The study design is a randomized, open-label, parallel group 3-way crossover study comparing adherence, preference and overall acceptability of 3 different-sized placebo IVRs (IVRs A, B and C) in 24 US couples. At enrollment, each couple will be randomly assigned to 1 of 6 sequences of IVR use: A-B-C, A-C-B, B-A-C, B-C-A, C-A-B or C-B-A. Each couple will use each of the 3 IVRs (IVRs A, B and C) for 30 days per IVR, 90 days total. Each couple will participate for approximately 4 months, including screening. After providing written informed consent at screening, females and their male partners will be evaluated against the inclusion and exclusion criteria by providing their medical, contraceptive, and sexual history as well as undergoing a clinical exam. The exam will include a visual inspection of the genitalia (men) and a speculum exam (women). Potential participants will be recruited by Emory University (Atlanta, GA) and Einstein College of Medicine (Bronx, NY) by contacting prior research participants who've consented to be contacted for new studies; advertising; and distribution of flyers in the study communities. All recruitment materials will be approved by the relevant IRBs prior to use. After screening, women will have an additional 4 visits and their male partners will have 1 additional in-person visit for enrollment and 3 remote visits. Before and after using each IVR, women will have a pelvic exam. If women report symptoms during interim visits, they will have a pelvic exam and will restart IVR use based on the clinical judgement of the site investigator. After enrollment, men who report symptoms possibly related to IVR use will be asked to attend the clinic for an examination. Follow-up visits (in-person for women and remote for men) will include counseling on protocol adherence, contraception, HIV risk reduction counseling. Women will be shown how to use the IVR at Visit 1/Enrollment and will be able to practice ring insertion and removal at that first visit. At monthly visits, women will be examined to check that the IVR is in place.
ADHERENCE: The primary adherence measure will be assessed via daily SMS text messages to women in which they will report if the IVR was out of the vagina in the previous 24h and if so, for how long. At monthly visits, women will respond to a computer assisted self-interview (CASI) questionnaire asking them to rate their adherence in terms of how well they feel they adhered to the IVR instructions for use. They will also be asked to report in more detail about expulsions and removals and the context in which those happen; feeling the ring during daily activities and during sex; and any symptoms experienced in the previous month.
PREFERENCE: We will ask women and their male partners to choose the IVR they think they will prefer at baseline -- before using any IVRs -- and then ask them to state their preference after using all 3 IVRs. Preferences at baseline and endline, and between males and females within each couple, will be compared.
ACCEPTABILITY: Acceptability will be assessed via the monthly CASI interviews according to an adapted version of the Merkatz et al IVR acceptability model.
SAFETY: Safety will be assessed by recording AEs.
