Table 2.

Residual drug level themes from in-depth interviews (n = 22)

RDL	Themes	Illustrative quotations
0	Navigating disappointment, denial and anger	OK, that was a challenging moment for the 0. You had [participant responses] in categories: there were those of 0 who would accept, “I didn’t use the ring.” Then there would be those at 0 and tell you, “I have never removed the ring. How come I have a 0?” So it was challenging. The easier ones were the other ones who would accept, “I have a 0. I didn’t use [the ring].”
		The participants thought like we are judging them with the results. Because if you could tell them that you have got a 1 or a 0, they’re responding like, “Okay, do whatever you want to us.” So whenever you are continuing the counseling session, they were like, made a mood already like, “These people they have given me a 0, and whatever – the counseling that’s being done, it has nothing to do with me.”
	An opportunity for candor	I also liked the way that she [participants in general] opened up. She would tell you the truth. And without even judging – I never even judged her to say, “Why are you not using the ring, and why have you changed?” She would easily open up to tell you what really was taking place.
		I used the tactic of not judging them but exploring, on what’s happened, if she forgot or whatever has happened to her for her not to use the ring but not judging her or pushing it. … With that strategy, some of the participants would just say, “Ah, maybe I might have forgotten what really happened to the ring,” something like that.
	Turning toward prevention	I shouldn’t try and make the participant feel like she’s doing things wrong, because this is all about choice. So, in those cases what I’ll do is to always emphasize the fact that, you know, you still have the opportunity to change, if you don’t want to use the ring anymore. So, me at times if I would inform a participants that they are 0, I would also try to just reemphasize that, you know, it’s actually not too late for them to decide not to use the ring at all, in cases where they are finding it difficult to communicate that.
		If really they cannot take the disappointment of the 0’s, even if they are saying that they are using the Ring, you would give them other options, to say, “You can change if you would like to. We have other options. It’s not like the Ring is the only option,” so that they don’t feel like they are failures.
1	“In-between” is better, even if hard to define	There was a slight difference. When someone gets a 1, at least she knows there is some – a reasonable amount of the drug in her blood – but compare the 1 with a 0. The 0 itself – actually, it’s like, it passes a message that there is nothing, because it is a 0. It’s like, there is nothing in your system which reflects that you have been wearing the ring, compared with the 1, which shows that at least there is something, so the participant would have some hope. … [T]hese are just feelings from participants, but a 1 is better respected compared to a 0.
		OK, there were moments where I’d feel helpless. I mean participants ask you “Why did I get a 1? I would use the ring all the time.” And then you wouldn’t really know – you’d be stuck, you didn’t know what exactly to say, and they would wonder, Is the ring really protecting me if I’m getting such low levels…
	A 1 is easier to leverage into HIV prevention than a 0	The women that got a 1, sometimes they don’t know where they … Because some of them will take 1 as a 0. “How I didn’t do well? I got a one!” And they will go on moaning and moaning and moaning, until you reassure them and say, but this 1 is showing that there was some level of protection. It’s not a 1 that is flying all over the place. It is showing that there was some level of protection. Now, let us look at your protection efforts. How can we improve your effort? And then you take it from there.
		They [who received a 1] understood it and admitted that it was possible that they could get a residual drug level of 1, and they promised to improve. Some of them for the following visits, they improved a lot.
	Tiptoeing toward prevention	For example, if this participant says, “I’ve got a 1 and I’m not worried, because I was using the ring,” then there’s nothing much you can – you say. But if the participant says, “I’ve got a 1 and I’m worried,” then you could ask her, like, check in with her. “Were you using the ring? Did you have any challenges?” Or what or what. If the participant said, “I had challenges,” then we could discuss on the challenges and help her on the challenges she had mentioned. But if she said that, “I didn’t have challenges, and I have been using the ring consistently,” then we would just tell her to continue using the ring. If she had chosen to continue using the ring, that is.
		[I]n my mind maybe I thought that maybe she could have been lying to me that she’s been perfectly using the ring so we were going back to the Options Counseling without showing her that I’m doubting her. But we go through all the options again and let her make a final decision if she wants to change or to go to any other method or to add on the method that she’s choosing just so that she will be protected.
		Some of them would then open to say, “Yeah, it’s because I remove the ring sometimes during bathing, I remove the ring sometimes during menses. Then this is why I am getting a 1.” They would then acknowledge the reason why they think they got a 1, though I couldn’t push on the reasons – they give me the reason – because it would be like judging them.
2	A 2 functioned almost like a 3	The women who got a 2, most of them were fine with it. They were fine that – the 2’s and the 3’s, they didn’t really question the result. They felt protected.
		[I]t was a bit of a challenge to competently explain why it’s in-between and not a three, because some participants got three rings and they would get a 3 in the first ring and they would get a 2 in the second one, and maybe another 2 in the third ring. So with the ring not being affected or taken out of her body, she would all at once inquire, “Why were the 2 results not a 3 as I used the ring the same way.”
	Discrepancies between a 2 and 3 easily motivated HIV prevention	It showed their protection, but they felt that, “Wow, if I managed to make 2, what can stop me to make 3?” And then they get that courage to either to, “Wow, I can make it better than this. I can make it 100%.” So they get courage.
		But the bottom line was, the 3 is the highest protected level, so if we had a 3, we would be confident that you are protected from HIV. So with a 2, it’s like there is some encouragement to have 3 as a protection level.
3	Protection	Most of the participants [who received a 3] were very, very happy to – I should say all of them. They were happy to get a 3. And they didn’t ask any questions when they had a 3.
		Oh, those would fly from your room to the waiting area … telling everyone, “I got a 3. I got a 3.” But now, imagine if people are singing, “I got a 3, I got a 3,” what if there’s a person that got a 0? And maybe the person that is trying to tell you that “I did everything that you said, but why am I getting a 0?”
	Ambassadors to prevention	[W]e need not to forgot about them [who received 3’s] because they showed their commitment to the Ring. … Some of them, I requested them to become an ambassador to other women. They used to – they came forth and used to share their story with others to encourage them that this thing’s possible. So we had a very good relationship with those women.
		So we actually used the 3’s to talk to these 1’s, those who were getting the low level.
	Prevention is not over	[T]hey were excited, and you’d actually feel proud of them, and you’d ask them how they feel, and they would tell you, “I’m excited.” But it became a challenge now dealing with those that end up seroconverting, and wondering how it did go wrong. And also, those who started off with 3, and then they may be having low residual drug levels now, the interaction, you’d tell that one is disappointed and one is wondering what is it, what has made her, you know move from a 3 to a 2 or a 1.
		But those are the people you actually, you don’t want them to go overboard being happy such that they forget about the bigger picture. Because the bigger picture is HIV prevention at the end. … [T]hey are happy, they are singing, they are doing everything – but at the end, it will also come back to HIV prevention. They will say, “I was using the ring as you instructed me. I was wearing it all the time. I never took it out. I think that’s why it worked for me.”