Constructs of “Sexual Satisfaction” arose in thirteen of the papers we reviewed [27,28,29,30,31,32,33,34,35,36,37,38,39]. These second-order constructs included: 1) general sexual satisfaction; 2) sexual performance and play; 3) implications of enhanced satisfaction; and 4) effects of vaginal lubrication and traditional vaginal practices. Particularly strong positive feelings were voiced in relation to vaginal microbicide gels [27, 28, 32], as a result of the “heat”, or kusisha in isiZulu, created through use . This also occurred in relation to diaphragms where many women reported increased vaginal tightness , or enhanced stimulation when a partner’s penis made contact with the vaginal ring . At the same time, women also reported negative reactions from some male partners who found the ring to be obstructive during sex .
Particularly striking in its primacy was discussion of how product use could form part of sexual performance and play between couples. Several papers describe how the use of microbicide gels and diaphragms was integrated into sexual foreplay, such as the product insertion performed by the male partner [29, 37]. Vaginal microbicide use was also associated with increased libido among some women [32, 37] and viewed as a means of overcoming sexual problems, particularly in limiting premature ejaculation by male partners [32, 36]. A perception that the microbicide gel could lead to tightening of the vagina meant that, as described in two papers, male partners would actively request their female partners to use the product to improve the sexual sensation [27, 37]. In a similar vein, the potential for product use was often seen as facilitating discussion and greater sexual intimacy between partners. Sexual pleasure itself had positive impacts on relationships, improving the performance and play among couples, but also improving the security of the relationship for some women when their husbands stopped seeing other women as a result of improved sexual encounters within the primary relationship .
Lubrication played a key role in shaping women’s perceptions of microbicide gel use with the majority of papers reporting a positive impact that helped to make sex feel more smooth or comfortable [27,28,29, 31, 37, 38]. Inserting the vaginal microbicide gel mirrored the use of other substances inserted into the vagina to create a pleasing environment for both themselves and their male partner .
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. 
The multiple dimensions of Trust
We found “Trust” to be a particularly strong, complex, and crosscutting construct, either positively or negatively influencing product uptake and use. From various perspectives, trust was either built up or broken down by interactions with partners in relation to product use. Three second-order constructs emerged under this theme including: 1) trust in one’s partner; 2) implications of product use for development and maintenance of trust; and 3) communication and enabling environments for trust building. These constructs were identified in 16 of the papers [15, 27,28,29,30,31,32,33,34,35,36,37,38, 40,41,42,43].
Women’s lack of trust in their partners was a strong motivator for use of PrEP, female condoms, microbicide gel, and gel with diaphragm [15, 29, 30, 35]. Product use helped ease the fear of possible infections a man might bring home with him, HIV or otherwise, especially when it was difficult to insist upon the use of male condoms within the context of a regular partnership [29, 30, 35].
Product use also had direct implications for the development and/or maintenance of trust within the couple. In several instances, women reported that bringing an HIV prevention product into the home was negatively seen by partners who felt it implied infidelity on their part or could encourage the woman’s promiscuity, thereby impacting their ability to use the products [15, 34].
Conversely, for many couples, the microbicide gel did not convey the same level of mistrust that the condom had, making use easier to negotiate [37, 38]. Communication improved product use, and product use in turn could improve sexual and relationship communication, allowing for new dialogues and trust around sex and intimacy. Disclosure of product use, or lack thereof, also had the potential to influence a woman’s standing in her home and her relationship, where use could result in violence or dissolution of the relationship, or help to improve sexual satisfaction and dynamics within a couple [28, 32, 38, 41, 43].
Partner support of product use was also a critical factor. Some partners plainly refused to use any prevention products citing mood, general disapproval, or dislike of added wetness from microbicide gel use [15, 28, 30]. However, in many instances, men could also be supportive and feel they were protected by the product, as well as become involved in supporting their female partner in use, such as providing transport to clinic appointments [28, 35, 42, 43].
Finally, there was an aspect of trust in the product itself, either negative or positive. Negative perceptions often manifested from male partner’s disapproval and mistrust in outsiders having influence on sexual relationships or in the efficacy of the product. On the other hand, some couples found that a new product with greater efficacy could actually improve trust and feelings of safety that would motivate use, particularly when they had previously found effective condom use problematic.
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. 
Empowerment and control
The interrelated constructs of “Empowerment and Control” were central to women’s narratives about how they perceived and used HIV prevention products. Two second-order constructs were identified under this theme: 1) self-esteem and personal agency; and 2) power positioning. These constructs emerged from 14 of the review papers [15, 28,29,30,31, 33,34,35,36,37, 40, 41, 44].
Some women expressed how products, in particular microbicide gel, vaginal ring, and diaphragm, gave them a sense of ownership and agency over preventing HIV, but also their own bodies and health [33,34,35]. They were able to make the decision to use a product, without a man’s consent or involvement. This was especially valuable when women felt that their partners would not necessarily agree or were untrustworthy. Participants suggested that women were responsible for their own health, as this quote notes in relation to the female condom:
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. 
In less common contexts, product use can also affect agency, as described in one paper about PEP use within the context of post-rape care. In this paper, successful PEP use after cases of sexual assault was directly related to how the rape was perceived and how the use of PEP affected the victim on an emotional level . Several women reported that the use of PEP reminded them of the rape or made them feel like they were HIV positive, leading to negative associations with the product and demotivated use.
In direct contrast to the generally improved self-agency from product use is the construct of power positioning which emerged as a barrier to product uptake and use. A key concern in this regard was a fear of violence should male partners’ discover covert use of the product.
‘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) 
Women had conflicting feelings about product use. Some felt product use could improve their ability to make choices and negotiate protection, however, this could also pose a threat to men’s authority and potentially destabilize the relationship .
“Personal Well-being” arose as an important construct in how women used and engaged with products. We identified three distinct constructs comprising this theme: 1) product use promoted health and well-being; 2) attributes of product use indicated the power of medication and good health; and 3) quality of care was a motivator for engaging in services and product use. These constructs emerged to varying degrees in five of the review papers [15, 32, 37, 39, 42].
Two of the papers [32, 37] explored how a microbicide gel gave women a sense of well-being, solved multiple health issues, and prevented other diseases or infections. Indeed the power of the prevention product was seen to have the ability to promote fertility and vaginal cleanliness, clean the blood, and cure ailments .
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. 
Another paper found that the experience of side effects from ARV-based prevention products encouraged perceptions of the power of the ARVs working in the body to protect the user [15, 39].
[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. 
Interaction with a health service, whether within a trial or actual clinic setting, driven by product use promoted an additional sense of personal well-being in which women could actively look after their own health and be seen by others as ‘healthy’ . Knowledge of one’s HIV status with regular check-ups could promote a negative status, leading to continued product use .
Additionally, the quality of care during clinic attendance was directly related to motivation for use in two of the papers [15, 42]. Women noted the importance of staff demonstrating their concern and care for their study participants or clinic clients through educational or one-on-one counselling sessions, in contrast to previous experiences in government public health clinics where staff were often quick to dismiss interests in new products and/or the feelings of their patients .
Product use in the social-cultural environment
The construct of “Product use in the social-cultural environment” incorporates 4 s-order constructs which, combined, represent a significant and sizeable component of the published evidence on the uptake and use of female controlled HIV prevention products [15, 27, 31, 34, 35, 37,38,39, 42, 43, 45, 46]. The four constructs include: 1) perceived implications of use; 2) dominant, setting-specific social construction of medication and product use; 3) conflation of ARVs for prevention and for treatment; and 4) interaction of products with normative vaginal practices and beliefs. Cutting across these constructs is the notion of how women use products within the social-cultural environment and interactions which point to their need or desire to protect their ‘social well-being’, including their observation of social norms and values.
Many women were concerned that use of vaginal microbicides, the diaphragm, or oral PrEP might suggest to others that they are either promiscuous or identified them as a sex worker [27, 34]. Clinic attendance and use of an ARV based technology also caused confusion for the family and friends of some female participants who struggled to distinguish between ARVs for treatment and for prevention [15, 42, 43]. The use of ARVs has become synonymous with HIV infection and, in some instances, sickness  and those using ARV-based prevention products were considered to be ill. As such, the social construction of medication and product use encapsulates particular beliefs regarding use of medications. Therefore, a woman’s own view of how she sees herself, and how she is seen by others, may be threatened by the use of a technology such as PrEP coming in the form of a tablet .
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. 
The impact of beliefs on uptake and use of new products also extend beyond those that relate to HIV stigma. Culturally appropriate or common hygiene practices as they relate to use of prevention products are the focus of several papers within this review [28, 37, 45, 46] and authors highlight the ways in which cleansing practices, in particular, are an important dimension of the social self. Hygiene practices, such as using cleansing products, were reported both as a barrier and an enabler to the effective use and acceptability of vaginal microbicides. Some women found vaginal microbicides highly acceptable given the existing cultural norms around intravaginal insertions for cleansing and preparation for sex [28, 32]. Partner and social preferences for “dry sex” motivated microbicide use which was seen to have cleansing effects on the vagina, translating into a reduction of STIs and foul-odours previously caused by traditional vaginal cleansing products . Interestingly, at least in the South African context, preferences for dry sex seem to actually refer to cleanliness or tightness rather than the desire for a dry vaginal environment, as presented by Stadler and Saethre .
The perception and extent of engagement with a biomedical product was also influenced by who was delivering the product and whether they were seen as part of the community. Four studies [15, 31, 32, 47] cite concerns relating to the fact that vaginal microbicides, PrEP or the diaphragm were delivered by muzungu (white people in Swahili) or people from the northern hemisphere, and a generic mistrust of foreign medications not common in the local setting.
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? 
In several instances it was male partner mistrust of ‘outsiders’ in their social setting that stood as a significant barrier to uptake and use of the product as they sought to prevent their female partners from engaging in use .
Efficacy and risk reduction
Constructs of perceived and actual efficacy of prevention products, or the potential for risk reduction, were a significant feature of nine papers [28,29,30, 34, 37, 40, 41, 45] and an implicit dimension of three [31, 32, 39]. Three constructs identified among these papers were 1) efficacy for HIV prevention as a central concern; 2) other (non-HIV) protective effects; and 3) perceptions around combination prevention.
The fear of infection was a dominant feature in participants’ narratives [28, 31] as was the hope that new products may succeed in stemming the epidemic where condoms have been insufficient . In several studies, women said that sex was more enjoyable when they felt protected from HIV, as described in Guest et al.:
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. 
Female participants were comforted by the additional protection that new prevention products offered. While they may maintain a desire to utilise male condoms for many sexual encounters (e.g. to prevent pregnancy or other STIs), it was felt that the diaphragm [34, 35] or vaginal microbicides  could provide an additional layer of protection from acquiring HIV.
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. 
The preference for use of more than one product at a time affording multiple layers of protection was not uniform. Kacanek et al. (2010) highlight the reluctance of women in their study to use both the diaphragm and condoms simultaneously. However, women did acknowledge that this was partly born from a desire to understand the effectiveness of the diaphragm as a preventative HIV transmission method in isolation.
For female condoms and the diaphragm, women articulated their belief, and feelings of comfort, that these methods could also protect them from other STIs and unwanted pregnancy [29, 34, 40, 41, 45]. The female condom was particularly favoured by women who had experienced problems with hormonal contraceptive methods .
Four second-order constructs emerged within the third order construct of “Practical Considerations”. These included: 1) accessing and storing products, 2) product attributes and acceptability, 3) ability to effectively take or use the product, and 4) issues relating directly to health services. These constructs were identified in 17 of the papers [15, 28,29,30, 32,33,34,35, 37, 39, 40, 42, 44,45,46,47].
While all of the studies included in this review report data on actual use of products in contexts where the products were provided for research purposes, either in trials or clinic settings, issues around access to the products still arose. This was directly related to women’s ability to get to the clinic for refills in between scheduled visits. In some cases women just waited for the their next appointment rather than making an extra trip, or were away from home due to family obligations [28, 42].
Storing the products could also pose problems in settings where there is little privacy in the home and women feared accidental discovery and potentially negative reactions from household members or partners [15, 32]. Some women used the discovery of a product as a means to establish health status and pride around use:
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. 
Attributes of the products themselves could directly influence the ability to use them. With regard to the diaphragm, users found that it could be problematic to insert or remove it without privacy or clean facilities in which to wash themselves and the product. Some women found it painful at first to use, while others appreciated the small size and that it was inconspicuous enough to fit in a handbag or in a pocket [34, 35]. The long-acting attribute of the vaginal ring contributed to a feeling of flexibility when sex occurred, as well as constant protection in case of rape .
Vaginal lubrication practices also arose under this third order construct from the practical perspective. After using microbicide gel, women articulated that the use of traditional lubricants was less preferred owing to their ability to cause foul-smelling odours, whereas the microbicide gel or the female condom had built-in, clean lubrication which was a strong motivator for use . This built-in lubrication would also prevent pain and tearing of condoms or vaginal tissues, as well as dryness, which can occur during longer sexual encounters and as such was preferable to male condoms [29, 32, 37]. The vaginal ring could bring added pleasure to sex as well where the ring itself would add stimulation to the male partner .
Other papers presented discussions of traditional or conventional vaginal practices and how they might affect the practical and effective use of products [37, 45, 46]. Women spoke of the “dirt” (or pollution resulting from perceived accumulation of semen, menstrual blood, and lubricants), either their partner’s or their own, which could get trapped in their vaginas after sex because of product use [37, 46]. However, the rinsing of a vaginal microbicide gel or diaphragm within an hour after vaginal intercourse could significantly negate its effectiveness. This issue was amplified for female sex workers who felt a need to cleanse their vagina between clients [45, 46]. Interestingly, some women felt that using the newer products actually made them feel cleaner, thus reducing cleansing practices and motivating use.
Side effects, whether real or perceived, were a critical influence on continued use of a product. Women stated they would use products providing there were no visible side effects which could alert friends, family, or partners to their use and potentially stigmatize them as being HIV positive . Women expressed fear of using products due to potential or experienced side effects [15, 33, 39], while others were able to quickly overcome the side effects and felt happy to use the product . Lack of side effects as experienced with the female condom was a big motivator for use, especially for those women who had experienced them with other products.
An additional practical consideration centres on the consciousness required for consistent and correct pill taking, in particular related to oral PrEP. Some women had difficulty remembering to use the product, such as in the case of oral PrEP, when they were intoxicated, “feeling bored or lazy, on the go”, or just not used to having to take a pill every day [15, 28].
Finally, issues with health services, even in trial settings, were also factors influencing product use. Waiting times at the clinic would cause women not to attend and pick up their products, as did availability of and ability to get transport, and family, community, or work obligations which disrupted clinic attendance .