“I had Made the Decision, and No One was Going to Stop Me” —Facilitators of PrEP Adherence During Pregnancy and Postpartum in Cape Town, South Africa

Davey, Dvora Joseph; Knight, Lucia; Markt-Maloney, Jackie; Tsawe, Nokwazi; Gomba, Yolanda; Mashele, Nyiko; Dovel, Kathryn; Gorbach, Pamina M.; Bekker, Linda‐Gail; Coates, Thomas J.; Myer, Landon

doi:10.1007/s10461-021-03320-x

Cited by 26 publications

(27 citation statements)

References 34 publications

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“…For example, having a partner who had not been tested for HIV or whose HIV status was unknown was associated with lower odds of retention. Previous studies have identified that home-based HIV testing is a cost-effective intervention associated with higher uptake of couples testing, higher uptake of male partner testing and improved HIV status disclosure [49][50][51]. As high anticipated stigma is associated with lower PrEP initiation and retention, interventions which aim to engage male partners in HIV prevention through partner testing and counseling, awareness building and adherence support could reduce the consistent barrier faced by pregnant and postpartum women who anticipate stigma or limited support from partners and significant others.…”

Section: Discussionmentioning

confidence: 99%

“…We recommend including enhanced counselling around PrEP use disclosure among family and partners and adherence clubs or PrEP ambassadors in antenatal and postnatal services to address anticipated and realized stigma. Disclosure of PrEP use to partners and family members may also help to reduce levels of internalized and anticipated stigma [ 51 ]. For example, having a partner who had not been tested for HIV or whose HIV status was unknown was associated with lower odds of retention.…”

Section: Discussionmentioning

confidence: 99%

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Maternal PrEP Use in HIV-Uninfected Pregnant Women in South Africa: Role of Stigma in PrEP Initiation, Retention and Adherence

et al. 2021

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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.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Maternal PrEP Use in HIV-Uninfected Pregnant Women in South Africa: Role of Stigma in PrEP Initiation, Retention and Adherence

et al. 2021

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“…While safety data are reassuring, more data on how best to provide and optimize PrEP use in pregnancy and the postpartum period are needed. There are multiple large‐scale PrEP in pregnancy programs ongoing in South Africa and Kenya [8,14,15]. Effective PrEP protection requires daily PrEP adherence, but little is known about how minor symptoms, which may occur more commonly during pregnancy, overlap with PrEP side effects and could impact PrEP persistence.…”

Section: Introductionmentioning

confidence: 99%

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

et al. 2022

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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.

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“…Some women were also concerned about partner reactions to their PrEP use. Direct partner education may help address these concerns [ 47 ], and relieve women of the burden of sharing information second‐hand. Though most women had independently decided to use PrEP, there was diversity in partner involvement both before and after the initial decision.…”

Section: Discussionmentioning

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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“I had Made the Decision, and No One was Going to Stop Me” —Facilitators of PrEP Adherence During Pregnancy and Postpartum in Cape Town, South Africa

Cited by 26 publications

References 34 publications

Maternal PrEP Use in HIV-Uninfected Pregnant Women in South Africa: Role of Stigma in PrEP Initiation, Retention and Adherence

Maternal PrEP Use in HIV-Uninfected Pregnant Women in South Africa: Role of Stigma in PrEP Initiation, Retention and Adherence

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

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

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