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Kestelyn E, Van Nuil JI, Umulisa MM, Umutoni G, Uwingabire A, De Baetselier I, Uwineza M, Agaba S, Crucitti T, Delvaux T, van de Wijgert JHHM. High adherence to intermittent and continuous use of a contraceptive vaginal ring among women in a randomized controlled trial in Kigali, Rwanda. Front Glob Womens Health 2024; 5:1278981. [PMID: 38680542 PMCID: PMC11047128 DOI: 10.3389/fgwh.2024.1278981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 03/20/2024] [Indexed: 05/01/2024] Open
Abstract
Background The introduction of female-initiated drug-delivery methods, including vaginal rings, have proven to be a promising avenue to address sexually transmitted infections and unintended pregnancies, which disproportionally affects women and girls in sub-Saharan Africa. Efficient uptake of existing and new technologies such as vaginal rings requires in depth understanding of product adherence. This remains a major challenge as data on adherence to vaginal rings from African countries is limited. In this study, we explored adherence of contraceptive vaginal ring (NuvaRing®) use in Kigali, Rwanda using a mixed methods approach. Methods We collected quantitative and qualitative data at multiple time points from women participating in a clinical trial exploring the safety and acceptability of either intermittent or continuous use of the NuvaRing®. Various adherence categories were used including monthly and cumulative adherence measurement. The quantitative data were analysed using R and the qualitative data were analysed using a deductive, content-analytical approach based on categories related to the quantitative adherence measures. All data were compared and triangulated. Results Data from 120 enrolled participants showed that self-reported adherence was high at every study visit in both study groups. At first study visit 80% of the intermittent ring users and 79.7% of the continuous ring users reported perfect adherence (assessed as "the ring was never out"). Reporting of ring expulsions and removals were highest (28.3%) at the beginning of the trial. Self-reported perfect ring adherence increased during the study and reports of ring expulsions and removals declined as familiarity with this contraceptive method increased. The percentage of women with perfect cumulative adherence was non-significantly higher in the intermittent (61.7%) than in the continuous use group (54.3%). The low rate of discrepant adherence data after triangulation (6%) is in line with the perception of the participants as adherent throughout the study. Conclusions Self-reported adherence in both study groups was high with removals and expulsions being within the expected product range. Comprehensive adherence data triangulation allowed for a deeper understanding of context-driven behaviour that shaped adherence patterns and challenges. Our data categorisation and triangulation approach has shown potential for implementation in future vaginal ring studies aiming to better understand and measure adherence.
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Affiliation(s)
- Evelyne Kestelyn
- Rinda Ubuzima, Kigali, Rwanda
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | - Jennifer Ilo Van Nuil
- Rinda Ubuzima, Kigali, Rwanda
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | | | | | | | - Irith De Baetselier
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | | | | | - Tania Crucitti
- Experimental Bacteriology Unit, Institut Pasteur Madagascar, Antananarivo, Madagascar
| | - Thérèse Delvaux
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Janneke H. H. M. van de Wijgert
- Rinda Ubuzima, Kigali, Rwanda
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
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2
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Katz AWK, Balán IC, Reddy K, Etima J, Weber K, Tauya T, Atujuna M, Scheckter R, Ngure K, Soto-Torres L, Mgodi N, Palanee-Phillips T, Baeten JM, van der Straten A. Women's experience receiving drug feedback and adherence counseling in MTN-025/HOPE - an HIV Prevention open-label trial of the Dapivirine Vaginal Ring. AIDS Behav 2022; 26:3607-3619. [PMID: 35536519 PMCID: PMC9561023 DOI: 10.1007/s10461-022-03663-z] [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: 03/18/2022] [Indexed: 11/01/2022]
Abstract
In the Phase IIIB MTN-025/HOPE open label extension trial, participants were offered the dapivirine vaginal ring as HIV prophylaxis, and those who accepted the ring received semi real-time individual adherence feedback, based on residual drug level (RDL) from returned rings, during Motivational Interviewing-based counseling. Counseling messages, based on the best knowledge at the time, framed RDL results in terms of ring use and HIV protection, from no use /no protection (0 RDL) to high use /high protection (3 RDL). At six HOPE sites, in-depth-Interviews (IDIs) about RDL were conducted with 64 participants who had received at least one RDL result. We found mixed interpretations of what the RDL meant and strong emotional reactions with a focus on the external validation of the level itself. Counseling was critical to help participants process their reactions to the RDL and make decisions accordingly (i.e., persistence, adherence improvement, and/or switching to another HIV prevention method). Providing drug adherence feedback was complex to implement yet proved useful as a component of a multi-pronged adherence support strategy.
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Affiliation(s)
| | - Iván C Balán
- HIV Center for Clinical and Behavioral Studies, Columbia University, New York, New York, United States
- Present affiliation Florida State University College of Medicine, Tallahassee, FL, USA
| | - Krishnaveni Reddy
- Wits Reproductive Health and HIV Institute (Wits RHI), Johannesburg, South Africa
| | - Juliane Etima
- Makerere University, Johns Hopkins University Research Collaboration, Kampala, Uganda
| | | | - Thelma Tauya
- College of Health Sciences Clinical Trials Unit, University of Zimbabwe, Harare, Zimbabwe
| | - Millicent Atujuna
- Desmond Tutu AIDS Foundation, University of Cape Town, Cape Town, South Africa
| | | | - Kenneth Ngure
- Department of Community Health, Jomo Kenyatta University of Agriculture and Technology, Juja, Kenya
| | | | - Nyaradzo Mgodi
- College of Health Sciences Clinical Trials Unit, University of Zimbabwe, Harare, Zimbabwe
| | | | - Jared M Baeten
- University of Washington, Seattle, WA, USA
- Present affiliation Gilead Sciences, Foster City, CA, USA
| | - Ariane van der Straten
- Center for AIDS Prevention Studies (CAPS), University of California San Francisco, San Francisco, CA, USA
- Present affiliation ASTRA Consulting, Kensington, CA, USA
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3
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The Influence of Perceived Dapivirine Vaginal Ring Effectiveness on Social Disclosure and Ring Adherence. AIDS Behav 2021; 25:4169-4179. [PMID: 33939034 DOI: 10.1007/s10461-021-03286-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2021] [Indexed: 10/21/2022]
Abstract
We analyzed data from 1428 users of the dapivirine vaginal ring, who participated in the MTN-020/ASPIRE phase III trial and subsequent open-label extension MTN-025/HOPE trial, to examine relationships between perceived ring protection, social disclosures, and self-reported ring adherence. In HOPE, 77% perceived the ring to be highly effective, and this view was associated with speaking: (a) to a greater number of people about the study, (b) with other participants, (c) to more people who were in favor of the ring, and (d) to more people whose opinions were valued. Reported adherence was not directly associated with perceived protection but was associated with disclosing to someone who was in favor of the ring. These findings suggest the importance of women's internalized ideas about the protective benefits of the DVR in sharing information about the ring and the importance of social support on adherence.
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4
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Garcia M, Luecke E, Mayo AJ, Scheckter R, Ndase P, Kiweewa FM, Kemigisha D, Musara P, Mansoor LE, Singh N, Woeber K, Morar NS, Jeenarain N, Gaffoor Z, Gondwe DK, Makala Y, Fleurs L, Reddy K, Palanee-Phillips T, Baeten JM, van der Straten A, Soto-Torres L, Torjesen K. Impact and experience of participant engagement activities in supporting dapivirine ring use among participants enrolled in the phase III MTN-020/ASPIRE study. BMC Public Health 2021; 21:2041. [PMID: 34749675 PMCID: PMC8576984 DOI: 10.1186/s12889-021-11919-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 09/24/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Low adherence to investigational products can negatively impact study outcomes, limiting the ability to demonstrate efficacy. To continue advancing potential new HIV prevention technologies, efforts are needed to improve adherence among study participants. In MTN-020/ASPIRE, a phase III randomized, double-blind, placebo-controlled study of the dapivirine vaginal ring carried out across 15 sites in sub-Saharan Africa, a multifaceted approach to adherence support was implemented, including a strong focus on participant engagement activities (PEAs). In this manuscript, we describe PEAs and participant attendance, and analyze the potential impact of PEAs on ring use. METHODS All sites implemented PEAs and submitted activity and attendance reports to the study management team throughout the study. Participant demographics were collected via case report forms. Residual dapivirine remaining in the last ring returned by each participant was used to estimate drug released from the ring, which was then adjusted for time participants had the ring to calculate probable use categorized into three levels (low/intermittent/high). Product use was connected to PEA attendance using participant identification numbers. We used multivariate Poisson regression with robust standard errors to explore differences in ring use between PEA attendance groups and reviewed qualitative reports for illustrative quotes highlighting participant experiences with PEAs. RESULTS 2312 of 2629 study participants attended at least one of 389 PEAs conducted across sites. Participant country and partner knowledge of study participation were most strongly associated with PEA attendance (p < 0.005) with age, education, and income status also associated with event attendance (p < 0.05). When controlling for these variables, participants who attended at least one event were more likely to return a last ring showing at least some use (RR = 1.40) than those who never attended an event. There was a stronger correlation between a last returned ring showing use and participant attendance at multiple events (RR = 1.52). CONCLUSIONS Our analysis supports the growing body of work illustrating the importance of meaningfully engaging research participants to achieve study success and aligns with other analyses of adherence support efforts during ASPIRE. While causation between PEA attendance and product use cannot be established, residual drug levels in returned rings strongly correlated with participant attendance at PEAs, and the benefits of incorporating PEAs should be considered when designing future studies of investigational products.
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Affiliation(s)
- Morgan Garcia
- Global Health Population and Nutrition, FHI, Durham, NC, 360, USA.
| | - Ellen Luecke
- Women's Global Health Imperative (WGHI) RTI International, Berkeley, CA, USA; ASTRA Consulting, Kensington, CA, USA
| | - Ashley J Mayo
- Global Health Population and Nutrition, FHI, Durham, NC, 360, USA
| | - Rachel Scheckter
- Global Health Population and Nutrition, FHI, Durham, NC, 360, USA
| | - Patrick Ndase
- Population Services International (PSI), 1120 19th St. NW, Washington, DC, USA
| | - Flavia Matovu Kiweewa
- Makerere University-Johns Hopkins University (MU-JHU) Research Collaboration, Kampala, Uganda
| | - Doreen Kemigisha
- Makerere University-Johns Hopkins University (MU-JHU) Research Collaboration, Kampala, Uganda
| | - Petina Musara
- University of Zimbabwe College of Health Sciences-Clinical Trials Research Centre, Harare, Zimbabwe
| | - Leila E Mansoor
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
| | - Nishanta Singh
- HIV Prevention Research Unit (HPRU), South African Medical Research Council (SAMRC), Durban, South Africa
| | - Kubashni Woeber
- HIV Prevention Research Unit (HPRU), South African Medical Research Council (SAMRC), Durban, South Africa
| | - Neetha S Morar
- HIV Prevention Research Unit (HPRU), South African Medical Research Council (SAMRC), Durban, South Africa
| | - Nitesha Jeenarain
- HIV Prevention Research Unit (HPRU), South African Medical Research Council (SAMRC), Durban, South Africa
| | - Zakir Gaffoor
- HIV Prevention Research Unit (HPRU), South African Medical Research Council (SAMRC), Durban, South Africa
| | - Daniel K Gondwe
- College of Medicine - Johns Hopkins Bloomberg School of Public Health, Blantyre, Malawi
| | - Yvonne Makala
- University of North Carolina Project, Lilongwe, Malawi
| | - Llewellyn Fleurs
- Desmond Tutu HIV Foundation, Emavundleni Clinical Research Site, Cape Town, South Africa
| | - Krishnaveni Reddy
- Wits Reproductive Health and HIV Institute (Wits RHI), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Thesla Palanee-Phillips
- Wits Reproductive Health and HIV Institute (Wits RHI), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Jared M Baeten
- Departments of Global Health, Medicine, and Epidemiology, University of Washington, Seattle, WA, USA
| | - Ariane van der Straten
- Women's Global Health Imperative (WGHI) RTI International, Berkeley, CA, USA; ASTRA Consulting, Kensington, CA, USA.,Center for AIDS Prevention Studies (CAPS), University of California San Francisco, San Francisco, CA, USA
| | - Lydia Soto-Torres
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
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Husnik MJ, Brown ER, Dadabhai SS, Gaffoor Z, Jeenarain N, Kiweewa FM, Livant E, Mansoor LE, Mirembe BG, Palanee-Phillips T, Singh D, Siva S, Soto-Torres L, van der Straten A, Baeten JM. Correlates of Adherence to the Dapivirine Vaginal Ring for HIV-1 Prevention. AIDS Behav 2021; 25:2801-2814. [PMID: 34117592 PMCID: PMC8577988 DOI: 10.1007/s10461-021-03231-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/10/2021] [Indexed: 12/31/2022]
Abstract
Understanding characteristics associated with adherence to pre-exposure prophylaxis (PrEP) methods for HIV-1 prevention may assist with optimizing implementation efforts. The dapivirine vaginal ring is a novel topical PrEP delivery method. Using data from a randomized, double-blind, placebo-controlled, phase III trial of the dapivirine vaginal ring conducted in four African countries, generalized estimating equation models were used to evaluate correlates of ring adherence. Two levels of quarterly dapivirine blood plasma, and dapivirine released from returned rings defined measures of adherence for recent and cumulative use, respectively. Time on study, calendar time, primary partner knowledge that the participant was taking part in the study, and use of long-acting contraceptive methods were associated with ring adherence whereas younger age, ring worries, condom use, episodes of menstrual bleeding and vaginal washing were associated with non-adherence. These findings may be useful for recruitment into future clinical studies and dapivirine ring implementation efforts.
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Affiliation(s)
- Marla J Husnik
- Fred Hutchinson Cancer Research Center, Seattle, USA
- University of Washington, Seattle, USA
| | | | - Sufia S Dadabhai
- Johns Hopkins Bloomberg School of Public Health, Blantyre, Malawi
| | - Zakir Gaffoor
- South African Medical Research Council, Durban, South Africa
| | | | | | | | - Leila E Mansoor
- Centre for the AIDS Programme of Research in South Africa, Durban, South Africa
| | | | - Thesla Palanee-Phillips
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, School of Clinical Medicine, Johannesburg, South Africa
| | - Devika Singh
- Magee-Womens Research Institute, Pittsburgh, USA
| | - Samantha Siva
- South African Medical Research Council, Durban, South Africa
| | | | - Ariane van der Straten
- RTI International, Women's Global Health Imperative, San Francisco, CA, USA
- Center for AIDS Prevention Studies, Department of Medicine, UCSF, San Francisco, CA, USA
| | - Jared M Baeten
- University of Washington, Seattle, USA.
- Department of Global Health, University of Washington, 325 Ninth Avenue, Box 359927, Seattle, WA, 98104, USA.
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6
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Baker Z, Javanbakht M, Moore J, Brosnan H, Squires K, Bunge K, Zimet G, Mensch B, Soto-Torres L, Kapogiannis B, Levy L, Hoesley C, Reirden D, Gaur A, Mayer K, Futterman D, Gorbach P. Qualitative Study on the Acceptability of and Adherence to a Vaginal Ring for HIV Prophylaxis Among Adolescent Girls. J Acquir Immune Defic Syndr 2021; 87:944-950. [PMID: 33675614 PMCID: PMC8192420 DOI: 10.1097/qai.0000000000002674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 12/30/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This study aims to assess the product-related, relationship-related, and sex-related factors that act as facilitators and barriers to the acceptability of a vaginal ring (VR) for HIV prevention among adolescent girls. DESIGN Qualitative study. METHODS Ninety-six girls aged 15-17 years from 6 urban US sites were enrolled in MTN-023/IPM 030, a 24-week randomized controlled trial, for assessing the safety and acceptability of a dapivirine VR for HIV prevention. At week 24, 21 girls were randomly selected to participate in in-depth interviews. Interviews were transcribed verbatim and data analyzed using a thematic analysis approach. Facilitators and barriers to VR acceptability related to participants' relationships, sexual activity, and characteristics of the VR product were identified. RESULTS Factors related to relationships rarely seemed to act as barriers to VR acceptability; most participants disclosed VR use to sexual partners, and positive reactions from sexual partners, which were common, seemed to facilitate VR acceptability. Emotional and/or physical discomfort surrounding VR use during sex was mentioned occasionally as a barrier to VR acceptability. Product characteristics were most frequently mentioned as barriers to VR acceptability. Many participants reported concerns about the large size of the VR on first impression. Although most found the VR comfortable, some reported pain with VR insertion. Several participants were concerned about VR cleanliness, particularly during menstruation. CONCLUSION Product considerations, specifically size and use during menstruation, were the most commonly reported barriers to VR acceptability in this study. Adolescent girls may require additional counseling to assuage product concerns regarding a VR for HIV prevention.
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Affiliation(s)
- Zoë Baker
- Division of Urology, Children's Hospital Los Angeles, Los Angeles, CA
| | - Marjan Javanbakht
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA
| | - Janell Moore
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA
| | - Hannah Brosnan
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA
| | - Kathleen Squires
- Division of Infectious Diseases, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA
- Global Center of Scientific Affairs, Merck Research Labs, Rahway, NJ
| | - Katherine Bunge
- Department of Obstetrics, Gynecology & Reproductive Services, University of Pittsburgh, Pittsburgh, PA
| | - Gregory Zimet
- Department of Pediatrics, Indiana University, Bloomington, IA
| | | | - Lydia Soto-Torres
- National Institute of Allergy and Infectious Diseases, Division of AIDS, Bethesda, MD
| | - Bill Kapogiannis
- Maternal and Pediatric Infectious Disease Branch, National Institute of Child Health and Human Development, Bethesda, MD
| | | | - Craig Hoesley
- Division of Infectious Diseases, University of Alabama, Birmingham, AL
| | - Daniel Reirden
- Department of Adolescent Medicine, Children's Hospital Colorado, Aurora, CO
| | - Aditya Gaur
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, TN
| | - Kenneth Mayer
- Department of Global Health and Population, Harvard School of Public Health, The Fenway Institute, Boston, MA; and
| | - Donna Futterman
- Department of Pediatrics, Albert Einstein College of Medicine, the Bronx, NY
| | - Pamina Gorbach
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA
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Abstract
PURPOSE OF REVIEW Although tremendous successes in HIV treatment and prevention have occurred in the past decade, existing HIV prevention options are inadequate, unacceptable or inaccessible to many. Topical antiretroviral-based preexposure prophylaxis (PrEP) options may offer effective, long-acting prevention to those who do not desire systemic exposure to anti-HIV drugs or who want greater control over their own prevention. RECENT FINDINGS Among long-acting topical PrEP agents, the dapivirine vaginal ring has advanced the furthest in product development; recent studies have shown high adherence and persistence and evidence of HIV protection in open-label studies as well as a well tolerated safety profile, across the life cycle in women. A range of other long-acting topical PrEP products for vaginal or rectal drug delivery are under development. Rigorous end-user research has explored how to develop products that are behaviorally congruent for the population at risk and has shown that no single product option will be desired by all, but rather different options will achieve the greatest prevention coverage. SUMMARY Topically delivered, long-acting antiretroviral PrEP options are being designed to align with user preferences and lifestyles, providing the potential to more effectively expand the HIV prevention method mix and use and achieve an important impact on HIV globally.
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Lentz C, Giguere R, Kutner BA, Dolezal C, Kajura-Manyindo C, Yambira M, Asiimwe F, Mugocha C, Mwenda W, Ndlovu T, Naidu N, Madlala B, Balán IC. Culturally-Based Challenges to and Recommendations for Delivering Adherence Counseling in a Multicultural Biomedical HIV Prevention Trial in Four African Countries. AIDS EDUCATION AND PREVENTION : OFFICIAL PUBLICATION OF THE INTERNATIONAL SOCIETY FOR AIDS EDUCATION 2020; 32:512-527. [PMID: 33779210 PMCID: PMC8059360 DOI: 10.1521/aeap.2020.32.6.512] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
Research is needed to identify how to effectively tailor evidence-based interventions across cultures with limited resources, particularly for behavioral components in large HIV prevention trials. Through surveys and interviews with counselors of sub-Saharan African women during an open-label microbicide trial (MTN-025), we examined language, education, and cultural barriers in delivering a motivational interviewing-based adherence counseling intervention (i.e., Options Counseling). Counselors encountered an array of barriers, most prominently that participants struggled to comprehend culturally incongruent pictorial guides, such as traffic light images, and to uphold product use when primary partners disapproved. Overwhelmingly, counselors cited the intervention's inherent flexibility as an asset; it encouraged them to tailor language and examples to be more culturally relevant to participants. Future resource-conscious researchers may preemptively offset similar barriers by consulting with communities during intervention development. Similarly, affording counselors flexibility while delivering the chosen intervention may enable them to troubleshoot barriers that arise on the ground.
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Affiliation(s)
- Cody Lentz
- HIV Center for Clinical and Behavioral Studies at New York State Psychiatric Institute and Columbia University, New York, New York, United States of America
| | - Rebecca Giguere
- HIV Center for Clinical and Behavioral Studies at New York State Psychiatric Institute and Columbia University, New York, New York, United States of America
| | - Bryan A. Kutner
- HIV Center for Clinical and Behavioral Studies at New York State Psychiatric Institute and Columbia University, New York, New York, United States of America
| | - Curtis Dolezal
- HIV Center for Clinical and Behavioral Studies at New York State Psychiatric Institute and Columbia University, New York, New York, United States of America
| | - Clare Kajura-Manyindo
- HIV Center for Clinical and Behavioral Studies at New York State Psychiatric Institute and Columbia University, New York, New York, United States of America
| | - Makanaka Yambira
- University of Zimbabwe College of Health Sciences Clinical Trials Research Center, Harare, Zimbabwe
| | - Florence Asiimwe
- Makerere University – Johns Hopkins University Research Collaboration Clinical Research Site, Kampala, Uganda
| | - Caroline Mugocha
- University of Zimbabwe College of Health Sciences Clinical Trials Research Center, Harare, Zimbabwe
| | - Wezi Mwenda
- Queen Elizabeth Central Hospital, College of Medicine Clinical Research Site, Blantyre, Malawi
| | - Thakasile Ndlovu
- South African Medical Research Council Clinical Trials Unit, Durban, South Africa
| | - Nalini Naidu
- South African Medical Research Council Clinical Trials Unit, Durban, South Africa
| | | | - Iván C. Balán
- HIV Center for Clinical and Behavioral Studies at New York State Psychiatric Institute and Columbia University, New York, New York, United States of America
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9
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A Mixed-Methods Study Examining Adherence to and Acceptability of Intravaginal Rings for HIV Prevention: Behavioral Results of MTN-027. AIDS Behav 2020; 24:607-616. [PMID: 30877580 DOI: 10.1007/s10461-019-02457-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Intravaginal rings (IVR) containing antiretroviral drugs are a promising method for HIV prevention. We triangulated quantitative and qualitative assessments to evaluate the acceptability of four IVRs used continuously for 28 days as part of a Phase I trial (N = 48 HIV-negative women; ages 18-45). Adherence was high throughout the trial, yet 30% of participants reported involuntary IVR expulsions followed by re-insertion. Most participants (93.6%) felt comfortable with the IVR being inside their body. Participants reported liking the IVR more (36.2%) or the same amount (55.3%) since starting the study. When given the option of choosing between the IVR and/or a male condom for HIV-prevention, most reported preferring the IVR (n = 29, 63.0%), and over a quarter of the sample reported liking them equally (n = 12, 26.1%). We observed no differences in IVR acceptability across the study arms. High adherence and acceptability underscores the promise of an IVR as a female-controlled, sustained mechanism for HIV prevention.
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10
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Duby Z, Katz AWK, Browne EN, Mutero P, Etima J, Zimba CC, Woeber K, Atujuna M, Reddy K, van der Straten A. Hygiene, Blood Flow, and Vaginal Overload: Why Women Removed an HIV Prevention Vaginal Ring During Menstruation in Malawi, South Africa, Uganda and Zimbabwe. AIDS Behav 2020; 24:617-628. [PMID: 31030301 DOI: 10.1007/s10461-019-02514-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
We assessed the interference between vaginal ring use and menses among women who participated in the qualitative component of the MTN-020/ASPIRE vaginal ring trial in Malawi, South Africa, Uganda and Zimbabwe (N = 214). A common reason for imperfect ring adherence and premature removal of the vaginal ring cited by participants related to vaginal bleeding or menses. Whereas self-reporting via survey questions suggested that the majority (60%) of women did not mind wearing the ring while menstruating, and did not remove it (91%) during menses, in the qualitative interviews women frequently described removing the ring during menses. Their reasons included hygiene, beliefs that the ring blocked the flow of menstrual blood, fears that the ring would come out with blood or during tampon removal, and concerns around an 'overburdened' vagina. Examining women's narratives and subjective experiences related to menstruation helps build a better understanding of factors affecting ring use and adherence.
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Affiliation(s)
- Zoe Duby
- Division of Social and Behavioural Sciences, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.
| | - Ariana W K Katz
- Women's Global Health Imperative, RTI International, San Francisco, CA, USA
| | - Erica N Browne
- Women's Global Health Imperative, RTI International, San Francisco, CA, USA
| | | | - Juliane Etima
- Makerere University - Johns Hopkins University, Research Collaboration, Kampala, Uganda
| | | | - Kubashni Woeber
- South African Medical Research Council, Kwazulu Natal, South Africa
| | - Millicent Atujuna
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Krishnaveni Reddy
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Ariane van der Straten
- Women's Global Health Imperative, RTI International, San Francisco, CA, USA
- Department of Medicine, Center for AIDS Prevention Studies, UCSF, San Francisco, CA, USA
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Griffin JB, Ridgeway K, Montgomery E, Torjesen K, Clark R, Peterson J, Baggaley R, van der Straten A. Vaginal ring acceptability and related preferences among women in low- and middle-income countries: A systematic review and narrative synthesis. PLoS One 2019; 14:e0224898. [PMID: 31703094 PMCID: PMC6839883 DOI: 10.1371/journal.pone.0224898] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 10/23/2019] [Indexed: 11/30/2022] Open
Abstract
The vaginal ring (VR) is a female-initiated drug-delivery platform used for different indications, including HIV pre-exposure prophylaxis (PrEP). We conducted a systematic review of VR acceptability, values and preferences among women in low- and middle-income countries (LMIC) to inform further investment and/or guidance on VR use for HIV prevention. Following PRISMA guidelines, we used structured methods to search, screen, and extract data from randomized controlled trials (RCTs) and observational studies reporting quantitative outcomes of acceptability of the VR for any indication published 1/1970-2/2019 (PROSPERO: CRD42019122220). Of 1,110 records identified, 68 met inclusion criteria. Studies included women 15-50+ years from 25 LMIC for indications including HIV prevention, contraception, abnormal bleeding, and menopause. Overall VR acceptability was high (71-98% across RCTs; 62-100% across observational studies), with 80-100% continuation rates in RCTs and favorable ease of insertion (greater than 85%) and removal 89-99%). Users reported concerns about the VR getting lost in the body (8-43%), although actual expulsions and adverse events were generally infrequent. Most women disclosed use to partners, with some worrying about partner anger/violence. The VR was not felt during intercourse by 70-92% of users and 48-97% of partners. Acceptability improved over time both within studies (as women gained VR experience and worries diminished), and over chronological time (as the device was popularized). Women expressed preferences for accessible, long-acting, partner-approved methods that prevent both HIV and pregnancy, can be used without partner knowledge, and have no impact on sex and few side effects. This review was limited by a lack of standardization of acceptability measures and study heterogeneity. This systematic review suggests that most LMIC women users have a positive view of the VR that increases with familiarity of use; and, that many would consider the VR an acceptable future delivery device for HIV prevention or other indications.
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Affiliation(s)
- Jennifer B. Griffin
- RTI International, Center for Global Health, Durham, NC, United States of America
| | - Kathleen Ridgeway
- FHI 360, Global Health Population and Nutrition, Durham, NC, United States of America
| | - Elizabeth Montgomery
- RTI International, Center for Global Health, Durham, NC, United States of America
| | - Kristine Torjesen
- FHI 360, Global Health Population and Nutrition, Durham, NC, United States of America
| | - Rachel Clark
- RTI International, Public Health Research Division, Durham, NC, United States of America
| | - Jill Peterson
- FHI 360, Global Health Population and Nutrition, Durham, NC, United States of America
| | | | - Ariane van der Straten
- RTI International, Center for Global Health, Durham, NC, United States of America
- University of California, San Francisco, Department of Medicine, San Francisco, CA, United States of America
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Singh K, Sarafianos SG, Sönnerborg A. Long-Acting Anti-HIV Drugs Targeting HIV-1 Reverse Transcriptase and Integrase. Pharmaceuticals (Basel) 2019; 12:E62. [PMID: 31010004 PMCID: PMC6631967 DOI: 10.3390/ph12020062] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Revised: 04/16/2019] [Accepted: 04/18/2019] [Indexed: 12/20/2022] Open
Abstract
One of the major factors contributing to HIV-1 drug resistance is suboptimal adherence to combination antiretroviral therapy (cART). Currently, recommended cART for HIV-1 treatment is a three-drug combination, whereas the pre-exposure prophylaxis (PrEP) regimens consist of one or two antivirals. Treatment regimens require adherence to a once or twice (in a subset of patients) daily dose. Long-acting formulations such as injections administered monthly could improve adherence and convenience, and thereby have potential to enhance the chances of expected outcomes, although long-lasting drug concentrations can also contribute to clinical issues like adverse events and development of drug resistance. Globally, two long-acting antivirals have been approved, and fifteen are in clinical trials. More than half of investigational long-acting antivirals target HIV-1 reverse transcriptase (HIV-1 RT) and/or integrase (HIV-1 IN). Here, we discuss the status and potential of long-acting inhibitors, including rilpivirine (RPV), dapivirine (DPV), and 4-ethynyl-2-fluoro-2-deoxyadenosine (EFdA; also known as MK-8591), which target RT, and cabotegravir (CAB), which targets IN. The outcomes of various clinical trials appear quite satisfactory, and the future of long-acting HIV-1 regimens appears bright.
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Affiliation(s)
- Kamal Singh
- Department of Molecular Microbiology and Immunology, University of Missouri, Columbia, MO 65211, USA.
- Bond Life Sciences Center, University of Missouri, Columbia, MO 65211, USA.
- Division of Clinical Microbiology, Department of Laboratory Medicine, Karolinska Institute, Huddinge 14186, Stockholm, Sweden.
| | - Stefan G Sarafianos
- Laboratory of Biochemical Pharmacology, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA 30322, USA.
| | - Anders Sönnerborg
- Department of Molecular Microbiology and Immunology, University of Missouri, Columbia, MO 65211, USA.
- Division of Clinical Microbiology, Department of Laboratory Medicine, Karolinska Institute, Huddinge 14186, Stockholm, Sweden.
- Division of Infectious Diseases, Department of Medicine Huddinge, Karolinska Institute, Huddinge 14186, Stockholm, Sweden.
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