Abstract
This study examines qualitative acceptability of the dapivirine vaginal ring (DVR) and oral daily pre-exposure prophylaxis (PrEP) among breastfeeding persons participating in Microbicide Trials Network 043/B-PROTECTED, a phase 3B safety and drug detectability study of DVR and oral PrEP in breastfeeding. A subsample of 52 participants were purposively sampled to participate in an in-depth interview (IDI). Breastfeeding participants found both study products to be acceptable, and easy to use. A common motivation for product use was to protect the baby from HIV, although participants’ understanding of how the study drug would work to protect their babies was often unclear. While most participants did not report experiencing side effects, fears about side effects were common as both initial worries about how the study products would affect their health and the health of their baby, and increased anxiety that health issues experienced by them, or their baby were from the products.
Similar content being viewed by others
Data Availability
Data are available through the Microbicide Trials Network.
Code Availability
N/A.
References
World Health Organization. WHO Technical brief: preventing HIV during pregnancy and breastfeeding in the context of pre-exposure prophylaxis (PrEP). Geneva: World Health Organization; 2017.
WHO. Promoting proper feeding for infants and young children. Geneva: World Health Organization; 2019 [cited 2021 Sep 24]. Available from: http://www.who.int/nutrition/topics/infantfeeding/en/
Drake AL, Wagner A, Richardson B, John-Stewart G. Incident HIV during pregnancy and postpartum and risk of mother-to-child HIV transmission: a systematic review and meta-analysis. PLoS Med. 2014;11(2): e1001608.
Thomson KA, Hughes J, Baeten JM, John-Stewart G, Celum C, Cohen CR, et al. Increased risk of HIV acquisition among women throughout pregnancy and during the postpartum period: a prospective per-coital-act analysis among women with HIV-infected partners. J Infect Dis. 2018;218(1):16–25.
Noguchi LM, Hoesley C, Kelly C, Scheckter R, Bunge K, Nel A, et al. Pharmacokinetics of dapivirine transfer into blood plasma, breast milk, and cervicovaginal fluid of lactating women using the dapivirine vaginal ring. Antimicrob Agents Chemother. 2019. https://doi.org/10.1128/AAC.01930-18.
Department of Health Republic of South Africa. Guidelines for expanding combination prevention and treatment options for sex workers: oral pre-exposure prophylaxis (PrEP) and test and treat (T&T). 2016. Available from: https://www.nicd.ac.za/assets/files/PrEPandTTGuidelines-FinalDraft-11May2016.pdf
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;367:399–410. https://doi.org/10.1056/NEJMoa1108524.
Brown ER, Hendrix CW, van der Straten A, Kiweewa FM, Mgodi NM, Palanee-Philips T, et al. Greater dapivirine release from the dapivirine vaginal ring is correlated with lower risk of HIV-1 acquisition: a secondary analysis from a randomized, placebo-controlled trial. J Int AIDS Soc. 2020; 23(11):e25634
van der Straten A, Ryan JH, Reddy K, Etima J, Taulo F, Mutero P, et al. Influences on willingness to use vaginal or oral HIV PrEP during pregnancy and breastfeeding in Africa: the multisite MAMMA study. J Int AIDS Soc 2020;23:e25536. https://doi.org/10.1002/jia2.25536
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.
Grant RM, Anderson PL, McMahan V, Liu A, Amico KR, Mehrotra M, et al. Uptake of pre-exposure prophylaxis, sexual practices, and HIV incidence in men and transgender women who have sex with men: a cohort study. Lancet Infect Dis. 2014;14:820–9.
Van Der Elst EM, Mbogua J, Operario D, Mutua G, Kuo C, Mugo P, et al. High acceptability of HIV pre-exposure prophylaxis but challenges in adherence and use: qualitative insights from a phase I trial of intermittent and daily PrEP in at-risk populations in Kenya. AIDS Behav. 2013;17(6):2162–72.
Van Den Straten A, Montgomery ET, Musara P, Etima J, Naidoo S, Laborde N, et al. Disclosure of pharmacokinetic drug results to understand nonadherence: results from a qualitative study. AIDS. 2015;29(16):2161–71.
Corneli A, Perry B, Agot K, Ahmed K, Malamatsho F, Van Damme L. Facilitators of adherence to the study pill in the FEM-PrEP clinical trial. PLoS ONE. 2015;10(4): e0125458.
Duby Z, Mensch B, Hartmann M, Montgomery E, Mahaka I, Bekker LG, et al. Achieving the optimal vaginal state: using vaginal products and study gels in Uganda, Zimbabwe, and South Africa. Int J Sex Health. 2017;29:247–57.
Montgomery ET, Stadler J, Naidoo S, Katz AWK, Laborde N, Garcia M, et al. Reasons for nonadherence to the dapivirine vaginal ring: narrative explanations of objective drug-level results. AIDS. 2018;32:1517–25.
WHO. WHO recommends the dapivirine vaginal ring as a new choice for HIV prevention for women at substantial risk of HIV infection [Internet]. Geneva: World Health Organization; 2021. Available from: https://www.who.int/news/item/26-01-2021-who-recommends-the-dapivirine-vaginal-ring-as-a-new-choice-for-hiv-prevention-for-women-at-substantial-risk-of-hiv-infection
The Health Times. #BREAKING: dapivirine, vaginal ring approved for use in Zimbabwe - HealthTimes. 2021 [cited 2021 Oct 7]. Available from: https://healthtimes.co.zw/2021/07/14/breaking-dapivirine-vaginal-ring-approved-for-use-in-zimbabwe/
Bunge K, Makanani B, Fairlie L. MTN-042 Phase 3b, Randomized, Open Label Safety Trial of Dapivirine Vaginal Ring and Oral TRUVADA® Use in Pregnancy Microbicide Trials Network. 2021.
Noguchi L, Owor M, Gat B, Horne E, Mgodi N, Taulo F, et al. Phase 3B, randomized, open-label, safety study of dapivirine vaginal ring and oral emtricitabine 200mg/tenofovir disoproxil fumarate 300 mg tablet in breastfeeding mother-infant pairs. AIDS 2022. [cited 2022 Aug 22]. Available from: https://programme.aids2022.org/Abstract/Abstract/?abstractid=12893
Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression: development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry. 1987;150:782–6.
Wisner KL, Parry BL, Piontek CM. Postpartum depression. N Engl J Med. 2002;347:194–9.
Sekhon M, Cartwright M, Francis JJ. Acceptability of healthcare interventions: an overview of reviews and development of a theoretical framework. BMC Heal Serv Res. 2017;17:1–13. https://doi.org/10.1186/s12913-017-2031-8.
Mayo AJ, Browne EN, Montgomery ET, Torjesen K, Palanee-Phillips T, Jeenarain N, et al. Acceptability of the dapivirine vaginal ring for HIV-1 prevention and association with adherence in a Phase III trial. AIDS Behav. 2021;25:2430–40. https://doi.org/10.1007/s10461-021-03205-z.
Van Der Straten A, Browne EN, Shapley-Quinn MK, Brown ER, Reddy K, Scheckter R, et al. First impressions matter: how initial worries influence adherence to the dapivirine vaginal ring. J Acquir Immune Defic Syndr. 2019;81:304–10.
Griffin JB, Ridgeway K, Montgomery E, Torjesen K, Clark R, Peterson J, et al. Vaginal ring acceptability and related preferences among women in low- And middle-income countries: a systematic review and narrative synthesis. PLoS ONE. 2019;14(11): e0224898.
Van Der Straten A, Shapley-Quinn MK, Reddy K, Cheng H, Etima J, Woeber K, et al. Favoring “peace of mind”: a qualitative study of African women’s HIV prevention product formulation preferences from the MTN-020/ASPIRE trial. AIDS Patient Care STDS. 2017;31:305.
Mofenson LM. Tenofovir Pre-exposure prophylaxis for pregnant and breastfeeding women at risk of hiv infection: the time is now. PLOS Med. 2016;13:e1002133. https://doi.org/10.1371/journal.pmed.1002133.
Mugwanya KK, Hendrix CW, Mugo NR, Marzinke M, Katabira ET, Ngure K, et al. Pre-exposure prophylaxis use by breastfeeding HIV-uninfected women: a prospective short-term study of antiretroviral excretion in breast milk and infant absorption. PLoS Med. 2016;13(9): e1002132.
Noguchi LM, Montgomery ET, Biggio JR, Hendrix CW, Bogen DL, Hillier SL, et al. Detectable tenofovir levels in breast-feeding infants of mothers exposed to topical tenofovir. Antimicrob Agents Chemother. 2016;60(9):5616–9. https://doi.org/10.1128/AAC.00645-16.
Palombi L, Pirillo M, Marchei E, Jere H, Sagno J, Luhanga R. Concentrations of tenofovir, lamivudine and efavirenz in mothers and children enrolled under Option B-Plus approach in Malawi. J Antimicrob Chemother. 2016;71(4):1027–30.
Noguchi LM, Hoesley C, Kelly C, Scheckter R, Bunge K, Nel A, et al. Pharmacokinetics of dapivirine transfer into blood plasma, breast milk, and cervicovaginal fluid of lactating women using the dapivirine vaginal ring. Antimicrob Agents Chemother. 2019;63(3):e01930-18.
Flax V, Hawley I, Ryan J, Chitukuta M, Mathebula F, Nakalega F, et al. After their wives have delivered, a lot of men like going out: Perceptions of HIV transmission risk and support for HIV prevention methods during breastfeeding in sub-Saharan Africa. Matern Child Nutr. 2021;17(2): e13120.
Chibanda D, Mangezi W, Tshimanga M, Woelk G, Rusakaniko S, Stranix-Chibanda L, et al. Postnatal depression by HIV status among women in Zimbabwe. J Womens Health (Larchmt). 2010;19:2071–7.
Nyamukoho E, Mangezi W, Marimbe B, Verhey R, Chibanda D. Depression among HIV positive pregnant women in Zimbabwe: a primary health care based cross-sectional study. BMC Pregnancy Childb. 2019;19:1–7. https://doi.org/10.1186/s12884-019-2193-y.
Hartley M, Tomlinson M, Greco E, Comulada WS, Stewart J, le Roux I, et al. Depressed mood in pregnancy: prevalence and correlates in two Cape Town peri-urban settlements. Reprod Health. 2011;8:9. https://doi.org/10.1186/1742-4755-8-9.
Acknowledgements
Full MTN-043/B-PROTECTED Study Team: Study Site Staff: Frank Taulo, MBBS, MPH, FCOG (Investigator of Record [IoR]), Linly Seyama, MSc, RNM (Study Coordinator [SC]), Zayithwa Fabiano, MBBS (SC), Sufia Dadabhai, PhD (Clinical Research Site [CRS] Leader), and Taha Taha, PhD (Clinical Trials Unit [CTU] Principal Investigator [PI], Johns Hopkins University Research Project; Brenda Gati Mirembe, MBChB, MSc (IoR), Phionah Bridget Kibalama Ssemambo, MBchB, MSc PH (SC), Clemensia Nakabiito, MBChB, MMed (Co-Investigator), and Mary Glenn Fowler, MD, MPH (CTU PI), Makerere University—Johns Hopkins University (MU-JHU) Research Collaboration; Elizea Horne, MBChB (IoR), Carlotta Mabuza, BS, PGDip, Dip (SC), Lee Fairlie, MBChB, FCPaeds (CRS Leader), and Hermien Gous, PharmD (CRS Leader), Wits RHI Shandukani Research Centre; Felix Mhlanga, MBChB, MMed (IoR), Nyaradzo M. Mgodi, MBChB, Mmed (IoR), Petina Musara, BSW (SC), and Z. Mike Chirenje, MD, FRCOG (CTU PI), University of Zimbabwe Clinical Trials Research Centre (UZ-CTRC)
Protocol Team: Jeanna M. Piper, MD (DAIDS Senior Medical Officer (MO)), Naana Cleland, PhD (Health Specialist Clinical Microbicide Research Branch (CMRB)), and Roberta Black, PhD (Chief, CMRB), National Institute of Allergy and Infectious Diseases (NIAID), Division of AIDS (DAIDS); Nahida Chakhtoura, MD, MsGH (NICHD MO), Maternal and Pediatric Infectious Disease Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) National Institutes of Health (NIH); Dianne M. Rausch, PhD (Director, DAIDS Research) and Teri Senn, PhD (Program Chief, Psychosocial Comorbidities of HIV Prevention and Treatment), National Institutes of Mental Health (NIMH); James F. Rooney, MD (Vice President Medical Affairs), Gilead Sciences; Zeda Rosenberg, ScD (Chief Executive Officer), International Partnership for Microbicides; Craig Hendrix, MD (Biomedical Science Working Group (BSWG) Representative, Protocol Pharmacologist), Jenny Robinson, MD, MPH, FACOG (BSWG Representative), Bonus Makanani MB BS, FCOG (SA), Department of Obstetrics & Gynecology, College of Medicine, University of Malawi, and College of Medicine-Johns Hopkins Research Project in Blantyre, Lisa Noguchi, PhD, CNM (Protocol Co-Chair), and Mark Marzinke, PhD, DABCC (Laboratory Center [LC] Pharmacology Core), Johns Hopkins University; Peter Anderson, PharmD (LC Pharmacology Core), University of Colorado School of Pharmacy; Rachel Scheckter, MPH (Sr. Clinical Research Manager [CRM]), Ashley J. Mayo, MPH (Sr. CRM), Tara McClure, MPH (Sr. CRM), Abraham Johnson, MPH (Community Program Associate), Cheryl Blanchette, MS(Sr. Community Program (MTN). Manager (CPM), Jontraye Davis, MHA (CPM), and Lisa Levy, MPH, MTN Associate Director, FHI 360; Katherine Bunge, MD, MPH (Protocol Safety Physician [PSP]), Richard H. Beigi, MD, MSc (Protocol Physician), and Sharon A. Riddler, MD, MPH (Protocol Physician), Magee-Womens Hospital and the University of Pittsburgh Medical Center (UPMC); Devika Singh, MD, MPH (PSP), University of Vermont; Cindy Jacobson, PharmD (Director of Pharmacy Affairs), Edward Livant, BSMT (ASCP), MPH (MTN LC Research Manager), May Beamer, BS (Laboratory Manager), Lisa Rossi, BA (MTN Director of Communications), Luis Duran, DrPH, MPIA (Project Manager), Mei Song, PhD (Project Manager), and Sharon Hillier, PhD (MTN Principal Investigator), Magee-Womens Research Institute-UPMC; Elizabeth Montgomery, PhD (Behavioral Research Working Group [BRWG] Lead), Imogen Hawley, MA, MSc (Qualitative Coordinator), and Marie Stoner, PhD (Qualitative Coordinator), RTI International; Ivan Balan, PhD (BRWG Representative), Florida State University College of Medicine; Maxensia Owor, MBChB, MMed (Paed), MPH (Protocol Chair), MU-JHU; Barbra Richardson, PhD (Statistician), Jennifer Balkus, PhD, MPH (Protocol Co-Chair), Holly Gundacker, MS (Statistical Research Associate), Jillian Zemanek, MPH (Lead Clinical Data Manager), and Wen-Min Hou, MPH, BSN (Lead Clinical Safety Associate), Statistical Center for HIV/AIDS Research and Prevention, Fred Hutchinson Cancer Research Center and the University of Washington.
Data Management: Data management was provided by The Statistical Center for HIV/AIDS Research & Prevention (Fred Hutchinson Cancer 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, Berkeley, CA). We would also like to acknowledge Maryam Matean and Alejandro Baez at RTI international for their support with qualitative coding and analysis.
Funding
The study was designed and implemented by the Microbicide Trials Network (MTN). From 2006 until November 30, 2021, the MTN was an HIV/AIDS clinical trial network 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 NIH.
Author information
Authors and Affiliations
Contributions
MCDS, IH and ETM managed qualitative data and did coding and data analysis. FM, EH, JE, DK, PM, AD, LS, and ZF conducted data collection, and quality control of transcripts. RS, LM, MO and JEB over saw study implementation. MCDS led manuscript writing with support from IH and ETM. All authors have read and approved the final manuscript.
Corresponding author
Ethics declarations
Conflict of interest
The authors have not disclosed any competing interests.
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. The study was approved by the following Institutional Review Boards/Ethics Committees and Drug Regulatory Authorities: Prevention Sciences Research Committee of the US National Institute of Allergy and Infectious Diseases; US Food and Drug Administration; College of Medicine Research and Ethics Committee; Johns Hopkins School of Public Health Institutional Review Board; Pharmacy, Medicines and Poisons Board of Malawi; Human Research Ethics Committee: (Medical), University of Witwatersrand, Johannesburg; South African Health Products Regulatory Authority; Joint Clinical Research Centre Institutional Review Board; Uganda National Council for Science and Technology; Johns Hopkins Medicine Office of Human Subjects Research Institutional Review Board; National Drug Authority of Uganda; Medical Research Council of Zimbabwe; Joint Research Ethics Committee for the University of Zimbabwe Faculty of Medicine and Health Sciences and Parirenyatwa Group of Hospitals; Research Council of Zimbabwe; Medicines Control Authority of Zimbabwe.
Consent to Participate
All participants provided informed consent for the study.
Study Products
The DVRs used in this study were developed and supplied by the International Partnership for Microbicides (IPM). Oral tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) was donated by Gilead Sciences.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Supplementary Information
Below is the link to the electronic supplementary material.
Rights and permissions
Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.
About this article
Cite this article
Stoner, M.C.D., Hawley, I., Mathebula, F. et al. Acceptability and Use of the Dapivirine Vaginal Ring and Daily Oral Pre-exposure Prophylaxis (PrEP) During Breastfeeding in South Africa, Malawi, Zimbabwe, and Uganda. AIDS Behav 27, 4114–4123 (2023). https://doi.org/10.1007/s10461-023-04125-w
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10461-023-04125-w