Scanning electron microscope observation of the biomass accumulated on contraceptive vaginal rings used for three weeks.

<p>Pictures 1a-3a: The contraceptive vaginal ring was used by a woman with a Nugent score of 10 and with presence of <i>Lactobacillus iners</i>, <i>Gardnerella vaginalis</i> and <i>Atopobium vaginae</i> as measured by qPCR. A vaginal biofilm consisting of <i>Gardnerella vaginalis</i> and <i>Atopobium vaginae</i> was identified using fluorescence in situ hybridization. On the ring <i>Lactobacillus species</i>, <i>Gardnerella vaginalis</i> and <i>Atopobium vaginae</i> were detected using qPCR, the crystal violet optical density was 3.7555 Pictures 1b-3b: Biomass on a contraceptive vaginal ring after use by a woman with a Nugent score of 0 and presence of <i>Lactobacillus iners</i> only. No biofilm was visualized using fluorescence in situ hybridization. On the ring <i>Lactobacillus species</i> was detected using qPCR, the crystal violet optical density was 3.7225.</p

Participant flow.

<p>N = number of participants, * 1 discontinued after one cycle of vaginal ring use.</p

Longitudinal analysis of qPCR concentrations (log₁₀ (geq)/mL of vaginal swab eluate) and Nugent scores in the Vagina and of qPCR concentrations (log₁₀ geq/mL of vaginal ring eluate) and density of contraceptive vaginal ring biomasses in both study groups.

<p>Longitudinal analysis of qPCR concentrations (log₁₀ (geq)/mL of vaginal swab eluate) and Nugent scores in the Vagina and of qPCR concentrations (log₁₀ geq/mL of vaginal ring eluate) and density of contraceptive vaginal ring biomasses in both study groups.</p

Baseline characteristics, reproductive tract and sexually transmitted infections of all randomised participants who used at least one contraceptive vaginal ring.

<p>Baseline characteristics, reproductive tract and sexually transmitted infections of all randomised participants who used at least one contraceptive vaginal ring.</p

Evolution over time of the mean vaginal Nugent score, the mean composite qPCR vaginal health score of vaginal specimens, and the mean composite qPCR vaginal health score of contraceptive vaginal ring biomass.

<p>The Y axis is a score from 0 to 10 for both the Nugent and the composite qPCR vaginal health score. RSV1: first ring removal visit; RSV2: second ring removal visit; LRV: last ring removal visit ____: mean Nugent score _ _ _: mean composite qPCR vaginal health score of the vaginal specimens ……: mean composite qPCR vaginal health score of the contraceptive vaginal rings The composite qPCR vaginal health score is calculated as log₁₀ (<i>Lactobacillus</i> spp.)-log₁₀ (<i>G</i>. <i>vaginalis</i>+ <i>A</i>. <i>vaginae</i>).</p

Longitudinal analysis of species presence in the vagina and in contraceptive vaginal ring biomasses in both study groups.

<p>Longitudinal analysis of species presence in the vagina and in contraceptive vaginal ring biomasses in both study groups.</p

Theoretical framework used for data collection and analysis as adapted from Van der Straten et al [38] and Merkatz et al [40].

<p>The framework proposed by van der Straten et al [<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0199096#pone.0199096.ref035" target="_blank">35</a>] was used for data collection and analysis; elements of the NES/EE CVR acceptability model by Merkatz et al [<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0199096#pone.0199096.ref037" target="_blank">37</a>] such as side effect and bodily changes were added.</p

Flow chart of the study process detailing screen failure rates.

<p>The study screen flow is presented detailing screen failure rates.</p

Flow chart of quantitative and qualitative data collection in the Ring Plus study.

<p>Quantitative and qualitative data collected before, during and after study end are presented.</p

Baseline characteristics of the screened population and enrolled population by randomisation group.

<p>Baseline characteristics of the screened population and enrolled population by randomisation group.</p