Skip to main content

Acceptability of a Tenofovir Disoproxil Fumarate Vaginal Ring for HIV Prevention Among Women in New York City


Vaginal rings for pre-exposure prophylaxis are a female-initiated HIV prevention method that does not require daily or coitally-dependent dosing. As part of a randomized placebo-controlled trial of a tenofovir disoproxil fumarate intravaginal ring, we assessed product acceptability through in-depth interviews with 18 women during and after 14 days of continuous use. Women reported that the ring was comfortable with few side effects, regardless of experimental arm. However, interest in future use by this cohort was modest for several reasons including: low self-perceived HIV risk; concern that use implied promiscuity; potential for interference with relationship formation and trust; concern for interference with menstruation and cleanliness; and worries about partners’ acceptability and sexual pleasure. Potential issues were raised with duration of use prior to ring exchange. Future studies should continue to identify and address individual and relationship factors that influence acceptability, early in the product development process.


Los anillos vaginales para la profilaxis preexposición (PrEP) son un método de prevención de VIH iniciado por mujeres que no requiere dosificación diaria o dependiente del coito. Como parte de un ensayo aleatorio controlado con placebo de un anillo intravaginal (IVR) de fumarato de disoproxilo de tenofovir (TDF), evaluamos la aceptabilidad del dispositivo a través de entrevistas en profundidad con 18 mujeres durante y después de 14 días de uso continuo. Las mujeres reportaron que el anillo era cómodo con pocos efectos secundarios, independiente del brazo experimental. Sin embargo, el interés en uso posterior por esta cohorte fue moderado por varias razones, incluyendo: autopercepción de bajo riesgo de VIH; preocupación de que el uso implica promiscuidad; potencial de interferencia con la formación de relaciones y la confianza; preocupación de interferencia con la menstruación y la limpieza; y preocupaciones sobre la aceptabilidad por parte del pareja y el placer sexual. Se plantearon cuestiones potenciales sobre la duración del uso antes del cambio de anillo. Los estudios futuros deben seguir identificando y abordando los factores individuales y de relación que influyen en la aceptabilidad en las primeras etapas del proceso de desarrollo del producto.

This is a preview of subscription content, access via your institution.


  1. World Health Organization. Global Summary of the AIDS epidemic. 2014.

  2. Padian NS, Shiboski SC, Glass SO, Vittinghoff E. Heterosexual transmission of human immunodeficiency virus (HIV) in northern California: results from a ten-year study. Am J Epidemiol 1997;146(4):350–57.

  3. Centers for Disease Control and Prevention. HIV Among Youth. 2016.

  4. Centers for Disease Control and Prevention. New HIV Infections in the United States. CDC Fact Sheet. 2016.

  5. Abdool Karim Q, Abdool Karim SS, Frohlich J a, Grobler a C, Baxter C, Mansoor LE, et al. Effectiveness and safety of tenofovir gel, an antiretroviral microbicide, for the prevention of HIV infection in women.[Erratum appears in Science. 2011 Jul 29;333(6042):524]. Science (80-). 2010;329(2010):1168–74.

  6. Grant RM, Lama JR, Anderson PL, McMahan V, Liu AY, Vargas L, et al. Preexposure chemoprophylaxis for HIV prevention in men who have sex with men. N Engl J Med. 2010 Dec 30 [cited 2016 Jan 10];363(27):2587–99.

  7. Baeten JM, Donnell D, Ndase P, Mugo NR, Campbell JD, Wangisi J, et al. Antiretroviral prophylaxis for HIV prevention in heterosexual men and women. N Engl J Med. 2012;367(5):399–410.

  8. Baeten JM, et al. Use of a vaginal ring containing dapivirine for HIV-1 prevention in women. N Engl J Med. 2016 [cited 2016 Mar 18];

  9. Choopanya K, Martin M, Suntharasamai P, Sangkum U, Mock PA, Leethochawalit M, et al. Antiretroviral prophylaxis for HIV infection in injecting drug users in Bangkok, Thailand (the Bangkok Tenofovir Study): a randomised, double-blind, placebo-controlled phase 3 trial. Lancet (London, England). Elsevier; 2013 Jun 15 [cited 2016 Mar 18];381(9883):2083–90.

  10. Nel A, Kapiga S, Bekker L, Devlin B, Borremans M, Rosenberg Z. Safety and efficacy of dapivirine vaginal ring for HIV-1 prevention in African women. In: CROI. Boston, MA; 2016 [cited 2016 Mar 18].

  11. Marrazzo JM, Ramjee G, Richardson BA, Gomez K, Mgodi N, Nair G, et al. Tenofovir-based preexposure prophylaxis for HIV infection among African women. N Engl J Med. NIH Public Access; 2015 Feb 5 [cited 2016 Jan 8];372(6):509–18.

  12. Van Damme L, Corneli A, Ahmed K, Agot K, Lombaard J, Kapiga S, et al. Preexposure prophylaxis for HIV infection among African women. N Engl J Med. 2012 Aug 2 [cited 2016 Feb 4];367(5):411–22.

  13. Rees H, Delany-moretlwe S, Baron D, Lombard C, Gray G, Myer L, et al. FACTS 001 phase III trial of pericoital tenofovir 1% gel for HIV prevention in women. In: Conference on Retroviruses and Oportunistic Infections, (CROI). Seattle; 2015. p. 23–6.

  14. Thurman AR, Clark MR, Hurlburt JA, Doncel GF. Intravaginal rings as delivery systems for microbicides and multipurpose prevention technologies. Int J Womens Health. Dove Press; 2013 Jan 21 [cited 2015 Aug 24];5:695–708.

  15. Gilliam ML, Neustadt A, Kozloski M, Mistretta S, Tilmon S, Godfrey E. Adherence and acceptability of the contraceptive ring compared with the pill among students. Obstet Gynecol. 2010;115(3):503–10.

    Article  PubMed  Google Scholar 

  16. 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 Womens Health (Larchmt). Mary Ann Liebert, Inc. 140 Huguenot Street, 3rd Floor New Rochelle, NY 10801 USA; 2010 Jan 18 [cited 2015 Aug 24];17(6):1025–34.

  17. van der Straten A, Montgomery ET, Cheng H, Wegner L, Masenga G, von Mollendorf C, et al. High acceptability of a vaginal ring intended as a microbicide delivery method for HIV prevention in African women. AIDS Behav. 2012;16(7):1775–86.

  18. 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.

  19. Nel, A. et al. Safety, acceptability and pharmacokinetic assessment (adherence) of monthly dapivirine vaginal microbicide rings (Ring-004) for HIV prevention. In: 19th Conference on Retroviruses and Opportunistic Infections. 2012.

  20. 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. Springer US; 2016 Feb 2 [cited 2016 Aug 8];20(11):2644–2653.

  21. Merkatz RB, Plagianos M, Hoskin E, Cooney M, Hewett PC, Mensch BS. Acceptability of the Nestorone®/ethinyl estradiol contraceptive vaginal ring: development of a model; implications for introduction. 2014 Nov [cited 2015 Feb 19];90(5):514–21.

  22. Roumen FJME, op ten Berg MMT, Hoomans EHM. The combined contraceptive vaginal ring (NuvaRing®): first experience in daily clinical practice in The Netherlands. Eur J Contracept Reprod Heal Care. 2006 Jan 6 [cited 2017 Aug 25];11(1):14–22.

  23. Dieben T, Roumen F, Apter D. Efficacy, cycle control, and user acceptability of a novel combined contraceptive vaginal ring. Obstet Gynecol. 2002;100(3):585–93.,_Cycle_Control,_and_User_Acceptability_of.30.aspx.

  24. Das U, Sharma M, Kilbourne-Brook M, Coffey PS. Exploring vaginal ring acceptability for contraception and sexually transmissible infection protection in India: a qualitative research study. Sex Health. 2015 [cited 2017 Aug 25];12(6):532.

  25. Rosen RK, van den Berg JJ, Vargas SE, Senocak N, Shaw JG, Buckheit RW, et al. Meaning-making matters in product design: users’ sensory perceptions and experience evaluations of long-acting vaginal gels and intravaginal rings. Contraception. 2015 Dec [cited 2017 Aug 25];92(6):596–601.

  26. 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. Le Grand R, editor. PLoS One. Sage; 2015 Dec 22 [cited 2017 Aug 25];10(12):e0145642.

  27. Van der Straten A, et al. Adherence and acceptability of a dapivirine vaginal ring in postmenopausal US Women. In: CROI. 2016. p. Oral abstract 873.

  28. 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 May [cited 2017 May 27];31(8):1159–67.

  29. 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. Public Library of Science; 2016 Jan 10 [cited 2016 May 11];11(3):e0147743.

  30. Keller MJ, Mesquita PM, Marzinke MA, Teller R, Espinoza L, Atrio JM, et al. A phase 1 randomized placebo-controlled safety and pharmacokinetic trial of a tenofovir disoproxil fumarate vaginal ring. AIDS. 2016 Nov 24 [cited 2016 Feb 15];30(5):743–51.

  31. Nel A, Haazen W, Nuttall J, Romano J, Rosenberg Z, van Niekerk N. A safety and pharmacokinetic trial assessing delivery of dapivirine from a vaginal ring in healthy women. AIDS. 2014 Jun [cited 2017 May 27];28(10):1479–87.

  32. Morse J. Sampling in grounded theory. In: Bryant A, Charmaz K, editors. The SAGE handbook of grounded theory. Longon: SAGE Publications; 2007. p. 229–44.

    Chapter  Google Scholar 

  33. Woodsong C, Alleman P. Sexual pleasure, gender power and microbicide acceptability in Zimbabwe and Malawi. AIDS Educ Prev. 2008;20(2):171–87.

    Article  PubMed  Google Scholar 

  34. Mensch BS, van der Straten A, Katzen LL. Acceptability in microbicide and PrEP trials: current status and a reconceptualization. Curr Opin HIV AIDS. 2012 Nov [cited 2015 Mar 20];7(6):534–41.

  35. Novák A, De La Loge C, Abetz L, Van Der Meulen EA. The combined contraceptive vaginal ring, NuvaRing®: an international study of user acceptability. Contraception. 2003;67(3):187–94.

    Article  PubMed  Google Scholar 

  36. Severy LJ, Tolley E, Woodsong C, Guest G. A framework for examining the sustained acceptability of microbicides. AIDS Behav. 2005;9(1):121–31.

    Article  PubMed  Google Scholar 

  37. Righi C, James J, Beasley M, Day DL, Fox JE, Gieber J, et al. Card sort analysis best practices. J Usability Stud. Usability Professionals’ Association; 2013 [cited 2017 May 20];8(3):69–89.

  38. SocioCultural Research Consultants. Dedoose version 6.1.18 web application for managing, analyzing, and presenting qualitative and mixed method research data. Los Angeles, CA; 2015.

  39. Charmaz K, Belgrave L. Qualitative interviewing and Grounded Theory analysis. In: Gubrium J, Holstein J, Marvasti A, McKinney K, editors. The SAGE handbook of interview research: the complexity of the craft. Thousand Oaks: SAGE Publications; 2012. p. 347–66.

    Google Scholar 

  40. Woodsong C. Covert use of topical microbicides: Implications for acceptability and use. Int Fam Plan Perspect. [cited 2015 Aug 13];30(2):94–8.

  41. Blashill AJ, Ehlinger PP, Mayer KH, Safren SA. Optimizing adherence to preexposure and postexposure prophylaxis: the need for an integrated biobehavioral approach. Clin Infect Dis. Oxford University Press; 2015 Jun 1 [cited 2016 Nov 14];60 Suppl 3(suppl 3):S187-90.

  42. Morrison-Beedy D, Passmore D. Insights into microbicide acceptability and preferences among urban adolescent girls. J HIV AIDS Soc Serv. Routledge; 2015 Apr 3 [cited 2017 Aug 31];14(2):154–70.

  43. Romo LF, Berenson AB. Tampon use in adolescence: differences among European American, African American and Latina women in practices, concerns, and barriers. J Pediatr Adolesc Gynecol. 2012 Oct [cited 2017 Aug 31];25(5):328–33.

  44. Namey E, Agot K, Ahmed K, Odhiambo J, Skhosana J, Guest G, et al. When and why women might suspend PrEP use according to perceived seasons of risk: implications for PrEP-specific risk-reduction counselling. Cult Health Sex. Taylor & Francis; 2016 Apr 19 [cited 2016 Jun 4];1–11.

  45. Rogers R, Prentice-Dunn S, Gochman D. Handbook of health behavior research 1: Personal and social determinants. xxviii. Gochman D, editor. New York, NY: Plenum Press; 1997. pp. 113–132.

  46. Becker MH. The health belief model and personal health behavior. Health Educ Monogr. 1974;2(4):324–473.

    Article  Google Scholar 

  47. Bandura A. Social foundations of thought and action: A social cognitive theory. Vol. xiii, Prentice-Hall series in social learning theory. 1986. p. 617.

  48. Witte K. Fear as motivator, fear as inhibitor: Using the extended parallel process model to explain fear appeal successes and failures. In: Anderson P, Guerrero L, editors. Handbook of communication and emotion: Research, theory, applications, and contexts. San Diego: Academic Press; 1998. p. 423–50.

    Google Scholar 

  49. Cho H, Witte K. Managing fear in public health campaigns: a theory-based formative evaluation process. Health Promot Pract. 2005;6(4):482–90.

  50. Catania JA, Kegeles SM, Coates TJ. Towards an Understanding of Risk Behavior: An AIDS Risk Reduction Model (ARRM). Heal Educ Behav. SAGE Publications; 1990 Jan 1 [cited 2016 Nov 3];17(1):53–72.

  51. Schroeder KEE, Hobfoll SE, Jackson AP, Lavin J. Proximal and Distal Predictors of AIDS Risk Behaviors among Inner-city African American and European American Women. J Health Psychol. 2001;6(2):169–90.

  52. Klein H, Elifson KW, Sterk CE. “At risk” women who think that they have no chance of getting HIV: self-assessed perceived risks. Women Heal. 2003;38(2):47–63.

    Article  Google Scholar 

  53. Baeten JM, Haberer JE, Liu AY, Sista N. Preexposure prophylaxis for HIV prevention: where have we been and where are we going? J Acquir Immune Defic Syndr. NIH Public Access; 2013 Jul 1 [cited 2015 Jan 31];63 Suppl 2(0 2):S122-9.

  54. Koo HP, Woodsong C, Dalberth BT, Viswanathan M, Simons-Rudolph A. Context of acceptability of topical microbicides: sexual relationships. J Soc Issues. 2005 Mar [cited 2015 Aug 15];61(1):67–93.

  55. Hoffman S, Morrow KM, Mantell JE, Rosen RK, Carballo-Diéguez A, Gai F. Covert use, vaginal lubrication, and sexual pleasure: a qualitative study of urban U.S. Women in a vaginal microbicide clinical trial. Arch Sex Behav. 2010 Jun [cited 2015 Aug 15];39(3):748–60.

  56. Hirsch JS, Higgins J, Bentley ME, Nathanson CA. The social constructions of sexuality: marital infidelity and sexually transmitted disease–HIV risk in a Mexican migrant community. Am J Public Health. American Public Health Association; 2002 Aug 10 [cited 2016 Feb 22];92(8):1227–37.

  57. Doggett EG, Lanham M, Wilcher R, Gafos M, Karim QA, Heise L. Optimizing HIV prevention for women: a review of evidence from microbicide studies and considerations for gender-sensitive microbicide introduction. J Int AIDS Soc. 2015 Jan [cited 2016 Feb 22];18(1):20536.

  58. Bentley ME, Fullem AM, Tolley EE, Kelly CW, Jogelkar N, Srirak N, et al. Acceptability of a microbicide among women and their partners in a 4-country phase I trial. Am J Public Health. American Public Health Association; 2004 Jul 10 [cited 2016 Jun 6];94(7):1159–64.

  59. Khawcharoenporn T, Kendrick S, Smith K. HIV risk perception and preexposure prophylaxis interest among a heterosexual population visiting a sexually transmitted infection clinic. AIDS Patient Care STDS. 2012 [cited 2015 Jun 6];26(4):222–33.

  60. Mantell JE, Myer L, Carballo-Diéguez A, Stein Z, Ramjee G, Morar NS, et al. Microbicide acceptability research: current approaches and future directions. Soc Sci Med. 2005 Jan [cited 2015 Feb 18];60(2):319–30.

  61. Braunstein S, Wijgert J Van De. Preferences and practices related to vaginal lubrication: implications for microbicide acceptability and clinical testing. J Women’s Heal. 2005 Jun [cited 2016 Nov 14];14(5):424–33.

  62. 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. Springer US; 2010 Oct 28 [cited 2016 Nov 14];14(5):1169–81.

  63. Myer L, Denny L, De Sousa M, Wright T, Barone M, Kuhn L. Intravaginal practices, HIV and other sexually transmitted diseases among South African women. Sex Transm Dis. 2004;31(3):174–9.

    Article  PubMed  Google Scholar 

  64. Hartmann M, Montgomery E, Stadler J, Laborde N, Magazi B, Mathebula F, et al. Negotiating the use of female-initiated HIV prevention methods in a context of gender-based violence: the narrative of rape. Cult Health Sex. Taylor & Francis; 2015 Nov 9 [cited 2016 Jun 4];

  65. 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. Springer US; 2011 Jul 16 [cited 2016 Oct 30];15(5):959–69.

  66. Woodsong C, Musara P, Chandipwisa A, Montgomery E, Alleman P, Chirenje M, et al. Interest in multipurpose prevention of HIV and pregnancy: perspectives of women, men, health professionals and community stakeholders in two vaginal gel studies in southern Africa. BJOG. 2014 Oct [cited 2015 Feb 19];121 Suppl:45–52.

  67. Malcolm RK, Boyd P, McCoy CF, Murphy DJ. Beyond HIV microbicides: multipurpose prevention technology products. BJOG. 2014 Oct [cited 2015 Feb 28];121 Suppl:62–9.

  68. IMPT for Reproductive Health. MPT product development database. 2016 [cited 2016 Nov 3].

Download references


The work was supported by Grants from the National Institutes of Health (AI076980, AI03461, TR001073) and by the Einstein-Rockefeller-CUNY Center for AIDS Research (P30-AI124414), which is supported by the following NIH Co-Funding and Participating Institutes and Centers: NIAID, NCI, NICHD, NHLBI, NIDA, NIMH, NIA, FIC, NIMHD, NIGMS and NIDDK. We thank Lilia Espinoza and Dafna Rebibo for assisting with protocol development, participant recruitment, and field operations. We also acknowledge the site staff and study participants.

Author information

Authors and Affiliations


Corresponding author

Correspondence to Dana Watnick.

Ethics declarations

Conflict of interest

The authors declare no conflicts 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.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Watnick, D., Keller, M.J., Stein, K. et al. Acceptability of a Tenofovir Disoproxil Fumarate Vaginal Ring for HIV Prevention Among Women in New York City. AIDS Behav 22, 421–436 (2018).

Download citation

  • Published:

  • Issue Date:

  • DOI:


  • Vaginal ring
  • Acceptability
  • Pre-exposure prophylaxis
  • Women
  • HIV prevention