Can This Ring Protect Women from HIV?
It’s not perfect, but if used regularly, it could reduce infection rates. The challenge is to convince African women it’s worth the risk.
Margaret Happy was 32 years old when she tested positive for HIV. Having already lost two sisters to AIDS, she was scared. “I had a lot of questions,” she said over Skype from Wakiso, Uganda. “Why me and why at this time?” Happy told her boss about her positive status, hoping to get her support — but things took a turn for the worse. “I was a program manager, but even a cleaner was more respected than me,” Happy recalled of her time at a non-profit in the field of women and child trafficking. She was unable to cope with the stigma at work and quit the job after three months.
Happy is one of millions of African women who face hardships because of their HIV status. In eastern and southern Africa alone, 19 million people were living with HIV in 2015 — and more than half were women. In many places around the region, domestic violence and cultural practices contribute towards such high prevalence of HIV in women. Men are often not expected to be loyal in relationships or use condoms. Moreover, it’s common for young women to date older men, which was found in 45 studies to be associated with unsafe sexual behavior. Women also have a difficult time accessing treatment, as there is stigma surrounding HIV and sexuality.
While many nonprofits are working to combat the stigma associated with having HIV, some researchers — like the creators of a product called the dapivirine ring — are going a step further and trying to reduce the risk of women contracting HIV at all.
Similar to the Nuvaring, this ring is also placed into the vagina, where it dispenses a microbicide, or a substance that can protect against sexually transmitted infections. In this case, the microbicide is an HIV drug called dapivirine, which combats the virus entering a woman’s body during sex. The ring slowly releases the drug over the course of a month, at which point the woman would remove and discard the ring, and replace it with a new one.
The ring is still being studied; the results of two separate Phase III clinical trials were published last year in December in two papers in The New England Journal of Medicine. In one study, the ring was 31% more effective than the placebo in preventing HIV infection. In the other, that rate was 27%. (Put together, around 4,500 women participated in the studies across many African countries.)
Jared Baeten, a professor of global health at the University of Washington who co-led one of the studies, considers the trials a victory. “Everyone would want these numbers to be higher,” he said. “But there has never been a microbicide that has shown HIV prevention in two trials.”
Anna Forbes, an independent consultant who formerly worked with a microbicides advocacy group, also believes the study was a good start. “If I were a woman who was going to bed with a man every night who might have HIV and someone said, ‘Here’s this thing you can use and it’s [somewhat] effective,’ I would use it,” she said. “I think providing partially effective tools to people is a wonderful thing to do if the alternative is zero.”
To get higher numbers, researchers may not need to build a better ring; they need to convince women to use it more consistently.
By looking at the traces of drug in the ring returned by a participant, the researchers could determine whether she had used it or not. When the women used it consistently for 30 days, their chances of contracting HIV were reduced by up to 75%.
So why did some participants not use the ring for the whole period?
While the participants were counseled throughout the studies to dispel any misconceptions about the product, concerns still persisted. “Even though that’s not the case, some women thought that they couldn’t use the ring during sex,” said Happy, who is now an advocate for vaginal rings in Uganda.
One in three women in Africa has reported having experienced either domestic or sexual violence. Fear of violence from their partners could have deterred some participants as well. “In the end, how the man feels about his own HIV status has a great deal to do with the woman’s ability to use this product,” said Forbes. If the man doesn’t know his status, then he might beat his wife up if he somehow finds out about the ring. He may wonder whether she suspects he has HIV.
“It’s an insult to him, and it’s an insult to his marriage,” said Forbes.
A woman’s partner can’t actually feel the ring during sex. If the women chose to, she could keep the ring a secret from her partner. “For many women, the ability to control the ring was very appealing,” said Baeten.
The researchers want to tailor the ring better to the needs of African women. That’s why they are conducting follow-up studies that will recruit participants from the two Phase III trials.
Baeten is again leading one of these new studies. He says the counseling message in the new studies will be different — and could make the women more adherent. “Earlier, we said we don’t know if this works to prevent HIV,” explained Baeten. “We said we think it’s safe, and there’s a 50–50% chance you may be getting a placebo.” This time around, the researchers can confidently tell the participants that the ring is safe and effective.
Even participants who choose not to use the ring will be allowed to be part of the trial and enjoy its other perks: free condoms and HIV testing. “It would be very helpful to know the characteristics of the women who may not want to use the ring,” said Zeda Rosenberg, head of the International Partnership of Microbicides (IPM), the non-profit that holds a license to the drug and developed the dapivirine ring.
In the meantime, the IPM is preparing to approach the European Medicines Agency and the South African government for regulatory approval. A nod from the European watchdog would set the stage for a WHO approval. That would make it easier for rest of the African countries to adopt it for their health programs.
While HIV has damaging effects on the lives of both men and women, in sub-Saharan Africa, it takes a heavier toll on the latter. The vaginal ring could change that. “I don’t want to see any women getting HIV,” said Happy. “If anyone is excited about the ring, it’s me.”
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