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

Abstract

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.

A Patient-Centered, Combination Intervention to Support Adherence to HIV Pre-exposure Prophylaxis During Pregnancy and Breastfeeding: A Randomized Pilot Study in Malawi

“…First, numerous factors may be associated with adherence during pregnancy, including male partner engagement, social support, and mental health factors. [37][38][39] Although participants were randomly assigned to study arms, the sample size was small and groups may have been imbalanced according to important covariates. Second, as a pilot trial, we instituted specific eligibility criteria that could limit the generalizability of our findings.…”

The potential benefits of long-acting injectable cabotegravir in pregnant and breastfeeding women and their infants

“…Data on the safety of CAB-LA in PBW are being collected in the open-label extension of HPTN 084 [9], and early data show promise in terms of safety and pharmacology [13]. While we wait for CAB-LA to be provided as 'standard of care', consideration should be given to other strategies to boost oral PrEP adherence, for example, through real-time adherence feedback [6,27], SMS communication [28], and addressing mental health barriers to adherence [29].…”

Early disengagement from HIV pre-exposure prophylaxis services and associated factors among female sex workers in Dar es Salaam, Tanzania: a socioecological approach

“…One of these factors was mental distress. Previous studies have pointed to mental health as a central concern for an effective PrEP care continuum 53 54. Mental health outcomes are typically situated at the individual level, but heavily influenced by social circumstances such as GBV, stigma and poverty, and often considered a sociopsychological factor.…”

“…Of the participants, about a third screened positive for mental distress (n=143, 32.2%), and these had an 18% higher risk of PrEP discontinuation. Mental distress could have affected health-seeking behaviour through pathways such as avoiding social situations, experiencing less interest and engagement in things and feelings of anxiety 54. Combining mental health services with HIV prevention and treatment could produce synergistic effects.…”

“…Mental distress could have affected health-seeking behaviour through pathways such as avoiding social situations, experiencing less interest and engagement in things and feelings of anxiety. 54 Combining mental health services with HIV prevention and treatment could produce synergistic effects. In this way, PrEP care could serve as an entry point for promoting mental health, and vice versa.…”