Vaginal Rings are Acceptable to Women and Provide an Important Option for HIV and Pregnancy Prevention

How do women feel about using a vaginally inserted ring to prevent pregnancy or HIV?

Every year approximately 14 million unintended pregnancies occur in sub-Saharan Africa. Women in Africa are also disproportionally impacted by HIV, with greater than three times the prevalence of men in some countries. Unintended pregnancies and HIV are major contributors to women’s morbidity and mortality in these settings. Given this high double burden, female-initiated methods are critical to prevent unintended pregnancy, HIV, or both. So, what are women’s experiences using the vaginal ring? We recently conducted a systematic review to explore the acceptability of vaginal rings among women in low- and middle-income countries.

Vaginal rings are long-acting, drug-delivery products that work by slowly releasing drugs into the inner lining of the vagina. Vaginal rings are used for contraception and HIV pre-exposure prophylaxis (PrEP), as well as other indications. The International Partnership for Microbicides’ dapivirine ring for PrEP is under review at the European Medicines Agency; and will soon be reviewed for regulatory approval at the United States Food and Drug Administration and the South African Health Products Regulatory Authority. One new indication of the ring, currently under development, is for multi-purpose prevention designed to prevent both HIV and unintended pregnancy. These multi-purpose prevention technologies are particularly exciting because they increase efficiencies for users and health systems by addressing multiple sexual and reproductive health needs at the same time.

In our systematic review, we looked at acceptability of the vaginal ring among women in low- and middle-income countries, considering vaginal ring use for contraception, HIV prevention, menopause symptom management, and other indications. In 86 studies, we found that vaginal ring acceptability was high among women ranging from 71-98% in randomized controlled trials and from 62-100% in observational studies. Measures of acceptability tended to improve over chronological time, as the method was popularized, as well as during study follow-up, as women gained experience with the vaginal ring. Most women found the ring easy to insert and remove. While some users reported concerns about the vaginal ring, including it getting lost in the body or expelled, worries likewise tended to decrease with use. Use of vaginal rings during sexual intercourse was generally acceptable to women. They liked that the vaginal ring had minimal impact on libido or sexual activity, although fear of interference with sex was a common initial concern with this method. In fact, the vaginal ring was not felt during intercourse by most women (70-92%) and their partners (48-97%).

Having access to a range of methods for contraception and HIV prevention is important. Women prefer and choose methods for many reasons and these preferences may change over the course of a woman’s reproductive life. In the field of contraception, more options have led to better population coverage, and we would expect a similar trend for HIV prevention when multiple methods become available. Our systematic review also explored women’s preferences around vaginal rings and alternate methods. We found that women expressed preferences for accessible, long-acting, partner-approved, effective methods that prevent both HIV and pregnancy, can be used without partner knowledge, and have no impact on sex and few side effects. Women’s desire for long-acting contraceptives and HIV prevention methods is important as long-acting methods lead to lower failure rates than short-acting methods, such as daily pills or condoms.

Women who find a method acceptable are more likely to use it consistently and correctly. Consistent and correct use, in turn, helps women prevent unplanned pregnancies and HIV infection. Our systematic review indicates that women in low- and middle-income countries have a positive view of the vaginal ring that increases with use experience; and, that many women would consider the vaginal ring an acceptable method for HIV prevention and contraception. Given the high acceptability of the vaginal ring and the importance of preventive options for women, the vaginal ring has the potential to reduce both unintended pregnancy and HIV in low- and middle-income countries.

Our team is currently conducting an analysis of vaginal ring acceptability in high-income countries. We expect our results to be published in 2020.