By Joyce Ouma (Image: International Partnership for Microbicides)
The European Medical Association (EMA) on July 24th 2020 gave a positive opinion on the dapivirine ring developed by the International Partnerships for Microbicides (IPM) for use by cisgender women aged 18 and above in supporting them not to acquire HIV during vaginal sex. The ring is made of flexible silicone and contains an antiretroviral known as dapivirine. The ring is inserted in the vagina for a period of 28 days and prides itself in being the first long-acting HIV prevention product and is self-controlled by the woman.
Is it a relief to young women?
The positive opinion on the dapivirine ring is a big step forward in expanding prevention methods available for cisgender women.
For a very long-time adolescent girls and young women have relied on the female condom, pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) for their HIV prevention needs, however these methods have several limitations when it comes to access, uptake and consistent use among us as Adolescent Girls and Young Women. For instance, in order to access PrEP, one has to walk into the Comprehensive Care Clinic (CCCs), get tested and explain why they think they are at risk before being given the product. Post its acquisition, adherence to a pill every day when not sick has become a total disaster. The stigma surrounding the usage and acquisition of PrEP makes it difficult for it to be a first option of HIV prevention for adolescent girls and young women.
The female condom is the least preferred option of HIV prevention among adolescent girls and young women despite it being 99% effective and one of the available multi prevention technologies (MPTs) alongside the male condom. The female condom is large, uncomfortable to use, not sexually appealing and not readily available unlike the male condoms which have evolved to different sizes, textures, flavours, colours and are readily available in pharmacies and in condom dispensers.
The dapivirine ring potentially provides a more preferred HIV prevention option to meet women’s HIV prevention needs as it is women-centred and controlled by the woman, the woman can insert it herself, remove it and replace it by herself. Its long-acting ability embraces the fact that sex for young women is spontaneous and sporadic and sometimes not wilful, hence women will be fully prepared against acquiring HIV for 28 days, and no evidence of long-term use safety concerns. The ring will save young women the agony of having to negotiate use of condom during sex with their partners should they not be in mutually respectful relationships. The approval of the dapivirine vaginal ring sets stage for the multi-purpose vaginal ring which is still in the research pipeline.
The ring presents more HIV prevention options for young women to choose from and own their health. However, studies have shown low uptake and use of the ring among young women aged 18-25, hence the EMA’s recommendation to the IPM to further conduct research on the ring among cisgender women in this age group.
What should not be overlooked.
While the ring provides another HIV prevention option for women, we cannot overlook the fact that it is currently reducing the risk of HIV by 35%. Women are also still at the risk of sexually transmitted infections and unintended pregnancies. The results of the Evidence for Contraceptive Options in HIV Outcomes (ECHO) Trial found that HIV incidence rates were alarming among women using widely available forms of contraception who were receiving a comprehensive HIV prevention package. Therefore, the rates of HIV acquisition are almost directly proportional to the rates of STI and unintended pregnancies. However, this statement begs further probing and tracking of HIV acquisition rates in relation to STIs and unintended pregnancy rates in relation to Intimate Partner Violence among women.
Before the availability of the multi-purpose vaginal ring that is still in the research pipeline, there is need to adopt complementing strategies and funding for work led by women, girls and communities, since the dapivirine ring potentially exposes women who will use it to social harms such as Intimate Partner Violence (IPV) and potential side effects of the ring. There is critical need to invest in the long term objective of building trust and mutually respectful relationships among women and their partners, including work to claim rights, develop relationship and communications skills, and supporting adolescent girls and young women in protection from STIs, violence and unintended pregnancies.
To read more about the dapivirine ring:
AVAC (July 24 2020) AVAC applauds positive opinion from EMA on woman-initiated prevention option
AVAC (July 24 2020) Understanding the EMA Opinion and Next Steps for the Dapivirine Vaginal Ring
IPM (July 24 2020) EMA adopts positive opinion on monthly vaginal ring to reduce HIV risk
IPM (July 24 2020) In Milestone for Women’s HIV Prevention, European Medicines Agency Adopts Positive Opinion on Monthly Vaginal Ring to Reduce HIV Risk
AVAC PrEPWatch (August 13 2020) Dapivirine Vaginal Ring
Wagner et al, Trust issues: Perspectives of male and female partners navigating dapivirine vaginal ring (VR) use in dyadic relationships; formative research outcomes from the CHARISMA study in Johannesburg, South Africa
USAID, Options, PEPFAR (March 2020) OPTIONS Dapivirine Ring Compendium of End-User Insights