Influences on willingness to use vaginal or oral HIV PrEP during pregnancy and breastfeeding in Africa: the multisite MAMMA study

Abstract

IntroductionWomen in sub‐Saharan Africa spend a substantial portion of their reproductive lives pregnant and/or breastfeeding (P/BF), yet they have limited options to prevent HIV during these maternal stages. In preparation for phase 3b prevention trials in P/BF women, we explored attitudes about using a vaginal ring or oral pills for pre‐exposure prophylaxis (PrEP), perceptions of HIV risk during P/BF and key influences on future PrEP use.MethodsIn 2018, we conducted 16 single‐sex focus group discussions (FGDs) with community‐ and clinic‐recruited HIV‐uninfected women, currently or recently P/BF, aged 18 to 40, and men with (currently or recently) P/BF partners, aged 18+. Participants completed a behavioural questionnaire, viewed an educational video and handled prototype placebo products. FGDs were conducted in local languages and transcribed, coded and analysed, using a socio‐ecological framework, for key influences on willingness to use products, HIV risk perceptions and opinions on product attributes.ResultsOf the 128 participants (65 women, 63 men) 75% lived with their partner and 84% had a child. Women reported the most important influencers when P/BF were partners, and all stated that health decisions when P/BF are typically made jointly (e.g. medication use; ante/postnatal and baby care). There was consensus that P/BF women are at high risk for HIV, primarily because of their partner’s infidelities, and new prevention options were welcomed. Participants valued multiple options and stated that woman’s personal preference would be key to product choice. Anticipated concerns about products included risk of miscarriage, impact on infant development, complications during delivery and adequate production or taste of breastmilk. Specific perceived disadvantages emerged for the ring (e.g. vaginal discomfort, difficulty inserting/removing) and for pills (e.g. nausea/vomiting) that may be exacerbated during pregnancy. Health care providers’ (HCPs) knowledge and approval of product use during P/BF was needed to mitigate anticipated fears.ConclusionsParticipants perceived pregnancy and breastfeeding as high HIV risk periods and valued new prevention options. HIV protection of the mother‐child dyad, safety of the baby, and ultimately, health of the family were paramount. Endorsement by HCPs and support from partners were key to future product acceptance. Participants recommended involving partners and HCPs in sensitization efforts for future trials.

After their wives have delivered, a lot of men like going out: Perceptions of HIV transmission risk and support for HIV prevention methods during breastfeeding in sub‐Saharan Africa

“…Pseudonyms were used to represent different participants in each FGD transcript. Additional details about study procedures can be found in van der Straten et al (2020).…”

“…The data were analysed using framework analysis, a qualitative method for applied research (Srivastava & Thomson, 2009). A codebook of inductive and deductive codes (Data S1) was iteratively developed with staff from the study sites using a modified socio‐ecological framework as previously described (van der Straten et al, 2020). A team of five qualitative analysts, three of whom were involved throughout the study, coded the transcripts using Dedoose software v7.0.23 and maintaining ~80% intercoder reliability.…”

Clinical Drug Trial Participation: Perspectives of Pregnant Women and Their Spouses

“…This is because pregnant women are routinely excluded from clinical trials because of ethical considerations and the fear of potential fetal harm. 3–5 …”

Pregnant and breastfeeding women’s prospective acceptability of two biomedical HIV prevention approaches in Sub Saharan Africa: A multisite qualitative analysis using the Theoretical Framework of Acceptability

“…To address women’s vulnerability to HIV during pregnancy and breastfeeding, evaluating HIV prevention methods that can be initiated and used by the women themselves are important. This includes daily oral Pre- Exposure Prophylaxis (PrEP) [ 4 , 5 ] and monthly vaginal rings [ 6 , 7 ]. The Word Health Organisation recommends offering daily Truvada™ or emtricitabine(FTC) / tenofovir disoproxil fumarate (TDF) pills to women at considerable risk of HIV infection [ 5 ].…”

“…Primary findings indicated that there was consensus amongst men and women, that P/BF women are at higher risk of HIV due to their partners infidelity. Both women and men welcomed new methods of prevention [ 7 ]. Reported influences on future product use included safety considerations for the mother and child dyad; women having support from their partners, men being involved in the decision making process; women expressing the importance of having support from the wider family on decision to use PrEP methods, and endorsement of products by healthcare professionals [ 7 ].…”