Women in a growing number of African countries will soon have access to a vaginal ring to help reduce their risk of acquiring HIV from an infected partner. And they can use it discreetly, without their partner or anyone else knowing. The ring is inserted and slowly releases the antiretroviral drug dapivirine for a month, when it is removed and replaced with a new ring.

The Population Council, a nonprofit global research organization which develops, supplies and distributes sexual and reproductive pharmaceuticals including the dapivirine vaginal ring, announced last month that the ring soon will be available in five additional African countries: Botswana, Malawi, Namibia, Rwanda and Zambia. It is currently available through recent pilot programs in six African countries: Eswatini, Kenya, Lesotho, South Africa, Uganda and Zimbabwe.

While Western and other governments can purchase the ring, that hasn't happened yet, says Anita Garg, senior director of strategy and commercial relations for The Population Council. The ring was specifically designed for women to use in countries that still carry a high level of stigma around HIV, where travel to clinics for monthly injections is difficult, and where even storage of a month's supply of pills might be difficult to do discreetly. There are other HIV prevention medicines, called pre-exposure prophylaxis or PrEP, that include pills taken daily or injections received every other month to prevent transmission. Other non-medical prevention strategies have long included abstinence from sex or using condoms correctly with each sexual encounter.

But the stigma associated with AIDS can stop women from using PrEP pills, fearful that their neighbors or partners might see the pills and falsely assume they are already infected with HIV, or judge them as promiscuous. The every-other-month PrEP injection is just beginning to make its way into Africa, but it is expensive and difficult for people in many areas to access.

"The evidence is clear that there is no single prevention solution," said Ben Phillips, communications director UNAIDS, in an email interview. "It's recognized that to prevent HIV transmission, there's a need to expand the choices people have."

In sub-Saharan Africa, girls and young women age 15 to 24 accounted for more than 77% of new HIV infections in 2022, according to UNAIDS.

Those young women, especially in places where females have little economic power or power over their sex lives, need the ability to make a private choice to protect themselves against HIV even if their partner objects, for example, to a condom. "Women are not always in charge of who they have sex with, nor can they always negotiate the use condoms," says Anita Garg of for The Population Council.

"The ring is very private," says Dr. Jeanne Marrazzo, director of the National Institute of Allergy and Infectious Diseases. "The male doesn't necessarily even know it's there."

There continues to be a lot of stigma around AIDS. "There have been devastating losses from AIDS, and so much confusion in the early days about transmission. People with AIDS were shunned, and still are," says Marrazzo. "It's clearly associated with sex, whether heterosexual or homosexual. It pulls up a curtain about sexual activity that is still uncomfortable." So privacy in protecting oneself from transmission can be important.

And while early studies of some PrEP products showed women didn't take the pills or use the ring consistently or properly — compliance rates several years ago were as low as 20% — it seems that as understanding of the methods grows, compliance goes up, says Dr. Connie Celum, director of the International Clinical Research Center at the University of Washington. She is an author of a study in the December 2023 The Lancet HIV that found compliance with either the vaginal ring or daily pills was higher than expected from earlier studies. "We provided supportive counseling, we listened to the women," Celum said. And adherence rates were moderate to high—more than 50 percent compliance for both daily use of the pills and leaving the ring in place for a month at a time.

In that study, 247 women were divided into two groups. Each got either the PrEP pills or the vaginal ring to use for six months. Then, those who took pills switched to the ring; and those using the ring switched to pills for another six months. Finally, all the women were given a choice of which method to continue for still another six months, and two-thirds of the women chose the ring.

"Women wanted something they could forget about for a month," says Celum. "It's discreet." Four of the women were infected with HIV during the trial period, and those women did not use the HIV prevention products consistently— or at all.

A new ring is in development that needs to be replaced only four times a year. "We're in the final stages of development for that product," says Garg. "It could be available in 2026."

That would mean women at high risk for HIV infection could put aside that worry for three months at a time while discreetly protecting themselves.

Susan Brink is a freelance writer who covers health and medicine. She is the author of The Fourth Trimester, and co-author of A Change of Heart.

link: https://www.npr.org/sections/goatsandsoda/2023/12/08/1217384103/anti-hiv-drugs-vaginal-ring