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Milford C, Ramlal H, Mofokeng R, Rambally Greener L, Nel A, Smit J, Malherbe M. Self-reported removal and expulsion of the dapivirine vaginal ring: qualitative reports from female ring users and their male partners in the Ring Study (IPM 027). BMC Public Health 2024; 24:1458. [PMID: 38822304 PMCID: PMC11140940 DOI: 10.1186/s12889-024-18795-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 05/08/2024] [Indexed: 06/02/2024] Open
Abstract
BACKGROUND/AIMS The dapivirine vaginal ring is a self-administered, women-initiated, discreet, long-acting HIV-1 prevention option for women. It was found to be safe and effective in healthy HIV-negative women who adhered to product use instructions, and has been approved for use in women aged 18 and older in some African countries. A qualitative study was conducted to explore participants' and their male partners' discussions on accidental/purposeful vaginal ring removals during The Ring Study (IPM 027 clinical trial). METHODS Data were collected via in-depth interviews and focus group discussions with female trial participants and their male partners, from seven research centres in South Africa and Uganda. Data were thematically analysed using NVivo. RESULTS More participants reported purposeful ring removals than accidental expulsions. Various factors influenced purposeful ring removal - including individual (discomfort during use/sex and to clean it), partner (to show them, because of discomfort during sex, to test if partners could feel it, and concerns of harm), organisational (doctor's request), and socio-cultural (rumours about sickness and infertility). Some described their own ring use removal, others discussed why other participants removed their rings. CONCLUSIONS Vaginal ring adherence is critical to improve and support product efficacy. Counselling on vaginal anatomy, vaginal ring insertion and importance of adherence is important to minimise vaginal ring removal. Couples counselling is also important to facilitate support and long-term vaginal ring adherence behaviour. Understanding factors influencing vaginal ring adherence is important for tailoring and targeting messages to support correct and consistent vaginal ring use as it is made available to the public.
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Affiliation(s)
- Cecilia Milford
- Wits MRU (MatCH Research Unit), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Commercial City Building, 40 Dr AB Xuma Street, Durban, 4001, South Africa.
- CAPRISA (Centre for the AIDS Programme of Research in South Africa), University of KwaZulu-Natal, Durban, South Africa.
| | - Hariska Ramlal
- Wits MRU (MatCH Research Unit), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Commercial City Building, 40 Dr AB Xuma Street, Durban, 4001, South Africa
| | - Rorisang Mofokeng
- Wits MRU (MatCH Research Unit), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Commercial City Building, 40 Dr AB Xuma Street, Durban, 4001, South Africa
| | - Letitia Rambally Greener
- Wits MRU (MatCH Research Unit), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Commercial City Building, 40 Dr AB Xuma Street, Durban, 4001, South Africa
| | - Annaléne Nel
- IPM South Africa NPC, an affiliate of The Population Council, Inc., New York, NY, USA
| | - Jennifer Smit
- Wits MRU (MatCH Research Unit), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Commercial City Building, 40 Dr AB Xuma Street, Durban, 4001, South Africa
| | - Mariëtte Malherbe
- IPM South Africa NPC, an affiliate of The Population Council, Inc., New York, NY, USA
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Junqueira LA, Raposo FJ, Vitral GSF, Tabriz AG, Douroumis D, Raposo NRB, Brandão MAF. Three-Dimensionally Printed Vaginal Rings: Perceptions of Women and Gynecologists in a Cross-Sectional Survey. Pharmaceutics 2023; 15:2302. [PMID: 37765271 PMCID: PMC10537249 DOI: 10.3390/pharmaceutics15092302] [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: 08/05/2023] [Revised: 09/04/2023] [Accepted: 09/07/2023] [Indexed: 09/29/2023] Open
Abstract
Three-dimensional printing technologies can be implemented for the fabrication of personalized vaginal rings (VRs) as an alternative approach to traditional manufacturing. Although several studies have demonstrated the potential of additive manufacturing, there is a lack of knowledge concerning the opinions of patients and clinicians. This study aimed to investigate the perception of women and gynecologists regarding VRs with personalized shapes. The devices were printed with different designs (traditional, "Y", "M", and flat circle) by Fused Deposition Modeling for a cross-sectional survey with 155 participants. Their anticipated opinion was assessed through a questionnaire after a visual/tactile analysis of the VRs. The findings revealed that most women would feel comfortable using some of the 3D-printed VR designs and demonstrated good acceptability for the traditional and two innovative designs. However, women presented multiple preferences when the actual geometry was assessed, which directly related to their age, previous use of the vaginal route, and perception of comfort. In turn, gynecologists favored prescribing traditional and flat circle designs. Overall, although there was a difference in the perception between women and gynecologists, they had a positive opinion of the 3D-printed VRs. Finally, the personalized VRs could lead to an increase in therapeutic adherence, by meeting women's preferences.
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Affiliation(s)
- Laura Andrade Junqueira
- Center for Research and Innovation in Health Sciences, Department of Pharmaceutical Science, Federal University of Juiz de Fora, Juiz de Fora 36036-900, MG, Brazil; (L.A.J.); (F.J.R.); (M.A.F.B.)
| | - Francisco José Raposo
- Center for Research and Innovation in Health Sciences, Department of Pharmaceutical Science, Federal University of Juiz de Fora, Juiz de Fora 36036-900, MG, Brazil; (L.A.J.); (F.J.R.); (M.A.F.B.)
| | - Geraldo Sérgio Farinazzo Vitral
- Woman Health Investigation Group, Department of Surgery, Federal University of Juiz de Fora, Juiz de Fora 36036-900, MG, Brazil;
| | - Atabak Ghanizadeh Tabriz
- Centre for Innovation and Process Engineering Research, University of Greenwich, Chatham Maritime, Chatham ME4 4TB, UK; (A.G.T.); (D.D.)
| | - Dennis Douroumis
- Centre for Innovation and Process Engineering Research, University of Greenwich, Chatham Maritime, Chatham ME4 4TB, UK; (A.G.T.); (D.D.)
| | - Nádia Rezende Barbosa Raposo
- Center for Research and Innovation in Health Sciences, Department of Pharmaceutical Science, Federal University of Juiz de Fora, Juiz de Fora 36036-900, MG, Brazil; (L.A.J.); (F.J.R.); (M.A.F.B.)
| | - Marcos Antônio Fernandes Brandão
- Center for Research and Innovation in Health Sciences, Department of Pharmaceutical Science, Federal University of Juiz de Fora, Juiz de Fora 36036-900, MG, Brazil; (L.A.J.); (F.J.R.); (M.A.F.B.)
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Cummins JE, Allen CL, Lee S, Senn TE. Biomedical, socio-behavioral, and implementation science gaps in multipurpose prevention technology research. FRONTIERS IN REPRODUCTIVE HEALTH 2023; 5:1244659. [PMID: 37744288 PMCID: PMC10513059 DOI: 10.3389/frph.2023.1244659] [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: 06/22/2023] [Accepted: 08/15/2023] [Indexed: 09/26/2023] Open
Abstract
There is strong global need for the development of Multipurpose Prevention Technologies (MPTs) that prevent HIV, pregnancy, and/or other sexually transmitted infections (STIs). However, despite decades of research focused on the development of MPTs, numerous research gaps remain, contributing to reproductive health disparities. This commentary will highlight biomedical, socio-behavioral, and implementation science gaps in MPT research. Biomedical gaps and barriers include limited dosage forms, challenges around drug selection and stable coformulation of multiple drugs, and an unclear regulatory pathway. Behavioral, social, and structural gaps include lack of research around MPT preferences for some subgroups of potential end users, lack of knowledge around whether MPTs improve uptake, adherence, and persistence vs. separate products, and a need to further understand how social and cultural factors might impact MPT interest and use. Gaps in implementation science research will need to be addressed to better understand how to implement MPTs to maximize effectiveness and benefit. This commentary will also identify opportunities for integrating biomedical and behavioral science around MPTs.
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Affiliation(s)
- James E. Cummins
- Preclinical Microbicide and Prevention Research Branch (PMPRB), National Institute of Allergy and Infectious Diseases (NIAID), Rockville, MD, United States
| | - C. Leigh Allen
- Contraception Research Branch (CRB), Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), Bethesda, MD, United States
| | - Sonia Lee
- Maternal and Pediatric Infectious Disease Branch (MPIDB), Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), Bethesda, MD, United States
| | - Theresa E. Senn
- HIV Prevention and Care Continuum, Co-Morbidities, and Translational Research Branch, National Institute of Mental Health (NIMH), Rockville, MD, United States
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Shapley-Quinn MK, Song M, Chen BA, Devlin B, Luecke E, Brown J, Blithe DL, Achilles SL, van der Straten A. Participant experiences with a multipurpose vaginal ring for HIV and pregnancy prevention during a phase 1 clinical trial: learning from users to improve acceptability. FRONTIERS IN REPRODUCTIVE HEALTH 2023; 5:1147628. [PMID: 37484873 PMCID: PMC10359149 DOI: 10.3389/frph.2023.1147628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 06/01/2023] [Indexed: 07/25/2023] Open
Abstract
Introduction With high concurrent global rates of HIV incidence and unintended pregnancy, there is a need to provide options beyond condoms to enable users to simultaneously prevent HIV acquisition and pregnancy. Multiple vaginal rings are in development as "MPTs" (multipurpose prevention technologies) as they are shown to provide several co-occurring benefits such as discretion, convenience, reversibility and user control. Methods In this Phase 1 trial of a 3-month MPT ring in the U.S., 25 participants (low-risk for HIV and pregnancy) were randomized to use the study ring for 90 days continuously or in 28-day cycles with 2-day removal periods in between. All participants completed in-depth interviews at the end of their study participation. Results Overall, the ring was well tolerated. Participants resoundingly endorsed the concept of an extended-use, dual-purpose vaginal ring, but reported too many functional challenges and side effects to endorse this particular ring. Participants assigned to the continuous regimen reported more positive experiences with ring use than those in the cyclic group. A minority of participants who experienced minimal side effects and did not experience challenges with vaginal retention of the ring found it appealing. However, the majority of participants experienced challenges (ring slippage, expulsions, side effects, vaginal bleeding changes) with product use that outweighed the potential benefits and led them to report that - in the future - they would not be interested in using this specific version of the ring in its current form. A subset expressed interest in using the current MPT ring under certain conditions (e.g., if fewer expulsions, less bleeding, higher risk for HIV/pregnancy). Discussion User feedback regarding participant experiences and challenges with the study ring was continuously shared with the product developer, underscoring the value of early-stage end-user feedback in product development.
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Affiliation(s)
| | - Mei Song
- Magee-Womens Research Institute, Pittsburgh, PA, United States
| | - Beatrice A. Chen
- Magee-Womens Research Institute, Pittsburgh, PA, United States
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh, School of Medicine, Pittsburgh, PA, United States
| | - Brid Devlin
- Center for Biomedical Research, Population Council, New York, NY, United States
| | - Ellen Luecke
- Women’s Global Health Imperative, RTI International, Berkeley, CA, United States
| | - Jill Brown
- Contraceptive Development Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, United States
| | - Diana L. Blithe
- Contraceptive Development Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, United States
| | - Sharon L. Achilles
- Magee-Womens Research Institute, Pittsburgh, PA, United States
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh, School of Medicine, Pittsburgh, PA, United States
| | - Ariane van der Straten
- Center for AIDS Prevention Studies, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
- ASTRA Consulting, Kensington, CA, United States
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Tolley EE, Hanif H, Thurman A, Brache V, Doncel GF. Preferred product attributes of a multipurpose vaginal ring: Findings from a phase 1 trial. FRONTIERS IN REPRODUCTIVE HEALTH 2023; 5:1148134. [PMID: 37064825 PMCID: PMC10097978 DOI: 10.3389/frph.2023.1148134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 03/09/2023] [Indexed: 04/01/2023] Open
Abstract
IntroductionMost women face multiple and co-occurring risks from unwanted pregnancy, human immunodeficiency virus (HIV) and other sexually transmitted infections (STIs) at some point during their lifetime. While a range of contraceptive methods exist and options for HIV prevention are increasing, to date, only male and female condoms provide multipurpose protection from both pregnancy and disease.MethodsFrom September 2017 to December 2018, 60 women from the United States and the Dominican Republic, randomized 1:1 to continuous or interrupted use and 4:1 to active vs. placebo ring, participated in a Phase I trial to assess the safety and tolerability of a three-month multipurpose intravaginal ring (IVR) containing the antiviral tenofovir and the contraceptive levonorgestrel. This study examines survey responses from all participants and qualitative data from a subset of 17 women to assess acceptability of and preferences for IVR characteristics.ResultsOverall, women liked the concept of a multipurpose IVR and found it easy to insert and remove. Initial concerns about the size or thickness of the ring generally disappeared with use experience. Women weighed trade-offs between the ease of continuous use for a longer duration against concerns about hygiene and discoloration of the ring when left in place during menses. Whether randomized to continuous or interrupted use, most women found ring attributes (size, thickness, flexibility) very acceptable. They provided recommendations via survey and qualitative interviews for ring modifications that would further increase acceptability. Insights into women's use experiences also suggest the need for clear counseling messages and introduction strategies that can facilitate women's choice and use of prevention methods.DiscussionStudy findings suggest that a multipurpose IVR would make a valuable contribution to women's sexual and reproductive health options, and that both continuous and interrupted use strategies may be preferred.
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Affiliation(s)
- Elizabeth E. Tolley
- FHI 360, Global Health and Population Research, Durham, NC, United States
- Correspondence: Elizabeth E. Tolley
| | - Homaira Hanif
- CONRAD and Eastern Virginia Medical School, Norfolk, VA, United States
| | - Andrea Thurman
- CONRAD and Eastern Virginia Medical School, Norfolk, VA, United States
| | | | - Gustavo F. Doncel
- CONRAD and Eastern Virginia Medical School, Norfolk, VA, United States
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Abstract
PURPOSE OF REVIEW To review the current literature on the multiple types and uses of progestins in reproductive healthcare. RECENT FINDINGS Progestins for contraceptive use are available in multiple forms, with the ongoing development of transdermal, intravaginal, and male contraception formulations. Noncontraceptive use of progestins often overlaps with contraceptive indications, which allows for simultaneous multipurpose progestin use, especially in reproductive-aged patients. More studies are needed to determine contraceptive doses of progestins used for noncontraceptive purposes. Side effect profiles of progestins are dependent on their formulation and cross-reactivity with other steroid receptors. Development of newer progestins includes manipulating pharmacologic properties to avoid undesired side effects. SUMMARY Progestins have multiple uses in reproductive healthcare, including contraception, menstrual suppression, endometrial protection, and hormonal replacement therapy. The development of progestins for these indications can expand therapy for people with contraindications to estrogen-based hormonal therapy.
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