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As part of an analysis funded by the OPTIONS Consortium (of which AVAC is a part), AVAC examined historical experiences introducing products that share characteristics with the dapivirine vaginal ring, specifically, products that were vaginally inserted and/or partially efficacious. Both are characteristics of the dapivirine vaginal ring and can represent a challenge to acceptance and use. However, products ranging from the rotavirus vaccine to the contraceptive ring have overcome these challenges. In our analysis – entitled The Dapivirine Ring: Key learnings from like-product introductions – we interrogate what facilitated their success and uptake, and conclude that with adequate planning and education, it is possible for products such as these to make an impact.
Developed by the International Partnership for Microbicides (IPM), the dapivirine vaginal ring is a silicone ring which looks similar to a contraceptive ring, but releases dapivirine (an antiretroviral drug) slowly over the course of one month. The ring is vaginally inserted, rests high inside of the vagina, and a woman can remove and reinsert the ring herself if she wants to. Also, its effect is localized (limited to the vagina) rather than systemic (affecting the whole body). The ring can give women control over their HIV prevention choices, without need to negotiate with or disclose to her partner.
Final results of the open-label studies HOPE and DREAM found the ring to be partially efficacious (with participants seeing a 39 percent and 63 percent reduction in HIV-risk respectively). These results were an improvement over the results of previous phase III trials ASPIRE and The Ring Study, in which the ring was demonstrated to reduce women’s risk of acquiring HIV by only 27 percent and 31 percent respectively.
Partially efficacious products and procedures have played a pivotal role in public health interventions for decades, and have been an important component of the HIV response for many years. For example, voluntary medical male circumcision (VMMC) is a well-known and effective tool for HIV prevention, and reduces the risk of HIV acquisition by 60-75 percent. The malaria vaccine and rotavirus vaccine are two other partially efficacious products that have become staples in prevention efforts.
In order to address concerns about partial efficacy, providers and implementers have employed a few key strategies. By focusing on interpersonal communication and using small groups to discuss the nuances of the products with both end-users and providers, it is possible to build confidence in a partially effective product. Product champions can also help drive up demand and acceptability of something like the ring. Integrating the ring with other health services may also draw new clients in and support uptake.
Researchers have noted that vaginal insertion of the ring has proven to be a barrier for some women, particularly due to lack of experience with these types of products in the African context and cultural norms which stigmatize female genitals.
The introduction of vaginally inserted products like the female condom, the progesterone contraceptive vaginal ring, tampons and the menstrual cup provide valuable lessons when considering how the dapivirine ring might be introduced. For example, peer-to-peer communications that include a product user can be effective in recruiting new users. Additionally, encouraging providers to try the ring themselves can help overcome provider bias. Acceptability of the ring among even a small group of vocal providers can influence uptake nationally, so those providers need to be found, encouraged and given a platform.
Finally, empowering women to explain the ring to partners, by promoting body awareness and knowledge of sexual and reproductive health, will be an essential component to ring introduction. To this end, education & communication (IEC) materials demonstrating how the ring fits in a woman’s body can alleviate concerns about the ring getting stuck or causing infertility.
With these strategies in mind, the HIV prevention field can better prepare for possible introduction of the dapivirine ring and ultimately help policy makers, health care providers and women interested in a new HIV prevention option make informed decisions about the ring. By clearly articulating the value of the ring as one component of the HIV prevention portfolio, and educating women and their providers about the benefits of a discreet and female-controlled prevention option, it is possible to accelerate the impact of the dapivirine ring in improving women’s health and reducing HIV incidence.