Early pre‐exposure prophylaxis (PrEP) initiation and continuation among pregnant and postpartum women in antenatal care in Cape Town, South Africa

Davey, Dvora Joseph; Mvududu, Rufaro; Mashele, Nyiko; Lesosky, Maia; Khadka, Nehaa; Bekker, Linda‐Gail; Gorbach, Pamina M.; Coates, Thomas J.; Myer, Landon

doi:10.1002/jia2.25866

Cited by 49 publications

(64 citation statements)

References 30 publications

(41 reference statements)

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“…When PrEP is offered to PPW in research studies, rates of uptake range but are relatively high. In two ongoing South Africa‐based cohorts, one that enrolled participants in antenatal care (ANC) [ 32 ] and one that recruited women planning for pregnancy [ 20 , 33 ], PrEP initiation rates were approximately 90% and 60%, respectively (though initiation rates appear to be lower in Kenya at 21.7% [ 34 ]). With the high utilization of ANC across SSA (78.9%) [ 35 ], these services are an opportune time to introduce PrEP and expand implementation.…”

Section: Discussionmentioning

confidence: 99%

“…PrEP persistence, or sustained PrEP adherence over time, is crucial during pregnancy and the postpartum transition. Recent studies among PPW have reported persistence rates of 75% and 62% at 1 and 3 months post‐initiation [ 32 ]. Rates in adolescent girls and younger women who become pregnant are likely lower; only a third of adolescents and younger women in Kenya who initiated PrEP continued use after 1 month [ 34 , 44 ].…”

Section: Discussionmentioning

confidence: 99%

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The importance of assessing and addressing mental health barriers to PrEP use during pregnancy and postpartum in sub‐Saharan Africa: state of the science and research priorities

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Introduction Pregnant and postpartum women (PPW) in sub‐Saharan Africa are at disproportionately high risk of HIV infection compared to non‐pregnant women. When used consistently, pre‐exposure prophylaxis (PrEP) can prevent HIV acquisition and transmission to the foetus or infant during these critical periods. Recent studies have demonstrated associations between mental health challenges (e.g. depression and traumatic stress associated with intimate partner violence) and decreased PrEP adherence and persistence, particularly among adolescents, younger women and women in the postpartum period. However, mental health is not currently a major focus of PrEP implementation research and programme planning for PPW. Discussion PrEP implementation programmes for PPW need to assess and address mental health barriers to consistent PrEP use to ensure effectiveness and sustainability in routine care. We highlight three key research priorities that will support PrEP adherence and persistence: (1) include mental health screening tools in PrEP implementation research with PPW, both to assess the feasibility of integrating these tools into routine antenatal and postpartum care and to ensure that limited resources are directed towards women whose symptoms may interfere most with PrEP use; (2) identify cross‐cutting, transdiagnostic psychological mechanisms that affect consistent PrEP use during these periods and can realistically be targeted with intervention in resource‐limited settings; and (3) develop/adapt and test interventions that target those underlying mechanisms, leveraging strategies from existing interventions that have successfully mitigated mental health barriers to antiretroviral therapy use among people with HIV. Conclusions For PPW, implementation of PrEP should be guided by a robust understanding of the unique psychological difficulties that may act as barriers to uptake, adherence and persistence (i.e. sustained adherence over time). We strongly encourage PrEP implementation research in PPW to incorporate validated mental health screening tools and ultimately treatment in routine antenatal and postnatal care, and we stress the potential public health benefits of identifying women who face mental health barriers to PrEP use.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

The importance of assessing and addressing mental health barriers to PrEP use during pregnancy and postpartum in sub‐Saharan Africa: state of the science and research priorities

et al. 2022

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“…We conducted surveys with participants enrolled in an observational cohort study assessing daily oral PrEP initiation and persistence among pregnant and breastfeeding women (PBFW) in Cape Town, South Africa (PrEP-PP) and an observational extension cohort of a cluster randomized trial offering daily oral PrEP among PBFW in Western Kenya (PrIMA-X)[23,24]. Eligibility criteria for PrEP-PP included: ≥16 years old, confirmed HIV-negative serostatus by a 4 th generation antigen/antibody combination HIV test (Abbott), intention to stay in Cape Town through the postpartum period, and no contraindications to PrEP use.…”

Section: Methodsmentioning

confidence: 99%

“…Daily oral tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) pre-exposure prophylaxis (PrEP) for HIV prevention is being rapidly scaled in South Africa and Kenya, and these two countries have the highest and second highest number of PrEP initiations globally[11]. Studies have reported high rates of oral PrEP uptake among pregnant and postpartum women in South Africa and Kenya[12,13]. However, the delivery of daily oral PrEP among pregnant and postpartum women is challenged by insufficient integration of PrEP provision and counseling into existing antenatal and postpartum systems[14].…”

Section: Introductionmentioning

confidence: 99%

Preferences and Acceptability for Long-Acting PrEP Agents Among Pregnant and Postpartum Women with Experience Using Daily Oral PrEP in South Africa and Kenya

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Mvududu

Marwa

et al. 2022

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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.

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“…Despite the promise of PrEP, significant implementation challenges exist [ 14 ]. Evidence suggests that PrEP may be highly acceptable among PrEP‐naïve women, yet attrition and non‐adherence are significant challenges for women using PrEP [ 15 , 16 , 17 , 18 , 19 ]. Women in PrEP trials have had consistently poor adherence despite adherence support [ 20 ].…”

Section: Introductionmentioning

confidence: 99%

Understanding PrEP decision making among pregnant women in Lilongwe, Malawi: A mixed‐methods study

et al. 2022

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Introduction Pre‐exposure prophylaxis (PrEP) is a promising tool for HIV prevention during pregnancy. With increasing rollout in antenatal settings, counselling strategies to help pregnant women make appropriate decisions about PrEP use are needed. Understanding women's motivations and concerns for PrEP use—and how these inform their decision making and feelings about the decision to start PrEP—are critical to inform these strategies. Methods We conducted a convergent mixed‐methods study from June 2020 to June 2021 in the context of a PrEP adherence support trial among HIV‐negative pregnant women in Lilongwe, Malawi. Two hundred women completed a survey reporting their motivations and concerns about PrEP use, and their feelings about the decision to start PrEP (Decisional Regret Scale). Thirty women completed in‐depth interviews to better understand the decision‐making process, including motivations and concerns weighed in women's decision to use PrEP. Analyses comprised descriptive and bivariate statistics, thematic qualitative analysis, and integration of quantitative and qualitative results. Results Women initiating PrEP during pregnancy were highly motivated to obtain HIV protection for themselves and their unborn child, often due to perceived HIV risk connoted by a recent sexually transmitted infection and/or concerns about partner non‐monogamy. These motivations prevailed despite some concerns about safety and side effects, anticipated stigmatization, and concerns about adherence burden and pill attributes. Many women had informed their partner of their decision to use PrEP yet few felt their decision was contingent upon partner approval. Most women felt positively about the decision to start PrEP (mean decisional regret = 1.2 out of 5), but those with a greater number of concerns reported greater decisional regret (B = 0.036; p = 0.005). Furthermore, women who were specifically concerned about partner disclosure, who disliked pills or who had no perceived HIV risk reported greater decisional regret. Conclusions Pregnant women were strongly motivated by the promise of HIV protection offered by PrEP and accepted it despite diverse concerns. A shared decision‐making approach that centres pregnant women and offers partner involvement may help identify and address initial concerns about PrEP use and support prevention‐effective use of PrEP during this important period.

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Early pre‐exposure prophylaxis (PrEP) initiation and continuation among pregnant and postpartum women in antenatal care in Cape Town, South Africa

Cited by 49 publications

References 30 publications

The importance of assessing and addressing mental health barriers to PrEP use during pregnancy and postpartum in sub‐Saharan Africa: state of the science and research priorities

The importance of assessing and addressing mental health barriers to PrEP use during pregnancy and postpartum in sub‐Saharan Africa: state of the science and research priorities

Preferences and Acceptability for Long-Acting PrEP Agents Among Pregnant and Postpartum Women with Experience Using Daily Oral PrEP in South Africa and Kenya

Understanding PrEP decision making among pregnant women in Lilongwe, Malawi: A mixed‐methods study

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