical studies in which no product was used. Social and behavioural studies implemented in conjunction with clinical trials and surrogate studies were also included. Although we recognize the importance of rectal microbicides to women, we did not include studies of rectal microbicides, as most of them focused on men who have sex with men. Using a standardized review template, three reviewers read the articles and looked for gender-related findings in key domains (e.g. product acceptability, sexual pleasure, partner communication, microbicide access and adherence). Results and discussion The gendered norms, roles and relations that will likely affect women's ability to access and use microbicides are related to two broad categories: norms regulating women's and men's sexuality and power dynamics within intimate relationships. Though norms about women's and men's sexuality vary among cultural contexts, women's sexual behaviour and pleasure are typically less socially acceptable and more restricted than men's. These norms drive the need for woman-initiated HIV prevention, but also have implications for microbicide acceptability and how they are likely to be used by women of different ages and relationship types. Women's limited power to negotiate the circumstances of their intimate relationships and sex lives will impact their ability to access and use microbicides. Men's role in women's effective microbicide use can range from opposition to non-interference to active support. Conclusions Identifying an effective microbicide that women can use consistently is vital to the future of HIV prevention for women. Once such a microbicide is identified and licensed, positioning, marketing and delivering microbicides in a way that takes into account the gendered norms and inequalities we have identified would help maximize access and adherence. It also has the potential to improve communication about sexuality, strengthen relationships between women and men and increase women's agency over their bodies and their health.
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Sepúlveda-Crespo D, Gómez R, De La Mata FJ, Jiménez JL, Muñoz-Fernández MÁ. Polyanionic carbosilane dendrimer-conjugated antiviral drugs as efficient microbicides: Recent trends and developments in HIV treatment/therapy. NANOMEDICINE-NANOTECHNOLOGY BIOLOGY AND MEDICINE 2015; 11:1481-98. [DOI: 10.1016/j.nano.2015.03.008] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Revised: 02/20/2015] [Accepted: 03/19/2015] [Indexed: 12/22/2022]
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Minnis AM, Doherty IA, Kline TL, Zule WA, Myers B, Carney T, Wechsberg WM. Relationship power, communication, and violence among couples: results of a cluster-randomized HIV prevention study in a South African township. Int J Womens Health 2015; 7:517-25. [PMID: 25999767 PMCID: PMC4435250 DOI: 10.2147/ijwh.s77398] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Inequitable gender-based power in relationships and intimate partner violence contribute to persistently high rates of HIV infection among South African women. We examined the effects of two group-based HIV prevention interventions that engaged men and their female partners together in a couples intervention (Couples Health CoOp [CHC]) and a gender-separate intervention (Men’s Health CoOp/Women’s Health CoOp [MHC/WHC]) on women’s reports of power, communication, and conflict in relationships. Methods The cluster-randomized field experiment included heterosexual couples from a high-density South African township in which neighborhoods were randomized to one of the intervention arms or a control arm that received the WHC only. Participants completed in-person study visits at baseline and 6-month follow-up. We examined group differences using one-way analysis of variance and multivariable regression models. Results Of the 290 couples enrolled, 255 women remained in the same partnership over 6 months. Following the intervention, women in the CHC arm compared with those in the WHC arm were more likely to report an increase in relationship control (β=0.92, 95% confidence interval [CI]: 0.02, 1.83, P=0.045) and gender norms supporting female autonomy in relationships (β=0.99, 95% CI: 0.07, 1.91, P=0.035). Women in the MHC/WHC arm were more likely to report increases in relationship equity, relative to those in the CHC arm, and had a higher odds of reporting no victimization during the previous 3 months (MHC/WHC vs WHC: odds ratio =3.05, 95% CI: 1.55, 6.0, P=0.001; CHC vs MHC/WHC: odds ratio =0.38, 95% CI: 0.20, 0.74, P=0.004). Conclusion Male partner engagement in either the gender-separate or couples-based interventions led to modest improvements in gender power, adoption of more egalitarian gender norms, and reductions in relationship conflict for females. The aspects of relationship power that improved, however, varied between the couples and gender-separate conditions, highlighting the need for further attention to development of both gender-separate and couples interventions.
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Affiliation(s)
- Alexandra M Minnis
- RTI International, Research Triangle Park, NC, USA ; School of Public Health, University of California, Berkeley, CA, USA
| | - Irene A Doherty
- RTI International, Research Triangle Park, NC, USA ; University of North Carolina, Chapel Hill, NC, USA
| | | | | | - Bronwyn Myers
- Alcohol, Tobacco and Other Drug Research Unit, South African Medical Research Council, University of Cape Town, Cape Town, South Africa ; Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Tara Carney
- Alcohol, Tobacco and Other Drug Research Unit, South African Medical Research Council, University of Cape Town, Cape Town, South Africa
| | - Wendee M Wechsberg
- RTI International, Research Triangle Park, NC, USA ; University of North Carolina, Chapel Hill, NC, USA ; North Carolina State University, Raleigh, NC, USA ; Duke University School of Medicine, Durham, NC, USA
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Corneli A, Perry B, Agot K, Ahmed K, Malamatsho F, Van Damme L. Facilitators of adherence to the study pill in the FEM-PrEP clinical trial. PLoS One 2015; 10:e0125458. [PMID: 25867624 PMCID: PMC4395082 DOI: 10.1371/journal.pone.0125458] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Accepted: 03/20/2015] [Indexed: 11/25/2022] Open
Abstract
Introduction FEM-PrEP did not demonstrate a reduction in HIV acquisition because of low study pill adherence. Yet, plasma and intracellular drug concentrations indicated that some participants had evidence of recent pill use. We conducted a follow-up study to identify, among other topics, participants’ reasons for taking the study pill. Methods Qualitative, semi-structured interviews (SSIs) were conducted with 88 FEM-PrEP participants. Participants were purposefully selected based on their adherence drug concentrations collected during FEM-PrEP and placed into three adherence interview groups: “high,” “moderate,” and “none/scarce.” Participants in the high and moderate groups described reasons why they adhered most or some of the time, including factors that facilitated their adherence. Participants in all groups described what they believed made it possible for other FEM-PrEP participants to adhere. In addition, 224 FEM-PrEP participants reported on their reasons for taking the study pills through a quantitative, audio computer-assisted self-interview (ACASI). Thematic analysis and descriptive statistics were used to analyze the qualitative and quantitative data, respectively. Results Five themes were identified from the SSIs as facilitating factors of adherence: 1) participants’ support for the research, 2) HIV risk reduction, 3) routine formation and use of tools, 4) adherence counseling, and 5) partner awareness and support. Participants described similar facilitators when they spoke about other participants’ adherence. Among the 172 participants who reported in ACASI that they had taken a study pill, wanting to help answer the research question was the most frequently stated reason for taking the pills (94%, n = 161). We also found evidence of preventive misconception. Conclusions Adherence was facilitated by personal motivations, such as risk reduction and interest in the research outcome, and by adherence strategies consisting of external cues, reminders, and support. These findings can inform future HIV prevention clinical trials and the rollout of effective antiretroviral-based HIV prevention technologies for women.
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Affiliation(s)
- Amy Corneli
- FHI 360, Durham, NC, United States of America
- * E-mail:
| | - Brian Perry
- FHI 360, Durham, NC, United States of America
| | - Kawango Agot
- Impact Research and Development Organization, Kisumu, Kenya
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Abstract
ARV-based HIV prevention methods available in pill, gel or ring formulations (broadly referred to as microbicides) offer the possibility of protection against HIV for women who find it difficult because they cannot ask their partners to use condoms or even refuse sex. Partial efficacy of ARV-based medications has been demonstrated in a number of clinical trials around the world among various populations, building the evidence that ARV-based technologies will contribute to reducing the AIDS epidemic worldwide. Disappointing results, however, from two trials in sub-Saharan Africa, where poor adherence contributed to study closure due to futility, have raised questions about whether women at the centre of the epidemic are able to effectively use products that require routine use. Also, there are fears by some of risk compensation by decreased condom use because of the availability of microbicides when only partial efficacy has been demonstrated in microbicide trials to date. Of note, sub-analyses of biologic measures of adherence in trials where this was possible have shown a strong correlation between good adherence and efficacy, reinforcing the necessity of good adherence. Research conducted in conjunction with clinical trials and post-trials in advance of possible rollout of ARV-based products have examined social and cultural factors, gender-related and otherwise, influencing adherence and other aspects of women's use of products. These include HIV stigma, women's perception of risk, partner and community influences and the differing needs of women in various stages of life and in different circumstances. It is the purpose of this supplement to give voice to the needs of women who can benefit from woman-initiated methods by presenting research results and commentary to contribute to the global conversation about optimizing women's experience with ARV-based prevention.
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