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

Abstract

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.

Barriers to Oral HIV Pre-exposure Prophylaxis (PrEP) Adherence Among Pregnant and Post-partum Women from Cape Town, South Africa

“…Of concern, a modelling study has predicted that 76,000 new cases of vertical transmission can be expected in South Africa between 2020 and 2030 if PrEP is not taken to scale with high levels of acceptance and persistence [ 12 ]. While some studies have identified barriers to PrEP adherence among pregnant and postpartum women such as stigma, overlapping side effects of PrEP use and pregnancy, and remembering to take PrEP [ 13 – 16 ], PrEP services for this population are limited [ 17 ], therefore data on PrEP use and adherence to PrEP among pregnant and postpartum women is sparse.…”

Daily Oral Pre-exposure Prophylaxis (PrEP) Continuation Among Women from Durban, South Africa, Who Initiated PrEP as Standard of Care for HIV Prevention in a Clinical Trial

“…An additional consideration is who a person discloses to, and the study among AGYW found that partners and parents provided the most support to participants who disclosed oral PrEP use [ 25 ]. Stigma was also found to be a barrier to oral PrEP continuation among pregnant women in South Africa [ 26 ]. We found that women who felt they would probably or definitely get infected with HIV had reduced odds of continuing oral PrEP at the final study visit.…”

“…This might be related to the timing of the questionnaire, as it was administered approximately 3 months after oral PrEP initiation, and women might have felt less at risk because of using daily oral PrEP. Alternatively, it is possible that women who felt at increased risk for HIV acquisition experienced additional challenges and barriers to oral PrEP continuation such as partner-related issues (i.e., difficulties with disclosure of oral PrEP use and issues relating to trust and/or fidelity in the relationship) or stigma (fear that others may think that oral PrEP is treatment for HIV) [ 26 ]. Surprisingly, women who had more than one sex partner had reduced odds of continuing oral PrEP, and this is an area that requires further exploration.…”

Influences on PrEP Uptake and Adherence Among South African Women During Periconception and Pregnancy: A Qualitative Analysis

“…More closely related to the present research is a small cluster of recent reports of PrEP use during pregnancy and postpartum for women in urban and rural settings in South Africa [42][43][44]. These investigations identified a number of the same concerns and influences on adherence that emerged from the present study, including the desire to remain free of HIV, fear of HIV-related stigma, the perception of being at high risk as a result of partner behavior, and disclosure of PrEP use and partner support.…”