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Sexually Transmitted Diseases:
doi: 10.1097/OLQ.0000000000000053
Original Study

Evaluation of 3 Approaches for Assessing Adherence to Vaginal Gel Application in Clinical Trials

van der Straten, Ariane PhD, MPH*†; Cheng, Helen MS*; Mensch, Barbara PhD; Friedland, Barbara MPH; Katzen, Lauren MPA; Littlefield, Sarah MPH; Buckley, Niall BS§; Espinoza, Lilia B§; Keller, Marla J. MD§; Herold, Betsy C. MD§; Einstein, Mark H. MD§¶

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Background: Accurate measurement of adherence to product use is an ongoing challenge in microbicide trials.

Methods: We compared adherence estimates using 2 applicator tests (a dye stain assay [DSA] and an ultraviolet light assay [UVA]), the Wisebag (an applicator container that electronically tracks container openings), and self-reported adherence (ability, frequency, and percent missed doses). Healthy, HIV-negative, nonpregnant US women aged 23 to 45 years received a Wisebag and 32 applicators filled with placebo gel were instructed to insert 1 applicator daily for 30 days, returned the Wisebag and all applicators, and completed an exit interview. Emptied applicators were tested by UVA and then DSA, and scored by 2 blinded readers. Positive and negative controls were randomly included in applicator batches.

Results: Among 42 women enrolled, 39 completed the study. Both DSA and UVA yielded similar sensitivity (97% and 95%) and specificity (79% and 79%). Two participants had fully inoperable Wisebags, and 9 had partially inoperable Wisebags. The proportion of participants considered to have high adherence (≥80%) varied: 43% (Wisebag), 46% (UVA), 49% (DSA), and 62% to 82% (self-reports). For estimating high adherence, Wisebag had a sensitivity of 76% (95% confidence interval, 50%–93%) and a specificity of 85% (95% confidence interval, 62%–97%) compared with DSA. Although 28% of participants reported forgetting to open the Wisebag daily, 59% said that it helped them remember gel use.

Conclusions: Dye stain assay and UVA performed similarly. Compared with these tests, self-reports overestimated and Wisebag underestimated adherence. Although Wisebag may encourage gel use, the applicator tests currently seem more useful for measuring use in clinical trials.

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