Engaging study participants in interpreting results: lessons from the TRIO study in Kenya and South Africa

Background: Women account for 56% of new HIV infections in sub-Saharan Africa. Multipurpose Prevention Technologies (MPTs) are promising interventions because they combine HIV prevention with a less stigmatizing indication, such as pregnancy. We conducted a study with three placebo-only MPT products in Kisumu, Kenya and Soshanguve, South Africa, to assess preferences for attributes of tablets, vaginal rings and injectable products for dual prevention of HIV and pregnancy (TRIO Study). Here, we present former TRIO participants' views on the study results. Methods: After study completion in 2017, we held five dissemination sessions (two in Kisumu and three in Soshanguve) and five one-on-one sharing sessions in Soshanguve. Key results were discussed, with a focus on why some study products were more popular than others, which findings were surprising and why some women changed products over time. A thematic approach was used for analysis. Results: All 277 TRIO participants were telephoned, 168 (60.6%) were reached and 117 (42.2%) attended the dissemination sessions: 71 in Kisumu and 46 in Soshanguve. Participants were engaged and interested in the TRIO findings and willingly shared their perspectives and views candidly. Ease of use, discretion and familiarity were highlighted as drivers of product choice whereas novelty presented a challenge. In explaining the discrepancy between preference ratings and choices, participants cited features such as tablets being easy to explain to a partner or to discontinue. In explaining why 20% of participants switched products after practical experience, issues related to relationships with partners and product attributes perceived as unfavorable were paramount. Conclusion: The dissemination sessions provided an important forum for study participants to interrogate and explain the results to minimize possible misinterpretation. This exercise helped give context to the results, ensured correct lessons were derived from those results and increased credibility of the findings reported by the investigators.

The Tablets, Ring, Injections as Options (TRIO) study: what young African women chose and used for future HIV and pregnancy prevention

Introduction

Preventing HIV and unintended pregnancies are key global health priorities. To inform product rollout and to understand attributes of future multipurpose prevention technologies (MPT) associated with preference and use, we evaluated three placebo delivery forms: daily oral tablets, a monthly vaginal ring, and two monthly intramuscular injections in TRIO, a five‐month study among young Kenyan and South African women.

Methods

HIV‐negative, sexually active, non‐pregnant women aged 18 to 30 were enrolled and randomized to use each placebo delivery form for one month (stage 1). Then, participants chose one product to use for two additional months (stage 2). We assessed safety, product ranking, choice, and use. We examined demographic and behavioural correlates of choice and, reciprocally, unwillingness to use in the future with logistic regression models.

Results

277 women enrolled, 249 completed stage 1 and 246 completed stage 2. Median age was 23 years, 49% were Kenyan and 51% were South African. Three participants became pregnant during the study and one participant HIV‐seroconverted. There were 18 product‐related adverse events, six tablets‐related, 11 ring‐related, and one injection‐related. After trying each product, 85% preferred a TRIO product over condoms. Injections were chosen most (64%, 95% confidence interval (CI) 58%, 70%; p < 0.001), and by more South Africans than Kenyans (odds ratio (OR) 2.01, 95% CI: 1.17, 3.43; p = 0.01). There was no significant difference in choosing tablets versus ring (21%, 95% CI: 16%, 26% vs. 15%, 95% CI: 11%, 20%; p = 0.11). Tablet and ring adherence, based on direct observations and self‐reports, improved over time. However, participants’ self‐reported use of tablets did not match objective data from the electronic dose monitoring device. Participants were fully compliant with injections.

Conclusion

In this population at risk for HIV and pregnancy, all participants agreed to choose and use a placebo MPT delivery form. A majority of participants preferred TRIO products to male condoms, an existing MPT. Injections were most liked and best used, however, they are years away from reaching the clinics. In the meantime, expanding the availability of tablets and giving access to rings can begin to fulfill the promise of choice for HIV prevention technologies and inform the development of suitable delivery forms as MPT.

"We are not the same": African women's view of multipurpose prevention products in the TRIO clinical study

Purpose

Unintended pregnancy and HIV infection present dual risks for young women in sub-Saharan Africa. New multipurpose prevention technologies (MPTs) are in development to simultaneously prevent unintended pregnancy and HIV, but there is a need for end-user research to ensure these products suit women’s needs. The Tablet, Rings and Injectables as Options (TRIO) for women study took place in Kisumu, Kenya, and Soshanguve, South Africa, with the goal of eliciting young women’s feedback on three potential MPTs.

Methods

Women in TRIO used three placebo products that represented potential MPTs: daily oral tablets, monthly vaginal rings, and monthly dual injections in a randomized crossover design followed by a period in which they chose a product to use. Eighty-eight TRIO participants completed in-depth interviews and focus group discussions to understand their experiences using each product. Qualitative analyses were conducted after stratifying by product preference at the end of the crossover period.

Results

The majority (65%) of participants preferred injections, with the remainder evenly split between tablets and rings. Discussions of preference for one product were closely linked with expressed dislike of another product’s attributes. Participants recognized heterogeneity in preferences and choices across users and stressed the need for multiple MPT options that confer a low burden on women’s daily lives.

Conclusion

Rather than choosing a product to use based on the product’s perceived advantages, women’s choices were based on the unfavorable attributes of other TRIO products. Moreover, the importance that women placed on a given disadvantage varied. Disadvantages that women deemed as most important emerged as a greater driver of product preference than selecting products based on their advantages and favorable characteristics.