Making the Case for Joint Decision‐Making in Future Multipurpose Prevention Technology (MPT) Choice: Qualitative Findings on MPT Attribute Preferences from the CUPID Study (MTN‐045)

Abstract

Introduction Young women in sub‐Saharan Africa account for two‐thirds of all new HIV infections and face high rates of unintended pregnancy. Multipurpose prevention technologies (MPTs) are promising products under development that are designed to simultaneously prevent HIV and unintended pregnancy. Since MPTs will be used in the context of sexual relationships, ensuring acceptability and use requires understanding the role of male partners in MPT use decision‐making. Methods This paper draws on qualitative data from 39 couples enrolled in the Microbicide Trials Network (MTN) 045 study, conducted in 2019–2020. Partners completed a discrete choice experiment (DCE), first separately and then jointly, to measure preferences for future MPT attributes and then completed a qualitative interview. We also draw on quantitative data from interviewer observation about who dominated the decision‐making process during the joint DCE. Content analysis was used to examine (1) how couples made decisions on existing non‐MPT HIV and pregnancy prevention products; (2) how couples made decisions on future ideal‐MPT product during the DCE; and (3) how these decision‐making processes varied by decision‐making dominance (10 male, 10 female and 19 equal) and interview type (19 joint and 20 separate). Results Existing non‐MPT product decisions focused on trust between partners and product attributes, while future ideal‐MPT product decisions exclusively focused on product attributes. Across existing and future products, preferences for product attributes varied by gender. Male partners were most concerned with limiting side effects impacting sexual pleasure, female partners were most concerned with limiting side effects causing physical symptoms and both were concerned with the return to fertility. Across all dominance and interview types, couples reported making decisions together and female partners were often able to negotiate with male partners for their preferred product or set of product attributes. Conclusions Research activities in this study provided an opportunity for couples to openly present their product attribute preferences to their partner, learn about their partner's attribute preferences, negotiate for their ideal set of attributes and ultimately choose attributes that benefited the couple without disempowering the female partner. Future research should focus on the utility of couple‐based decision‐making aids or similar tools for facilitating joint MPT decision‐making.

Synthesis of end-user research to inform future multipurpose prevention technologies in sub-Saharan Africa: a scoping review

“…Effects of MPT use on fertility and product-related preferences to facilitate return to fertility were explored infrequently in the reviewed articles. This topic was largely examined within studies on nanofiber fabric and implants and constituted one of the attributes included in MTN 045/CUPID, which included vaginal film/inserts, vaginal ring, and oral tablets ( 24 , 29 , 31 , 42 , 45 ). Some end users expressed preferences for MPT products that allowed for flexibility in contraception administration or similarly noted that lack of flexibility in contraception coverage was a limitation of specific methods ( 31 , 45 ).…”

“…Across most studies, female participants revealed a preference for products that did not interfere with sex or sexual pleasure for their male partners ( 6 , 23 , 24 , 31 , 34 , 37 , 38 , 40 , 51 ). Consequently, participants were initially disinterested in products (ring, diaphragm, fabric) that would be inserted into the vagina, could potentially change vaginal dryness or wetness, or become dislodged during sex.…”

“…Consequently, participants were initially disinterested in products (ring, diaphragm, fabric) that would be inserted into the vagina, could potentially change vaginal dryness or wetness, or become dislodged during sex. However, acceptability and ratings for vaginally inserted products increased after participants had the opportunity to learn more about the product or try the product ( 6 , 23 , 24 , 31 , 42 , 51 ). Lack of interference with sex was described as a positive attribute for products (injectable, tablet) that could be taken before an encounter as they would make participants feel prepared and limit the opportunity for partners to notice or stop product use ( 29 , 51 ).…”

“…Overwhelmingly, end users preferred products that improved the sexual experience, did not alter the vaginal environment, or did not interfere with sex ( 6 , 31 ), a sentiment echoed among end users' male partners ( 24 , 51 ). Similarly, the expected or actual interference with sex was described as a barrier to product acceptability and use ( 37 ), whereas perceiving a product to have a limited influence on sex was associated with more favorable overall acceptability ratings ( 34 , 38 ).…”

“…Opinions were mixed on whether MPTs should equally emphasize pregnancy and HIV prevention in their packaging, rather than only one indication. Some participants believed that emphasizing only pregnancy prevention might be more discreet, amenable for wary male partners, and a way to avoid HIV-related stigma or assumptions of infidelity ( 20 , 24 , 45 , 47 ).…”