Key findings from the ASPIRE study of a vaginal ring
releasing the antiretroviral drug dapivirine were announced at conferences in February
Women in four African countries who were able to use the ring consistently had at
least 65% fewer HIV infections, but many younger women had lower levels of
adherence and were not protected. In qualitative interviews, many women said
that they found the ring to be simple and discreet to use.
Several further analyses from the study were presented at
the HIV Research for Prevention conference this week. One showed that many of women’s
initial concerns about using a ring lessened over time.
During interviews at the beginning of the study, 29% of
women said that they were worried about having a vaginal ring inside them for over
a year, but at the end of the study only 4% expressed such concerns.
Specific worries included the ring not staying in place, falling
out during sex, being uncomfortable or felt by a partner during sex, getting
stuck inside, causing infertility or other health problems, and being difficult
to insert or remove.
The attitudes of sexual partners towards the ring and the
effect of a vaginal product on sexual experience are key to its acceptability. At the beginning of the study, 64% of
women told their primary partner that they were using the vaginal ring, rising
to 77% at the end. While not disclosing use of the ring might be expected to be
associated with poor adherence, this was not the case. This does suggest that
it is possible to use the ring without a sexual partner being aware of it.
Indeed, in-depth interviews showed that few women and
partners noticed the ring during sex, as a Zimbabwean woman explained:
“My husband never
complained that he is feeling it or that you are wearing something. Even
myself, when we were having sex I did not feel anything or that he is hitting
something that has been disturbed.”
Nonetheless many women had concerns about partners
discovering the ring inadvertently. A woman in Uganda said:
“It’s better you tell
him because you never know he might eventually find out, when he feels it
during sex and question you about what you have put there… I think it would be
better if you told him earlier so that even if he reached it during sex, you
wouldn’t be afraid.”
To prevent partners noticing the ring, some women avoided
specific sexual practices, such as letting a partner insert his fingers in the
vagina, or sex while standing up.
When a partner found out about study participation or use of
the ring, suspicious or angry responses sometimes followed. The researchers
note that the study was conducted in communities where violence against women
is a significant problem.
Among 2629 study participants, 85 women reported intimate
partner violence (IPV) or other difficulties with a partner linked to the study.
Younger women and those with a new partner were more likely to suffer IPV.
In only 26 cases did this result in physical harm to the
participant and in most cases the woman said that the incident only had a
minimal impact on her quality of life. But the researchers commented that
this could be due to women in these environments treating partner violence as a
fact of life.
Intimate partner violence (IPV) strongly influenced
adherence and use of the vaginal ring:
- Among women who never reported IPV, 15% of women had poor adherence (as
indicated by drug levels in blood).
women who reported IPV at least once, 29% had poor adherence.
study visits in the month after IPV had been reported, 53% of women had poor
Study staff endeavoured to provide support and link to
services when IPV was reported. This appeared to help adherence – two to three
months after IPV had been reported, the proportion of women with poor adherence
dropped to 19%. “Disclosing exposure to intimate partner violence was a major
step forward for many of these women,” commented researcher Thesla
In the eastern and southern African countries where the ring
was studied, young women have the greatest vulnerability to HIV. However the youngest
women in the study (those aged 18 to 21) were the most likely to have worries
about using the ring, to experience intimate partner violence and to have poor