Background
Methods
Search strategy and inclusion criteria
Screening and selection process
Analysis and synthesis
Weight of evidence review
Author | Title | Publication Year | Product | Data Type | Study Context | Location | Population | N | Study Dates | Theory | Soundness | Appropriateness of study design | Relevance | Overall Rating |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Abrahams, Naeemah & Jewkes, Rachel | Barriers to post exposure prophylaxis [PEP] completion after rape: a South African qualitative study | 2010 | PEP | IDIs | Stand-alone qualitative | South Africa | Victims of sexual assault | 29 | 2005-2006 | Not specified | Medium-High: no theoretical approach articulated for study | High: standalone qualitative research | High: though an outlier, specifically discusses barriers to PEP use | High |
Behets, Frieda M T F; Van Damme, Kathleen; Turner, Abigail Norris; Rabenja, Ny Lovaniaina; Ravelomanana, Noro L R; Raharinivo, Mbolatiana S M; Zeller, Kimberly A; Rennie, Stuart M & Swezey, Teri A | Evidence-based planning of a randomized controlled trial on diaphragm use for prevention of sexually transmitted infections | 2008 | Diaphragm | FGDs | Formative, qualitative | Madagascar | Female sex workers | 266 | 2004 | Not specified | Medium-High: no theoretical approach articulated for study | Medium-High: qualitative research within a formative research activity, mixed methods | Medium-High: qualitative research focusing on acceptability, data on motivations and barriers come through | Medium-High |
Gafos, Mitzy; Mzimela, Misiwe; Sukazi, Sizakele; Pool, Robert; Montgomery, Catherine & Elford, Jonathan | Intravaginal insertion in KwaZulu-Natal: sexual practices and preferences in the context of microbicide gel use | 2010 | Pro2000 gel | IDIs and FGDs | MDP 301 Phase III RCT | South Africa | Sexually active adultwomen/trial participants | 136 | March 2006 - August 2008 | Not specified | Medium-High: no theoretical approach articulated for study | Medium-High: qualitative research within a larger trial setting | Medium-High: qualitative research on vaginal practices | Medium-High |
Greene, Elizabeth; Batona, Georges; Hallad, Jyoti; Johnson, Sethulakshmi; Neema, Stella & Tolley, Elizabeth E | Acceptability and adherence of a candidate microbicide gel among high-risk women in Africa and India | 2010 | Celulose Sulfate | IDIs | Phase III RCT | Uganda, Benin | High risk women/trial participants | 30 | Feb-Aug 2007 | A variation of the socio-ecological model (Mcleroy et al. 1988) | High - all details included | Medium-High: qualitative research within a larger trial setting | High - specifically evaluates barriers to use of gel among users | High |
Guest, Greg; Johnson, Laura; Burke, Holly; Rain-Taljaard, Reathe; Severy, Lawrence; von Mollendorf, Claire & Van Damme, Lut | Changes in sexual behavior during a safety and feasibility trial of a microbicide/diaphragm combination: an integrated qualitative and quantitative analysis | 2008 | ACIDFORM Gel and Diaphragm | IDIs and FGDs | Safety and Feasibility study | South Africa | Sexually active adult women | 120 | April 2004 - Nov 2005 | Data analysis conducted within a positivist framework (Bernard & Ryan, 1998), no specific theory for study | Medium-High: no theoretical approach articulated for study | Medium-High: qualitative research within a larger trialsetting | Medium: paper is focused on changes in sexual behaviour and not motivators/barriers to use, although these come out in the data | Medium-High |
Guest, G; Shattuck, D; Johnson, L; Akumatey, B; Clarke, E E K; Chen, P & MacQueen, K M | Acceptability of PrEP for HIV prevention among women at high risk for HIV | 2010 | Oral TDF PrEP | IDIs | Phase III RCT | Nigeria, Cameroon, Ghana | Sexually active adult women/trial participants | 24 | June 2004-March 2006 | Not specified | Medium-High: no theoretical approach articulated for study | Medium-High: qualitative research within a larger trial setting | Medium-High: qualitative research focusing on acceptability, data on motivations and barriers come through | Medium-High |
Kacanek, Deborah; Dennis, Amanda; Sahin-Hodoglugil, Nuriye; Montgomery, Elizabeth T; Morar, Neetha; Mtetwa, Sibongile; Nkala, Busi; Phillip, Jessica; Watadzaushe, Connie & Van, der Straten | A qualitative study of obstacles to diaphragm and condom use in an HIV prevention trial in sub-Saharan Africa | 2012 | Diaphragm | FGDs | MIRA Trial phase III RCT | South Africa and Zimbabwe | Sexually active adult women/trial participants | 206 | Aug 2006 - Jan 2007 | Modified grounded theory (Glaser & Strauss, 1967) for analysis, no specific theory for study | Medium-High: no theoretical approach articulated for study | Medium-High: qualitative research within a larger trial setting | Medium-High: data focused on ability to use condoms with diaphragm, though barriers to use of diaphragm came through | Medium-High |
Mathenjwa, T & Maharaj, P | Female condoms give women greater control’: A qualitative assessment of the experiences of commercial sex workers in Swaziland | 2012 | Female condom | IDIs and FGDs | Stand-alone qualitative | Swaziland | Female sex workers | 25 | Jan - May 2010 | Not specified | Medium-High: no theoretical approach articulated for study | High: standalone qualitative research | High: specifically looks at experiences, motivations and barriers to use of female condom | High |
Montgomery, C M; Lees, S; Stadler, J; Morar, N S; Ssali, A; Mwanza, B; Mntambo, M; Phillip, J; Watts, C & Pool, R | The role of partnership dynamics in determining the acceptability of condoms and microbicides | 2008 | Pro2000 gel | IDIs | Component of pilot study for MDP 301 phase III randomized trial | South Africa, Tanzania, Uganda and Zambia | general population women in couples | 45 | Not specified | none specified (though used relationship based questions and anthropological approaches) | Medium: study dates not specified, though can assess date of data collection knowing this was connected with larger MDP301 study; no theoretical approach articulated for the study | Medium-High: qualitative research within a pilot for a larger trial | High: specifically evaluates experiences of gel use | Medium-High |
Montgomery, Catherine M; Gafos, Mitzy; Lees, Shelley; Morar, Neetha S; Mweemba, Oliver; Ssali, Agnes; Stadler, Jonathan & Pool, Robert | Re-framing microbicide acceptability: findings from the MDP301 trial | 2010 | Pro2000 gel | Semi-structured, serial IDIs | Component of MDP 301 phase III randomized trial | South Africa, Zambia, Uganda and Tanzania | Sexually active adult women/trial participants | 464 | The trial started in October 2005 and completed followup in August 2009 | emic approach to acceptability | High: all details included | Medium-High: qualitative research within a larger trial setting | High: specific to women’s experiences of gel, and their interpretations of use | High |
van der Straten, A, Montgomery, Elizabeth T; Straten, A; Cheng, H; Wegner, L; Masenga, G; Mollendorf, C; Bekker, L; Ganesh, S; Young, K; Romano, J; Nel, A; Woodsong, C; & von Mollendorf, C | High Acceptability of a Vaginal Ring Intended as a Microbicide Delivery Method for HIV Prevention in African Women | 2012 | Placebo vaginal ring | FGDs | randomized safety and acceptability study (mixed methods) | South Africa and Tanzania | Sexually active adult women/trial participants | 48 | April 2007 to March 2010 | Not specified | Medium-High: no theoretical approach articulated for study | High: qualitativeresearch within a pilot/acceptability study | High: specifically aimed at understanding possible motivations and barriers to use of the ring | High |
Montgomery, Elizabeth T; Chidanyika, Agnes; Chipato, Tsungai; Van, der Straten; Montgomery T, Elizabeth & Ariane | Sharing the trousers: gender roles and relationships in an HIV-prevention trial in Zimbabwe | 2012 | MIRA diaphragm and replens lubricant | FGDs and IDIs | MIRA Male Involvement Study (ancillary to MIRA trial) | Zimbabwe | Sexually active adult women/trial participants | 85 | August 2006 to June 2007 | Not specified | Medium-High: no theoretical approach articulated for study | Medium-High: qualitative research within a larger trial setting | Medium: specifically looks at gender roles around decision making in the house and around sex, but experiences with diaphragm come through | Medium-High |
Okal, Jerry; Stadler, Jonathan; Ombidi, Wilkister; Jao, Irene; Luchters, Stanley; Temmerman, Marleen & Chersich, Matthew F | Secrecy, disclosure and accidental discovery: perspectives of diaphragm users in Mombasa, Kenya | 2008 | Diaphragm | IDIs and FGDs | prospective study investigating diaphragm continuation rates | Kenya | Sexually active adult women | 39 | January 2004 - July 2005 | None specified | Medium-High: no theoretical approach articulated for study | High: standalone qualitative research | High: specifically aimed at understanding possible motivations and barriers to use of the diaphragm | High |
Sahin-Hodoglugil, Nuriye; Montgomery, Elizabeth; Kacanek, Deborah; Morar, Neetha; Mtetwa, Sibongile; Nkala, Busisiwe; Philip, Jessica; Ramjee, Gita; Cheng, Helen; Ariane; SahinHodoglugil, N N; Straten, A & Team, The Mira | User experiences and acceptability attributes of the diaphragm and lubricant gel in an HIV prevention trial in southern Africa | 2011 | MIRA diaphragm and replens lubricant | FGDs | MIRA Trial phase III RCT | Zimbabwe and South Africa | Sexually active adult women/trial participants | 105 | August 2006 to January 2007 | None specified | Medium-High: no theoretical approach articulated for study | Medium-High: qualitative research within a larger trial setting | High: specifically evaluates experiences of diaphragm and gel use | Medium-High |
Stadler, Jonathan & Saethre, Eirik | Blockage and flow: intimate experiences of condoms and microbicides in a South African clinical trial | 2011 | Pro2000 gel | IDIs, FGDs, and participant observation | Qualitative research conducted during MDP301 phase III efficacy trial | South Africa | Sexually active adult women/trial participants | 179 women in 401 IDIs, 42 FGDs | Trial was completed in August 2008 and follow upcompleted in August 2009 | Not specified | Medium-High: no theoretical approach articulated for study | Medium-High: qualitative research within a larger trial setting | Medium-High: examined women’s interpretation and meanings of condom and gel use; leads to motivations and barriers but not explictily examining | Medium-High |
van der Straten A, Stadler J, Montgomery E, Hartmann M, Magazi B, Mathebula F, Schwartz K, Laborde N, Soto-Torres L. | Women’s Experiences with Oral and Vaginal Pre-Exposure Prophylaxis: The VOICE-C Qualitative Study in Johannesburg, South Africa. | 2014 | TDF gel and Oral TDF and Truvada | IDIs, serial ethnographic interviews, FGDs, observations | Qualitative sub-study in VOICE phase III randomized clinical trial | South Africa | Sexually active adult women/trial participants | 102 | July 2010 and August 2012 | social-ecological model | High: all details included | High: qualitative sub-study for larger trial | High: specifically examines user experiences of gel and pill use | High |
Gafos, Mitzy; Pool, Robert; Mzimela, Misiwe Adelaide; Ndlovu, Hlengiwe Beauty; McCormack, Sheena; Elford, Jonathan & Team, M D P | The implications of post-coital intravaginal cleansing for the introduction of vaginal microbicides in South Africa | 2014 | Pro2000 gel | serial ethnographic interviews | Qualitative research conducted during MDP301 phase III efficacy trial | South Africa | Sexually active adult women/trial participants | 84 | March 2006 to August 2008 with follow-up visits continuing until August 2009 | Not specified | Medium-High: no theoretical approach articulated for study | Medium-High: qualitative research within a larger trial setting | Medium - explores vaginal hygiene practices within context of gel use | Medium-High |
Lees, S | Emergent HIV technology: urban Tanzanian women’s narratives of medical research, microbicides and sexuality | 2015 | Pro2000 gel | IDIs and observations | Qualitative research conducted during MDP301 phase III efficacy trial | Tanzania | Sexually active adult women/trial participants | 99 | November 2005 to August 2009 | None specified (though used anthropological approach) | Medium-High: no theoretical approach articulated for study | Medium-High: qualitative research within a larger trial setting | Medium-High: specifically explores motivations for participating in research, but also includes experiences and interpretations of gel use | Medium-High |
Magazi, Busisiwe; Stadler, Jonathan; Delany-Moretlwe, Sinead; Montgomery, Elizabeth; Mathebula, Florence; Hartmann, Miriam & van der Straten, Ariane | Influences on visit retention in clinical trials: insights from qualitative research during the VOICE trial in Johannesburg, South Africa | 2014 | TDF gel and Oral TDF and Truvada | IDIs and FGDs | Qualitative sub-study in VOICE phase III randomized clinical trial | South Africa | Sexually active adult women/trial participants | 102 | July 2010 to August 2012 | social-ecological model | High: all details included | High: qualitative sub-study for larger trial | High: specifically examines user experiences of gel and pill use | High |
Montgomery, Elizabeth T; van der Straten, Ariane; Stadler, Jonathan; Hartmann, Miriam; Magazi, Busisiwe; Mathebula, Florence; Laborde, Nicole & Soto-Torres, Lydia | Male partner influence on women’s hiv prevention trial participation and use of pre-exposure prophylaxis: The importance of understanding | 2015 | TDF gel and Oral TDF and Truvada | IDIs and FGDs | Qualitative sub-study in VOICE phase III randomized clinical trial | South Africa | Sexually active adult women/trial participants | 102 | July 2010 to August 2012 | social-ecological model | High: all details included | High: qualitative sub-study for larger trial | Medium-High: looked more at partnership dynamics than experiences of product use, but influences of dynamics on use is explored | High |
Stadler, J; Delany-Moretlwe, S; Palanee, T & Rees, H | Hidden harms: women’s narratives of intimate partner violence in a microbicide trial, South Africa | 2014 | Pro2000 gel | serial IDIs | Qualitative research conducted during MDP301 phase III efficacy trial | South Africa | Sexually active adult women/trial participants | 401 IDIs with 150 women | Not actually specified except “up to 2010” (see other MDP papers) | None specified | Medium: study dates not specified, though can assess date of data collection knowing this was connected with larger MDP301 study; no theoretical approach articulated for the study | Medium-High: qualitative research within a larger trial setting | Medium-High: looked more at partnership dynamics than experiences of product use, but influences of dynamics on use is explored | Medium-High |
Van Der Straten, A; Stadler, J; Luecke, E; Laborde, N; Hartmann, M & Montgomery, E T | Perspectives on use of oral and vaginal antiretrovirals for HIV prevention: The VOICE-C qualitative study in Johannesburg, South Africa | 2014 | TDF gel and Oral TDF and Truvada | IDIs and FGDs | Qualitative sub-study in VOICE phase III randomized clinical trial | South Africa | Sexually active adult women/trial participants | 102 | July 2010 to August 2012 | social-ecological model | High: all details included | High: qualitative sub-study for larger trial | High: specifically examines user experiences of gel and pill use, and in particular how meanings of ARVs for prevention can become conflated with treatment and being HIV + | High |
Results
Third Order Labels | Second Order Constructs | Summary definition (translation) of the 1st and 2nd order constructs | Sources |
---|---|---|---|
Sexual Satisfaction | General Sexual Satisfaction | The use of HIV prevention products like the microbicide gel can improve sexual satisfaction within the individual, partner, client, and couple combined. | Gafos et al., 2010; Greene et al., 2010; Montgomery et al., 2010; van der Straten et al., 2012; Okal 2008 |
Sexual Performance and Play | Product use can improve performance allowing the user or indiviudal to perform better, be hotter, for her partner, and partners or clients can last longer. There is also the added foreplay of initiating product use (ex. applying the gel). | Guest et al., 2008; Stadler & Saethre, 2011; Montgomery et al., 2010; Stadler et al., 2014; Gafos et al., 2010 | |
Implications of enhanced satisfaction | Enhanced sexual satisfaction increases trust among some couples, can promote security in the relationship if male partners find their main partners more attractive because of improved sex, and the sense of additional safety from the protection conferred adds to the sexual satisfaction. | Montgomery et al., 2010; van der Straten, et al. 2014 | |
Lubrication and traditional vaginal practices | Previous intravaginal cleansing and insertion practices can be replaced by product use (ex microbicide), and can improve feeling of sex and feeling of vaginal, making sex more smooth. This more often improves sexual satisfaction, but added wetness can also imply promiscuity in some instances. | Gafos et al., 2010; Greene et al., 2010; Guest 2008; Lees, 2015; Montgomery et al., 2008; Stadler & Saethre, 2011; Montgomery et al., 2010; Sahin-Hodoglugil et al., 2011 | |
Trust | Trust or lack of trust in partner | Product use could be motivated by fear of an unfaithful partner, where they had been and whether they would use a condom. General trust that a partner would use a condom properly was also often missing. In these cases, other HIV prevention products (gel, PrEP, or diaphragm) could confer added protection and peace of mind. | Sahin-Hodoglugil et al., 2011; Kacenek et al., 2012; van der straten et al., 2014; Guest et al., 2008; Kacenek et al., 2010; Sahin-Hodoglugil et al., 2011; Mathenjwa et al., 2012; Lees 1015 |
Implications of product use for development and maintenance of trust | Initimacy and creating and maintaining trust are important in relationships where other HIV prevention product use could reaffirm the relationship while condoms carried negative connotations of distrust, denoting infidelity. However, there was sometimes a worry that gels or oral PrEP could promote promiscuity, or at least suggest it. | Okal et al., 2008; van der Straten et al., 2014 | |
Communication and Enabling Environments | Partner trust of a product was critical, because the trust in the product would translate to trust in a partner as well. Communication and disclosure of product use would improve use of the product, as well as overall communication in the relationship. If not discussed, or if the male partner did not trust the product, there was possibility for arguing and violence. | Montgomery et al., 2008; Stadler & Saethre, 2011; Montgomery et al., 2010, Greene et al., 2010; Montgomery et al., 2012; Montgomery et al., 2014; Montgomery et al., 2008; Kacanek et al., 2012; van der straten et al., 2014; Magazi et al., 2014; Montgomery et al., 2015; Sahin-Hodoglugil et al., 2011; Stadler et al., 2014 | |
Empowerment and Control | Self-esteem and personal agency | Product use had positive affects on personal agency and self-esteem leading women to feel empowered by the ability to decide to use a particular product and that there was something they could use without necessarily needing a male partner’s consent. However, in some cases the product could reduce the sense of personal power if it reminded the user of previous trauma. | Sahin-Hodoglugil et al., 2011; Okal et al., 2008; van der Straten et al., 2012; Mathenjwa et al., 2012; Abrahams et al., 2010; van der Straten 2014; Lees 2015; Stadler & Saethre, 2011; Kacanek et al., 2012; Guest et al., 2008; Greene et al., 2010 |
Power positioning (Negotiation and control, Product use and engagement in services affects power dynamic) | Male partners could react negatively to women having decision making power over product use, clinic attendance, or even knowledge that they did not possess. This could result in anger or violence in the household. | Stadler et al., 2014; Montgomery et al., 2015; Montgomery et al., 2012 | |
Personal Well-being | Product use promotes health and well-being | The use of HIV prevention products was seen as a deliberate action to promote one’s own health and sense of well-being. Products could strengthen the sense of self and empowerment, as well as prevent multiple diseases and improve health issues. The physical experience of side effects could also contribute to the sense of protection from the products. The engagement in health services in connection with HIV prevention product use was also a part of seeing onself as being healthy and promoting that image to others. | Stadler & Saethre 2011: Montogomery et al., 2010; Magazi et al., 2014; van der straten et al., 2014 |
Quality of care as motivation for engaging in healthcare | The quality of care could motivate or demotivate use of HIV prevention products, negative or positive attitudes from health worker staff would transfer to the individual and promote either their sense of good health or negative feelings towards health. | Van der Straten 2014, Magazi 2014 | |
Social Well-being | Perceived implications of use (how I’m seen by others) | People using products can fear what others will think of them as someone who uses HIV prevention products, largely because of an association with promiscuous sexual activity | Okal et al., 2008; Gafos et al., 2010 |
Social construction of medication and product use | The use of a medication can symbolise illness for some women and can challenge their understanding of what it means to be healthy. | van der Straten et al., 2014; van der Straten et al., 2014; Montgomery et al., 2015 | |
Conflation of ARVs for treatment and prevention | Family members, partners or wider community members can mistake use of ART based PrEP, for ART used to treat HIV infection. This can lead to stigmatisation of people believed to be HIV positive | van der Straten et al., 2014; Magazi et al., 2014; Montgomery et al., 2015 | |
Interaction with normative vaginal practices and beliefs | The use of vaginal microbicides in some settings compliments locally normative vaginal practices in helping to cleanse the vagina prior to, or after, sex. However, the converse was also observed and vaginal microbicides can be rendered less effectiveness by virtue of cultural norms relating to vaginal cleansing immediately after sex. | Gafos et al., 2014; Greene et al., 2014; Behets et al., 2008, Stadler & Saethre, 2011 | |
The role of outsiders | Many of the product trials or demonstration projects have been led and/or delivered by people perceived as ‘outsiders’, largely relating to a perception that the originate in the Nothern Hemisphere. | van der Straten, 2014; Guest et al., 2010; Montgomery et al., 2010; Lees, 2015; Montgomery et al., 2014 | |
Practical Considerations | Accessing and storing medication | Physically getting to the clinic to pick up medication or product refills could prove difficult and was an issue in terms of consistent access. Storing medications was sometimes problematic due to stigma within the household or among friends, where personal privacy was minimal. | Greene et al., 2010; Magazi et al., 2014; Montgomery et al., 2010; van der Straten et al., 2014; Abrahams et al., 2010; Mathenjwa et al., 2012 |
Taking and adhering to medication | Strategies for using products, such as gel within a certain time period or pills on a daily regimen, could be interrupted by changes in routines or boredom with use. Perceived or actual side effects were also barriers, as was the need to use multiple products such as condoms and gel when wanting to also prevent other STIs or pregnancy. If product use or associated clinic attendance got in the way of livelihood then product use was also demotivated. | Guest et al., 2010, van der Straten et al., 2014; van der Straten et al., 2014; Montgomery et al., 2012, | |
Health service level issues | The health service itself, including waiting times at the clinic, required frequency of visits in relation to livelihoods, and transport and ability to get to the clinic could also cause problems in consistent and continued product use. | Magazi et al., 2014 | |
Product attributes and acceptability | The ease or difficulty in using a product would directly affect whether a product could be taken up and used. These included need for privacy or washing facilities, whether the product stayed where it was supposed to, ability to transport it inconspicuously, and flexibility around when sex occurred. Pain or irritation with use was also a demotivator. Ability to use covertly was positively regarded, even if rarely done. | Okal et al., 2008; Sahin-Hodoglugil et al., 2011; Montgomery et al., 2012; Greene et al., 2010; Kacanek et al., 2012; van der Straten et al., 2014; Guest et al., 2010; Behets et al., 2008; Gafos et al., 2014; Stadler & Saethre 2011; Guest et al., 2008; Mathenjwa et al., 2012; van der Straten et al., 2012 | |
Efficacy and Risk Reduction | Efficacy for HIV prevention central concern | Whether or not the product can effectively protect them from acquiring HIV was a key concern of women engaged with the products via trials or demonstration projects. A recognition that condoms are not always sufficient drives interest in their concern for new product efficacy. | Lees, 2015; Greene et al., 2010; Stadler & Saethre 2011; 2014; van der Straten et al., 2014; Montgomery et al., 2010 |
Other (non-HIV) protective effects | While not necessarily acurate in all instances, some female participants expressed beliefs that products could protect them from other STIs or from unwanted pregnancy. | Montgomery et al., 2012; Okal et al., 2008; Mathenjwa et al., 2012; Guest et al., 2008; Behets et al., 2008 | |
Perceptions around combination prevention | While women may not always be using new technologies in isolation, sometimes a result of concerns for their effectiveness, they were comforted by a feeling that products could provide an additional layer of protection should their primary prevention mechanism (usually condoms) fail. | Sahin-Hodoglugil et al., 2011; Okal, et al., 2008; Guest et al., 2008; Kacenek et al., 2012 |
Weight of evidence review
Meta-ethnography
Sexual satisfaction
There are others who insert traditional medicines for her to be enjoyable (during sex) . . . I used to love things that are inserted that make you enjoyable. . . . Now that I am old I don’t have that time of going to buy such things. I get help from the gel. [32]
The multiple dimensions of Trust
I like using the diaphragm a lot. My partner likes condoms, but he says they are weak. I also think they are weak [...] [Condoms] burst just like D said. It burst while we were busy [having sex]...So I sometimes use [the condom], but I trust the diaphragm more. [35]
Empowerment and control
Men cannot be trusted to act in our best interests. He can wear the condom at the start of the act and then remove it later or he will just tear it. … So we have to take care of ourselves by using condoms. [40]
‘I was scared of the conflict it would cause’; ‘if he finds out he is going to be angry’; ‘I had seen that he didn’t like the gel and I thought if I told him he would fight with me’; ‘I think he will fight with me for using the gel with him in secret...’ (multiple respondents) [36]
Personal well-being
As a result of continuous use, my pores are now open. My body is no longer stiff and I don’t get tired any more. I am not unsure about my health anymore. Since I started using the gel, I am always energetic like somebody who is using drugs. It has even opened the veins to my kidneys. [37]
[T]he tablets are also working because they have some reaction on us like some of us have headaches and become nauseous and stuff like that, so you would believe that means that these tablets have a certain possibility of reducing the risk of contracting HIV, you know. [15]
Product use in the social-cultural environment
Like my family, I explained that I am attending a [PrEP] study but they don’t [believe] that I am attending a study, they just thinking I am HIV positive and I am hiding it. [15]
So I sometimes think what if what my friends are saying is true, as they say ‘what if they are infecting you with AIDS using that gel? [15]
Efficacy and risk reduction
It is the diaphragm and gel that made us enjoy sex more because there is no virus that goes inside me or penetrates me. I don't know what he is doing in my absence, and he doesn't know what I am doing in his absence so we are safe when we are using the diaphragm. [29]
I feel free when the diaphragm inside me in this 6 hours I do simply know that even if it has happened that a condom burst, no HIV will be passed on to me. It will go back. [35]
Practical considerations
At first I was putting [the tablets] inside my bag and then I took them out of it and put them inside my wardrobe but then one of my friends opened my wardrobe. Because she saw that I was taking the tablets and she didn’t understand why I was taking the tablets even my partner didn’t understand why I was taking the tablets. So I put the tablets in open field so that they could understand that I was taking the tablets for the study and it’s not that I was sick or anything like that. [15]