Skip to main content

Advertisement

SpringerLink
Log in

Hygiene, Blood Flow, and Vaginal Overload: Why Women Removed an HIV Prevention Vaginal Ring During Menstruation in Malawi, South Africa, Uganda and Zimbabwe

  • Original Paper
  • Published:
AIDS and Behavior Aims and scope Submit manuscript

Abstract

We assessed the interference between vaginal ring use and menses among women who participated in the qualitative component of the MTN-020/ASPIRE vaginal ring trial in Malawi, South Africa, Uganda and Zimbabwe (N = 214). A common reason for imperfect ring adherence and premature removal of the vaginal ring cited by participants related to vaginal bleeding or menses. Whereas self-reporting via survey questions suggested that the majority (60%) of women did not mind wearing the ring while menstruating, and did not remove it (91%) during menses, in the qualitative interviews women frequently described removing the ring during menses. Their reasons included hygiene, beliefs that the ring blocked the flow of menstrual blood, fears that the ring would come out with blood or during tampon removal, and concerns around an ‘overburdened’ vagina. Examining women’s narratives and subjective experiences related to menstruation helps build a better understanding of factors affecting ring use and adherence.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Jewkes RK, Wood K. Problematizing pollution: dirty wombs, ritual pollution, and pathological processes. Med Anthropol. 1999;18(2):163–86.

    Article  Google Scholar 

  2. Tamiru S, Mamo K, Acidria P, Mushi R, Ali CS, Ndebele L. Towards a sustainable solution for school menstrual hygiene management: cases of Ethiopia, Uganda, South-Sudan, Tanzania, and Zimbabwe. Waterlines. 2015;34(1):92–102.

    Article  Google Scholar 

  3. Hawkey AJ, Ussher JM, Perz J, Metusela C. Experiences and constructions of menarche and menstruation among migrant and refugee women. Qualitative Health Research. 2017;27(10):1473–90.

    Article  PubMed  Google Scholar 

  4. Johnston-Robledo I, Chrisler JC. The menstrual mark: menstruation as social stigma. Sex Roles. 2011;68(1–2):9–18.

    Google Scholar 

  5. Scheff TJ. Shame in self and society. Symb Inter. 2003;26(2):239–62.

    Article  Google Scholar 

  6. Farage MA, Miller KW, Davis A. Cultural aspects of menstruation and menstrual hygiene in adolescents. Expert Rev Obstet Gynecol. 2011;6(2):127.

    Article  Google Scholar 

  7. Laher F, Todd CS, Stibich MA, Phofa R, Behane X, Mohapi L, et al. Role of menstruation in contraceptive choice among HIV-infected women in Soweto, South Africa. Contraception. 2010;81(6):547–51.

    Article  PubMed  Google Scholar 

  8. Allen CF, Desmond N, Chiduo B, Medard L, Lees SS, Vallely A, et al. Intravaginal and menstrual practices among women working in food and recreational facilities in Mwanza, Tanzania: implications for microbicide trials. AIDS Behav. 2010;14(5):1169–81.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Scorgie F, Foster J, Stadler J, Phiri T, Hoppenjans L, Rees H, et al. “Bitten By Shyness”: menstrual hygiene management, sanitation, and the quest for privacy in South Africa. Med Anthropol. 2015;35(2):161–76.

    Article  PubMed  Google Scholar 

  10. Wood K, Jewkes R. Blood blockages and scolding nurses: barriers to adolescent contraceptive use in South Africa. Reproductive Health Matters. 2006;14(27):109–18.

    Article  PubMed  Google Scholar 

  11. 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.

    Article  PubMed  Google Scholar 

  12. Watnick D, Keller MJ, Stein K, Bauman LJ. Acceptability of a tenofovir disoproxil fumarate vaginal ring for HIV prevention among women in New York City. AIDS Behav. 2017;22(2):421–36.

    Article  Google Scholar 

  13. 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;22:1–12.

    Google Scholar 

  14. 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.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  15. Srivastava P, Hopwood N. A practical iterative framework for qualitative data analysis. Int J Qual Methods. 2009;8(1):76–84.

    Article  Google Scholar 

  16. Nel A, Bekker L-G, Bukusi E, Hellstrӧm 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):e0147743–19.

    Article  Google Scholar 

  17. 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.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Vallely A, Fitzgerald L, Fiya V, Aeno H, Kelly A, Sauk J, et al. Intravaginal practices and microbicide acceptability in Papua New Guinea: implications for HIV prevention in a moderate-prevalence setting. BMC Res Notes. 2012;5(1):1.

    Article  Google Scholar 

  19. Green EC. Purity, pollution and the invisible snake in Southern Africa. Med Anthropol. 1996;17(1):83–100.

    Article  CAS  PubMed  Google Scholar 

  20. Stadler J, Saethre E. Blockage and flow: intimate experiences of condoms and microbicides in a South African clinical trial. Culture Health Sex. 2011;13(1):31–44.

    Article  Google Scholar 

  21. Collumbien M, Busza J, Cleland J, Campbell O. Social science methods for research on sexual and reproductive health. Geneva. 2012;14:1–101.

    Google Scholar 

  22. Hollander JA. The social contexts of focus groups. J Contemp Ethnogr. 2004;33(5):602–37.

    Article  Google Scholar 

  23. Smithson J. Using and analysing focus groups: limitations and possibilities. Int J Res Methodol. 2000;3(2):103–19.

    Article  Google Scholar 

  24. Mensch BS, Hewett PC, Abbott S, Rankin J, Littlefield S, Ahmed K, et al. Assessing the reporting of adherence and sexual activity in a simulated microbicide trial in South Africa: an interview mode experiment using a placebo gel. AIDS Behav. 2011;15(2):407–21.

    Article  PubMed  Google Scholar 

  25. Mensch BS, Richardson BA, Husnik M, Brown ER, Kiweewa FM, Mayo AJ, et al. Vaginal ring use in a phase 3 microbicide trial: a comparison of objective measures and self-reports of non-adherence in ASPIRE for the MTN-020/ASPIRE study team. AIDS Behav. 2018;23:504–12.

    Article  Google Scholar 

  26. Turner AN, De Kock AE, Meehan-Ritter A, Blanchard K, Sebola MH, Hoosen AA, et al. Many vaginal microbicide trial participants acknowledged they had misreported sensitive sexual behavior in face-to-face interviews. J Clin Epidemiol. 2009;62(7):759–65.

    Article  PubMed  Google Scholar 

  27. 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):e25094–9.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Chen BA, Panther L, Marzinke MA, Hendrix CW, Hoesley CJ, van der Straten A, et al. Phase 1 Safety, Pharmacokinetics, and Pharmacodynamics of Dapivirine and Maraviroc Vaginal Rings. JAIDS J Acquir Immune Defic Syndr. 2015;70(3):242–9.

    Article  CAS  PubMed  Google Scholar 

  29. Gfos M, Pool R, Mzimela MA, Ndlovu HB, McCormack S, Elford J, et al. The Implications of Post-coital Intravaginal Cleansing for the Introduction of Vaginal Microbicides in South Africa. AIDS Behav. 2013;18(2):297–310.

    Article  Google Scholar 

  30. Morrow Guthrie K, Vargas S, Shaw JG, Rosen RK, van den Berg JJ, Kiser PF, et al. The promise of intravaginal rings for prevention: user perceptions of biomechanical properties and implications for prevention product development. PLoS ONE. 2015;10(12):e0145642–17.

    Article  Google Scholar 

Download references

Acknowledgements

The study was designed and implemented by the Microbicide Trials Network (MTN) and funded by the National Institute of Allergy and Infectious Diseases (UM1AI068633, UM1AI068615, UM1AI106707), with co-funding from the Eunice Kennedy Shriver National Institute of Child Health and Human Development and the National Institute of Mental Health, all components of the U.S. National Institutes of Health (NIH). The work presented here was funded by NIH grants UM1AI068633. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The International Partnership for Microbicides (IPM) supplied the vaginal rings used in this study. Study Team Leadership Jared Baeten, University of Washington (Protocol Chair); Thesla Palanee-Phillips, Wits Reproductive Health and HIV Institute (Protocol Co-chair); Elizabeth Brown, Fred Hutchinson Cancer Research Center (Protocol Statistician); Lydia Soto-Torres, US National Institute of Allergy and Infectious Diseases (Medical Officer); Katie Schwartz, FHI 360 (Clinical Research Manager). Study sites and site Investigators of Record Malawi, Blantyre site (Johns Hopkins University, Queen Elizabeth Hospital): Bonus Makanani. Malawi, Lilongwe site (University of North Carolina, Chapel Hill): Francis Martinson. South Africa, Cape Town site (University of Cape Town): Linda-Gail Bekker. South Africa, Durban – Botha’s Hill, Chatsworth, Isipingo, Tongaat, Umkomaas, Verulam sites (South African Medical Research Council): Vaneshree Govender, Samantha Siva, Zakir Gaffoor, Logashvari Naidoo, Arendevi Pather, and Nitesha Jeenarain. South Africa, Durban, eThekwini site (Center for the AIDS Programme for Research in South Africa): Gonasagrie Nair. South Africa, Johannesburg site (Wits Reproductive Health and HIV Institute): Thesla Palanee-Phillips. Uganda, Kampala site (John Hopkins University, Makerere University): Flavia Matovu. Zimbabwe, Chitungwiza, Seke South and Zengeza sites (University of Zimbabwe College of Health Sciences Clinical Trials Unit): Nyaradzo Mgodi. Zimbabwe, Harare, Spilhaus site (University of Zimbabwe College of Health Sciences Clinical Trials Unit):): Felix Mhlanga. Data management was provided by The Statistical Center for HIV/AIDS Research & Prevention (Fred Hutchinson Cancer Research Center, Seattle, WA) and site laboratory oversight was provided by the Microbicide Trials Network Laboratory Center (Pittsburgh, PA). For qualitative data, management was provided by the Women’s Global Health Imperative Program (RTI International, San Francisco, CA).

Funding

The study was designed and implemented by the Microbicide Trials Network (MTN) and funded by the National Institute of Allergy and Infectious Diseases (UM1AI068633, UM1AI068615, UM1AI106707), with co-funding from the Eunice Kennedy Shriver National Institute of Child Health and Human Development and the National Institute of Mental Health, all components of the U.S. National Institutes of Health (NIH). The work presented here was funded by NIH Grants UM1AI068633.

Author information

Authors and Affiliations

  1. Division of Social and Behavioural Sciences, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa

    Zoe Duby

  2. Women’s Global Health Imperative, RTI International, San Francisco, CA, USA

    Ariana W. K. Katz, Erica N. Browne & Ariane van der Straten

  3. UZCHS-CTU, Harare, Zimbabwe

    Prisca Mutero

  4. Makerere University – Johns Hopkins University, Research Collaboration, Kampala, Uganda

    Juliane Etima

  5. UNC Lilongwe, Lilongwe, Malawi

    Chifundo Colleta Zimba

  6. South African Medical Research Council, Kwazulu Natal, South Africa

    Kubashni Woeber

  7. Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa

    Millicent Atujuna

  8. Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa

    Krishnaveni Reddy

  9. Department of Medicine, Center for AIDS Prevention Studies, UCSF, San Francisco, CA, USA

    Ariane van der Straten

Authors
  1. Zoe Duby
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Ariana W. K. Katz
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Erica N. Browne
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Prisca Mutero
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Juliane Etima
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Chifundo Colleta Zimba
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Kubashni Woeber
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Millicent Atujuna
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Krishnaveni Reddy
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Ariane van der Straten
    View author publications

    You can also search for this author in PubMed Google Scholar

Consortia

the MTN-020/ASPIRE Study Team

  • Jared Baeten
  • , Thesla Palanee-Phillips
  • , Elizabeth Brown
  • , Lydia Soto-Torres
  • , Katie Schwartz
  • , Bonus Makanani
  • , Francis Martinson
  • , Linda-Gail Bekker
  • , Vaneshree Govender
  • , Samantha Siva
  • , Zakir Gaffoor
  • , Logashvari Naidoo
  • , Arendevi Pather
  • , Nitesha Jeenarain
  • , Gonasagrie Nair
  • , Thesla Palanee-Phillips
  • , Flavia Matovu
  • , Nyaradzo Mgodi
  •  & Felix Mhlanga

Corresponding author

Correspondence to Zoe Duby.

Ethics declarations

Conflict of interest

All author declares that they have no conflict of interest.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained from all individual participants included in the study.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

The members of the MTN-020/ASPIRE Study Team are listed in the acknowledgments.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Duby, Z., Katz, A.W.K., Browne, E.N. et al. Hygiene, Blood Flow, and Vaginal Overload: Why Women Removed an HIV Prevention Vaginal Ring During Menstruation in Malawi, South Africa, Uganda and Zimbabwe. AIDS Behav 24, 617–628 (2020). https://doi.org/10.1007/s10461-019-02514-8

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10461-019-02514-8

Keywords

Search

Navigation