Does the ring work? Perceptions and understandings of the efficacy of a vaginal ring for HIV prevention amongst women participating in the MTN-032/AHA study.



MTN-020/ASPIRE showed the dapivirine vaginal ring as a safe and partially effective (in part due to suboptimal adherence) HIV prevention option. ASPIRE was placebo-controlled, and a potential influence on participants’ ring use was their perception of its efficacy. The MTN-032/AHA study was an exploratory qualitative study with women who exited ASPIRE to understand reasons for nonuse and use of the ring during the trial.


Following ASPIRE, clinicians disseminated results of a 27% reduction in HIV acquisition for all women and no reduction among women under 25 through group meetings with participants. In AHA, single in-depth interviews (n=98) and 12 focus group discussions (n=89) were conducted with women at 7 sites in Malawi, South Africa, Uganda and Zimbabwe. Eligibility included participation in the ASPIRE active arm, and ring use for >3 months. Interview guides elicited an in-depth assessment of how perceptions of ring efficacy impacted adherence and sexual risk behaviors during ASPIRE, and how perceptions and understanding of efficacy results impacted future ring use interest. Interviews were audio-recorded, transcribed into English, coded and thematically analyzed.


AHA women were on average 27 years old, mostly unmarried (62%), and 48% had completed secondary school. Many didn’t know their partner’s HIV status (37%) or if their partner had other sexual partners (58%). Perceptions of ring efficacy while in ASPIRE varied; majority described efficacy as a binary assessment: the ring worked or not. Women who believed it worked described simply trusting it, or having confidence in the ring because they, or others in risky situations remained HIV-uninfected. Participants recounted ASPIRE results through feelings of happiness and pride that the ring they used, and their trial participation, were successful. Many did not remember exact figures because of lack of comprehension or memory but recalled key details about differences in efficacy by age. The majority expressed interest in future ring use since it provided some level of protection.


Perceptions and understanding of efficacy influenced some women’s adherence to and eventual interest in future ring use. Numeric trial efficacy results were not well comprehended/understood suggesting the need for cultural/linguistic specificity and end-user involvement in message development.