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Reasons for nonadherence to the dapivirine vaginal ring: narrative explanations of objective drug-level results

Montgomery, Elizabeth T.a; Stadler, Jonathanb; Naidoo, Saritac; Katz, Ariana W.K.a; Laborde, Nicolea; Garcia, Morgand; Reddy, Krishnavenie; Mansoor, Leila E.f; Etima, Julianeg; Zimba, Chifundoh; Chitukuta, Miriai; Soto-Torres, Lydiaj

doi: 10.1097/QAD.0000000000001868
Epidemiology and Social

Objective(s): MTN-020/ASPIRE trial and IPM-027/Ring Study recently proved the dapivirine vaginal ring was safe and effective with consistent use. To optimize the ring's impact, the barriers and facilitators to ring adherence must be understood and addressed.

Methods: Former ASPIRE participants were stratified by age group (18–21; 22–45) and randomly selected at seven sites in Malawi, South Africa, Uganda and Zimbabwe, 12–17 months after trial exit. Using in-depth interviews or focus group discussions, ring use barriers were explored using structured guides and visual tools including individual-level depictions of dapivirine levels detected in plasma and returned rings.

Results: A total of 187 were enrolled; 37% were 18–21 years when they began ASPIRE. Most (75%) had drug-level results, suggesting inconsistent ring use throughout ASPIRE. Participants viewed themselves as adherent, while simultaneously describing regular instances and reasons for ring removal (e.g. for sex or menses). Less adherent women reported fears that partners would oppose the ring or feel it during sex. High adherers expressed altruistic motivations for ring use. Women of all ages attributed young women's nonadherence to their tendency to be less ‘serious’ about the future, HIV prevention and the study; motivated predominantly by benefits; more fearful of fertility-related consequences; and to having less relationship control.

Conclusion: When presented with objective adherence data, participants provided reasons for intermittent ring use, while simultaneously portraying themselves as consistent ring users. Further research is needed to understand how women could use the ring in a way that fits into the context of their relationships and their lives while still conferring adequate HIV prophylaxis.

aWomen's Global Health Imperative, RTI International, San Francisco, California, USA

bDepartment of Anthropology and Development Studies, University of Johannesburg, Johannesburg

cHIV Prevention Research Unit, South African Medical Research Council, Durban, South Africa

dFHI 360, Durham, North Carolina, USA

eWits Reproductive Health and HIV Institute, University of the Witwatersrand, School of Clinical Medicine, Johannesburg

fCentre for the AIDS Programme of Research in South African (CAPRISA), Durban, South Africa

gMakerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda

hUNC Project-Malawi, Lilongwe, Malawi

iUniversity of Zimbabwe College of Health Sciences Clinical Trials Unit (UZCHS-CTU), Harare, Zimbabwe

jDivision of AIDS, NIH, Bethesda, Maryland, USA.

Correspondence to Elizabeth T. Montgomery, Women's Global Health Imperative, RTI International, San Francisco, California, USA. E-mail:

Received 24 January, 2018

Revised 24 April, 2018

Accepted 27 April, 2018

Copyright © 2018 Wolters Kluwer Health, Inc.