Abstract
BackgroundWomen bear a disproportionate burden of HIV throughout the world prompting extensive research into HIV prevention products for women which has met with varied success. With an aim of informing future policy and programming, this review examines the barriers and motivations to the uptake and use of female initiated products in sub-Saharan countries.MethodsWe conducted a systematic review as an adapted meta-ethnography of qualitative data focused on actual use of products. After deduplication, 10,581 and 3861 papers in the first and second round respectively were screened. Following the PRISMA guidance, 22 papers were selected and synthesized using Malpass’s definitions of first, second, and third order constructs. First order constructs, consisting of participant data published in the selected papers, were extracted and categorised by second and third order constructs for analysis. A weight of evidence review was conducted to compare and assess quality across the papers.ResultsThe 22 papers selected span 11 studies in 13 countries. We derived 23 s order constructs that were translated into seven overarching third order constructs: Sexual Satisfaction, Trust, Empowerment and Control, Personal Well-being, Product use in the social-cultural environment, Practical Considerations, Risk Reduction, and Perceptions of Efficacy. Relationships and trust were seen to be as or more important for product use as efficacy. These constructs reveal an inherent inter-relationality where decision making around HIV prevention uptake and use cannot be binary or mono-faceted, but rather conducted on multiple levels. We developed a framework illustrating the central and proximal natures of constructs as they relate to the decision-making process surrounding the use of prevention products.ConclusionsHealth systems, structural, and individual level HIV prevention interventions for women should adopt a holistic approach. Interventions should attend to the ways in which HIV prevention products can serve to reduce the likelihood of HIV transmission, as well as help to protect partnerships, enhance sexual pleasure, and take into account woman’s roles in the social environment. Stigma, as well as sexuality, is likely to continue to influence product uptake and use and should be prominently taken into account in large-scale interventions.Trial registrationNot applicable.
Highlights
Women bear a disproportionate burden of Human Immunodeficiency Virus (HIV) throughout the world prompting extensive research into HIV prevention products for women which has met with varied success
We identified three distinct constructs comprising this theme: 1) product use promoted health and well-being; 2) attributes of product use indicated the power of medication and good health; and 3) quality of care was a motivator for engaging in services and product use
The analysis and synthesis of the data included in this review reveal nuanced personal, relational, social and cultural factors that women perceive and attempt to manage as they consider the uptake and use of biomedical HIV prevention products
Summary
Women bear a disproportionate burden of HIV throughout the world prompting extensive research into HIV prevention products for women which has met with varied success. Female condoms were at one time a promising new option, lack of support from international agencies and funders translated into challenges in delivery and access [2,3,4]. This meant that male condoms have remained the dominant form of HIV prevention for decades. This review did not include one study completed with people who inject drugs [10], which found a moderate but significant level of efficacy, nor did it include two microbicide gel studies (CAPRISA004 and FACTS001), the results of which together did not prove product efficacy [11, 12]. The non-significant levels of efficacy in the two microbicide trials, as well as the similar results of the VOICE (comparing oral PrEP and microbicide gel) and FEMPrEP (oral PrEP only) trials were either partially or largely due to poor adherence [13, 14], opening up questions around the ability to take oral PrEP effectively
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