Abstract
The vaginal ring (VR) is a female-initiated drug-delivery platform used for different indications, including HIV pre-exposure prophylaxis (PrEP). We conducted a systematic review of VR acceptability, values and preferences among women in low- and middle-income countries (LMIC) to inform further investment and/or guidance on VR use for HIV prevention. Following PRISMA guidelines, we used structured methods to search, screen, and extract data from randomized controlled trials (RCTs) and observational studies reporting quantitative outcomes of acceptability of the VR for any indication published 1/1970-2/2019 (PROSPERO: CRD42019122220). Of 1,110 records identified, 68 met inclusion criteria. Studies included women 15-50+ years from 25 LMIC for indications including HIV prevention, contraception, abnormal bleeding, and menopause. Overall VR acceptability was high (71-98% across RCTs; 62-100% across observational studies), with 80-100% continuation rates in RCTs and favorable ease of insertion (greater than 85%) and removal 89-99%). Users reported concerns about the VR getting lost in the body (8-43%), although actual expulsions and adverse events were generally infrequent. Most women disclosed use to partners, with some worrying about partner anger/violence. The VR was not felt during intercourse by 70-92% of users and 48-97% of partners. Acceptability improved over time both within studies (as women gained VR experience and worries diminished), and over chronological time (as the device was popularized). Women expressed preferences for accessible, long-acting, partner-approved methods that prevent both HIV and pregnancy, can be used without partner knowledge, and have no impact on sex and few side effects. This review was limited by a lack of standardization of acceptability measures and study heterogeneity. This systematic review suggests that most LMIC women users have a positive view of the VR that increases with familiarity of use; and, that many would consider the VR an acceptable future delivery device for HIV prevention or other indications.
Highlights
The vaginal ring (VR) is a long-acting drug-delivery platform that diffuses drugs embedded in polymeric matrices into the vaginal epithelium [1]
This systematic review adheres to Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines [19] and the protocol is registered with PROSPERO (ID: CRD42019122220)
Twenty-four observational studies and 14 Randomized controlled trial (RCT) were included from the peer-reviewed literature; nine additional observational studies and one RCT were identified in the grey literature (Table 2)
Summary
The vaginal ring (VR) is a long-acting drug-delivery platform that diffuses drugs embedded in polymeric matrices into the vaginal epithelium [1]. By avoiding gastrointestinal absorption and first-pass hepatic metabolism, VRs provide sustained, therapeutic levels of drugs with lower systemic exposure compared to oral therapies, possibly resulting in fewer side effects [1, 2]. A dapivirine ring for HIV prevention demonstrated moderate efficacy for HIV pre-exposure prophylaxis (PrEP) [8, 9] and is under review by the European Medicines Agency, with upcoming regulatory submissions to the US Food and Drug Administration and South African Health Products Regulatory Authority. Other VRs for HIV PrEP and multi-purpose prevention technologies (MPTs) are at various stages in the development pipeline [8, 10,11,12,13]. MPT VRs are promising, as they increase efficiencies for users and health systems by simultaneously addressing multiple sexual and reproductive health needs [14]
Sign-in/Register to view highlights & summary Sign-in/Register to access full text options 
Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Schedule a callDisclaimer: All third-party content on this website/platform is and will remain the property of their respective owners and is provided on "as is" basis without any warranties, express or implied. Use of third-party content does not indicate any affiliation, sponsorship with or endorsement by them. Any references to third-party content is to identify the corresponding services and shall be considered fair use under The CopyrightLaw.
