Vaginal ring acceptability: A systematic review and meta-analysis of vaginal ring experiences from around the world

Kathleen Ridgeway, Elizabeth T Montgomery, Kevin Smith, Kristine Torjesen, Ariane van der Straten, Sharon L Achilles, Jennifer B Griffin, Kathleen Ridgeway, Elizabeth T Montgomery, Kevin Smith, Kristine Torjesen, Ariane van der Straten, Sharon L Achilles, Jennifer B Griffin

Abstract

Objective: The vaginal ring (ring) is a female-initiated, long-acting drug delivery system for different indications, including HIV prevention. Our aim was to provide evidence for acceptability of the vaginal ring across indications to support dapivirine and multipurpose prevention technology ring introduction and roll out.

Study design: This systematic review and meta-analysis followed PRISMA guidelines. We searched PubMed, Web of Science, Embase, and grey literature for publications reporting favorable ring acceptability and secondary outcomes involving actual ring use (comfort, ease of ring use, ring comfort during sex, expulsions, and vaginal symptoms) or hypothetical acceptability for any indication published January 1, 1970-June 15, 2021. We estimated random-effects pooled prevalence, assessing between-study variation using meta-regression.

Results: Of 2,234 records, we included 123 studies with 40,434 actual and hypothetical ring users. The primary outcome assessment included 50 studies with 60 ring subgroups totaling 19,271 ring users. The favorable acceptability pooled prevalence was 85.6% (95%CI 81.3, 89.0), while hypothetical acceptability among non-ring users was 27.6% (95%CI 17.5, 40.5). In meta-regression, acceptability was higher in menopause (95.4%; 95%CI 88.4, 98.2) compared to contraceptive rings (83.7%; 95%CI 75.6, 89.5). Acceptability was lower in pharmacokinetic studies (50%; 95%CI 22.1, 77.9) compared to RCTs (89.5%; 95%CI 85.8.92.4) and in studies assessing acceptability at ≥12 months (78.5%; 95%CI 66.5, 87.1) versus studies assessing acceptability at <3 months (91.9%; 95%CI 83.7, 96.1). European (90.6%; 95%CI 83.9, 94.7), Asian (97.1%; 95%CI 92.0, 99.0), and multi-region studies (93.5%; 95%CI 84.6, 97.4) reported more favorable acceptability compared to African studies (59.4%; 95%CI 38.3, 77.5). Secondary outcomes were similarly favorable, including ring comfort (92.9%; 95%CI 89.2, 95.4), ease of use (90.9%; 95%CI 86.5, 94.0), and comfort during sex (82.7%; 95%CI 76.4, 87.6). Limitations include inconsistent outcome definitions and unmeasured factors affecting acceptability.

Conclusions: Women who used vaginal rings reported they were acceptable across indications geographic regions and indications. Policy makers should consider the ring as an important option for pregnancy and HIV prevention drug development.

Implications: This review found favorable acceptability among vaginal ring users across indications and geographic areas, in contrast to low hypothetical acceptability among non-users. Vaginal rings are an important drug delivery system for pregnancy and HIV preventions, and scale-up should plan to address initial hesitancy among new users.

Keywords: Acceptability; Contraception; HIV prevention; Meta-analysis; Systematic review; Vaginal ring.

Conflict of interest statement

Declaration of Competing Interest

SA has received consulting fees from Mayne Pharma and research grants from Mithra, Evofem, and Merck that are managed by Magee-Womens Research Institute. The other authors declare no competing interests.

Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.

Figures

Fig 1.
Fig 1.
PRISMA flowchart of publication screening and inclusion for systematic review and meta-analysis.
Fig 2.
Fig 2.
Forest plot of vaginal ring acceptability from meta-analysis.

References

    1. Malcolm RK, Edwards KL, Kiser P, Romano J, Smith TJ. Advances in microbicide vaginal rings. Antiviral Res 2010;88(1):S30–9 Suppl. doi:10.1016/j.antiviral.2010.09.003.
    1. Roumen FJ, Apter D, Mulders TM, Dieben TO. Efficacy, tolerability and acceptability of a novel contraceptive vaginal ring releasing etonogestrel and ethinyl oestradiol. Hum Reprod 2001;16(3):469–75. doi:10.1093/humrep/16.3.469.
    1. Efficacy Speroff L. and tolerability of a novel estradiol vaginal ring for relief of menopausal symptoms. Obstet Gynecol 2003;102(4):823–34. doi:10.1016/s0029-7844(03)00764-6.
    1. IPM’s Dapivirine Ring for Women’s HIV Prevention Receives WHO Prequalification [press release], Silver Spring, MD, USA: IPM; 2020; November 30 2020. Available from , [Accessed 1 August 2021].
    1. WHO recommends the dapivirine vaginal ring as a new choice for HIV prevention for women at substantial risk of HIV infection [press release], Geneva, Switzerland: World Health Organization; 2021. Available from , [Accessed 1 August 2021].
    1. IPM Welcomes WHO’s Recommendation for Dapivirine Vaginal Ring as New Women’s HIV Prevention Option [press release], Silver Spring, MD, USA: IPM; 2021. Available from , [Accessed 1 August 2021].
    1. Vaginal ring to reduce the risk of HIV infection for women in non-EU countries with high disease burden [press release], Amsterdam, Netherlands: EMA; 2020. Available from , [Accessed 1 August 2021].
    1. Gwarisa M #BREAKING: Dapivirine, Vaginal Ring Approved for Use in Zimbabwe. HealthTimes; 2021. Available from , [Accessed 1 August 2021].
    1. IPM’s New Drug Application for Dapivirine Vaginal Ring to Reduce HIV Risk in Women Accepted for Filing by US Food and Drug Administration [press release], Silver Spring, MD, USA: IPM; 2021. Available from , [Accessed 1 August 2021].
    1. Baeten JM, Palanee-Phillips T, Brown ER, Schwartz K, Soto-Torres LE, Govender V, et al. Use of a Vaginal Ring Containing Dapivirine for HIV-1 Prevention in Women. N Engl J Med 2016;375(22):2121–32. doi:10.1056/NEJMoa1506110.
    1. PrEPWatch About the Dapivirine Ring New York City, NY, USA: AVAC; 2021. [cited 2021 August 1]. Available from .
    1. Achilles SL, Hendrix CW, Poloyac SM, Hoesley CJ, Peda M, Gundacker H, et al. Safety and Pharmacokinetics of Dapivirine and Levonorgestrel Vaginal Rings for Multipurpose Prevention of HIV and Pregnancy. In: Society IA, editor. HIV Research for Prevention conference; 21–25 October, 2018; Madrid. Spain: International AIDS Society; 2018. p. 46.
    1. Bearak J, Popinchalk A, Alkema L, Sedgh G. Global, regional, and subregional trends in unintended pregnancy and its outcomes from 1990 to 2014: estimates from a Bayesian hierarchical model. Lancet Global Health 2018;6(4):e380–e3e9. doi:10.1016/S2214-109X(18)30029-9.
    1. UNAIDS Women and Girls and HIV, Geneva, Switzerland: UNAIDS; 2018. from , [Accessed 1 August 2021].
    1. Trends in maternal mortality 2000 to 2017: estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. 2017.
    1. Ross J, Stover J. Use of modern contraception increases when more methods become available: analysis of evidence from 1982–2009. Glob Health Sci Pract 2013;1(2):203–12. doi:10.9745/GHSP-D-13-00010.
    1. 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. doi:10.1371/journal.pone.0224898.
    1. Vargas SE, Midoun MM, Guillen M, Getz ML, Underhill K, Kuo C, et al. A Qualitative Systematic Review of Women’s Experiences Using Contraceptive Vaginal Rings: Implications for New Technologies. Perspect Sex Reprod Health 2019;51(2):71–80. doi:10.1363/psrh.12103.
    1. Sekhon M, Cartwright M, Francis JJ. Acceptability of healthcare interventions: an overview of reviews and development of a theoretical framework. BMC Health Serv Res 2017;17(1):88. doi:10.1186/s12913-017-2031-8.
    1. Lopez LM, Grimes DA, Gallo MF, Stockton LL, Schulz KF. Skin patch and vaginal ring versus combined oral contraceptives for contraception. Cochrane Database Syst Rev 2013(4):CD003552. doi:10.1002/14651858.CD003552.pub4.
    1. Moher D, Liberati A, Tetzlaff J, Altman DG, Group P. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 2009;6(7):e1000097.
    1. Hoy D, Brooks P, Woolf A, Blyth F, March L, Bain C, et al. Assessing risk of bias in prevalence studies: modification of an existing tool and evidence of interrater agreement. J Clin Epidemiol 2012;65(9):934–9. doi:10.1016/j.jclinepi.2011.11.014.
    1. Morrow KM, Ruiz MS. Assessing microbicide acceptability: a comprehensive and integrated approach. AIDS Behav 2008;12(2):272–83. doi:10.1007/s10461-007-9266-z.
    1. Nyaga VN, Arbyn M, Aerts M. Metaprop: a Stata command to perform meta-analysis of binomial data. Arch Public Health 2014;72(1):39. doi:10.1186/2049-3258-72-39.
    1. Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. Br Med J 2003;327(7414):557–60. doi:10.1136/bmj.327.7414.557.
    1. Harbord R, Higgins J. Meta-regression in Stata. Stata J 2008;8:493–519.
    1. Egger M, Davey Smith G, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test. Br Med J 1997;315(7109):629–34. doi:10.1136/bmj.315.7109.629.
    1. Baeten JM, Palanee-Phillips T, Mgodi NM, Mayo AJ, Szydlo DW, Ramjee G, et al. Safety, uptake, and use of a dapivirine vaginal ring for HIV-1 prevention in African women (HOPE): an open-label, extension study. Lancet HIV 2021;8(2):e87–95. doi:10.1016/S2352-3018(20)30304-0.
    1. Chen MJ, Creinin MD, Turok DK, Archer DF, Barnhart KT, Westhoff CL, et al. Dose-finding study of a 90-day contraceptive vaginal ring releasing estradiol and segesterone acetate. Contraception 2020;102(3):168–73. doi:10.1016/j.contraception.2020.05.004.
    1. Barreiros FA, Guazzelli CA, de Araujo FF, Barbosa R. Bleeding patterns of women using extended regimens of the contraceptive vaginal ring. Contraception 2007;75(3):204–8. doi:10.1016/j.contraception.2006.10.009.
    1. Bauermeister JA, Golinkoff JM, Carballo-Dieguez A, Giguere R, Lopez D, Hoesley CJ, et al. A Mixed-Methods Study Examining Adherence to and Acceptability of Intravaginal Rings for HIV Prevention: Behavioral Results of MTN-027. AIDS Behav 2020;24(2):607–16. doi:10.1007/s10461-019-02457-0.
    1. Bunge K, Levy L, Szydlo D, Zhang J, Gaur A, Reirden D, et al. Safety and acceptability trial of the dapivirine vaginal ring in US adolescents. J Int Aids Soc 2017;20:115–16.
    1. Caruso S, Cianci S, Malandrino C, Cicero C, Lo Presti L, Cianci A. Quality of sexual life of women using the contraceptive vaginal ring in extended cycles: preliminary report. Eur J Contracept Reprod Health Care 2014;19(4):307–14. doi:10.3109/13625187.2014.914488.
    1. Casper F, Petri E. Local treatment of urogenital atrophy with an estradiol-releasing vaginal ring: a comparative and a placebo-controlled multicenter study. Vaginal Ring Study Group. Int Urogynecol J Pelvic Floor Dysfunct 1999;10(3):171–6. doi:10.1007/s001920050040.
    1. Chen JH, Wu SC, Shao WQ, Zou MH, Hu J, Cong L, et al. The comparative trial of TCu 380A IUD and progesterone-releasing vaginal ring used by lactating women. Contraception 1998;57(6):371–9. doi:10.1016/s0010-7824(98)00043-2.
    1. Faught BM, Soulban G, Yeaw J, Maroun C, Coyle K, Schaffer S, et al. Ospemifene versus local estrogen: adherence and costs in postmenopausal dyspareunia. J Comp Eff Res 2019;8(13):1111–23. doi:10.2217/cer-2019-0091.
    1. Fruzzetti F, Perini D, Fornaciari L, Russo M, Bucci F, Gadducci A. Discontinuation of modern hormonal contraceptives: an Italian survey. Eur J Contracept Reprod Health Care 2016;21(6):449–54. doi:10.1080/13625187.2016.1234598.
    1. Gupta P, Ozel B, Stanczyk FZ, Felix JC, Mishell DR Jr. The effect of transdermal and vaginal estrogen therapy on markers of postmenopausal estrogen status. Menopause 2008;15(1):94–7. doi:10.1097/gme.0b013e318148b98b.
    1. Lete I, Perez-Campos E, Correa M, Robledo J, de la Viuda E, Martinez T, et al. Continuation rate of combined hormonal contraception: a prospective multicenter study. J Women’s Health 2012;21(5):490–5. doi:10.1089/jwh.2011.2967.
    1. Milsom I, Lete I, Bjertnaes A, Rokstad K, Lindh I, Gruber CJ, et al. Effects on cycle control and bodyweight of the combined contraceptive ring, NuvaRing, versus an oral contraceptive containing 30 microg ethinyl estradiol and 3 mg drospirenone. Hum Reprod 2006;21(9):2304–11. doi:10.1093/humrep/del162.
    1. Oddsson K, Leifels-Fischer B, Wiel-Masson D, de Melo NR, Benedetto C, Verhoeven CH, et al. Superior cycle control with a contraceptive vaginal ring compared with an oral contraceptive containing 30 microg ethinylestradiol and 150 microg levonorgestrel: a randomized trial. Hum Reprod 2005;20(2):557–62. doi:10.1093/humrep/deh604.
    1. Raine TR, Foster-Rosales A, Upadhyay UD, Boyer CB, Brown BA, Sokoloff A, et al. One-year contraceptive continuation and pregnancy in adolescent girls and women initiating hormonal contraceptives. Obstet Gynecol 2011;117(2):363–71 Pt 1. doi:10.1097/AOG.0b013e31820563d3.
    1. Sabatini R, Cagiano R. Comparison profiles of cycle control, side effects and sexual satisfaction of three hormonal contraceptives. Contraception 2006;74(3):220–3. doi:10.1016/j.contraception.2006.03.022.
    1. Shaaban MM. Contraception with progestogens and progesterone during lactation. J Steroid Biochem Mol Biol 1991;40(4–6):705–10. doi:10.1016/0960-0760(91)90294-f.
    1. Sivin I, Mishell DR Jr, Victor A, Diaz S, Alvarez-Sanchez F, Nielsen NC, et al. A multicenter study of levonorgestrel-estradiol contraceptive vaginal rings. I-Use effectiveness. An international comparative trial. Contraception 1981;24(4):341–58. doi:10.1016/0010-7824(81)90003-2.
    1. van der Straten A, Agot K, Ahmed K, Weinrib R, Browne EN, Manenzhe K, et al. The Tablets, Ring, Injections as Options (TRIO) study: what young African women chose and used for future HIV and pregnancy prevention. J Int AIDS Soc 2018;21(3):e25094. doi:10.1002/jia2.25094.
    1. Westhoff C, Osborne LM, Schafer JE, Morroni C. Bleeding patterns after immediate initiation of an oral compared with a vaginal hormonal contraceptive. Obstet Gynecol 2005;106(1):89–96. doi:10.1097/01.AOG.0000164483.13326.59.
    1. Diedrich JT, Zhao Q, Madden T, Secura GM, Peipert JF. Three-year continuation of reversible contraception. Am J Obstet Gynecol 2015;213(5):662 e1–8. doi:10.1016/j.ajog.2015.08.001.
    1. Cepuliene R, Sveikatiene R, Gutauskas K, Vanagiene V. Factors influencing women’s preference to select a combined hormonal contraceptive method: a cross-sectional survey in Lithuania. Medicina (B Aires) 2012;48(8):424–30.
    1. Palmeira-de-Oliveira R, Duarte P, Palmeira-de-Oliveira A, das Neves J, Amaral MH, Breitenfeld L, et al. Women’s experiences, preferences and perceptions regarding vaginal products: Results from a cross-sectional web-based survey in Portugal. Eur J Contracept Reprod Health Care 2015;20(4):259–71. doi:10.3109/13625187.2014.980501.
    1. Ahrendt HJ, Nisand I, Bastianelli C, Gomez MA, Gemzell-Danielsson K, Urdl W, et al. Efficacy, acceptability and tolerability of the combined contraceptive ring, NuvaRing, compared with an oral contraceptive containing 30 microg of ethinyl estradiol and 3 mg of drospirenone. Contraception 2006;74(6):451–7. doi:10.1016/j.contraception.2006.07.004.
    1. Al-Azzawi F, Lees B, Thompson J, Stevenson JC. Bone mineral density in postmenopausal women treated with a vaginal ring delivering systemic doses of estradiol acetate. Menopause 2005;12(3):331–9. doi:10.1097/01.gme.0000163870.03388.4d.
    1. Antoniou G, Kalogirou D, Karakitsos P, Antoniou D, Kalogirou O, Giannikos L. Transdermal estrogen with a levonorgestrel-releasing intrauterine device for climacteric complaints versus estradiol-releasing vaginal ring with a vaginal progesterone suppository: clinical and endometrial responses. Maturitas 1997;26(2):103–11. doi:10.1016/s0378-5122(96)01087-0.
    1. Barentsen R, van de Weijer PH, Schram JH. Continuous low dose estradiol released from a vaginal ring versus estriol vaginal cream for urogenital atrophy. Eur J Obstet Gynecol Reprod Biol 1997;71(1):73–80. doi:10.1016/s0301-2115(96)02612-7.
    1. Brucker C, Karck U, Merkle E. Cycle control, tolerability, efficacy and acceptability of the vaginal contraceptive ring, NuvaRing: results of clinical experience in Germany. Eur J Contracept Reprod Health Care 2008;13(1):31–8. doi:10.1080/13625180701577122.
    1. Buckler H, Al-Azzawi F, Group UVMT. The effect of a novel vaginal ring delivering oestradiol acetate on climacteric symptoms in postmenopausal women. Br J Obstet Gynaecol 2003;110(8):753–9.
    1. Buhling KJ, Klovekorn L, Daniels B, Studnitz FS, Eulenburg C, Mueck AO. Contraceptive counselling and self-prescription of contraceptives of German gynaecologists: results of a nationwide survey. Eur J Contracept Reprod Health Care 2014;19(6):448–56. doi:10.3109/13625187.2014.945164.
    1. Henriksson L, Stjernquist M, Boquist L, Alander U, Selinus I. A comparative multicenter study of the effects of continuous low-dose estradiol released from a new vaginal ring versus estriol vaginal pessaries in postmenopausal women with symptoms and signs of urogenital atrophy. Am J Obstet Gynecol 1994;171(3):624–32. doi:10.1016/0002-9378(94)90074-4.
    1. Henriksson L, Stjernquist M, Boquist L, Cedergren I, Selinus I. A one-year multicenter study of efficacy and safety of a continuous, low-dose, estradiol-releasing vaginal ring (Estring) in postmenopausal women with symptoms and signs of urogenital aging. Am J Obstet Gynecol 1996;174(1):85–92 1 Pt. doi:10.1016/s0002-9378(96)70378-2.
    1. Lose G, Englev E. Oestradiol-releasing vaginal ring versus oestriol vaginal pessaries in the treatment of bothersome lower urinary tract symptoms. Br J Obstet Gynaecol 2000;107(8):1029–34. doi:10.1111/j.1471-0528.2000.tb10408.x.
    1. Merki-Feld GS, Hund M. Clinical experience with NuvaRing in daily practice in Switzerland: cycle control and acceptability among women of all reproductive ages. Eur J Contracept Reprod Health Care 2007;12(3):240–7. doi:10.1080/13625180701440180.
    1. Merki-Feld GS, Hund M. Clinical experience with the combined contraceptive vaginal ring in Switzerland, including a subgroup analysis of previous hormonal contraceptive use. Eur J Contracept Reprod Health Care 2010;15(6):413–22. doi:10.3109/13625187.2010.524717.
    1. 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;28(10):1479–87. doi:10.1097/QAD.0000000000000280.
    1. Roumen F The clinical acceptability of a non-medicated vaginal ring. Contraception 1990;42(2):201–7. doi:10.1016/0010-7824(90)90103-3.
    1. Roumen FJ, op ten Berg MM, Hoomans EH. The combined contraceptive vaginal ring (NuvaRing): first experience in daily clinical practice in The Netherlands. Eur J Contracept Reprod Health Care 2006;11(1):14–22. doi:10.1080/13625180500389547.
    1. Roumen FJ, Dieben TO. Clinical acceptability of an ethylene-vinyl-acetate nonmedicated vaginal ring. Contraception 1999;59(1):59–62. doi:10.1016/s0010-7824(98)00145-0.
    1. Sahota J, Barnes PM, Mansfield E, Bradley JL, Kirkman RJ. Initial UK experience of the levonorgestrel-releasing contraceptive intravaginal ring. Adv Contracept 1999;15(4):313–24. doi:10.1023/a:1006748626008.
    1. Say R, Mansour D. Contraceptive choice for young people. J Fam Plann Reprod Health Care 2009;35(2):81–5. doi:10.1783/147118909787931780.
    1. Smith P, Heimer G, Lindskog M, Ulmsten U. Oestradiol-releasing vaginal ring for treatment of postmenopausal urogenital atrophy. Maturitas 1993;16(2):145–54. doi:10.1016/0378-5122(93)90059-q.
    1. Spencer CP, Cooper AJ, Ross D, Ptaszynska T, Graham J, Whitehead MI. Patient acceptability of and tolerance to a placebo intravaginal ring in hysterectomized women: a pilot study. Climacteric 1999;2(2):110–14. doi:10.3109/13697139909025574.
    1. Vercellini P, Barbara G, Somigliana E, Bianchi S, Abbiati A, Fedele L. Comparison of contraceptive ring and patch for the treatment of symptomatic endometriosis. Fertil Sterilil 2010;93(7):2150–61. doi:10.1016/j.fertnstert.2009.01.071.
    1. Algorta J, Diaz M, de Benito R, Lefebvre M, Sicard E, Furtado M, et al. Pharmacokinetic bioequivalence, safety and acceptability of Ornibel((R)), a new polymer composition contraceptive vaginal ring (etonogestrel/ethinylestradiol 11.00/3.474 mg) compared with Nuvaring((R)) (etonogestrel/ethinylestradiol 11.7/2.7 mg). Eur J Contracept Reprod Health Care 2017;22(6):429–38. doi:10.1080/13625187.2017.1413179.
    1. Ayton RA, Darling GM, Murkies AL, Farrell EA, Weisberg E, Selinus I, et al. A comparative study of safety and efficacy of continuous low dose oestradiol released from a vaginal ring compared with conjugated equine oestrogen vaginal cream in the treatment of postmenopausal urogenital atrophy. Br J Obstet Gynaecol 1996;103(4):351–8. doi:10.1111/j.1471-0528.1996.tb09741.x.
    1. Bachmann G, Notelovitz M, Nachtigall L, Birgerson L. A comparative study of a low-dose estradiol vaginal ring and conjugated estrogen cream for postmenopausal urogenital atrophy. Primary Care Update for OB/GYNS 1997;4(3):109–15. doi:10.1016/s1068-607x(97)00001-2.
    1. Bunge KE, Levy L, Szydlo DW, Zhang J, Gaur AH, Reirden D, et al. Brief Report: Phase IIa Safety Study of a Vaginal Ring Containing Dapivirine in Adolescent Young Women. J Acquir Immune Defic Syndr 2020;83(2):135–9. doi:10.1097/QAI.0000000000002244.
    1. Carey AS, Tremont K, Chiappetta L, Murray PJ, Gold MA. 33: Female adolescent’s knowledge, attitudes, and perceived barriers to the vaginal contraceptive ring: Early results. J Adolesc Health 2006;38(2):129.
    1. Carey AS, Chiappetta L, Tremont K, Murray PJ, Gold MA. The contraceptive vaginal ring: female adolescents’ knowledge, attitudes and plans for use. Contraception 2007;76(6):444–50. doi:10.1016/j.contraception.2007.07.013.
    1. Chen BA, Zhang J, Gundacker HM, Hendrix CW, Hoesley CJ, Salata RA, et al. Phase 2a Safety, Pharmacokinetics, and Acceptability of Dapivirine Vaginal Rings in US Postmenopausal Women. Clin Infect Dis 2019;68(7):1144–51. doi:10.1093/cid/ciy654.
    1. Creinin MD, Meyn L, Paris Study G. An open-label, randomized, multi-center trial to evaluate continuation rates, side effects and acceptability of the contraceptive ring vs. the contraceptive patch in women previously using combined oral contraceptives. Contraception 2007;76(2):157–8.
    1. Dempsey A, Roca C, Westhoff C. Vaginal estrogen supplementation during Depo-Provera initiation: a randomized controlled trial. Contraception 2010;82(3):250–5. doi:10.1016/j.contraception.2010.04.003.
    1. Faundes A, Hardy E, Reyes C, Pastene L, Portes-Carrasco R. Acceptability of the contraceptive vaginal ring by rural and urban population in two Latin American countries. Contraception 1981;24(4):393–414. doi:10.1016/0010-7824(81)90006-8.
    1. Fine PM, Tryggestad J, Meyers NJ, Sangi-Haghpeykar H. Safety and acceptability with the use of a contraceptive vaginal ring after surgical or medical abortion. Contraception 2007;75(5):367–71. doi:10.1016/j.contraception.2007.01.009.
    1. Gilliam M, Holmquist S, Berlin A. Factors associated with willingness to use the contraceptive vaginal ring. Contraception 2007;76(1):30–4. doi:10.1016/j.contraception.2007.03.009.
    1. 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: a randomized controlled trial. Obstet Gynecol 2010;115(3):503–10. doi:10.1097/AOG.0b013e3181cf45dc.
    1. Ginsburg ES, Jellerette-Nolan T, Daftary G, Du Y, Silverberg KM. Patient experience in a randomized trial of a weekly progesterone vaginal ring versus a daily progesterone gel for luteal support after in vitro fertilization. Fertil Steril 2018;110(6):1101–8 e3. doi:10.1016/j.fertnstert.2018.07.014.
    1. Haney AF, Ballagh S, Wysocki S. Evaluation of acceptance and satisfaction with the use of a vaginal ring delivery system in postmenopausal women. Menopause 2003;10(6):580.
    1. Hardy E, Hebling EM, Sousa MH, Almeida AF, Amaral E. Delivery of microbicides to the vagina: difficulties reported with the use of three devices, adherence to use and preferences. Contraception 2007;76(2):126–31. doi:10.1016/j.contraception.2007.04.013.
    1. Hynes JS, Sheth AN, Lathrop E, Sales JM, Haddad LB. Preferred Product Attributes of Potential Multipurpose Prevention Technologies for Unintended Pregnancy and Sexually Transmitted Infections or HIV Among U.S. Women. J Women’s Health 2019;28(5):665–72. doi:10.1089/jwh.2018.7001.
    1. Keller MJ, Wood L, Billingsley JM, Ray LL, Goymer J, Sinclair S, et al. Tenofovir disoproxil fumarate intravaginal ring for HIV pre-exposure prophylaxis in sexually active women: a phase 1, single-blind, randomised, controlled trial. Lancet HIV 2019;6(8):e498–508. doi:10.1016/S2352-3018(19)30145-6.
    1. Leonard-Segal A, Weiss H, Richardson ER, Stetka A, Martell BA, Oleka N, et al.. In: 28th Annual Meeting of The North American Menopause Society October 11–14, 2017, 24. Philadelphia, PA.: Menopause; 2017. p. 1418–61. doi:10.1097/gme.0000000000000997.
    1. Liu KE, Alhajri M, Greenblatt E. A randomized controlled trial of NuvaRing versus combined oral contraceptive pills for pretreatment in in vitro fertilization cycles. Fertil Steril 2011;96(3):605–8. doi:10.1016/j.fertnstert.2011.06.073.
    1. Maheux-Lacroix S, Leboeuf M, Dufresne A, Dodin S. Adolescents’ willingness to use the contraceptive vaginal ring. J Obstet Gynaecol Can 2011;33(4):353–60. doi:10.1016/S1701-2163(16)34853-8.
    1. Nachtigall LE. Clinical trial of the estradiol vaginal ring in the U.S. Maturitas 1995;22:S43–7 Suppl. doi:10.1016/0378-5122(95)00963-9.
    1. Nash HA, Brache V, Alvarez-Sanchez F, Jackanicz TM, Harmon TM. Estradiol delivery by vaginal rings: potential for hormone replacement therapy. Maturitas 1997;26(1):27–33. doi:10.1016/s0378-5122(96)01072-9.
    1. Nelken RS, Ozel BZ, Leegant AR, Felix JC, Mishell DR Jr. Randomized trial of estradiol vaginal ring versus oral oxybutynin for the treatment of overactive bladder. Menopause 2011;18(9):962–6. doi:10.1097/gme.0b013e3182104977.
    1. Ortiz-Gonzalez KM, Benabe E, Rivera-Rosa E, Negron I, Romaguera J. Knowledge and choices of postpartum contraception among pregnant teens. P R Health Sci J 2014;33(3):117–21.
    1. Peitzmeier SM, Tomko C, Wingo E, Sawyer A, Sherman SG, Glass N, et al. Acceptability of microbicidal vaginal rings and oral pre-exposure prophylaxis for HIV prevention among female sex workers in a high-prevalence US city. AIDS Care 2017;29(11):1453–7. doi:10.1080/09540121.2017.1300628.
    1. Schafer JE, Osborne LM, Davis AR, Westhoff C. Acceptability and satisfaction using Quick Start with the contraceptive vaginal ring versus an oral contraceptive. Contraception 2006;73(5):488–92. doi:10.1016/j.contraception.2005.11.003.
    1. Stewart FH, Brown BA, Raine TR, Weitz TA, Harper CC. Adolescent and young women’s experience with the vaginal ring and oral contraceptive pills. J Pediatr Adolesc Gynecol 2007;20(6):345–51. doi:10.1016/j.jpag.2007.06.001.
    1. Terrell LR, Tanner AE, Hensel DJ, Blythe MJ, Fortenberry JD. Acceptability of the vaginal contraceptive ring among adolescent women. J Pediatr Adolesc Gynecol 2011;24(4):204–10. doi:10.1016/j.jpag.2011.02.003.
    1. van der Straten A, Laborde N, Cheng H, Hoesley C, Salata RA, Johnson S, et al. Adherence and acceptability of a dapivirine vaginal ring in postmenopausal us women. Topics Antiviral Med 2016;24(E-1):370.
    1. 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 2016;20(11):2644–53. doi:10.1007/s10461-016-1299-8.
    1. Veres S, Miller L, Burington B. A comparison between the vaginal ring and oral contraceptives. Obstet Gynecol 2004;104(3):555–63. doi:10.1097/01.AOG.0000136082.59644.13.
    1. Vincent KL, Moss JA, Marzinke MA, Hendrix CW, Anton PA, Pyles RB, et al. Safety and pharmacokinetics of single, dual, and triple antiretroviral drug formulations delivered by pod-intravaginal rings designed for HIV-1 prevention: A Phase I trial. PLoS Med 2018;15(9):e1002655. doi:10.1371/journal.pmed.1002655.
    1. Weisberg E, Ayton R, Darling G, Farrell E, Murkies A, O’Neill S, et al. Endometrial and vaginal effects of low-dose estradiol delivered by vaginal ring or vaginal tablet. Climacteric 2005;8(1):83–92. doi:10.1080/13697130500087016.
    1. Weisberg E, Fraser IS, Mishell DR Jr, Lacarra M, Darney P, Jackanicz TM. A comparative study of two contraceptive vaginal rings releasing norethindrone acetate and differing doses of ethinyl estradiol. Contraception 1999;59(5):305–10. doi:10.1016/s0010-7824(99)00036-0.
    1. de Jesus Antunes N, de Oliveira Filho RV, de Oliveira Ilha J, Moreno RA, Nahoum AF, Wedemeyer RS, et al. Single-dose pharmacokinetics and pharmacodynamics assessment of oestriol and trimegestone containing vaginal rings in healthy women with childbearing potential. Eur J Contracept Reprod Health Care 2021;26(3):184–94. doi:10.1080/13625187.2021.1884219.
    1. Liu A, Islas CD, Gundacker H, Hoesley C, Van der Straten A, Hendrix C, et al. Phase 1 PK, safety, and acceptability study of 3-month dapivirine vaginal rings. Topics Antiviral Med 2021;29(1):43.
    1. Liu AY, Dominguez Islas C, Gundacker H, Neradilek B, Hoesley C, van der Straten A, et al. Phase 1 pharmacokinetics and safety study of extended duration dapivirine vaginal rings in the United States. J Int AIDS Soc 2021;24(6):e25747. doi:10.1002/jia2.25747.
    1. Liu AY, Zhang J, Anderson PL, Wagner T, Pan Z, Peda M, et al. Phase 1 Pharmacokinetic Trial of 2 Intravaginal Rings Containing Different Dose Strengths of Vicriviroc (MK-4176) and MK-2048. Clin Infect Dis 2019;68(7):1129–35. doi:10.1093/cid/ciy652.
    1. 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):e01918–30.
    1. Dobkin A, McWalters J, Barnett R, Ray LL, Espinoza L, McGinn AP, et al. Acceptability of a Tenofovir Disoproxil Fumarate Intravaginal Ring for HIV Pre-Exposure Prophylaxis Among Sexually Active Women. Sex Transm Dis 2020;47(12):819–24. doi:10.1097/OLQ.0000000000001254.
    1. Tolley E, Hanif H, Zissette S, Ju S, Adams ML, Schwartz J, et al. 4th HIV Research for Prevention conference (HIVR4P //Virtual), 27 & 28 January 3 & 4 February 2021. J Int AIDS Soc 2021;24(1):e25659 SupplSUPPL 1. doi:10.1002/jia2.25659.
    1. Agarwal N, Gupta M, Kriplani A, Bhatla N, Singh N. Comparison of combined hormonal vaginal ring with ultralow-dose combined oral contraceptive pills in the management of heavy menstrual bleeding: A pilot study. J Obstet Gynaecol 2016;36(1):71–5. doi:10.3109/01443615.2015.1024210.
    1. Buckshee K, Kumar S, Saraya L. Contraceptive vaginal ring–a rising star on the contraceptive horizon. Adv Contracept 1990;6(3):177–83. doi:10.1007/BF01849492.
    1. Dahiya P, Dalal M, Yadav A, Dahiya K, Jain S, Silan V. Efficacy of combined hormonal vaginal ring in comparison to combined hormonal pills in heavy menstrual bleeding. Eur J Obstet Gynecol Reprod Biol 2016;203:147–51. doi:10.1016/j.ejogrb.2016.05.009.
    1. Das S, Sanyal A, Roy R, Mistri P, Vernekar M, Naskar TK. Combined Contraceptive Vaginal Ring-its Acceptability in Indian Women. Indian J Public Health Res Dev 2016;7(1):57–63. doi:10.5958/0976-5506.2016.00012.7.
    1. Fan GS, Ren M, Di W, Su P, Chang Q, Wu S, et al. Efficacy and safety of the contraceptive vaginal ring (NuvaRing) compared with a combined oral contraceptive in Chinese women: a 1-year randomised trial. Eur J Contracept Reprod Health Care 2016;21(4):303–9. doi:10.1080/13625187.2016.1186269.
    1. Gupta AN, Dhaliwal LK, Gulati K. Clinical performance with contraceptive vaginal rings containing levonorgestrel. Indian J Med Res 1986;84:321–5.
    1. Hamada AL, Maruo T, Samoto T, Yoshida S, Nash H, Spitz IM, et al. Estradiol/progesterone-releasing vaginal rings for hormone replacement therapy in postmenopausal women. Gynecol Endocrinol 2003;17(3):247–54.
    1. Jain S, Vaid NB, Narang Y, Suneja A, Guleria K. A Randomised Controlled Trial Comparing the Efficacy and Side-Effects of Intravaginal Ring (Nuvaring((R))) With Combined Oral Hormonal Preparation in Dysfunctional Uterine Bleeding. J Clin Diagn Res 2016;10(3):QC21–4. doi:10.7860/JCDR/2016/16545.7516.
    1. Madhavan Nair K, Sivakumar B, Prema K, Narasinga Rao BS. Bioavailability of levonorgestrel from intravaginal rings in women of low income groups. Contraception 1986;33(3):307–22. doi:10.1016/0010-7824(86)90022-3.
    1. Mehta S, Joshi UM, Sankolli GM, Adatia A, Donde UM, Saxena BN. Clinical performance and endocrine profiles with contraceptive vaginal rings containing a combination of estradiol and D-norgestrel. Contraception 1981;23(3):241–50. doi:10.1016/0010-7824(81)90046-9.
    1. Pandit SN, Chauhan AR, Anagani M, Reddy S, Birla A, Ray SK. Multicenter study of contraceptive vaginal ring (NuvaRing((R))) in normal daily practice in Indian women. J Obstet Gynecol India 2014;64(6):409–16. doi:10.1007/s13224-014-0559-7.
    1. Priya K, Rajaram S, Goel N. Comparison of combined hormonal vaginal ring and low dose combined oral hormonal pill for the treatment of idiopathic chronic pelvic pain: a randomised trial. Eur J Obstet Gynecol Reprod Biol 2016;207:141–6. doi:10.1016/j.ejogrb.2016.10.026.
    1. Sharma R, Kapur A, Fotedar S. Comparison of efficacy, compliance, acceptability and tolerability of hormonal contraceptive vaginal ring (NuvaRing) versus combined oral contraceptives (COCs) - a prospective randomized controlled study in a district level hospital in East Delhi. Int J Sci Res 2018;7(1).
    1. Santibenchakul S, Jaisamrarn U. Acceptability, tolerability, and satisfaction of a contraceptive vaginal ring (the NuvaRing) among Thai women. Asian Biomed 2016;10(3):235–41. doi:10.5372/1905-7415.1003.485.
    1. Soni A, Garg S, Bangar R. Efficacy, user acceptability, tolerability, and cycle control of a combined contraceptive vaginal ring: the Indian perspective. J Obstet Gynecol India 2013;63(5):337–41. doi:10.1007/s13224-013-0391-5.
    1. Vijayaletchumi T, Siraj HH, Azmi MT, Jamil MA. Acceptablity of contraceptive vaginal ring (NuvaRing®) amongst nurses in a Malaysian Teaching Hospital. Br J Obstet Gynaecol 2012;119:136–57. doi:10.1111/j.1471-0528.2012.03378.x.
    1. Abu Hashim H, Alsherbini W, Bazeed M. Contraceptive vaginal ring treatment of heavy menstrual bleeding: a randomized controlled trial with norethisterone. Contraception 2012;85(3):246–52. doi:10.1016/j.contraception.2011.07.012.
    1. Ipsos Healthcare Assessing the potential of MPTs in South Africa, Uganda and Nigeria, Seattle, WA: Bill and Melinda Gates Foundation; 2014. Available from , [Accessed 1 August 2021]..
    1. Kestelyn E, Agaba S, Van Nuil JI, Uwineza M, Umulisa MM, Mwambarangwe L, et al. A randomised trial of a contraceptive vaginal ring in women at risk of HIV infection in Rwanda: Safety of intermittent and continuous use. PLoS One 2018;13(6):e0197572. doi:10.1371/journal.pone.0197572.
    1. McLellan-Lemal E, Gvetadze R, Desai MA, Makanga EM, Pan Y, Haaland RE, et al. Non-adherence among women enrolled in a contraceptive vaginal ring use study in Kisumu, Kenya, 2014–2015. J Global Health Rep 2018;2. doi:10.29392/joghr.2.e2018032.
    1. Mohamed AM, El-Sherbiny WS, Mostafa WA. Combined contraceptive ring versus combined oral contraceptive (30-mug ethinylestradiol and 3-mg drospirenone). Int J Gynecol Obstet 2011;114(2):145–8. doi:10.1016/j.ijgo.2011.03.008.
    1. Montgomery ET, Beksinska M, Mgodi N, Schwartz J, Weinrib R, Browne EN, et al. End-user preference for and choice of four vaginally delivered HIV prevention methods among young women in South Africa and Zimbabwe: the Quatro Clinical Crossover Study. J Int AIDS Soc 2019;22(5):e25283.
    1. Nel A, Bekker LG, Bukusi E, Hellstrm 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 2016;11(3):e0147743. doi:10.1371/journal.pone.0147743.
    1. RamaRao S, Obare F, Ishaku S, Mane B, Clark H, Liambila W, et al. Do women find the progesterone vaginal ring acceptable? Findings from Kenya, Nigeria, and Senegal. Stud Fam Plann 2018;49(1):71–86. doi:10.1111/sifp.12046.
    1. 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. doi:10.1007/s10461-012-0215-0.
    1. Gill K, Happel AU, Pidwell T, Mendelsohn A, Duyver M, Johnson L, et al. An open-label, randomized crossover study to evaluate the acceptability and preference for contraceptive options in female adolescents, 15 to 19 years of age in Cape Town, as a proxy for HIV prevention methods (UChoose). J Int AIDS Soc 2020;23(10):e25626. doi:10.1002/jia2.25626.
    1. Nel A, van Niekerk N, Kapiga S, Bekker LG, Gama C, Gill K, et al. Safety and Efficacy of a Dapivirine Vaginal Ring for HIV Prevention in Women. N Engl J Med 2016;375(22):2133–43. doi:10.1056/NEJMoa1602046.
    1. Nel A, van Niekerk N, Van Baelen B, Malherbe M, Mans W, Carter A, et al. Safety, adherence, and HIV-1 seroconversion among women using the dapivirine vaginal ring (DREAM): an open-label, extension study. Lancet HIV 2021;8(2):e77–86. doi:10.1016/S2352-3018(20)30300-3.
    1. Tubert J, Packel L, Hunter LA, Mfaume R, Njau P, Ramadhani AA, et al. HIV prevention at drug shops: awareness and attitudes among shop dispensers and young women about oral pre-exposure prophylaxis and the dapivirine ring in Shinyanga, Tanzania. AIDS Res Ther 2021;18(1):21. doi:10.1186/s12981-021-00343-1.
    1. 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(8):2430–40. doi:10.1007/s10461-021-03205-z.
    1. Dieben TO, Roumen FJ, Apter D. Efficacy, cycle control, and user acceptability of a novel combined contraceptive vaginal ring. Obstet Gynecol 2002;100(3):585–93. doi:10.1016/s0029-7844(02)02124-5.
    1. Koetsawang S, Ji G, Krishna U, Cuadros A, Dhall GI, Wyss R, et al. Microdose intravaginal levonorgestrel contraception: a multicentre clinical trial. I. Contraceptive efficacy and side effects. World Health Organization. Task Force on Long-Acting Systemic Agents for Fertility Regulation. Contraception 1990;41(2):105–24. doi:10.1016/0010-7824(90)90141-h.
    1. Miller L, Verhoeven CH, Hout J. Extended regimens of the contraceptive vaginal ring: a randomized trial. Obstet Gynecol 2005;106(3):473–82. doi:10.1097/01.AOG.0000175144.08035.74.
    1. Nash HA, Alvarez-Sanchez F, Mishell DR Jr, Fraser IS, Maruo T, Harmon TM. Estradiol-delivering vaginal rings for hormone replacement therapy. Am J Obstet Gynecol 1999;181(6):1400–6. doi:10.1016/s0002-9378(99)70383-2.
    1. Plagianos M, Kallianes V, Savel C, Pickett J, Guthrie K, Martinez C, et al. End-User opinions about the future of HIV prevention: results from a global Internet survey about multipurpose prevention technologies (MPTs). In: Society IA, editor. HIV Research for Prevention conference; 21–25 October, 2018; Madrid. Spain: International AIDS Society; 2018. p. 1–407.
    1. Sivin I, Diaz S, Croxatto HB, Miranda P, Shaaban M, Sayed EH, et al. Contraceptives for lactating women: a comparative trial of a progesterone-releasing vaginal ring and the copper T 380A IUD. Contraception 1997;55(4):225–32. doi:10.1016/s0010-7824(97)00008-5.
    1. Sivin I, Mishell DR Jr, Alvarez F, Brache V, Elomaa K, Lahteenmaki P, et al. Contraceptive vaginal rings releasing Nestorone and ethinylestradiol: a 1-year dose-finding trial. Contraception 2005;71(2):122–9. doi:10.1016/j.contraception.2004.08.010.
    1. Stifani BM, Plagianos M, Vieira CS, Merkatz RB. Factors associated with nonadherence to instructions for using the Nestorone(R)/ethinyl estradiol contraceptive vaginal ring. Contraception 2018;97(5):415–21. doi:10.1016/j.contraception.2017.12.011.
    1. Thurman AR, Schwartz JL, Brache V, Clark MR, McCormick T, Chandra N, et al. Randomized, placebo controlled phase I trial of safety, pharmacokinetics, pharmacodynamics and acceptability of tenofovir and tenofovir plus levonorgestrel vaginal rings in women. PLoS One 2018;13(6):e0199778. doi:10.1371/journal.pone.0199778.
    1. Weisberg E, Fraser IS, Lacarra M, Mishell DR Jr, Alvarez F, Brache V, et al. Efficacy, bleeding patterns, and side effects of a 1-year contraceptive vaginal ring. Contraception 1999;59(5):311–18. doi:10.1016/s0010-7824(99)00035-9.
    1. Weisberg E, Brache V, Alvarez F, Massai R, Mishell DR Jr, Apter D, et al. Clinical performance and menstrual bleeding patterns with three dosage combinations of a Nestorone progestogen/ethinyl estradiol contraceptive vaginal ring used on a bleeding-signaled regimen. Contraception 2005;72(1):46–52. doi:10.1016/j.contraception.2004.12.014.
    1. Minnis AM, Roberts ST, Agot K, Weinrib R, Ahmed K, Manenzhe K, et al. Young Women’s Ratings of Three Placebo Multipurpose Prevention Technologies for HIV and Pregnancy Prevention in a Randomized, Cross-Over Study in Kenya and South Africa. AIDS Behav 2018;22(8):2662–73. doi:10.1007/s10461-018-2078-5.
    1. Montgomery ET, Beksinska M, Mgodi N, Schwartz J, Weinrib R, Browne EN, et al. End-user preference for and choice of four vaginally delivered HIV prevention methods among young women in South Africa and Zimbabwe: the Quatro Clinical Crossover Study. J Int AIDS Soc 2019;22(5):e25283. doi:10.1002/jia2.25283.
    1. 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. doi:10.1097/QAD.0000000000001452.
    1. 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(7):305–14.
    1. 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(3):304–10.
    1. Epstein LB, Sokal-Gutierrez K, Ivey SL, Raine T, Auerswald C. Adolescent experiences with the vaginal ring. J Adolesc Health 2008;43(1):64–70. doi:10.1016/j.jadohealth.2007.12.007.
    1. McLellan-Lemal E, Ondeng’e K, Gust D, Desai M, Otieno F, Madiega P, et al. Contraceptive vaginal ring experiences among women and men in Kisumu, Kenya: a qualitative study. Frontiers in Women’s. Health (N Y) 2017;2(1).
    1. Raine TR, Epstein LB, Harper CC, Brown BA, Boyer CB. Attitudes toward the vaginal ring and transdermal patch among adolescents and young women. J Adolesc Health 2009;45(3):262–7. doi:10.1016/j.jadohealth.2009.02.007.
    1. 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(11):1517–25. doi:10.1097/QAD.0000000000001868.
    1. Nair G, Ngure K, Szydlo D, Brown E, Akello C, Philips TP-, et al. Adherence to the dapivirine vaginal ring and oral PrEP among adolescent girls and young women in Africa: interim results from the REACH study Virtual: International AIDS Society. Society IA, editor. IAS; 2021; 2021.
    1. Gjersing L, Caplehorn JR, Clausen T. Cross-cultural adaptation of research instruments: language, setting, time and statistical considerations. BMC Med Res Method 2010;10(1):13. doi:10.1186/1471-2288-10-13.
    1. Sekhon M, Cartwright M, Francis JJ. Acceptability of health care interventions: A theoretical framework and proposed research agenda. Br. J. Health Psychol. 2018;23:519–31. doi:10.1111/bjhp.12295.
    1. Squires A, Aiken LH, van den Heede K, Sermeus W, Bruyneel L, Lindqvist R, et al. A systematic survey instrument translation process for multi-country, comparative health workforce studies. Int J Nurs Stud 2013;50(2):264–73. doi:10.1016/j.ijnurstu.2012.02.015.
    1. Tepe M, Mestad R, Secura G, Allsworth JE, Madden T, Peipert JF. Association between tampon use and choosing the contraceptive vaginal ring. Obstet Gynecol 2010;115(4):735.
    1. Latka M Female-initiated barrier methods for the prevention of STI/HIV: where are we now? Where should we go? J Urban Health 2001;78(4):571–80.
    1. Minnis AM, Gandham S, Richardson BA, Guddera V, Chen BA, Salata R, et al. Adherence and acceptability in MTN 001: a randomized cross-over trial of daily oral and topical tenofovir for HIV prevention in women. AIDS Behav 2013;17(2):737–47. doi:10.1007/s10461-012-0333-8.
    1. Alexander NJ, Baker E, Kaptein M, Karck U, Miller L, Zampaglione E. Why consider vaginal drug administration? Ferti Steril 2004;82(1):1–12. doi:10.1016/j.fertnstert.2004.01.025.
    1. Barbosa CD, Balp MM, Kulich K, Germain N, Rofail D. A literature review to explore the link between treatment satisfaction and adherence, compliance, and persistence. Patient Prefer Adherence 2012;6:39–48. doi:10.2147/PPA.S24752.
    1. Kestelyn E, Van Nuil JI, Umulisa MM, Umutoni G, Uwingabire A, Mwambarangwe L, et al. High acceptability of a contraceptive vaginal ring among women in Kigali, Rwanda. PLoS One 2018;13(6):e0199096. doi:10.1371/journal.pone.0199096.
    1. RamaRao S, Clark H, Rajamani D, Ishaku S, Mane B, Obare F, et al. Progesterone vaginal ring: Results of a three-country acceptability study. New York: Population Council; 2015.
    1. Ishaku Salisu Mohammed, Kayode Afolabi, Unumeri Godwin, Oginni Ayodeji, Adeyemi Adekunle, Rajamani Deepa, Clark Heather, Rijo Naomi, and RamaRao Saumya. 2015. Progesterone vaginal ring: Results of an acceptability study in Nigeria. New York: Population Council.
    1. Creinin MD, Meyn LA, Borgatta L, Barnhart K, Jensen J, Burke AE, et al. Multicenter comparison of the contraceptive ring and patch: a randomized controlled trial. Obstet Gynecol 2008;111(2):267–77 Pt 1. doi:10.1097/01.AOG.0000298338.58511.d1.
    1. Hardy EE, Reyes Q, Gomez F, Portes-Carrasco R, Faundes A. User’s perception of the contraceptive vaginal ring: a field study in Brazil and the Dominican Republic. Stud Fam Plann 1983;14(11):284–90.
    1. Weisberg E, Fraser IS, Mishell DR Jr, Lacarra M, Bardin CW. The acceptability of a combined oestrogen/progestogen contraceptive vaginal ring. Contraception 1995;51(1):39–44.
    1. Weisberg E, Fraser IS, Lacarra M, Mishell DR Jr, Jackanicz T. Effect of different insertion regimens on side effects with a combination contraceptive vaginal ring. Contraception 1997;56(4):233–9.
    1. Siraj HH, Thandayathany V, Tamil A. Nurses and contraceptive vaginal ring: To use or not to use? Int J Gynecol Obstet 2015;131:E385.
    1. Roumen F Contraceptive efficacy and tolerability with a novel combined contraceptive vaginal ring, NuvaRing. Eur J Contracept Reprod Health Care 2002;7(2):19–24 SUPPL..
    1. Elder MG, Lawson JP, Elstein M, Nuttall ID. The efficacy and acceptability of a low-dose levonorgestrel intravaginal ring for contraception in a UK cohort. Contraception 1991;43(2):129–37.
    1. Archer DF, Merkatz RB, Bahamondes L, Westhoff CL, Darney P, Apter D, et al. Efficacy of the 1-year (13-cycle) segesterone acetate and ethinylestradiol contraceptive vaginal system: results of two multicentre, open-label, single-arm, phase 3 trials. Lancet Global Health 2019.
    1. Ipsos H Summary Booklet: Assessing the Potential of MPTs in South Africa, Uganda, and Nigeria. 2021
    1. Montgomery ET, Beksinska M, Mgodi N, Schwartz J, Weinrib R, Browne EN, et al. End-user preference for and choice of four vaginally delivered HIV prevention methods among young women in South Africa and Zimbabwe: the Quatro Clinical Crossover Study. J Int AIDS Soc 2019;22(5):e25283. doi:10.1002/jia2.25283.
    1. Nel A, Martins J, Bekker LG, Ramjee G, Masenga G, Rees H, et al. Safety of a silicone elastomer vaginal ring as potential microbicide delivery method in African women: A Phase 1 randomized trial. PLoS One 2018;13(5):e0196904. doi:10.1371/journal.pone.0196904.
    1. 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. doi:10.1007/s10461-012-0248-4.
    1. Chen BA, Zhang J, Gundacker HM, Hendrix CW, Hoesley CJ, Salata RA, et al. Phase 2a Safety, Pharmacokinetics, and Acceptability of Dapivirine Vaginal Rings in US Postmenopausal Women. Clin Infect Dis 2018. [Epub ahead of print]. doi:10.1093/cid/ciy654. doi:10.1093/cid/ciy654.
    1. Guthrie KM, Vargas SE, Rosen RK, Dawson LN, Getz ML, Guillen M, et al. Initial feasibility, acceptability and user experience of a multi-drug POD-IVR: A mixed methods study. AIDS Res Hum Retroviruses 2016;32:380. doi:10.1089/aid.2016.5000.abstracts.
    1. Guthrie KM, Rosen RK, Vargas SE, Getz ML, Dawson L, Guillen M, et al. User evaluations offer promise for pod-intravaginal ring as a drug delivery platform: A mixed methods study of acceptability and use experiences. PLoS One 2018;13(5):e0197269. doi:10.1371/journal.pone.0197269.
    1. Roy M, Hazra A, Merkatz R, Plagianos M, Alami M, Gaur L, et al. Progesterone vaginal ring as a new contraceptive option for lactating mothers: Evidence from a multicenter non-randomized comparative clinical trial in India. Contraception 2020;102(3):159–67.

Source: PubMed

Sponsor e collaboratori

Condizioni mediche

Interventi farmacologici

3
Sottoscrivi