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Meta-Analysis
. 2022 Feb:106:16-33.
doi: 10.1016/j.contraception.2021.10.001. Epub 2021 Oct 10.

Vaginal ring acceptability: A systematic review and meta-analysis of vaginal ring experiences from around the world

Kathleen Ridgeway  1 , Elizabeth T Montgomery  2 , Kevin Smith  3 , Kristine Torjesen  1 , Ariane van der Straten  2 , Sharon L Achilles  4 , Jennifer B Griffin  5
Affiliations
Meta-Analysis

Vaginal ring acceptability: A systematic review and meta-analysis of vaginal ring experiences from around the world

Kathleen Ridgeway et al. Contraception. 2022 Feb.

Abstract

Objective: The vaginal ring (ring) is a female-initiated, long-acting drug delivery system for different indications, including HIV prevention. Our aim was to provide evidence for acceptability of the vaginal ring across indications to support dapivirine and multipurpose prevention technology ring introduction and roll out.

Study design: This systematic review and meta-analysis followed PRISMA guidelines. We searched PubMed, Web of Science, Embase, and grey literature for publications reporting favorable ring acceptability and secondary outcomes involving actual ring use (comfort, ease of ring use, ring comfort during sex, expulsions, and vaginal symptoms) or hypothetical acceptability for any indication published January 1, 1970-June 15, 2021. We estimated random-effects pooled prevalence, assessing between-study variation using meta-regression.

Results: Of 2,234 records, we included 123 studies with 40,434 actual and hypothetical ring users. The primary outcome assessment included 50 studies with 60 ring subgroups totaling 19,271 ring users. The favorable acceptability pooled prevalence was 85.6% (95%CI 81.3, 89.0), while hypothetical acceptability among non-ring users was 27.6% (95%CI 17.5, 40.5). In meta-regression, acceptability was higher in menopause (95.4%; 95%CI 88.4, 98.2) compared to contraceptive rings (83.7%; 95%CI 75.6, 89.5). Acceptability was lower in pharmacokinetic studies (50%; 95%CI 22.1, 77.9) compared to RCTs (89.5%; 95%CI 85.8.92.4) and in studies assessing acceptability at ≥12 months (78.5%; 95%CI 66.5, 87.1) versus studies assessing acceptability at <3 months (91.9%; 95%CI 83.7, 96.1). European (90.6%; 95%CI 83.9, 94.7), Asian (97.1%; 95%CI 92.0, 99.0), and multi-region studies (93.5%; 95%CI 84.6, 97.4) reported more favorable acceptability compared to African studies (59.4%; 95%CI 38.3, 77.5). Secondary outcomes were similarly favorable, including ring comfort (92.9%; 95%CI 89.2, 95.4), ease of use (90.9%; 95%CI 86.5, 94.0), and comfort during sex (82.7%; 95%CI 76.4, 87.6). Limitations include inconsistent outcome definitions and unmeasured factors affecting acceptability.

Conclusions: Women who used vaginal rings reported they were acceptable across indications geographic regions and indications. Policy makers should consider the ring as an important option for pregnancy and HIV prevention drug development.

Implications: This review found favorable acceptability among vaginal ring users across indications and geographic areas, in contrast to low hypothetical acceptability among non-users. Vaginal rings are an important drug delivery system for pregnancy and HIV preventions, and scale-up should plan to address initial hesitancy among new users.

Keywords: Acceptability; Contraception; HIV prevention; Meta-analysis; Systematic review; Vaginal ring.

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Conflict of interest statement

Declaration of Competing Interest

SA has received consulting fees from Mayne Pharma and research grants from Mithra, Evofem, and Merck that are managed by Magee-Womens Research Institute. The other authors declare no competing interests.

Figures

Fig 1.
Fig 1.
PRISMA flowchart of publication screening and inclusion for systematic review and meta-analysis.
Fig 2.
Fig 2.
Forest plot of vaginal ring acceptability from meta-analysis.
See this image and copyright information in PMC

References

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