Bibliographic Info
GuidelineConsolidated guidelines on HIV, viral hepatitis and STI prevention, diagnosis, treatment and care for key populations
Year of Publication2022
Issuing InstitutionWHO
Recommendation
Status
Maintained
Recommended in favor
Conditional
Certainty of evidence
Moderate
The dapivirine vaginal ring may be offered as an additional prevention choice for women at substantial risk of HIV infection as part of combination prevention approaches
Notes and Remarks
- 1.Substantial risk of HIV infection is defined as HIV incidence greater than 3 per 100 person-years in the absence of PrEP 2. Comprehensive services Similar to oral PrEP, the dapivirine vaginal ring should be provided to women in combination with other prevention interventions and health services. This should include provision of condoms, a range of contraceptive methods, testing and treatment of sexually transmitted infections and provision or referral to services that prevent and protect against gender-based violence. Where feasible, providing voluntary partner services should also be considered (49). HIV testing should be provided before initiating the use of the dapivirine vaginal ring and every three months while using it as part of the service provision package. 3. Choice Although the studies reviewed for this question did not directly compare oral PrEP to using the dapivirine vaginal ring, current evidence suggests that oral daily PrEP, when taken as prescribed, has greater efficacy for HIV prevention than the dapivirine vaginal ring. Oral PrEP should be offered at sites where the dapivirine vaginal ring is provided to enable women to make a choice. Women should be provided with full information and counselling on the available prevention options and their relative efficacy and safety and counselled to help them to make an informed choice regarding the best option for them. 4. The dapivirine vaginal ring for adolescent girls and young women The data from the trials were not able to demonstrate efficacy among women younger than 21 years, who had low adherence to ring use. More data are needed to understand dapivirine vaginal ring use among younger women. Experience from oral PrEP services for adolescent girls and young women has shown that younger women may need more support, especially during the early stages of taking oral PrEP, to support continuation. This may be similar for dapivirine vaginal ring use, and studies are ongoing and/or planned in this age group to understand implementation issues and adherence challenges and to ascertain effectiveness, if these can be overcome. 5. The dapivirine vaginal ring for women from key populations Although there is no experience with providing the dapivirine vaginal ring to women from key populations, including sex workers and women who use drugs, the dapivirine vaginal ring is expected to protect sex workers and women who use drugs from HIV transmission via vaginal sex. However, before focused implementation is planned for these populations, understanding and considering the values and references of women from key populations will be key to ascertain whether they would consider the dapivirine vaginal ring an acceptable and helpful additional prevention choice and, if so, what would be the most acceptable way to deliver it. 6. Delivery sites Currently there is no experience with providing the dapivirine vaginal ring outside of research and open-label extension projects. Careful consideration, including engagement with women and providers, is needed when deciding where the dapivirine vaginal ring could be offered . These could include reproductive health services, sexually transmitted infection services, contraception services, gender-based violence services and services specific to adolescent girls and young women or youth-friendly services and other services that make oral PrEP available to women. Special considerations will be needed for acceptable and safe approaches for women from key populations. Implementing demonstration projects can be helpful in furthering the understanding of the sites best suited to offer the dapivirine vaginal ring 7. Adherence support Similar to oral daily PrEP, the dapivirine vaginal ring needs to be used continuously as prescribed for effectiveness. adherence support should therefore be a key part of service provision. Flexible and tailored support will be needed, especially as women start to use this new product. The opportunity for frequent check-ins with a health (or lay) provider may be needed to support use as women start to use the product. Additional adherence support should be considered for younger women. Partner and peer support should also be considered. 8. Demand creation The dapivirine vaginal ring is a new product. In many communities where women experience higher HIV risk, it could be provided even if there is little or no awareness or experience with using other vaginal ring products, such as the contraceptive vaginal ring. If a community is considering implementing the dapivirine vaginal ring, it will be important to develop an awareness programme for both the community and providers that is rolled out before and during introduction of the product. This should include engagement with women’s networks, women’s key population networks and the opportunity to understand concerns and respond to questions about this new product. Messages for men and male partners should also be considered. Some women reported that being able to discuss ring use with partners was supportive and helpful in continuing ring use. 9. Training and support for providers The dapivirine vaginal ring is a new product. In settings with a high burden of HIV infection considering mplementing the dapivirine vaginal ring, provider experience in offering vaginal ring products is unlikely. National programmes should work to provide adequate training support, since this will be needed to develop and provide this service. Ongoing mentoring and supportive supervision, as programmes continue, should also be considered. Understanding provider issues and concerns, and addressing these concerns, will be key.
Also Featured In
This recommendation also appears in the following guidelines:
Originally Developed
Guideline
Guidelines: updated recommendations on HIV prevention, infant diagnosis, antiretroviral initiation and monitoring
Year2021
InstitutionWHO
Guideline
Consolidated guidelines on HIV prevention, testing, treatment, service delivery and monitoring: recommendations for a public health approach
Year2021
InstitutionWHO