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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


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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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).


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.

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