Impact of women's home environment on use of the dapivirine ring for HIV prevention in MTN-025/HOPE


BACKGROUND: The monthly dapivirine vaginal ring was shown to reduce HIV risk in two Phase 3 clinical trials. When considering the potential future availability of the ring to the public, key questions remain about the feasibility of integrating the ring as an HIV prevention intervention into women's lives. We examined how women's home environments influenced ring use, storage and disclosure in MTN-025/HOPE, an open-label trial of the dapivirine vaginal ring conducted in Malawi, South Africa, Uganda and Zimbabwe.
METHODS: We conducted 66 qualitative in-depth interviews with women who accepted (n=35) and did not accept the vaginal ring (n=31) in MTN-025/HOPE. In HOPE, participants were given the option to take home three rings at a time for monthly replacement. During interviews, participants drew and labeled a map of their homes, indicating ring storage and changing areas. Maps and debrief reports were summarized and analyzed using matrices.
RESULTS: Most women lived in crowded households, with over a third (n=27) sharing a bedroom with children or family members. Most ring-acceptors stored their rings in personal wardrobes which were locked or restricted from household members. Several stored them in concealed bags or suitcases to keep safe from others. Some participants reported fearing that children would play with rings, however, there were minimal incidents of this occurring. A few reported concerns that rats could eat them. These concerns led a few women to replace and dispose of rings at study clinics monthly. Although nearly all ring acceptors had disclosed ring use to at least some household members, some emphasized waiting until they were home alone for ring replacement. Women who lived in homes with indoor toilets often replaced rings in the bathroom, whereas those with outdoor toilets replaced rings in their bedrooms. Ring non-acceptors described similar living arrangements to ring acceptors; however, they tended to report less secure locations, such as bags, where they could store rings if they were to accept them.
CONCLUSIONS: Though vaginal rings are discreet, women's ability to properly store and change rings varies across contexts. Efforts to improve feasibility of vaginal rings for home use should focus on secure disposal and storage.