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.

OBJECTIVE: The pipeline of vaginal microbicides for HIV prevention has expanded to include products for multipurpose prevention, but the interests of potential users and those advising on use have not been sufficiently investigated. Rather, assumptions about interest in multipurpose prevention technologies (MPTs) are inferred from what is known about acceptability and use of microbicides or contraceptives. DESIGN AND SETTING: This paper presents data on concerns and preferences for multipurpose prevention of HIV and pregnancy. Data were collected in two microbicide gel studies in Malawi and Zimbabwe. Participants were women using candidate vaginal products, their male partners, health professionals and community stakeholders. METHODS: An individual interview was conducted with participants. Interviews were audio-recorded, transcribed, coded for content and analysed for key themes. RESULTS: Participants indicated strong interest in a vaginal HIV prevention product that could also prevent pregnancy. Reasons for this interest were convenience, problems with adverse effects with current contraceptive methods, concerns about long-term effects of contraceptives, and concerns about the health burdens of HIV infection during pregnancy. The main disadvantage of an MPT was recognition that while interest in preventing HIV is constant, contraceptive needs change over time. CONCLUSION: The study population indicated support for an MPT to prevent HIV and pregnancy. This support may be further strengthened if the product is also available for prevention of only HIV. Women and men will be more willing to use an MPT if they can be reassured that its use will have no long-term effect on fertility.

High acceptability of a vaginal ring intended as a microbicide delivery method for HIV prevention in African women.

Vaginal rings (VRs) are new methods for continuous delivery of microbicides. This is the first study to quantitatively and qualitatively explore the acceptability of rings in Africa: 157 HIV-negative, sexually active women aged 18-35 used a placebo silicone elastomer ring for 12 weeks. They completed product acceptability questionnaires every 4 weeks. We conducted 6 exit focus group discussions with a subset of 48 women and 19 in-depth interviews with male partners. Retention in the study was high (97 %). Initial insertion at the clinic was successful on first attempt for 81 % of participants. Most women were comfortable using the ring, and very few (≤2 %) could feel it during daily activities or had ring-related physical or emotional problems. In the qualitative interviews many participants reported that they initially had concerns about using the ring. However, only a minority of women actually reported concerns with the ring during the study. The most frequent concern was that the ring would get lost inside the body (20 %), and this was significantly correlated with study site, frequently thinking about the ring and reporting that the ring was not very easy to remove. Qualitative data suggest that informants grew to like the ring because it felt securely placed, was unnoticeable during daily activities, and felt "normal" during sex. The ring appeared to be highly acceptable for women and men. Initial concerns with this novel method suggest a need for enhanced product counseling when VRs are introduced.

Vaginal ring adherence in sub-Saharan Africa: expulsion, removal, and perfect use.

In sub-Saharan Africa, HIV incidence and prevalence remain disproportionately high among women. Vaginal rings (VRs) have been formulated for the delivery of antiretroviral-based microbicides, and their favorable safety and tolerability profiles reported in clinical studies. Although the concept of drug release through a VR has existed since 1970, and VRs have been marketed since 1992 for contraceptive or hormone replacement purposes, VR use as a microbicide delivery system is a novel application. This is the first study to evaluate VR adherence among African women in the context of its potential use as an HIV prevention method, to examine predictors of adherence, and to describe clinical or contextual reasons for VR removals or nonadherence. This was a randomized trial of the safety and acceptability of a placebo VR worn for 12 weeks in 170 HIV-negative, African women aged 18-35 in four clinic sites in South Africa and Tanzania. The findings suggest that adherence to VR use in the context of HIV prevention trials in these communities should be high, thereby enabling more accurate assessment of an active microbicide safety and efficacy.

Two good reasons: women's and men's perspectives on dual contraceptive use.

In the US, continued high rates of unintended pregnancy, combined with increases in heterosexual transmission of HIV to women, have sharply magnified concern about the factors leading to or barring the use of contraceptive methods to protect concurrently against both risks. This paper reports on results of focus group research among African-American women participating in a longitudinal study and African-American men who are either partners of the women or are of similar socio-economic status as their partners. We found a high level of agreement between men and women on the issues and problems that both sexes face. People felt that regardless of a woman's use of other contraceptive methods, a condom should always be used for protection. This belief, however, differed markedly from actual practice. Although we attempted to discern the relative salience of concern about pregnancy versus STIs, we conclude that people may not separate these two concerns in their resolve to use two methods. Furthermore, they recognized the need for dual protection, but expected conflict with their partners from using condoms as a second method because of high levels of distrust regarding sexual fidelity. Thus people are caught in a bind: distrust further increases the sense of a need for dual methods, but using condoms exacerbates the problems people have with achieving trust in relationships.

Old farmers, invisible farmers: Age and agriculture in Jamaica.

Increases in both the percentage and absolute numbers of elders, originally observed in industrialized countries, are now a concern for a growing number of developing countries. At present, most elders are found in rural areas where many remain active in agriculture to very advanced years. There is concern that the rural concentration of elders may have negative consequences for agricultural production. This paper presents ethnographic material from Jamaica, where agriculture occupies an important place in the life course of many elders. Contrary to popular perceptions, farming is not exclusively the domain of elderly Jamaicans, but rather occurs at various stages in the life course in ways which make such activity 'invibible" to farm surveys and agricultural development policy. Such policies fail to account for the special abilities and needs of elder farmers.