Relationship Type and Use of the Vaginal Ring for HIV-1 Prevention in the MTN 020/ASPIRE Trial

  • E. PleasantsEmail author
  • T. Tauya
  • K. Reddy
  • B. G. Mirembe
  • K. Woeber
  • T. Palanee-Phillips
  • C. Zimba
  • M. Atujuna
  • E. T. Montgomery
  • the MTN-020/ASPIRE Study Team
Original Paper


Gender roles and imbalances in sexual power contribute to the heightened HIV-1 risk faced by women in Sub-Saharan Africa. This has led prevention research to focus on the development of female controlled methods. Despite the design of products such as vaginal rings to be used autonomously by women, male partners and women’s perceptions of relationships influence HIV prevention choices. To understand the influences that male partners and dyadic dynamics had on the use of the Dapivirine Vaginal Ring in the ASPIRE trial, this analysis of qualitative data explored the types of intimate partner relationships that women engaged in. This paper describes how partners facilitated or challenged women’s ring use and how women dealt with these challenges within six different types of relationships characterized by power dynamics and commitment levels. We offer insights into how future use of female-initiated HIV prevention products can be promoted through recognition of different relationship types.


Gender HIV Clinical trial Vaginal ring Sexual relationship Sub-Saharan Africa Women Microbicide Qualitative research Gender relations Couples Adherence Female controlled HIV prevention 



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 content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The vaginal rings used in this study were developed and supplied by the International Partnership for Microbicides (IPM).

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 RHI): 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).


  1. 1.
    UNAIDS U. The gap report. Geneva: UNAIDS U; 2014.Google Scholar
  2. 2.
    Joint United Nations Programme on HIV/AIDS. Global AIDS update 2016. Geneva: UNAIDS; 2016.Google Scholar
  3. 3.
    Greene E, Batona G, Hallad J, Johnson S, Neema S, Tolley EE. Acceptability and adherence of a candidate microbicide gel among high-risk women in Africa and India. Cult Health Sex. 2010;12:739–54.CrossRefPubMedGoogle Scholar
  4. 4.
    Woodsong C. Covert use of topical microbicides: implications for acceptability and use. Perspect Sex Reprod Health. 2004;36:127–31.CrossRefPubMedGoogle Scholar
  5. 5.
    Jewkes R, Morrell R. Gender and sexuality: emerging perspectives from the heterosexual epidemic in South Africa and implications for HIV risk and prevention. J Int AIDS Soc. 2010;13:6.CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Lanham M, Wilcher R, Montgomery ET, Pool R, Schuler S, Lenzi R, Friedland B. Engaging male partners in women’s microbicide use: evidence from clinical trials and implications for future research and microbicide introduction. J Int AIDS Soc. 2014;17(3 Suppl 2):19159.PubMedPubMedCentralGoogle Scholar
  7. 7.
    Pool R, Whitworth JA, Green G, et al. An acceptability study of female-controlled methods of protection against HIV and STDs in south-western Uganda. Int J STD AIDS. 2000;11:162–7.CrossRefPubMedGoogle Scholar
  8. 8.
    Montgomery ET, van der Straten A, Cheng H, et al. Vaginal ring adherence in sub-Saharan Africa: expulsion, removal, and perfect use. AIDS Behav. 2012;16:1787–98.CrossRefPubMedGoogle Scholar
  9. 9.
    Woodsong C, Holt JDS. Acceptability and preferences for vaginal dosage forms intended for prevention of HIV or HIV and pregnancy. Adv Drug Deliv Rev. 2015;92:146–54.CrossRefPubMedGoogle Scholar
  10. 10.
    Montgomery ET, van der Straten A, Chidanyika A, Chipato T, Jaffar S, Padian N. The importance of male partner involvement for women’s acceptability and adherence to female-initiated HIV prevention methods in Zimbabwe. AIDS Behav. 2011;15:959–69.CrossRefPubMedGoogle Scholar
  11. 11.
    Dayton R, Lanham M, Wilcher R. Engaging male partners in womens microbicide use. Evid Recomm. 2014;17:19159.Google Scholar
  12. 12.
    Baeten JM, Palanee-Phillips T, Brown ER, et al. Use of a vaginal ring containing dapivirine for HIV-1 prevention in women. N Engl J Med. 2016;375:2121–32.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Montgomery ET, van der Straten A, Chitukuta M, et al. Acceptability and use of a dapivirine vaginal ring in a phase III trial. AIDS. 2017;31:1159–67.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Nel A, Bekker LG, Bukusi E, 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.CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Smith DJ, Wakasiaka S, Hoang TDM, Bwayo JJ, del Rio C, Priddy FH. An evaluation of intravaginal rings as a potential HIV prevention device in urban Kenya: behaviors and attitudes that might influence uptake within a high-risk population. J Women’s Health. 2008;17:1025–34.CrossRefGoogle Scholar
  16. 16.
    Kiser P, Johnson T, Clark J. State of the art in intravaginal ring technology for topical prophylaxis of HIV infection. AIDS Rev. 2012;14(1):62–77.PubMedGoogle Scholar
  17. 17.
    Malcolm RK, Edwards K-L, Kiser P, Romano J, Smith TJ. Advances in microbicide vaginal rings. Antiviral Res. 2010;88:S30–9.CrossRefPubMedGoogle Scholar
  18. 18.
    Guthrie KM, 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.CrossRefGoogle Scholar
  19. 19.
    Montgomery CM, Gafos M, Lees S, et al. Re-framing microbicide acceptability: findings from the MDP301 trial. Cult Health Sex. 2010;12:649–62.CrossRefPubMedGoogle Scholar
  20. 20.
    Maughan-Brown Brendan, Kenyon Chris, Lurie Mark N. Partner age differences and concurrency in South Africa: implications for HIV-infection risk among young women. AIDS Behav. 2014;18(12):2469–76.CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Montgomery CM, Lees S, Stadler J, Morar NS, Ssali A, Mwanza B, Mntambo M, Phillip J, Watts C, Pool R. The role of partnership dynamics in determining the acceptability of condoms and microbicides. AIDS Care. 2008;20(6):733–40.CrossRefPubMedGoogle Scholar
  22. 22.
    Montgomery ET, Stadler J, Hartmann M, et al. Male partner roles and influence on women’s use of HIV pre-exposure prophylaxis in Johannesburg. In: Paper presented at: AIDS Impact; Sept 29–Oct 3, 2013, Barcelona; 2013.Google Scholar
  23. 23.
    Montgomery ET, van der Straten A, Stadler J, et al. Male partner influence on women’s HIV prevention trial participation and use of pre-exposure prophylaxis: the importance of “understanding”. AIDS Behav. 2014;2014(11/22):1–10.Google Scholar
  24. 24.
    MacQueen KM, Dlamini S, Perry B, et al. Social context of adherence in an open-label 1% tenofovir gel trial: gender dynamics and disclosure in KwaZulu-Natal, South Africa. AIDS Behav. 2016;20(11):2682–91.CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Mensch BS, van der Straten A, Katzen LL. Acceptability in microbicide and PrEP trials: current status and a reconceptualization. Curr Opin HIV AIDS. 2012;7(6):534–41.CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    van der Straten A, Stadler J, Montgomery E, et al. Women’s experiences with oral and vaginal pre-exposure prophylaxis: the VOICE-C qualitative study in Johannesburg, South Africa. PLoS ONE. 2014;9(2):e89118.CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Jewkes Rachel K, Levin Jonathan B, Penn-Kekana Loveday A. Gender inequalities, intimate partner violence and HIV preventive practices: findings of a South African cross-sectional study. Soc Sci Med. 2003;56(1):125–34.CrossRefPubMedGoogle Scholar
  28. 28.
    Laborde ND, Pleasants E, Reddy K, Atujuna M, Nakyanzi T, Chitukuta M, Naidoo S, Palanee-Phillips T, Baeten JM, Montgomery EM. Impact of the dapivirine vaginal ring on sexual experiences and intimate partnerships of women in an HIV prevention clinical trial: managing ring detection and hot sex. AIDS Behav. 2018;22:437–46.CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Van der Straten A, Montgomery E, Cheng H, et al. High acceptability of a vaginal ring intended as a microbicide delivery method for HIV prevention in African women. AIDS Behav. 2012;16:1775–86.CrossRefPubMedGoogle Scholar
  30. 30.
    Green G, Pool R, Harrison S, et al. Female control of sexuality: illusion or reality? Use of vaginal products in south west Uganda. Soc Sci Med. 2001;52:585–98.CrossRefPubMedGoogle Scholar
  31. 31.
    Sahin-Hodoglugil NN, van der Straten A, Cheng H, et al. Degrees of disclosure: a study of women’s covert use of the diaphragm in an HIV prevention trial in sub-Saharan Africa. Soc Sci Med. 2009;69:1547–55.CrossRefPubMedGoogle Scholar
  32. 32.
    Harrison A, O’Sullivan LF, Hoffman S, Dolezal C, Morrell R. Gender role and relationship norms among young adults in South Africa: measuring the context of masculinity and HIV risk. J Urban Health. 2006;83(4):709–22.CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Dunkle Kristin L, Jewkes Rachel K, Brown Heather C, Gray Glenda E, McIntryre James A, Harlow Siobán D. Gender-based violence, relationship power, and risk of HIV infection in women attending antenatal clinics in South Africa. Lancet. 2004;363(9419):1415–21.CrossRefPubMedGoogle Scholar
  34. 34.
    Stadler Jonathan J, Delany Sinead, Mntambo Mdu. Women’s perceptions and experiences of HIV prevention trials in Soweto, South Africa. Soc Sci Med. 2008;66(1):189–200.CrossRefPubMedGoogle Scholar
  35. 35.
    Jewkes R, Morrell R. Sexuality and the limits of agency among South African teenage women: theorising femininities and their connections to HIV risk practises. Soc Sci Med. 2012;74(11):1729–37.CrossRefPubMedGoogle Scholar
  36. 36.
    Stern E, Buikema R. The relational dynamics of hegemonic masculinity among South African men and women in the context of HIV. Cult Health Sex. 2013;15(9):1040–54.CrossRefPubMedGoogle Scholar
  37. 37.
    Hunter M. Cultural politics and masculinities: multiple-partners in historical perspective in KwaZulu-Natal. Cult Health Sex. 2005;7(3):209–23.CrossRefPubMedGoogle Scholar
  38. 38.
    Pettifor A, MacPhail C, Anderson AD, Maman S. ‘If I buy the Kellogg’s then he should [buy] the milk’: young women’s perspectives on relationship dynamics, gender power and HIV risk in Johannesburg, South Africa. Cult Health Sex. 2012;14(5):477–90.CrossRefPubMedPubMedCentralGoogle Scholar
  39. 39.
    Koo Helen P, Woodsong Cynthia, Dalberth Barbara T, Viswanathan Meera, Simons-Rudolph Ashley. Context of acceptability of topical microbicides: sexual relationships. J Soc Issues. 2005;61(1):67–93.CrossRefPubMedPubMedCentralGoogle Scholar
  40. 40.
    Luke Nancy. Age and economic asymmetries in the sexual relationships of adolescent girls in sub-Saharan Africa. Stud Fam Plan. 2003;34(2):67–86.CrossRefGoogle Scholar
  41. 41.
    Jewkes Rachel K, Dunkle Kristin, Nduna Mzikazi, Shai Nwabisa. Intimate partner violence, relationship power inequity, and incidence of HIV infection in young women in South Africa: a cohort study. Lancet. 2010;376(9734):41–8.CrossRefPubMedGoogle Scholar
  42. 42.
    Harvey SM, ThorburnBird S, Galavotti C, Duncan EAW, Greenberg D. Relationship power, sexual decision making and condom use among women at risk for HIV/STDs. Women Health. 2002;36(4):69–84.CrossRefPubMedGoogle Scholar
  43. 43.
    Vamos Szonja, Cook Ryan, Chitalu Ndashi, Mumbi Miriam, Weiss Stephen M, Jones Deborah. Quality of relationship and sexual risk behaviors among HIV couples in Lusaka, Zambia. AIDS Care. 2013;25(9):1102–8.CrossRefPubMedPubMedCentralGoogle Scholar
  44. 44.
    United Nations. Department of Economic and Social Affairs. World Fertility Report 2013: Fertility at the Extremes. United Nations Publications; 2015.Google Scholar
  45. 45.
    Meekers D, Calvès A-E. ‘Main’ girlfriends, girlfriends, marriage, and money: the social context of HIV risk behaviour in sub-Saharan Africa. Health Transit Rev 361–75; 1997.Google Scholar
  46. 46.
    Whitehead SJ, McLean C, Chaikummao S, et al. Acceptability of Carraguard vaginal microbicide gel among HIV-infected women in Chiang Rai, Thailand. PLoS ONE. 2011;6:e14831.CrossRefPubMedPubMedCentralGoogle Scholar
  47. 47.
    Woodsong C, MacQueen K, Amico KR, et al. Microbicide clinical trial adherence: insights for introduction. J Int AIDS Soc. 2013;16:18505.CrossRefPubMedPubMedCentralGoogle Scholar
  48. 48.
    Kanekar AS. HIV/AIDS counseling skills and strategies: can testing and counseling curb the epidemic? Int J Prev Med. 2011;2(1):10.PubMedPubMedCentralGoogle Scholar
  49. 49.
    Baker M, Bell C, Brathwaite N, Brathwaite W, Cicatelli B. Technical guidance on HIV counseling. MMWR. 1993;42(RR-2):8–17.Google Scholar
  50. 50.
    Kelly Robert J, Gray Ronald H, Sewankambo Nelson K, Serwadda David, Wabwire-Mangen Fred, Lutalo Tom, Wawer Maria J. Age differences in sexual partners and risk of HIV-1 infection in rural Uganda. JAIDS. 2003;32(4):446–51.PubMedGoogle Scholar
  51. 51.
    Leclerc-Madlala Suzanne. Age-disparate and intergenerational sex in southern Africa: the dynamics of hypervulnerability. AIDS. 2008;22:S17–25.CrossRefPubMedGoogle Scholar
  52. 52.
    Kelly Christine A, Friedland Barbara A, Morar Neetha S, Katzen Lauren L, Ramjee Gita, Mokgatle Mathildah M, Ahmed Khatija. To tell or not to tell: male partner engagement in a Phase 3 microbicide efficacy trial in South Africa. Cult Health Sex. 2015;17(8):1004–20.CrossRefPubMedGoogle Scholar
  53. 53.
    Montgomery ET, van der Straten A, Stadler J, et al. Male partner influence on women’s HIV prevention trial participation and use of pre-exposure prophylaxis: the importance of “understanding”. AIDS Behav. 2015;19:784–93.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.RTI International, Women’s Global Health ImperativeUC Berkeley SPHOaklandUSA
  2. 2.University of Zimbabwe-University of California San Francisco Collaborative Research Program (UZ-UCSF)San FranciscoUSA
  3. 3.University of the Witwatersrand, Wits Reproductive Health and HIV Institute (Wits RHI)JohannesburgSouth Africa
  4. 4.Makerere University - Johns Hopkins University Research Collaboration (MU-JHU)KampalaUganda
  5. 5.South African Medical Research Council (SAMRC), HIV Prevention Research UnitCape TownSouth Africa
  6. 6.UNC Project, Tidziwe CentreLilongweMalawi
  7. 7.Kamuzu Central HospitalLilongweMalawi
  8. 8.The Desmond Tutu HIV Foundation, Desmond Tutu HIV Centre (DTHC) at the University of Cape TownCape TownSouth Africa

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