Experiences with simultaneous use of contraception and the vaginal ring for HIV prevention in sub-Saharan Africa

Abstract

Background Clinical trials have found that a monthly dapivirine vaginal ring was well-tolerated and reduced HIV-1 risk among women in sub-Saharan Africa. However, in order for the ring or other novel prevention methods to have optimal impact, it is necessary to understand and address women’s challenges to uptake and adherence. This paper provides insight into a few key challenges noted by women using the ring and contraceptives simultaneously. Methods The qualitative portion of the MTN-020/ASPIRE study consisted of data collection using single in-depth interviews, serial in-depth interviews, and focus group discussions, conducted with 214 participants across 15 sites in Malawi, South Africa, Uganda and Zimbabwe. A coding team used qualitative analysis software to identify themes within the interviews. Results The primary qualitative themes among participant data pertained to side effects. Participants reported negative side effects related to menses, in some cases attributing these effects to their contraceptives and in others to the vaginal ring. Participants also expressed concern over the long-term impact of contraception and ring use on fertility, including the reversibility of the contraceptive, especially among nulliparous women. Conclusions Women’s attitudes toward contraceptives can impact their willingness to concurrently use and adhere to a novel HIV prevention product. To optimize the potential of both prevention products, researchers should pre-emptively address concerns about contraceptive impact on fertility and counsel women about the expected side effects of contraceptives versus the ring. Clinical trials identifier NCT01617096. Registered on 6-12-2012 at clinicaltrials.gov https://clinicaltrials.gov/ct2/show/NCT01617096

Experiences and attitudes towards Menstrual Suppression among Women with Bacterial vaginosis Randomised to Continuous Use of NuvaRing in Kenya

“…As other studies have shown, some participants reported negative experiences following menses suppression with a preference in non-suppression (13,18,22). Similar to these studies, we found that menstrual suppression caused worry, fear, and anxiety about unintended pregnancies, among negative health outcomes like infections, hormonal imbalances, and cancer.…”

“…Following pregnancy tests and a doctor's confirmation of no underlying health issues, the majority of participants felt at ease. However, like other studies (13,16,18,19,22), a few participants had persistent fear and anxiety whenever they missed menses, and uncertainty about when they expected menses disincentivizing them from NuvaRing use. These negative experiences may be associated with existing literature ( 16) that the community regarded women without menses as pregnant or infertile, abnormal, bewitched, or unhealthy.…”

“…In this study, participants with positive experiences expressed acceptance and a desire to continue using NuvaRing; however, those with negative attitudes had mixed emotions, with some expressing a desire to continue using NuvaRing but had fears of the unintended negative consequences. These findings have been found with the use of other products as well, such as contraception, other rings, and microbicides (13,13,18,22), showing the significance of end-user experiences in influencing the acceptability and use of an intervention or product, in this case, the NuvaRing.…”

“…Similar to these studies, we found that menstrual suppression caused worry, fear, and anxiety about unintended pregnancies, among negative health outcomes like infections, hormonal imbalances, and cancer. Existing literature demonstrate that contraceptives or ring users worry about future infertility and are uncertain about birth control effectiveness hence preventing their use or result in discontinuation (13,18,22). Although comprehensive counselling may not sufficient by itself, these concerns illustrate how crucial it is to understand the user pregnancy intentions among other concerns to support designing and providing complete counselling messages on use and adherence to avoid unintended consequences and support mental health (6,7,(13)(14)(15)17,21,22).…”

“…As indicated in other studies, results from this study demonstrate varied participants' knowledge of potential side effects of continued NuvaRing use on menses suppression, highlighting the importance of enduser regular tailored comprehensive counseling of an interventions use including side effects. This counseling should consider and align with individual and community levels of knowledge, needs, feelings, perceptions and concerns to address potentially harmful or negative perceptions that may influence an intervention or product acceptability, use and adherence (6,7,17,18,22).…”