Abstract
Background: Women bear a disproportionate burden of HIV throughout the world prompting extensive research
into HIV prevention products for women which has met with varied success. With an aim of informing future policy
and programming, this review examines the barriers and motivations to the uptake and use of female initiated products
in sub-Saharan countries.
Methods: We conducted a systematic review as an adapted meta-ethnography of qualitative data focused on actual use
of products. After deduplication, 10,581 and 3861 papers in the first and second round respectively were screened.
Following the PRISMA guidance, 22 papers were selected and synthesized using Malpass’s definitions of first, second,
and third order constructs. First order constructs, consisting of participant data published in the selected papers,
were extracted and categorised by second and third order constructs for analysis. A weight of evidence review was
conducted to compare and assess quality across the papers.
Results: The 22 papers selected span 11 studies in 13 countries. We derived 23 s order constructs that were translated
into seven overarching third order constructs: Sexual Satisfaction, Trust, Empowerment and Control, Personal Well-being,
Product use in the social-cultural environment, Practical Considerations, Risk Reduction, and Perceptions of Efficacy.
Relationships and trust were seen to be as or more important for product use as efficacy. These constructs reveal an
inherent inter-relationality where decision making around HIV prevention uptake and use cannot be binary or
mono-faceted, but rather conducted on multiple levels. We developed a framework illustrating the central
and proximal natures of constructs as they relate to the decision-making process surrounding the use of
prevention products.
Conclusions: Health systems, structural, and individual level HIV prevention interventions for women should
adopt a holistic approach. Interventions should attend to the ways in which HIV prevention products can serve to reduce
the likelihood of HIV transmission, as well as help to protect partnerships, enhance sexual pleasure, and take into account
woman’s roles in the social environment. Stigma, as well as sexuality, is likely to continue to influence product
uptake and use and should be prominently taken into account in large-scale interventions.
Trial registration: Not applicable.