Too often, health products are developed and brought to
communities without stopping to ask whether the product is something people
want and will use. A small number of researchers and funders are attempting to
rectify this problem by conducting detailed studies with people at risk of HIV
to understand their preferences, some of which was presented at HIVR4P.
The QUATRO study enrolled 200 women aged 18 to 30 in Harare
(Zimbabwe) and Durban (South Africa). Each month for the first four months of
the study, women were randomly allocated to be given a product to try – an
intravaginal ring, a vaginal film, a vaginal insert (a small tablet that
rapidly disintegrates) or a vaginal gel. They were asked to use the ring
continuously for the month and to take a vaginal swab each week. For the other
three products, they were asked to use them at the time of sex, at least once a
week, and take a vaginal swab a few hours later.
Each of the products was a placebo, with no active
ingredient. This allowed the researchers to put aside issues of efficacy and
side-effects (which they already knew were important to end users) and pay
attention to other aspects of product design and acceptability.
The majority of participants were aged 18 to 24, almost all had
a primary partner and most had children.
After one month of use, participants were asked how much
they liked the product, rating it from 1 (dislike very much) to 5 (like very
much). The mean scores were very similar for each one – 3.3 for the ring, 3.8
for the film, 3.7 for the insert and 3.5 for the gel. For each one there were
some users who rated it very poorly as well as users who rated it very
And after trying all of them, the women were asked to rank
them in order of preference. Again, there was no one product which stood out above
ring was the preferred choice of 29%, but also the least favourite of 42%.
film was preferred by 29%, but also the least favourite of 23%.
insert was preferred by 26%, but the least favourite of 12%.
gel was the preferred choice of 16%, but also the least favourite of 23%.
There were some important differences between respondents in
the two cities – the vaginal film was much more popular in Harare than in
Durban, whereas the reverse was true for the vaginal gel. This suggests that if
and when products are rolled out across several African countries, there may
be significant variations in uptake in different regions and in different
Importantly, ratings for all products improved over time and
with experience of use. This was especially the case for the ring – when women
were first told about the ring at study entry, many were sceptical. Ratings
improved after watching a video demonstrating all products, and then again
after actually using it.
In the fifth month of the study, women were given the product
that they had rated most highly and asked to use it each time they had vaginal
sex. Analysis of returned vaginal rings showed that 78% had used them for the
full month. Analysis of vaginal swabs suggested that 38% of film users, 58% of
insert users and 77% of gel users did use them during sex.
These results were broadly consistent with self-reported
use: 88% of those who had chosen the ring, 42% of those who had chosen the film,
50% of those who chose the insert and 55% of those who chose the gel said they
had used them.
The final stage of the research was a ‘discrete choice
experiment’. This involved the women being asked to state their preferences
when presented with alternative but hypothetical products. Each alternative was
described by several attributes; the responses were analysed to determine which
attributes significantly influenced their preferences.
The efficacy of the product in preventing HIV infection was the
most important attribute. In addition, women preferred a multi-purpose product
that provided protection against pregnancy as well as HIV. They favoured products
that caused some vaginal wetness over ones that caused a lot of wetness; they
favoured products inserted with a reusable applicator over ones inserted with a
finger. They disliked a product that needed to be used every day. Whether or
not a sexual partner would notice the product was not a significant factor.
The discrete choice experiment showed that it is the
combination of attributes that influenced choice, rather than any single one.
For example although product efficacy was very important, it is not the only one
A hypothetical product which provided 80% efficacy but which
also had a number of attributes that tend to be seen negatively (inserted every
day, with a finger, causing a lot of wetness, not preventing pregnancy,
noticeable by a partner) was chosen by 27% of participants. Lowering the
efficacy to 50% but positively modifying all of the other attributes resulted
in a hypothetical product that would be chosen by 73% of participants.
Ariane van der Straten, one of the researchers, summed up
the overall picture. “Young women want choice,” she said. “They want a product
that is low burden, provides peace of mind, is fool proof and multi-purpose,
but what form this product takes does vary.”