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Hygiene, Blood Flow, and Vaginal Overload: Why Women Removed an HIV Prevention Vaginal Ring During Menstruation in Malawi, South Africa, Uganda and Zimbabwe

Abstract

We assessed the interference between vaginal ring use and menses among women who participated in the qualitative component of the MTN-020/ASPIRE vaginal ring trial in Malawi, South Africa, Uganda and Zimbabwe (N = 214). A common reason for imperfect ring adherence and premature removal of the vaginal ring cited by participants related to vaginal bleeding or menses. Whereas self-reporting via survey questions suggested that the majority (60%) of women did not mind wearing the ring while menstruating, and did not remove it (91%) during menses, in the qualitative interviews women frequently described removing the ring during menses. Their reasons included hygiene, beliefs that the ring blocked the flow of menstrual blood, fears that the ring would come out with blood or during tampon removal, and concerns around an ‘overburdened’ vagina. Examining women’s narratives and subjective experiences related to menstruation helps build a better understanding of factors affecting ring use and adherence.

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References

  1. 1.

    Jewkes RK, Wood K. Problematizing pollution: dirty wombs, ritual pollution, and pathological processes. Med Anthropol. 1999;18(2):163–86.

  2. 2.

    Tamiru S, Mamo K, Acidria P, Mushi R, Ali CS, Ndebele L. Towards a sustainable solution for school menstrual hygiene management: cases of Ethiopia, Uganda, South-Sudan, Tanzania, and Zimbabwe. Waterlines. 2015;34(1):92–102.

  3. 3.

    Hawkey AJ, Ussher JM, Perz J, Metusela C. Experiences and constructions of menarche and menstruation among migrant and refugee women. Qualitative Health Research. 2017;27(10):1473–90.

  4. 4.

    Johnston-Robledo I, Chrisler JC. The menstrual mark: menstruation as social stigma. Sex Roles. 2011;68(1–2):9–18.

  5. 5.

    Scheff TJ. Shame in self and society. Symb Inter. 2003;26(2):239–62.

  6. 6.

    Farage MA, Miller KW, Davis A. Cultural aspects of menstruation and menstrual hygiene in adolescents. Expert Rev Obstet Gynecol. 2011;6(2):127.

  7. 7.

    Laher F, Todd CS, Stibich MA, Phofa R, Behane X, Mohapi L, et al. Role of menstruation in contraceptive choice among HIV-infected women in Soweto, South Africa. Contraception. 2010;81(6):547–51.

  8. 8.

    Allen CF, Desmond N, Chiduo B, Medard L, Lees SS, Vallely A, et al. Intravaginal and menstrual practices among women working in food and recreational facilities in Mwanza, Tanzania: implications for microbicide trials. AIDS Behav. 2010;14(5):1169–81.

  9. 9.

    Scorgie F, Foster J, Stadler J, Phiri T, Hoppenjans L, Rees H, et al. “Bitten By Shyness”: menstrual hygiene management, sanitation, and the quest for privacy in South Africa. Med Anthropol. 2015;35(2):161–76.

  10. 10.

    Wood K, Jewkes R. Blood blockages and scolding nurses: barriers to adolescent contraceptive use in South Africa. Reproductive Health Matters. 2006;14(27):109–18.

  11. 11.

    Montgomery ET, van der Straten A, Cheng H, Wegner L, Masenga G, von Mollendorf C, et al. Vaginal ring adherence in Sub-Saharan Africa: expulsion, removal, and perfect use. AIDS Behav. 2012;16(7):1787–98.

  12. 12.

    Watnick D, Keller MJ, Stein K, Bauman LJ. Acceptability of a tenofovir disoproxil fumarate vaginal ring for HIV prevention among women in New York City. AIDS Behav. 2017;22(2):421–36.

  13. 13.

    Baeten JM, Palanee-Phillips T, Brown ER, Schwartz K, Soto-Torres LE, Govender V, et al. Use of a vaginal ring containing dapivirine for HIV-1 prevention in women. N Engl J Med. 2016;22:1–12.

  14. 14.

    Montgomery ET, van der Straten A, Chitukuta M, Reddy K, Woeber K, Atujuna M, et al. Acceptability and use of a dapivirine vaginal ring in a phase III trial. AIDS. 2017;31(8):1159–67.

  15. 15.

    Srivastava P, Hopwood N. A practical iterative framework for qualitative data analysis. Int J Qual Methods. 2009;8(1):76–84.

  16. 16.

    Nel A, Bekker L-G, Bukusi E, Hellstrӧm E, Kotze P, Louw C, et al. Safety, acceptability and adherence of dapivirine vaginal ring in a microbicide clinical trial conducted in multiple countries in Sub-Saharan Africa. PLoS ONE. 2016;11(3):e0147743–19.

  17. 17.

    van der Straten A, Panther L, Laborde N, Hoesley CJ, Cheng H, Husnik MJ, et al. Adherence and acceptability of a multidrug vaginal ring for HIV prevention in a phase i study in the United States. AIDS Behav. 2016;20(11):2644–53.

  18. 18.

    Vallely A, Fitzgerald L, Fiya V, Aeno H, Kelly A, Sauk J, et al. Intravaginal practices and microbicide acceptability in Papua New Guinea: implications for HIV prevention in a moderate-prevalence setting. BMC Res Notes. 2012;5(1):1.

  19. 19.

    Green EC. Purity, pollution and the invisible snake in Southern Africa. Med Anthropol. 1996;17(1):83–100.

  20. 20.

    Stadler J, Saethre E. Blockage and flow: intimate experiences of condoms and microbicides in a South African clinical trial. Culture Health Sex. 2011;13(1):31–44.

  21. 21.

    Collumbien M, Busza J, Cleland J, Campbell O. Social science methods for research on sexual and reproductive health. Geneva. 2012;14:1–101.

  22. 22.

    Hollander JA. The social contexts of focus groups. J Contemp Ethnogr. 2004;33(5):602–37.

  23. 23.

    Smithson J. Using and analysing focus groups: limitations and possibilities. Int J Res Methodol. 2000;3(2):103–19.

  24. 24.

    Mensch BS, Hewett PC, Abbott S, Rankin J, Littlefield S, Ahmed K, et al. Assessing the reporting of adherence and sexual activity in a simulated microbicide trial in South Africa: an interview mode experiment using a placebo gel. AIDS Behav. 2011;15(2):407–21.

  25. 25.

    Mensch BS, Richardson BA, Husnik M, Brown ER, Kiweewa FM, Mayo AJ, et al. Vaginal ring use in a phase 3 microbicide trial: a comparison of objective measures and self-reports of non-adherence in ASPIRE for the MTN-020/ASPIRE study team. AIDS Behav. 2018;23:504–12.

  26. 26.

    Turner AN, De Kock AE, Meehan-Ritter A, Blanchard K, Sebola MH, Hoosen AA, et al. Many vaginal microbicide trial participants acknowledged they had misreported sensitive sexual behavior in face-to-face interviews. J Clin Epidemiol. 2009;62(7):759–65.

  27. 27.

    van der Straten A, Agot K, Ahmed K, Weinrib R, Browne EN, Manenzhe K, et al. The Tablets, Ring, Injections as Options (TRIO) study: what young African women chose and used for future HIV and pregnancy prevention. J Int AIDS Soc. 2018;21(3):e25094–9.

  28. 28.

    Chen BA, Panther L, Marzinke MA, Hendrix CW, Hoesley CJ, van der Straten A, et al. Phase 1 Safety, Pharmacokinetics, and Pharmacodynamics of Dapivirine and Maraviroc Vaginal Rings. JAIDS J Acquir Immune Defic Syndr. 2015;70(3):242–9.

  29. 29.

    Gfos M, Pool R, Mzimela MA, Ndlovu HB, McCormack S, Elford J, et al. The Implications of Post-coital Intravaginal Cleansing for the Introduction of Vaginal Microbicides in South Africa. AIDS Behav. 2013;18(2):297–310.

  30. 30.

    Morrow Guthrie K, Vargas S, Shaw JG, Rosen RK, van den Berg JJ, Kiser PF, et al. The promise of intravaginal rings for prevention: user perceptions of biomechanical properties and implications for prevention product development. PLoS ONE. 2015;10(12):e0145642–17.

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Acknowledgements

The study was designed and implemented by the Microbicide Trials Network (MTN) and funded by the National Institute of Allergy and Infectious Diseases (UM1AI068633, UM1AI068615, UM1AI106707), with co-funding from the Eunice Kennedy Shriver National Institute of Child Health and Human Development and the National Institute of Mental Health, all components of the U.S. National Institutes of Health (NIH). The work presented here was funded by NIH grants UM1AI068633. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The International Partnership for Microbicides (IPM) supplied the vaginal rings used in this study. Study Team Leadership Jared Baeten, University of Washington (Protocol Chair); Thesla Palanee-Phillips, Wits Reproductive Health and HIV Institute (Protocol Co-chair); Elizabeth Brown, Fred Hutchinson Cancer Research Center (Protocol Statistician); Lydia Soto-Torres, US National Institute of Allergy and Infectious Diseases (Medical Officer); Katie Schwartz, FHI 360 (Clinical Research Manager). Study sites and site Investigators of Record Malawi, Blantyre site (Johns Hopkins University, Queen Elizabeth Hospital): Bonus Makanani. Malawi, Lilongwe site (University of North Carolina, Chapel Hill): Francis Martinson. South Africa, Cape Town site (University of Cape Town): Linda-Gail Bekker. South Africa, Durban – Botha’s Hill, Chatsworth, Isipingo, Tongaat, Umkomaas, Verulam sites (South African Medical Research Council): Vaneshree Govender, Samantha Siva, Zakir Gaffoor, Logashvari Naidoo, Arendevi Pather, and Nitesha Jeenarain. South Africa, Durban, eThekwini site (Center for the AIDS Programme for Research in South Africa): Gonasagrie Nair. South Africa, Johannesburg site (Wits Reproductive Health and HIV Institute): Thesla Palanee-Phillips. Uganda, Kampala site (John Hopkins University, Makerere University): Flavia Matovu. Zimbabwe, Chitungwiza, Seke South and Zengeza sites (University of Zimbabwe College of Health Sciences Clinical Trials Unit): Nyaradzo Mgodi. Zimbabwe, Harare, Spilhaus site (University of Zimbabwe College of Health Sciences Clinical Trials Unit):): Felix Mhlanga. Data management was provided by The Statistical Center for HIV/AIDS Research & Prevention (Fred Hutchinson Cancer Research Center, Seattle, WA) and site laboratory oversight was provided by the Microbicide Trials Network Laboratory Center (Pittsburgh, PA). For qualitative data, management was provided by the Women’s Global Health Imperative Program (RTI International, San Francisco, CA).

Funding

The study was designed and implemented by the Microbicide Trials Network (MTN) and funded by the National Institute of Allergy and Infectious Diseases (UM1AI068633, UM1AI068615, UM1AI106707), with co-funding from the Eunice Kennedy Shriver National Institute of Child Health and Human Development and the National Institute of Mental Health, all components of the U.S. National Institutes of Health (NIH). The work presented here was funded by NIH Grants UM1AI068633.

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Correspondence to Zoe Duby.

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All author declares that they have no conflict of interest.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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Informed consent was obtained from all individual participants included in the study.

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The members of the MTN-020/ASPIRE Study Team are listed in the acknowledgments.

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Duby, Z., Katz, A.W.K., Browne, E.N. et al. Hygiene, Blood Flow, and Vaginal Overload: Why Women Removed an HIV Prevention Vaginal Ring During Menstruation in Malawi, South Africa, Uganda and Zimbabwe. AIDS Behav 24, 617–628 (2020). https://doi.org/10.1007/s10461-019-02514-8

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Keywords

  • Vaginal ring
  • Adherence
  • Menses
  • Menstruation
  • HIV prevention
  • Hygiene