Introduction Pre‐exposure prophylaxis (PrEP) is a safe and effective prevention strategy to reduce women's risk of HIV in pregnancy and postpartum. Effective PrEP protection requires daily PrEP adherence, but little is known about maternal PrEP continuation and factors that influence PrEP use. Methods The PrEP in pregnancy and postpartum (PrEP‐PP) study enrolled consenting pregnant, HIV‐negative women at first antenatal care (ANC) visit with follow‐up through 12 months postpartum. Eligible and consenting women and girls ≥16 years received HIV prevention counselling and were offered PrEP. Interviewers collected socio‐demographic and behavioural data from participants at each visit. We analysed the proportion of women who initiated PrEP and the proportion who continued PrEP after 3 months with associated correlates by estimating the prevalence ratio adjusting for a priori confounders. Results Between August 2019 and October 2021, we enrolled 1201 pregnant women (median gestation 21 weeks; age 26 years); 84% of women initiated PrEP at their first ANC visit (n = 1014); 55% were married or cohabiting. Overall, 66% of women on PrEP returned for a repeat prescription at 1 month; 58% returned at 3 months (n = 493 of 844). Almost one‐half of women on PrEP reported a side effect at 1 month, mostly nausea/vomiting. Women on PrEP in the first and second trimesters had higher odds of reporting side effects (aOR 2.61; 95% CI 1.17–5.84) versus postpartum women. Women who reported side effects continued with PrEP less than those who did not report side effects (aPR = 0.87; 95% CI 0.77–0.97). Women with ≥1 previous pregnancy (aPR = 0.76; 95% CI 0.57–1.01) or were postpartum (aPR 0.85; 95% CI 0.75–0.97) were less likely to continue PrEP compared to women who were primigravid or pregnant. Women who reported having an HIV+ partner (aPR = 1.45; 95% CI 1.13–1.85) or high HIV risk perception (aPR = 1.20, 95% CI = 1.01–1.41) were more likely to continue on PrEP than those who had HIV‐negative partners or low risk perception. Conclusions PrEP initiation and early continuation were high in this setting, compared to other studies in women. Being postpartum and experiencing side effects were associated with lower PrEP continuation, presenting opportunities for counselling on early transient side effects. Interventions for postpartum women on PrEP are needed.

Pregnant women in sub-Saharan Africa are at high risk of HIV acquisition and require effective methods to prevent HIV. In a cohort of pregnant women offered Pre-exposure prophylaxis (PrEP), we evaluate the relationship between internalized and anticipated stigma and PrEP initiation at first antenatal visit, 3-month continuation and adherence using multivariable logistic regression. High internalized and anticipated PrEP stigma are associated with lower PrEP care initiation at first antenatal visit (aOR internalized stigma = 0.06; 95% CI = 0.03-0.11 and aOR anticipated stigma = 0.55; 95% CI = 0.31-1.00) compared to women with low reported stigma, after controlling for covariates. Women whose partners have not been tested for HIV or whose serostatus remains unknown have 1.6-times odds of PrEP retention at 3-months compared to women whose partners have been tested (aOR = 1.60; 95% CI = 1.02-2.52) after adjusting for covariates. PrEP counseling and maternal PrEP interventions must consider individual-and relational-level interventions to overcome anticipated PrEP stigma and other barriers to PrEP initiation and adherence.

Introduction Daily oral pre‐exposure prophylaxis (PrEP) can reduce HIV acquisition. However, prevention effectiveness requires daily adherence prior to and during periods of sexual activity. Little is known about pharmacologic measures of PrEP adherence during pregnancy and postpartum and the factors related to optimal adherence during periods of sexual activity in this population. Methods Between August 2019 and October 2021, we enrolled pregnant women without HIV at their first antenatal care visit followed‐up through 12 months postpartum. Eligible women ≥16 years old received HIV prevention counselling and were offered oral PrEP (TDF‐FTC). We quantified tenofovir‐diphosphate (TFV‐DP) in dried blood spots in women who reported taking PrEP in the past 30 days (at quarterly follow‐up visits). We used regression models with generalized estimating equations to evaluate correlates of TFV‐DP (any vs. none, and ≥2 vs. <2 doses/week), adjusting for maternal age and pregnancy status. Results and discussion In 382 women who started PrEP in pregnancy, returned for follow‐up and reported PrEP use in the past 30 days, the median age was 27 years (interquartile range [IQR] = 23–32), and the median time on PrEP was 168 days (IQR = 84–252 days). Half of the samples had quantifiable TFV‐DP at any time point (52%), declining from 67% of pregnant women 3 months post‐initiation to 31% of postpartum women by 12 months. Overall, 72% had concentrations corresponding to <2 doses/week; 25% ≥2 doses/week; 3% 7 doses/week. Concentrations were lower in postpartum versus pregnancy (age‐adjusted odds ratio [aOR] = 0.44; 95% confidence interval [CI] = 0.35–0.54). The correlation of self‐reported adherence and TFV‐DP ranged from –0.07 in pregnancy to 0.25 in postpartum women. Variables associated with having quantifiable TFV‐DP included partner living with HIV/unknown serostatus (aOR = 1.50; 95% CI = 1.01–2.22), and reported frequency of sexual activity in the past month (aOR sex >5/month vs. no sex or <5 times/month = 2.11; 95% CI = 1.58–2.82) adjusting for age and pregnancy versus postpartum status. TFV‐DP concentrations declined over follow‐up time (aOR for 6 vs. 3 months = 0.49; 95% CI = 0.36–0.67). Conclusions Objectively measured adherence to PrEP was low overall and did not correlate with self‐reported use. There is an urgent need for objective adherence measures to support clinical decision‐making as well as adherence support interventions as part of PrEP services for pregnant and postpartum women at risk of HIV.

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Introduction: Long-acting pre-exposure prophylaxis (PrEP) options could overcome some barriers to oral PrEP persistence during pregnancy and postpartum. We evaluated long-acting PrEP preferences among oral PrEP-experienced pregnant and postpartum women in South Africa and Kenya, two countries with high coverage of oral PrEP and with pending regulatory approvals for long-acting injectable cabotegravir and the dapivirine vaginal ring (approved in South Africa, under review in Kenya). Methods: From September 2021 to February 2022, we surveyed pregnant and postpartum women enrolled in oral PrEP studies in South Africa and Kenya. We evaluated oral PrEP attitudes and preferences for existing and future long-acting PrEP methods. Results: We surveyed 190 women in South Africa (67% postpartum; median age 27 years [IQR 22-32]) and 204 women in Kenya (79% postpartum; median age 29 years [IQR 25-33]). 75% of participants reported oral PrEP use within the last 30 days. Overall, 49% of participants reported negative oral PrEP attributes, including side effects (21% South Africa, 30% Kenya) and pill burden (20% South Africa, 25% Kenya). Preferred PrEP attributes included long-acting method, effectiveness, safety while pregnant and breastfeeding, and free medication. Most participants (75%, South Africa and Kenya) preferred a potential long-acting injectable over oral PrEP, most frequently for longer duration of effectiveness in South Africa (87% South Africa, 42% Kenya) versus discretion in Kenya (5% South Africa, 49% Kenya). 87% of participants preferred oral PrEP over a potential long-acting vaginal ring, mostly due to concern about possible discomfort with vaginal insertion (82% South Africa, 48% Kenya). Significant predictors of long-acting PrEP preference included past use of injectable contraceptive (aOR 2.48, 95% CI: 1.34, 4.57), disliking at least one oral PrEP attribute (aOR 1.72, 95% CI: 1.05, 2.80), and preferring infrequent PrEP use (aOR 1.58, 95% CI: 0.94, 2.65). Conclusions: Oral PrEP-experienced pregnant and postpartum women expressed a theoretical preference for long-acting injectable PrEP over other modalities, demonstrating potential acceptability among a key population who must be at the forefront of injectable PrEP rollout. Reasons for PrEP preferences differed by country, emphasizing the importance of increasing context-specific options and choice of PrEP modalities for pregnant and postpartum women.