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Naidoo M, Naidoo KL, Lombard C, Desmond AC, Clark R, Rooney JF, Gray G, Moodley D. In-utero exposure to tenofovir disoproxil fumarate pre-exposure prophylaxis and growth metrics in HIV unexposed breastfed infants in South Africa: a post hoc analysis of the CAP 016 PrEP in pregnancy RCT. Front Pediatr 2024; 12:1447173. [PMID: 39184858 PMCID: PMC11341386 DOI: 10.3389/fped.2024.1447173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2024] [Accepted: 07/16/2024] [Indexed: 08/27/2024] Open
Abstract
Objective We evaluated growth metrics in HIV unexposed African breastfed infants in the first 18 months of life in association with in-utero exposure to Tenofovir Diphosphate Fumarate (TDF) containing pre-exposure prophylaxis (PrEP). Design We conducted a secondary data analysis of a TDF-PrEP randomized control trial (CAP016 RCT). Pregnant women without HIV were randomized to initiating TDF-PrEP in pregnancy (Immediate-PrEP-IP) or deferred initiation of TDF-PrEP at cessation of breastfeeding (Deferred-PrEP-DP). Methods Infant weight (W), length (L), and head circumference (HC) were measured at birth and 6, 26, 50, and 74 weeks of age. Stored dried blood spot samples from pregnant women randomized to the IP arm were used to measure tenofovir-diphosphate (TFV-DP) levels. Age-stratified mean weight-for-age (WAZ), length-for-age (LAZ), weight-for-length (WLZ), and head circumference-for-age (HCAZ) Z-scores were compared between infants exposed to varying TFV-DP concentrations and infants in the DP arm. Results A total of 455 mother-infant pairs were included in the secondary analysis, 228 in the IP arm and 227 in the DP arm. WAZ, LAZ, WLZ, and HCAZ scores were comparable between infants in the Deferred-PrEP arm and Immediate-PrEP arm. In a mixed-effects linear regression model adjusting for maternal age, body mass index, socioeconomic and newborn characteristics, in-utero exposure to varying TFV-DP levels was not associated with WAZ (β = -0.52), LAZ (β = -0.46), WLZ (β = -0.43) and HCAZ (β = -0.11) scores over time. Conclusion There was no evidence of an association between growth metrics in the first 18 months of life and in-utero exposure to TFV-DP among breastfed HIV unexposed infants.
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Affiliation(s)
- Megeshinee Naidoo
- Centre for the Program of AIDS Research in South Africa (CAPRISA), Durban, South Africa
| | - Kimesh L. Naidoo
- Department of Paediatrics and Child Health, School of Clinical Medicine, University of KwaZulu Natal, Durban, South Africa
| | - Carl Lombard
- Biostatistics Unit, South African Medical Research Council, Tygerberg, South Africa
- Division of Epidemiology and Biostatistics, Department of Global Health, University of Stellenbosch, Tygerberg, South Africa
| | - Alicia C. Desmond
- Centre for the Program of AIDS Research in South Africa (CAPRISA), Durban, South Africa
| | | | | | - Glenda Gray
- South African Medical Research Council, Cape Town, South Africa
| | - Dhayendre Moodley
- Centre for the Program of AIDS Research in South Africa (CAPRISA), Durban, South Africa
- Department of Obstetrics and Gynaecology, School of Clinical Medicine, University of KwaZulu Natal, Durban, South Africa
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Broad J, Robertson RC, Evans C, Perussolo J, Lum G, Piper JD, Loucaides E, Ziruma A, Chasekwa B, Ntozini R, Bourke CD, Prendergast AJ. Maternal inflammatory and microbial drivers of low birthweight in low- and middle-income countries. Paediatr Int Child Health 2024; 44:79-93. [PMID: 39066726 DOI: 10.1080/20469047.2024.2380974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 07/10/2024] [Indexed: 07/30/2024]
Abstract
BACKGROUND Low birthweight (LBW) is when an infant is born too soon or too small, and it affects one in seven infants in low- and middle-income countries. LBW has a significant impact on short-term morbidity and mortality, and it impairs long-term health and human capital. Antenatal microbial and inflammatory exposure may contribute to LBW. METHODS Ovid-Medline, Embase and Cochrane databases were searched for English-language articles evaluating inflammatory, microbial or infective causes of LBW, small-for-gestational age, intra-uterine growth restriction or prematurity. Inclusion criteria were human studies including published data; conference abstracts and grey literature were excluded. A narrative synthesis of the literature was conducted. RESULTS Local infections may drive the underlying causes of LBW: for example, vaginitis and placental infection are associated with a greater risk of prematurity. Distal infection and inflammatory pathways are also associated with LBW, with an association between periodontitis and preterm delivery and environmental enteric dysfunction and reduced intra-uterine growth. Systemic maternal infections such as malaria and HIV are associated with LBW, even when infants are exposed to HIV but not infected. This latter association may be driven by chronic inflammation, co-infections and socio-economic confounders. Antimicrobial prophylaxis against other bacteria in pregnancy has shown minimal impact in most trials, though positive effects on birthweight have been found in some settings with a high infectious disease burden. CONCLUSION Maternal inflammatory and infective processes underlie LBW, and provide treatable pathways for interventions. However, an improved understanding of the mechanisms and pathways underlying LBW is needed, given the impact of LBW on life-course.
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Affiliation(s)
- Jonathan Broad
- Maternal and Child Health Research Department, Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
- Blizard Institute, Queen Mary University of London, London, UK
- Paediatrics Department, Croydon University Hospital, London, UK
| | - Ruairi C Robertson
- Maternal and Child Health Research Department, Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
- Blizard Institute, Queen Mary University of London, London, UK
| | - Ceri Evans
- Maternal and Child Health Research Department, Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
- Blizard Institute, Queen Mary University of London, London, UK
- Institute of Infection, Veterinary and Ecological Sciences, Liverpool, UK
| | - Jeniffer Perussolo
- Maternal and Child Health Research Department, Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
- Blizard Institute, Queen Mary University of London, London, UK
| | - Gina Lum
- Centre for Genomics and Child Health, Barts and The London School of Medicine and Dentistry, London, UK
| | - Joe D Piper
- Maternal and Child Health Research Department, Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
- Blizard Institute, Queen Mary University of London, London, UK
| | - Eva Loucaides
- Paediatrics Department, Croydon University Hospital, London, UK
| | - Asaph Ziruma
- Blizard Institute, Queen Mary University of London, London, UK
| | - Bernard Chasekwa
- Maternal and Child Health Research Department, Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
- Blizard Institute, Queen Mary University of London, London, UK
| | - Robert Ntozini
- Maternal and Child Health Research Department, Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
- Blizard Institute, Queen Mary University of London, London, UK
| | - Claire D Bourke
- Maternal and Child Health Research Department, Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
- Blizard Institute, Queen Mary University of London, London, UK
| | - Andrew J Prendergast
- Maternal and Child Health Research Department, Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
- Blizard Institute, Queen Mary University of London, London, UK
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Young AM, Stoner MCD, Mathebula F, Mohuba R, Baez A, Seyama L, Mutero P, Etima J, Fabiano Z, Fairlie L, Mayo AJ, Balkus JE, Song M, Bunge K, Piper J, Balan IC, van der Straten A, Montgomery ET. Acceptability of the Dapivirine Vaginal Ring and Daily Oral Pre-exposure Prophylaxis (PrEP) during Pregnancy in Malawi, South Africa, Uganda, and Zimbabwe. AIDS Behav 2024:10.1007/s10461-024-04421-z. [PMID: 39052199 DOI: 10.1007/s10461-024-04421-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/18/2024] [Indexed: 07/27/2024]
Abstract
Pregnant and lactating persons in sub-Saharan Africa face a heightened risk of HIV acquisition, due to biological and behavioral factors, combined with limited access to prevention and treatment services. Oral pre-exposure prophylaxis (PrEP) and the dapivirine vaginal ring are promising tools for HIV prevention, and the ring's recent approval in multiple African countries represents a significant advancement in expanding access to HIV prevention. In a nested qualitative study within the MTN-042 trial, we explored the acceptability of study products among pregnant persons in the second and early third trimesters. Interviews were conducted privately, using a semi-structured guide with 77 participants, in participants' preferred language. Topics explored included product acceptability (using the theoretical framework of acceptability), user experience, satisfaction, disclosure, community attitudes, and sexual activity during pregnancy. Interview transcripts were analyzed using Dedoose software. We observed positive attitudes among participants towards the study products, which they found generally user-friendly, despite the added complexities of using them during pregnancy. Participants recognized that consistent and correct use would provide protection for both them and their unborn children. Although initial concerns existed, most of these worries dissipated over time, with study staff support and increased product use experience. These findings emphasize the importance of continued surveillance, support, and education to ensure the successful rollout of new HIV prevention measures during pregnancy.
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Affiliation(s)
- Alinda M Young
- Women's Global Health Imperative at RTI International, 2150 Shattuck Avenue, Berkeley, CA, 94104, USA.
- Department of Maternal and Child Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Marie C D Stoner
- Women's Global Health Imperative at RTI International, 2150 Shattuck Avenue, Berkeley, CA, 94104, USA
| | - Florence Mathebula
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Rebone Mohuba
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Alejandro Baez
- Women's Global Health Imperative at RTI International, 2150 Shattuck Avenue, Berkeley, CA, 94104, USA
| | - Linly Seyama
- Johns Hopkins Project - Kamuzu University of Health Science, Blantyre, Malawi
| | - Prisca Mutero
- University of Zimbabwe - Clinical Trials Research Centre, 15 Phillips Road, Belgravia, Harare, Zimbabwe
| | - Juliane Etima
- Makerere University - Johns Hopkins University Research Collaboration, Upper Mulago Hill Road Kampala, Kampala, Uganda
| | - Zayithwa Fabiano
- Johns Hopkins Project - Kamuzu University of Health Science, Blantyre, Malawi
| | - Lee Fairlie
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Ashley J Mayo
- FHI 360, 359 Blackwell St., Suite 200, Durham, NC, USA
| | - Jennifer E Balkus
- Department of Epidemiology, University of Washington School of Public Health, Seattle, USA
- Vaccine and Infectious Disease Division, Fred Hutch Cancer Center, Seattle, USA
| | - Mei Song
- Magee-Women's Hospital of UPMC, 300 Halket Street, Pittsburgh, PA, USA
| | | | | | - Ivan C Balan
- Department of Behavioral Science and Social Medicine, Florida State University College of Medicine, Tallahassee, FL, USA
| | - Ariane van der Straten
- ASTRA consulting, 256 Stanford Avenue, Kensington, CA, USA
- Center for AIDS Prevention Studies (CAPS) UCSF, San Franscico, CA, USA
| | - Elizabeth T Montgomery
- Women's Global Health Imperative at RTI International, 2150 Shattuck Avenue, Berkeley, CA, 94104, USA
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Chhun N, Rothschild CW, Penumetsa M, Matemo D, Kithao P, Richardson BA, John-Stewart G, Kinuthia J, Drake AL. Evaluating the performance of a risk assessment score tool to predict HIV acquisition among pregnant and postpartum women in Kenya. PLoS One 2024; 19:e0306992. [PMID: 38985777 PMCID: PMC11236202 DOI: 10.1371/journal.pone.0306992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 06/25/2024] [Indexed: 07/12/2024] Open
Abstract
BACKGROUND Clinical risk score tools require validation in diverse settings and populations before they are widely implemented. We aimed to externally validate an HIV risk assessment tool for predicting HIV acquisition among pregnant and postpartum women. In the context of prevention of mother-to-child transmission programs, risk score tools could be used to prioritize retesting efforts and delivery of pre-exposure prophylaxis (PrEP) to pregnant and postpartum women most at risk for HIV acquisition while minimizing unnecessary perinatal exposure. METHODS Data from women enrolled in a cross-sectional study of programmatic HIV retesting and/or receiving maternal and child health care services at five facilities in Western Kenya were used to validate the predictive ability of a simplified risk score previously developed for pregnant/postpartum women. Incident HIV infections were defined as new HIV diagnoses following confirmed negative or unknown status during pregnancy. Predictive performance was assessed using the area under the receiver operating characteristic curve (AUC) and Brier score. RESULTS Among 1266 women with 35 incident HIV infections, we found an AUC for predicting HIV acquisition of 0.60 (95% CI, 0.51, 0.69), with a Brier score of 0.27. A risk score >6 was associated with a 2.9-fold increase in the odds of HIV acquisition (95% CI, 1.48, 5.70; p = 0.002) vs scores ≤6. Women with risk scores >6 were 27% (346/1266) of the population but accounted for 52% of HIV acquisitions. Syphilis, age at sexual debut, and unknown partner HIV status were significantly associated with increased risk of HIV in this cohort. CONCLUSION The simplified risk score performed moderately at predicting risk of HIV acquisition in this population of pregnant and postpartum women and may be useful to guide PrEP use or counseling.
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Affiliation(s)
- Nok Chhun
- Department of Global Health, University of Washington, Seattle, WA, United States of America
| | - Claire W. Rothschild
- Department of Epidemiology, University of Washington, Seattle, WA, United States of America
| | - Monalisa Penumetsa
- Department of Epidemiology, University of Washington, Seattle, WA, United States of America
| | - Daniel Matemo
- Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Peninah Kithao
- Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Barbra A. Richardson
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- Department of Biostatistics, University of Washington, Seattle, WA, United States of America
| | - Grace John-Stewart
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- Department of Epidemiology, University of Washington, Seattle, WA, United States of America
- Department of Medicine, University of Washington, Seattle, WA, United States of America
- Department of Pediatrics, University of Washington, Seattle, WA, United States of America
| | - John Kinuthia
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Alison L. Drake
- Department of Global Health, University of Washington, Seattle, WA, United States of America
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Liu Y, Zhang L, Chen H. Barriers and facilitators to uptake and use of oral pre-exposure prophylaxis in pregnant and postpartum women: a qualitative meta-synthesis. BMC Public Health 2024; 24:1653. [PMID: 38902766 PMCID: PMC11191323 DOI: 10.1186/s12889-024-19168-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 06/17/2024] [Indexed: 06/22/2024] Open
Abstract
BACKGROUND Acute HIV infection during pregnancy and in the postpartum period increases the risk of vertical transmission. The World Health Organization (WHO) has recommended preexposure prophylaxis for pregnant and postpartum women at risk of acquiring HIV. However, there are significant gaps between the actual practice and the ideal goal of preexposure prophylaxis implementation among pregnant and postpartum women. Therefore, it is important to determine what influences women's implementation of preexposure prophylaxis during pregnancy and in the postpartum period. This review aims to aggregate barriers and facilitators to preexposure prophylaxis implementation among pregnant and postpartum women. METHODS A range of electronic databases, including PubMed, CINAHL Plus with Full Text, Embase, and Web of Science, were searched for potentially relevant qualitative studies. The search period extended from the establishment of the databases to March 16, 2023. This review used the ENTREQ (Enhancing transparency in reporting of qualitative research synthesis) statement to guide the design and reporting of qualitative synthesis. The methodological quality of the included studies was assessed using the Joanna Briggs Institute Critical Appraisal Checklist. The JBI meta-aggregation method was applied for guiding the data extraction, and the JBI ConQual method was applied for guiding the evaluation of the level of evidence for the synthesis. RESULTS Of retrieved 2042 studies, 12 met the inclusion criteria. The total population sample included 447 participants, including 231 pregnant and postpartum women, 21 male partners, 75 healthcare providers (HCPs)/healthcare workers (HCWs), 18 policymakers, 37 mothers, and 65 women of childbearing age. A total of 149 findings with credibility ratings of "unequivocal" or "equivocal" were included in this meta-synthesis. Barriers and facilitators to preexposure prophylaxis implementation were coded into seven categories, including three facilitator categories: perceived benefits, maintaining relationships with partners, and external support, and four barriers: medication-related barriers, stigma, barriers at the level of providers and facilities, and biases in risk perception. CONCLUSION This systematic review and meta-synthesis aggregated the barriers and facilitators of preexposure prophylaxis implementation among pregnant and postpartum women. We aggregated several barriers to maternal preexposure prophylaxis implementation, including medication-related factors, stigma, barriers at the level of providers and facilities, and risk perception biases. Therefore, intervention measures for improving preexposure prophylaxis services can be developed based on these points. PROSPERO NUMBER CRD42023412631.
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Affiliation(s)
- Ying Liu
- West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, Sichuan, China
| | - Liao Zhang
- West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, Sichuan, China
| | - Hong Chen
- West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, Sichuan, China.
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Erlwanger A, Rocroi I, Kirtley S, Hemelaar J. Perinatal outcomes associated with pre-exposure prophylaxis for HIV prevention during pregnancy: a systematic review and meta-analysis. EClinicalMedicine 2024; 70:102532. [PMID: 38685925 PMCID: PMC11056414 DOI: 10.1016/j.eclinm.2024.102532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 02/21/2024] [Accepted: 02/22/2024] [Indexed: 05/02/2024] Open
Abstract
Background The World Health Organization (WHO) recommends tenofovir disoproxil fumarate (TDF)-based oral pre-exposure prophylaxis (PrEP), the dapivirine vaginal ring, and long-acting intramuscular injectable cabotegravir (CAB-LA) for HIV prevention in populations at substantial risk of HIV infection. Pregnancy is a period of elevated risk of maternal HIV infection and transmission to the infant. This systematic review and meta-analysis assessed the risk of adverse perinatal outcomes among HIV-negative pregnant women with exposure to any PrEP modality. Methods We conducted a systematic review by searching Medline, EMBASE, CINAHL, Global Health, the Cochrane Library, WHO ICTR, ISRCTN, PACTR, and ClinicalTrials.gov for studies published between 1 January 2000 and 29 August 2023. We included studies reporting on the association of antenatal exposure to any PrEP modality with 13 perinatal outcomes: preterm birth (PTB), very PTB, spontaneous PTB, spontaneous very PTB, low birthweight (LBW), very LBW, term LBW, preterm LBW, small for gestational age (SGA), very SGA, miscarriage, stillbirth, or neonatal death (NND). Quality assessments of included studies were performed. Fixed-effect meta-analyses were conducted to calculate odds ratios (ORs) and 95% confidence intervals (95% CIs). The protocol is registered with PROSPERO, CRD42022339825. Findings Of 18,598 citations identified, 13 studies (eight randomised controlled trials (RCTs) and five cohort studies), assessing 8712 pregnant women in Africa, were included. Oral PrEP, compared to no PrEP, was not associated with PTB in meta-analyses of six RCTs (OR 0.73, 95% CI 0.43-1.26; I2 = 0.0%) or five unadjusted cohort studies (OR 0.84, 95% CI 0.69-1.03; I2 = 0.0%), but was associated with a reduced risk of PTB in three adjusted cohort studies (aOR 0.67; 95% CI 0.52-0.88, I2 = 0.0%). There was no association of oral PrEP with LBW, vLBW, SGA, or NND, compared to no PrEP. There was no association with PTB when oral TDF/emtricitabine (FTC) PrEP, oral TDF PrEP, and tenofovir vaginal gel were compared to each other. There was no association of the dapivirine vaginal ring with PTB or NND, compared to placebo or oral TDF/FTC PrEP. We found no data on CAB-LA. Interpretation We found no evidence of adverse perinatal outcomes associated with PrEP exposure during pregnancy. Our findings support the WHO recommendation to provide oral PrEP to women of reproductive age and pregnant women. More data is needed to assess the safety of all PrEP modalities in pregnancy. Funding None.
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Affiliation(s)
- Alison Erlwanger
- National Perinatal Epidemiology Unit, Infectious Disease Epidemiology Unit, Oxford Population Health, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Isabelle Rocroi
- National Perinatal Epidemiology Unit, Infectious Disease Epidemiology Unit, Oxford Population Health, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Shona Kirtley
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Joris Hemelaar
- National Perinatal Epidemiology Unit, Infectious Disease Epidemiology Unit, Oxford Population Health, Nuffield Department of Population Health, University of Oxford, Oxford, UK
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Henderson AC, Cholli P, Lampe MA, Kourtis AP. Challenges, risks, and opportunities of antiretroviral drugs in women of reproductive potential. Expert Rev Anti Infect Ther 2024; 22:153-167. [PMID: 38517686 DOI: 10.1080/14787210.2024.2334054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 03/19/2024] [Indexed: 03/24/2024]
Abstract
INTRODUCTION The HIV/AIDS epidemic has been one of the greatest challenges in global health, significantly affecting women of reproductive potential. Considerable advances in antiretroviral therapy for women living with HIV have contributed to improvements in quality of life, better reproductive and birth outcomes, and a reduced risk of perinatal transmission. AREAS COVERED Despite the progress made, persistent challenges in access and adherence to antiretroviral drugs may limit their benefits for some women. More pharmacokinetic and safety studies in pregnant and lactating women are urgently needed, as are prospective surveillance systems to evaluate associations between fetal and infant antiretroviral exposures, drug-drug interactions, and pregnancy outcomes. EXPERT OPINION Multipurpose technologies, such as combined HIV and other STI or unintended pregnancy prevention, and innovative delivery methods, such as the development of long-acting antiretrovirals, have the potential to reduce adherence challenges and enhance quality of life for women with HIV. Parallel advances in drug safety testing and surveillance are needed to ensure the health and safety of women with or at risk for HIV and children at risk for perinatal transmission.
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Affiliation(s)
- Alexis C Henderson
- Division of HIV Prevention, National Center for HIV, Viral Hepatitis, STD and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Preetam Cholli
- Division of HIV Prevention, National Center for HIV, Viral Hepatitis, STD and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Margaret A Lampe
- Division of HIV Prevention, National Center for HIV, Viral Hepatitis, STD and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Athena P Kourtis
- Division of HIV Prevention, National Center for HIV, Viral Hepatitis, STD and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
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Van Praet JT, Henrard S, Kenyon C, Libois A, Meuwissen A, Sauvage AS, Vincent A, Vanhamel J, Scheerder G. Belgian 2024 guidance on the use of pre-exposure prophylaxis. Acta Clin Belg 2024; 79:121-129. [PMID: 38775082 DOI: 10.1080/17843286.2024.2356337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Accepted: 05/12/2024] [Indexed: 05/24/2024]
Abstract
OBJECTIVES We aimed to develop a guidance on the use of pre-exposure prophylaxis (PrEP) for HIV tailored to the Belgian context. METHODS Different aspects of PrEP care were judged by an expert group of nine Belgian clinicians, seeking consensus for areas of controversies. RESULTS PrEP should be considered in HIV negative patients at high risk of acquiring HIV. Currently, only oral tenofovir/emtricitabine is available in Belgium for PrEP, which can be used daily, or also event-driven in cisgender men and trans women who are not taking exogenous estradiol-based hormones. Personal counselling directed at medication adherence and sexual health should have a central role in PrEP care. At the initial assessment clinicians should give attention to symptoms of an acute HIV infection, the patients' immunization status and renal function. A regular follow-up must be set up to diagnose HIV seroconversion, treat sexually transmitted infections, and manage side effects of PrEP. CONCLUSION The Belgian guidance on the use of PrEP provides a point of reference for standard PrEP care in Belgium and will be periodically updated.
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Affiliation(s)
- Jens T Van Praet
- Department of Nephrology and Infectious Diseases, AZ Sint-Jan Brugge AV, Brugge, Belgium
| | - Sophie Henrard
- Department of Internal Medicine and Immunodeficiency, Clinique Universitaire de Bruxelles - Hôpital Erasme, Brussels, Belgium
| | - Chris Kenyon
- Department of Clinical Sciences, Institute of Tropical Medicine Antwerp, Antwerp, Belgium
| | - Agnès Libois
- Department of Infectious Diseases, Saint Pierre University Hospital, Brussels, Belgium
| | - Annelies Meuwissen
- Department of Internal Medicine, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Anne-Sophie Sauvage
- Department of Infectious Diseases, Liège University Hospital, Liège, Belgium
| | - Anne Vincent
- Department of Internal Medicine, Cliniques Universitaires, Saint-Luc, Brussels, Belgium
| | - Jef Vanhamel
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Gert Scheerder
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
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Montgomery ET, Hawley I, Fairlie L, Bunge K, Mathebula F, Etima J, Mutero P, Senyama L, Mayo A, Stoner MCD, Piper J, Balan I, van der Straten A. Acceptability of the Dapivirine Vaginal Ring and Oral Truvada Among African Users in Late-Stage of Pregnancy. AIDS Behav 2024; 28:963-973. [PMID: 37932492 PMCID: PMC10896786 DOI: 10.1007/s10461-023-04203-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2023] [Indexed: 11/08/2023]
Abstract
The Microbicide Trials Network 042 study (MTN-042/DELIVER) is a two-arm, randomized, open-label Phase 3b trial that is evaluating the safety, adherence, and acceptability of the monthly ring and daily oral PrEP among HIV-uninfected pregnant people in four African countries. This analysis focuses on acceptability data captured qualitatively from a subset (n = 48) of the 150 people in the first cohort of the trial who were enrolled in late-stage pregnancy at 36 to 38 weeks gestational age and followed until after delivery. Single IDIs were conducted by trained interviewers at each clinic site using a semi-structured guide. Data excerpts of key codes pertaining to acceptability, pregnancy, and maternal health were summarized, reviewed and interpreted by multinational analyst teams. Although the product use period was relatively short, the data suggested several acceptability findings that may directly translate to longer durations of product use in pregnancy. The first was the overarching maternal sentiment that being able to protect both oneself and their baby was highly valued. The second was the importance of counseling support from providers not only because participants used methods that might generate side effects, but because pregnancy itself is a period with its own set of side effects. The third was that, similar to non-pregnant participants in other trials, here study products were generally liked and described as easy to use. Concerns about ring and oral PrEP use could be addressed with provider counseling and support and should form an essential component rollout among pregnant people.
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Affiliation(s)
- Elizabeth T Montgomery
- Women's Global Health Imperative, RTI International, 2150 Shattuck Avenue, Berkeley, CA, 94104, USA.
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA.
| | - Imogen Hawley
- Women's Global Health Imperative, RTI International, 2150 Shattuck Avenue, Berkeley, CA, 94104, USA
| | - Lee Fairlie
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Katie Bunge
- MMWRI, University of Pittsburgh, Pittsburgh, PA, USA
| | - Florence Mathebula
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Juliane Etima
- Makerere University - Johns Hopkins University (MU-JHU) Research Collaboration, Kampala, Uganda
| | - Prisca Mutero
- Clinical Trials Research Centre, University of Zimbabwe, Harare, Zimbabwe
| | - Linly Senyama
- Johns Hopkins Project, College of Medicine, University of Malawi, Blantyre, Malawi
| | | | - Marie C D Stoner
- Women's Global Health Imperative, RTI International, 2150 Shattuck Avenue, Berkeley, CA, 94104, USA
| | | | - Ivan Balan
- Department of Behavioral Science and Social Medicine, Florida State University College of Medicine, Tallahassee, FL, USA
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10
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Joseph Davey DL, Nyemba DC, Mvududu R, Mashele N, Johnson L, Bekker LG, Dean SS, Bheemraj K, Coates TJ, Myer L. Pregnancy outcomes following self-reported and objective-measured exposure to oral preexposure prophylaxis in South Africa. AIDS 2024; 38:75-83. [PMID: 37720980 PMCID: PMC10715696 DOI: 10.1097/qad.0000000000003729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 09/05/2023] [Accepted: 09/07/2023] [Indexed: 09/19/2023]
Abstract
OBJECTIVE To compare pregnancy outcomes using self-reported and objective levels of intracellular tenofovir diphosphate (TFV-DP) in pregnant women using preexposure prophylaxis (PrEP). DESIGN We enrolled pregnant women >15 years without HIV at first antenatal care visit in an observational cohort study to compare pregnancy outcomes by PrEP use. METHODS Exposure defined as: any PrEP use [tenofovir disoproxil and emtricitabine (TDF/FTC]) prescription + reported taking PrEP], or objectively-measured TFV-DP in dried blood spots in PrEP-using pregnant women. The primary outcome was a composite of pregnancy loss, preterm birth (<37weeks), low birthweight (<2500 g), small for gestational age ([SGA] ≤ tenth percentile), or neonatal death. Multivariable logistic regression models evaluated individual and composite adverse outcomes by self-reported or objectively measured PrEP use adjusting for age, gestational age, gravidity and socio-economic status. RESULTS Between August 19 and February 23, we followed 1195 pregnant women and ascertained 1145 pregnancy outcomes (96%); 72% ( n = 826) reported taking PrEP while pregnant, 16% did not take PrEP ( n = 178), 12% were unconfirmed ( n = 141). Overall, 94.5% ( n = 1082) had singleton live births with a median birthweight of 3.2 kg [interquartile range (IQR) = 2.9-3.5], with no difference in pregnancy loss between self-reported PrEP exposed vs. unexposed [4.0 vs. 5.6%; adjusted odds ratio (aOR) = 0.65, 95% confidence interval (CI) = 0.32-1.47]. Composite adverse outcomes did not differ by reported PrEP use (20% for both groups; aOR = 1.07, 95% CI = 0.71-1.63). Comparing objective PrEP use (any TFV-DP vs. no TFV-DP or not on PrEP), adverse outcomes did not differ (aOR = 0.64, 95% CI = 0.39-1.04), nor did other outcomes including preterm birth nor SGA. CONCLUSIONS Pregnancy outcomes did not differ by PrEP exposure (self-reported or objective), suggesting real-world efficacy that TDF/FTC as PrEP is safe in pregnancy.
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Affiliation(s)
- Dvora Leah Joseph Davey
- Department of Epidemiology, Fielding School of Public Health
- Division of Infectious Diseases, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town
| | - Dorothy C. Nyemba
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town
- Wits RHI, University of the Witwatersrand, Johannesburg
| | - Rufaro Mvududu
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town
| | - Nyiko Mashele
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town
| | - Leigh Johnson
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa
| | | | - Sarah Schoetz Dean
- Department of Epidemiology, Fielding School of Public Health
- Division of Infectious Diseases, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Kalisha Bheemraj
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town
| | - Thomas J. Coates
- Division of Infectious Diseases, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Landon Myer
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town
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11
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Khumalo PN, Mkhonta SS, Kindandi K, Matse S, Dlamini PB, Tukei V, Machekano R, Woelk G. Uptake of and intention to use oral pre-exposure prophylaxis for HIV among pregnant and post-natal women in Eswatini: a cross-sectional survey. FRONTIERS IN REPRODUCTIVE HEALTH 2023; 5:1253384. [PMID: 37965589 PMCID: PMC10641516 DOI: 10.3389/frph.2023.1253384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 10/11/2023] [Indexed: 11/16/2023] Open
Abstract
Introduction In Eswatini, HIV incidence among women of childbearing age is 1.45%. Eswatini introduced oral pre-exposure prophylaxis (PrEP) for HIV prevention in 2016 and requires that all HIV-negative pregnant and post-natal women (PPW) visiting health care facilities be offered PrEP. Methods Between September-November 2021, we conducted a survey among HIV-negative PPW from 16 purposively selected healthcare facilities in the Hhohho and Shiselweni regions in Eswatini. We interviewed consenting HIV-negative PPW using a structured questionnaire to collect data on PrEP knowledge, attitudes, intentions, and practices, as well as information on partner HIV status and stigma. Multivariate logistic regression was used to determine predictors of PrEP use and intention, adjusted for significant covariates. Results Of 1,484 PPW women approached, 1,149 consented and were interviewed, of whom 704 (61.3%) were post-partum and 445 (38.7%) pregnant. The median age was 25 years [Interquartile Range (IQR) = 21-30 years], with 533 (46.4%) 18-24 years old. Among the 1,149 women, 930 (80.7%) had ever heard about PrEP; 635 (55.3%) had knowledge about PrEP; 183 (15.9%) were currently using PrEP; and 285 (24.8%) had ever used PrEP. Increased odds of PrEP use were associated having HIV-positive male partner (aOR:7.76, 95%CI 3.53- 17.04); positive attitudes to PrEP (aOR:1.56, 95%CI: 1.02-2.40); and high self-efficacy (aOR:1.49, 95%CI:1.13-1.98). Among 864 women who never used PrEP, 569 (65.3%) intended to use PrEP in the future. Odds of intention to use PrEP were higher among women with low levels of education (aOR:2.23, 95% CI: 1.32-3.77); who ever heard about PrEP (aOR:1.69, 95%CI: 1.12-2.56); and had high self-efficacy (aOR:1.57, 95%CI: 1.31-1.87). Regarding stigma, among all women, 759 (66%) either agreed or strongly agreed that people would think they have HIV if they were to use PrEP; 658 (57.3%) reported they would be labelled as having multiple sex partners; 468 (40.7%) reported that their partner would think they are having risky sex with other people. Of 102 women who had discontinued PrEP, a majority stopped due to side effects 32 (35.2%). Conclusion Only about 50% of women had knowledge of PrEP, and PrEP uptake among PPW was low, though intention to use appeared high. More efforts to reduce stigma and promote PrEP use, including adequate information on side effects, are needed.
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Affiliation(s)
- Philisiwe Ntombenhle Khumalo
- Strategic Information and Evaluation/Clinical Services Delivery Department, Elizabeth Glaser Pediatric AIDS Foundation, Mbabane, Eswatini
| | - Siphiwesihle Sibonisiwe Mkhonta
- Strategic Information and Evaluation/Clinical Services Delivery Department, Elizabeth Glaser Pediatric AIDS Foundation, Mbabane, Eswatini
| | - Kikanda Kindandi
- Strategic Information and Evaluation/Clinical Services Delivery Department, Elizabeth Glaser Pediatric AIDS Foundation, Mbabane, Eswatini
| | - Sindy Matse
- Eswatini National AIDS Program, Ministry of Health, Mbabane, Eswatini
| | - Phinda Brian Dlamini
- Strategic Information and Evaluation/Clinical Services Delivery Department, Elizabeth Glaser Pediatric AIDS Foundation, Mbabane, Eswatini
| | - Vincent Tukei
- Strategic Information and Evaluation/Clinical Services Delivery Department, Elizabeth Glaser Pediatric AIDS Foundation, Mbabane, Eswatini
| | - Rhoderick Machekano
- Research, Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC, United States
| | - Godfrey Woelk
- Research, Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC, United States
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12
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Fairlie L, Lavies D, Kalk E, Mhlongo O, Patel F, Technau KG, Mahtab S, Moodley D, Subedar H, Mullick S, Sawry S, Mehta U. Safety surveillance for PrEP in pregnant and breastfeeding women. FRONTIERS IN REPRODUCTIVE HEALTH 2023; 5:1221101. [PMID: 37854936 PMCID: PMC10581206 DOI: 10.3389/frph.2023.1221101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 09/14/2023] [Indexed: 10/20/2023] Open
Abstract
The risk of HIV acquisition is higher during pregnancy and postpartum than other times. Newly acquired maternal HIV infection associated with high primary viraemia, substantially increases the risk of vertical HIV transmission. Pre-exposure prophylaxis (PrEP) reduces the risk of HIV acquisition. Currently available products include oral tenofovir/emtricitabine (TDF/FTC) and tenofovir alafenamide (TAF)/FTC), long-acting cabotegravir (CAB-LA) and the dapivirine ring (DVR). All except oral TDF/FTC have limited safety data available for use in pregnant and breastfeeding women. The safety of new PrEP agents for pregnant women and the fetus, infant and child, either exposed in utero or during breastfeeding is an ongoing concern for health care workers and pregnant and breastfeeding women, particularly as the safety risk appetite for antiretroviral (ARV) agents used as PrEP is lower in pregnant and breastfeeding women who are HIV-uninfected, compared to women living with HIV taking ARVs as treatment. With the widespread rollout of TDF/FTC among pregnant women in South Africa and other low-middle income countries (LMIC) and the potential introduction of new PrEP agents for pregnant women, there is a need for safety surveillance systems to identify potential signals of risk to either the mother or fetus, measure the burden of such a risk, and where appropriate, provide specific reassurance to PrEP users. Safety data needs to be collected across the continuum of the product life cycle from pre-licensure into the post-marketing period, building a safety profile through both passive and active surveillance systems, recognising the strengths and limitations of each, and the potential for bias and confounding. Pharmacovigilance systems that aim to assess the risk of adverse birth outcomes in pregnant women exposed to PrEP and other agents need to consider the special requirements of pregnancy epidemiology to ensure that the data derived from surveillance are sufficiently robust to inform treatment policies. Here we review the known safety profiles of currently available PrEP candidates in women of child-bearing potential, pregnancy and breastfeeding and discuss pragmatic approaches for such surveillance in HIV-endemic LMICs.
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Affiliation(s)
- Lee Fairlie
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Diane Lavies
- Centre for Infectious Disease Epidemiology and Research, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Emma Kalk
- Centre for Infectious Disease Epidemiology and Research, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | | | - Faeezah Patel
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Karl-Günter Technau
- Empilweni Services and Research Unit, Rahima Moosa Mother and Child Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Sana Mahtab
- Wits Vaccines & Infectious Diseases Analytics (VIDA) Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Dhayendre Moodley
- Department of Obstetrics and Gynaecology, School of Clinical Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | | | - Saiqa Mullick
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Shobna Sawry
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Ushma Mehta
- Centre for Infectious Disease Epidemiology and Research, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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13
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Wagner AD, Beima-Sofie K, Awuor M, Owade W, Neary J, Dettinger JC, Pintye J, Abuna F, Lagat H, Weiner BJ, Kohler P, Kinuthia J, John-Stewart G, O’Malley G. Implementation determinants and strategies in integration of PrEP into maternal and child health and family planning services: experiences of frontline healthcare workers in Kenya. FRONTIERS IN REPRODUCTIVE HEALTH 2023; 5:1205925. [PMID: 37799494 PMCID: PMC10548203 DOI: 10.3389/frph.2023.1205925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 09/04/2023] [Indexed: 10/07/2023] Open
Abstract
Background Delivery of PrEP to adolescent girls and young women (AGYW) and to pregnant women through maternal and child health (MCH) and family planning (FP) clinics is scaling up in Kenya. Evaluation of implementation challenges and strategies is critical to optimize delivery. Methods We conducted focus group discussions (FGDs) with healthcare workers (HCWs) in MCH and FP clinics offering PrEP in a large implementation project in Kisumu, Kenya. Discussion guides were based on the Consolidated Framework for Implementation Research (CFIR). FGDs were audio recorded and transcribed. Directed content analysis was used to identify implementation challenges and strategies to overcome them. Results Fifty HCWs from 26 facilities participated in 8 FGDs. HCWs believed PrEP integration was appropriate because it met the needs of AGYW and pregnant women by providing a female-controlled prevention strategy and aligned with policy priorities of elimination of vertical HIV transmission. They were universally accepting of PrEP provision, especially through MCH clinics, noting the relative advantage of this approach because it: (1) enabled high coverage, (2) harmonized PrEP and MCH visits, and (3) minimized stigma compared to PrEP offered through HIV care clinics. However, HCWs noted implementation challenges affecting feasibility and adoption including: (1) increased workload and documentation burden amid workforce shortages, (2) insufficient health care worker knowledge (3) multiple implementing partners with competing priorities (4) drug and documentation form stockouts. HCWs employed various implementation strategies to overcome challenges, including task shifting from nurses to HIV testing providers, patient flow modifications (e.g., fast-tracking PrEP clients to reduce wait times), PrEP demand generation and myth clarification during health talks, provider education, dedicated PrEP delivery rooms, and coordination with adolescent-friendly services. Additional suggested strategies to improve PrEP integration included community education to increase broader PrEP awareness and enable shorter counseling sessions, and task-shifting data entry and client risk assessments. Conclusions HCWs were enthusiastic about the appropriateness and acceptability of integrating PrEP services into MCH and FP clinics but noted challenges to adoption and feasibility. Strategies to address challenges focused on improving provider time and space constraints, and increasing provider and client knowledge.
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Affiliation(s)
- Anjuli D. Wagner
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Kristin Beima-Sofie
- Department of Global Health, University of Washington, Seattle, WA, United States
| | | | | | - Jillian Neary
- Department of Epidemiology, University of Washington, Seattle, WA, United States
| | - Julia C. Dettinger
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Jillian Pintye
- Department of Biobehavioral Nursing and Health Informatics, School of Nursing, University of Washington, Seattle, WA, United States
| | - Felix Abuna
- Research & Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Harison Lagat
- Research & Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Bryan J. Weiner
- Department of Global Health, University of Washington, Seattle, WA, United States
- Department of Health Systems and Population Health, University of Washington, Seattle, WA, United States
| | - Pamela Kohler
- Department of Global Health, University of Washington, Seattle, WA, United States
- Department of Child, Family, and Population Health Nursing, University of Washington, Seattle, WA, United States
| | - John Kinuthia
- Research & Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Grace John-Stewart
- Department of Global Health, University of Washington, Seattle, WA, United States
- Department of Epidemiology, University of Washington, Seattle, WA, United States
- Departments of Pediatrics and Medicine, University of Washington, Seattle, WA, United States
| | - Gabrielle O’Malley
- Department of Global Health, University of Washington, Seattle, WA, United States
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14
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Hicks S, Odhiambo B, Abuna F, Dettinger JC, Ngumbau N, Gómez L, Sila J, Oketch G, Sifuna E, Weiner BJ, John-Stewart G, Kinuthia J, Wagner AD. Selecting implementation strategies to improve implementation of integrated PrEP for pregnant and postpartum populations in Kenya: a sequential explanatory mixed methods analysis. Implement Sci Commun 2023; 4:93. [PMID: 37580795 PMCID: PMC10424426 DOI: 10.1186/s43058-023-00481-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 07/29/2023] [Indexed: 08/16/2023] Open
Abstract
BACKGROUND There is a higher risk for HIV acquisition during pregnancy and postpartum. Pre-exposure prophylaxis (PrEP) is recommended during this period for those at high risk of infection; integrated delivery in maternal and child health (MCH) clinics is feasible and acceptable but requires implementation optimization. METHODS The PrEP in Pregnancy, Accelerating Reach and Efficiency study (PrEPARE; NCT04712994) engaged stakeholders to prioritize determinants of PrEP delivery (using Likert scores) and prioritize PrEP delivery implementation strategies. Using a sequential explanatory mixed methods design, we conducted quantitative surveys with healthcare workers at 55 facilities in Western Kenya and a stakeholder workshop (including nurses, pharmacists, counselors, and county and national policymakers), yielding visual plots of stakeholders' perceived feasibility and effectiveness of the strategies. A stepwise elimination process was used to identify seven strategies for empirical testing. Facilitator debriefing reports from the workshop were used to qualitatively assess the decision-making process. RESULTS Among 146 healthcare workers, the strongest reported barriers to PrEP delivery were insufficient providers and inadequate training, insufficient space, and high volume of patients. Sixteen strategies were assessed, 14 of which were included in the final analysis. Among rankings from 182 healthcare workers and 44 PrEP policymakers and implementers, seven strategies were eliminated based on low post-workshop ranking scores (bottom 50th percentile) or being perceived as low feasibility or low effectiveness for at least 50% of the workshop groups. The top seven strategies included delivering PrEP within MCH clinics instead of pharmacies, fast-tracking PrEP clients to reduce waiting time, delivering PrEP-related health talks in waiting bays, task shifting PrEP counseling, task shifting PrEP risk assessments, training different providers to deliver PrEP, and retraining providers on PrEP delivery. All top seven ranked strategies were grouped into bundles for subsequent testing. Facilitator debriefing reports generally aligned with rankings but noted how stakeholders' decision-making changed when considering the impact of strategies on facility staff and non-PrEP clients. CONCLUSIONS The most impactful barriers to integrated PrEP delivery in MCH clinics were insufficient staffing and space. Implementation strategies prioritized through multiple methods of stakeholder input focused on co-location of services and increasing clinic efficiency. Future testing of these stakeholder-prioritized strategy bundles will be conducted to assess the effectiveness and implementation outcomes.
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Affiliation(s)
- Sarah Hicks
- Department of Epidemiology, University of Washington, Seattle, WA, USA.
| | | | | | - Julia C Dettinger
- Department of Global Health, University of Washington, Seattle, WA, USA
| | | | - Laurén Gómez
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Department of Global Health, University of Washington, Seattle, WA, USA
| | | | | | | | - Bryan J Weiner
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Health Systems and Population Health, University of Washington, Seattle, WA, USA
| | - Grace John-Stewart
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Department of Global Health, University of Washington, Seattle, WA, USA
- Departments of Medicine, University of Washington, Seattle, WA, USA
- Departments of Pediatrics, University of Washington, Seattle, WA, USA
| | | | - Anjuli D Wagner
- Department of Global Health, University of Washington, Seattle, WA, USA
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15
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Joseph Davey DL, Wilkinson L, Grimsrud A, Nelson A, Gray A, Raphael Y, Wattrus C, Pillay Y, Bekker LG. Urgent appeal to allow all professional nurses and midwives to prescribe pre-exposure prophylaxis (PrEP) in South Africa. S Afr Med J 2023; 113:12-16. [PMID: 37882113 DOI: 10.7196/samj.2023.v113i8.1191] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Indexed: 10/27/2023] Open
Affiliation(s)
- D L Joseph Davey
- Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of Cape Town, South Africa; Division of Infectious Diseases, Geffen School of Medicine, University of California Los Angeles, USA; Desmond Tutu HIV Centre, University of Cape Town, South Africa.
| | - L Wilkinson
- Centre for Infectious Disease and Epidemiological Research, School of Public Health, Faculty of Health Sciences, University of Cape Town, South Africa; International AIDS Society, Johannesburg, South Africa.
| | - A Grimsrud
- International AIDS Society, Johannesburg, South Africa.
| | - A Nelson
- Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of Cape Town, South Africa.
| | - A Gray
- Discipline of Pharmaceutical Sciences, School of Health Sciences, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa.
| | - Y Raphael
- Advocacy for Prevention of HIV and AIDS, Johannesburg, South Africa.
| | - C Wattrus
- Southern African HIV Clinicians Society, Johannesburg, South Africa.
| | - Y Pillay
- Division of Health Systems and Public Health, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
| | - L-G Bekker
- Desmond Tutu HIV Centre, University of Cape Town, South Africa.
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16
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Hicks S, Abuna F, Odhiambo B, Dettinger JC, Sila J, Oketch G, Sifuna E, Ngumbau N, Gómez L, John-Stewart GC, Kinuthia J, Wagner AD. Integrating PrEP in maternal and child health clinics in Kenya: analysis of a service availability and readiness assessment (SARA) survey. FRONTIERS IN REPRODUCTIVE HEALTH 2023; 5:1206150. [PMID: 37484872 PMCID: PMC10359145 DOI: 10.3389/frph.2023.1206150] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Accepted: 06/12/2023] [Indexed: 07/25/2023] Open
Abstract
Background Risk of HIV acquisition is high during pregnancy and postpartum, and pre-exposure prophylaxis (PrEP) is recommended for peripartum populations. Integrating PrEP into maternal and child health (MCH) clinics is feasible and acceptable. Understanding clinics' service availability and readiness is essential for effective scale up. Methods The PrEP in Pregnancy, Accelerating Reach and Efficiency study (PrEPARE; NCT04712994) engaged PrEP-experienced facilities previously linked to a programmatic or research study in Western Kenya to document available services and commodities via a modified service availability and readiness assessment (SARA) survey with 20 PrEP tracer items covering: staffing/guidelines, services/equipment, and medicines/commodities. Facilities' prior study engagement occurred between 2017 and 2019; SARA survey data was collected between April 2020 and June 2021. Descriptive statistics were stratified by prior study engagement. ANOVA tests assessed associations between facility characteristics and gaps. Fisher's tests assessed differences in commodity availability and stockouts. Results Of the 55 facilities surveyed, 60% had received PrEP training in the last two years, 95% offered PrEP integrated into MCH, and 64% and 78% had both auditory and visual privacy in PrEP and HIV testing service (HTS) delivery spaces, respectively. Supervision frequency was heterogeneous, but 82% had received a supervision visit within 3 months. Availability of commodities was variable and the most commonly unavailable commodities were PrEP in MCH (71% available) and risk assessment screening tool (RAST) and PrEP cards (60% and 75% available, respectively). The number of service and commodity gaps per facility ranged from zero to eight (median: 3; IQR: 2, 5). The most frequent gaps were: PrEP training and risk assessment cards (40% each), lack of privacy in PrEP (36%) and HIV testing services (31%) spaces, PrEP pills in MCH (29%), and PrEP cards (25%). There were no differences in mean number of gaps by county, previous study engagement, or public vs. private status. Level 4 facilities had fewer gaps (mean 2.2) than level 2, 3, and 5 facilities (mean 5.7, 4.5, and 5.3 respectively; p < 0.001). Conclusions PrEP service availability and readiness was generally high across MCH facilities. However, there is a need for increased frequency of provider training and supportive supervision focused on fidelity. To address key commodity stockouts such as PrEP pills, implementation of electronic logistics management information systems may be needed. Targeting these gaps is essential to effectively scale up integrated PrEP delivery, especially among facilities with limited infrastructure.
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Affiliation(s)
- Sarah Hicks
- Department of Epidemiology, University of Washington, Seattle, WA, United States
| | - Felix Abuna
- Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Ben Odhiambo
- Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Julia C Dettinger
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Joseph Sila
- Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - George Oketch
- Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Enock Sifuna
- Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Nancy Ngumbau
- Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Laurén Gómez
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Grace C John-Stewart
- Department of Epidemiology, University of Washington, Seattle, WA, United States
- Department of Global Health, University of Washington, Seattle, WA, United States
- Departments of Medicine, University of Washington, Seattle, WA, United States
- Departments of Pediatrics, University of Washington, Seattle WA, United States
| | - John Kinuthia
- Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Anjuli D Wagner
- Department of Global Health, University of Washington, Seattle, WA, United States
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17
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Ortblad KF, Mogere P, Omollo V, Kuo AP, Asewe M, Gakuo S, Roche S, Mugambi M, Mugambi ML, Stergachis A, Odoyo J, Bukusi EA, Ngure K, Baeten JM. Stand-alone model for delivery of oral HIV pre-exposure prophylaxis in Kenya: a single-arm, prospective pilot evaluation. J Int AIDS Soc 2023; 26:e26131. [PMID: 37306128 PMCID: PMC10258863 DOI: 10.1002/jia2.26131] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 05/25/2023] [Indexed: 06/13/2023] Open
Abstract
INTRODUCTION The delivery of daily, oral HIV pre-exposure prophylaxis (PrEP) at private pharmacies may overcome barriers to PrEP delivery at public healthcare facilities, including HIV-associated stigma, long wait times and overcrowding. METHODS At five private, community-based pharmacies in Kenya, a care pathway for PrEP delivery (ClinicalTrials.gov: NCT04558554) was piloted-the first of its kind in Africa. Pharmacy providers screened clients interested in PrEP for HIV risk, then used a prescribing checklist to identify clients without medical conditions that might contraindicate PrEP safety, counsel them on PrEP use and safety, conduct provider-assisted HIV self-testing and dispense PrEP. For complex clinical cases, a remote clinician was available for consultation. Clients who did not meet the checklist criteria were referred to public facilities for free services delivered by clinicians. Pharmacy providers dispensed a 1-month PrEP supply at initiation and a 3-month supply thereafter at a client fee of 300 KES (∼$3 USD) per visit. RESULTS From November 2020 to October 2021, pharmacy providers screened 575 clients, identified 476 who met the prescribing checklist criteria and initiated 287 (60%) on PrEP. Among pharmacy PrEP clients, the median age was 26 years (IQR 22-33) and 57% (163/287) were male. The prevalence of behaviours associated with HIV risk among clients was high; 84% (240/287) reported sexual partners with unknown HIV status and 53% (151/287) reported multiple sexual partners (past 6 months). PrEP continuation among clients was 53% (153/287) at 1 month, 36% (103/287) at 4 months and 21% (51/242) at 7 months. During the pilot observation period, 21% (61/287) of clients stopped and restarted PrEP and overall pill coverage was 40% (IQR 10%-70%). Nearly, all pharmacy PrEP clients (≥96%) agreed or strongly agreed with statements regarding the acceptability and appropriateness of pharmacy-delivered PrEP services. CONCLUSIONS Findings from this pilot suggest that populations at HIV risk frequently visit private pharmacies and PrEP initiation and continuation at pharmacies is similar to or exceeds that at public healthcare facilities. Private pharmacy-based PrEP delivery, conducted entirely by private-sector pharmacy staff, is a promising new delivery model that has the potential to expand PrEP reach in Kenya and similar settings.
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Affiliation(s)
- Katrina F. Ortblad
- Public Health Sciences DivisionFred Hutchinson Cancer CenterSeattleWashingtonUSA
| | - Peter Mogere
- Centre for Clinical ResearchKenya Medical Research InsitituteNairobiKenya
| | - Victor Omollo
- Centre for Microbiology ResearchKenya Medical Research InsitituteNairobiKenya
| | - Alexandra P. Kuo
- Department of PharmacyUniversity of WashingtonSeattleWashingtonUSA
| | - Magdaline Asewe
- Centre for Microbiology ResearchKenya Medical Research InsitituteNairobiKenya
| | - Stephen Gakuo
- Centre for Clinical ResearchKenya Medical Research InsitituteNairobiKenya
| | - Stephanie Roche
- Public Health Sciences DivisionFred Hutchinson Cancer CenterSeattleWashingtonUSA
| | - Mary Mugambi
- National AIDS and STI Control ProgrammeKenya Ministry of HealthNairobiKenya
| | | | - Andy Stergachis
- Department of PharmacyUniversity of WashingtonSeattleWashingtonUSA
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
| | - Josephine Odoyo
- Centre for Microbiology ResearchKenya Medical Research InsitituteNairobiKenya
| | - Elizabeth A. Bukusi
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
- Department of Obstetrics and GynecologyUniversity of WashingtonSeattleWashingtonUSA
| | - Kenneth Ngure
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
- School of Public HealthJomo Kenyatta University of Agriculture and TechnologyNairobiKenya
| | - Jared M. Baeten
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
- Department of EpidemiologyUniversity of WashingtonSeattleWashingtonUSA
- Department of MedicineUniversity of WashingtonSeattleWashingtonUSA
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Yang L, Cambou MC, Nielsen-Saines K. The End Is in Sight: Current Strategies for the Elimination of HIV Vertical Transmission. Curr HIV/AIDS Rep 2023; 20:121-130. [PMID: 36971951 DOI: 10.1007/s11904-023-00655-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/08/2023] [Indexed: 03/29/2023]
Abstract
PURPOSE OF REVIEW The goal of this review is to highlight and interpret recent trends and developments in the diagnosis, treatment, and prevention of HIV vertical transmission from a clinical perspective. RECENT FINDINGS Universal third-trimester retesting and partner testing may better identify incident HIV among pregnant patients and result in early initiation of antiretroviral therapy to prevent vertical transmission. The proven safety and efficacy of integrase inhibitors such as dolutegravir may be particularly useful in suppressing viremia in pregnant persons who present late for ART treatment. Pre-exposure prophylaxis (PrEP) during pregnancy may play a role in preventing HIV acquisition; however, its role in preventing vertical transmission is difficult to elucidate. Substantial progress has been made in recent years to eliminate HIV perinatal transmission. Future research hinges upon a multipronged approach to improving HIV detection, risk-stratified treatment strategies, and prevention of primary HIV infection among pregnant persons.
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Affiliation(s)
- Lanbo Yang
- Warren Alpert Medical School, Brown University, 222 Richmond Street, Providence, RI, 02903, USA.
| | - Mary Catherine Cambou
- Division of Infectious Diseases, Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - Karin Nielsen-Saines
- Division of Pediatric Infectious Diseases, Department of Pediatrics, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
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Moodley D, Lombard C, Govender V, Naidoo M, Desmond AC, Naidoo K, Mhlongo O, Sebitloane M, Newell ML, Clark R, Rooney JF, Gray G, Lombard C, Govender V, Naidoo M, Desmond AC, Naidoo KL, Mhlongo O, Sebitloane M, Newell ML, Clark R, Rooney JF, Gray GE, Ngaleka L, Pillay N, Booi S, Samsunder N, Pillay L, Gray R, Gazu R, Nkosi T. Pregnancy and neonatal safety outcomes of timing of initiation of daily oral tenofovir disoproxil fumarate and emtricitabine pre-exposure prophylaxis for HIV prevention (CAP016): an open-label, randomised, non-inferiority trial. Lancet HIV 2023; 10:e154-e163. [PMID: 36746169 DOI: 10.1016/s2352-3018(22)00369-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 11/26/2022] [Accepted: 11/29/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND The safety of tenofovir disoproxil fumarate and emtricitabine as pre-exposure prophylaxis (PrEP) in pregnant women not living with HIV is uncertain. We aimed to compare pregnancy and neonatal outcomes in women exposed and not exposed to PrEP during pregnancy. METHODS In this single-site, open-label, randomised, non-inferiority trial in Durban, South Africa, we evaluated pregnancy and neonatal outcomes in pregnant women aged 18 years or older, not living with HIV, and at 14-28 weeks' gestation at the time of enrolment. Eligible participants were randomly assigned (1:1) using a computer-generated permuted block (block size of ten) randomisation list to immediate initiation or deferred initiation of PrEP until breastfeeding cessation. Participants in the immediate PrEP group received a monthly supply of once daily oral tenofovir disoproxil fumarate 300 mg and emtricitabine 200 mg. Participants in the deferred PrEP group received standard of care for HIV prevention. The primary outcomes were the occurrence of preterm live birth (<37 weeks gestational age) and very preterm birth (<34 weeks gestational age) determined by menstrual dating, low birthweight (<2500 g), very low birthweight (<1500 g), stillbirth (≥20 weeks gestational age), and small for gestational age (birthweight less than the tenth percentile). Post-natal safety outcomes will be reported elsewhere. We used binomial regression models to estimate risk differences and two-sided 90% CIs. Immediate PrEP was non-inferior to deferred PrEP if the upper bound of the 90% CI of the risk difference was less than the upper predefined non-inferiority margin for preterm birth (7·5%), very preterm birth (2·6%), low birthweight (5·5%), very low birthweight (1·2%), stillbirth (1·0%), and small for gestational age (3·7%). All outcomes were analysed in the intention-to-treat population. This study is registered with ClinicalTrials.gov, NCT3227731. FINDINGS Between Sept 25, 2017, and Dec 6, 2019, we screened 693 women, of whom 540 were randomly assigned to immediate PrEP (n=271) or deferred PrEP (n=269). The median gestational age was 19 weeks (IQR 15-23 for immediate PrEP and 16-23 for deferred PrEP). The risk difference between the immediate PrEP group and the deferred PrEP group for preterm birth was -4·7% (90% CI -10·7 to 1·2; immediate PrEP was non-inferior), for very preterm birth was 0·6% (-3·4 to 4·6; upper limit exceeded the non-inferiority margin), for low birthweight was 2·5% (-1·6 to 6·6; upper limit exceeded the non-inferiority margin), for very low birthweight was 0% (-1·4 to 1·4; upper limit exceeded the non-inferiority margin), for stillbirth was 1·2% (-1·5 to 3·8; upper limit exceeded the non-inferiority margin), and for small for gestational age was 0·9% (-1·2 to 2·9; immediate PrEP was non-inferior). INTERPRETATION In our study, PrEP was not associated with preterm birth or small for gestational age infants. Our data support the use of tenofovir disoproxil fumarate and emtricitabine in pregnancy and our reassuring findings can be used to allay safety concerns among pregnant women. FUNDING South African Medical Research Council and Gilead Sciences.
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Affiliation(s)
- Dhayendre Moodley
- Department of Obstetrics and Gynaecology, School of Clinical Medicine, University of KwaZulu Natal, Durban, South Africa; Centre for the Program of AIDS Research in South Africa (CAPRISA), Durban, South Africa.
| | - Carl Lombard
- Biostatistics Unit, South African Medical Research Council, Tygerberg, South Africa; Division of Epidemiology and Biostatistics, Department of Global Health, University of Stellenbosch, Tygerberg, South Africa
| | - Vani Govender
- Centre for the Program of AIDS Research in South Africa (CAPRISA), Durban, South Africa
| | - Megeshinee Naidoo
- Centre for the Program of AIDS Research in South Africa (CAPRISA), Durban, South Africa
| | - Alicia C Desmond
- Centre for the Program of AIDS Research in South Africa (CAPRISA), Durban, South Africa
| | - Kimesh Naidoo
- Department of Paediatrics and Child Health, School of Clinical Medicine, University of KwaZulu Natal, Durban, South Africa
| | - Ottacia Mhlongo
- KwaZulu-Natal Department of Health, Pietermaritzburg, South Africa
| | - Motshedisi Sebitloane
- Department of Obstetrics and Gynaecology, School of Clinical Medicine, University of KwaZulu Natal, Durban, South Africa
| | - Marie-Louise Newell
- School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa; Human Health and Development, Faculty of Medicine, University of Southampton, Southampton, UK
| | | | | | - Glenda Gray
- South African Medical Research Council, Cape Town, South Africa
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Kinuthia J, Dettinger JC, Stern J, Ngumbau N, Ochieng B, Gómez L, Abuna F, Watoyi S, Marwa M, Odinga D, Wagner AD, Richardson BA, Pintye J, Baeten JM, John‐Stewart G. Risk-based versus universal PrEP delivery during pregnancy: a cluster randomized trial in Western Kenya from 2018 to 2019. J Int AIDS Soc 2023; 26:e26061. [PMID: 36807505 PMCID: PMC9939942 DOI: 10.1002/jia2.26061] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 01/19/2023] [Indexed: 02/22/2023] Open
Abstract
INTRODUCTION Integrating pre-exposure prophylaxis (PrEP) delivery for pregnant and postpartum women within maternal and child health (MCH) clinics is feasible and acceptable. It is unknown whether a risk-guided model would facilitate appropriate PrEP use among MCH attendees better than universally offering PrEP. METHODS The PrEP Implementation for Mothers in Antenatal Care (PrIMA) study was a cluster randomized trial to assess two models for PrEP delivery among pregnant women seeking routine MCH care at 20 public clinics in Kenya between January 2018 and July 2019 (NCT03070600). In the Universal arm, all participants received PrEP counselling and self-selected whether to initiate PrEP. In the Targeted arm, participants underwent an HIV risk assessment, including an objective risk-scoring tool and an offer of HIV self-tests for at-home partner testing; those determined to be at high risk received a PrEP offer. Participants were followed through 9 months postpartum. Primary outcomes included incident HIV and appropriate PrEP use (defined as PrEP uptake among those at high risk and no PrEP uptake for those not at risk). Outcomes were compared using intention-to-treat analyses, adjusting for baseline HIV risk and marital status. RESULTS Among 4447 women enrolled, the median age was 24.0 years (interquartile range [IQR]: 20.9, 28.3), and most were married (84.8%). The median gestational age at enrolment was 24 weeks (IQR: 20, 30). Women in the Targeted arm were more likely to be at high risk for HIV acquisition at baseline (51.6% vs. 33.3%). During 4638 person-years (p-yr) of follow-up, there were 16 maternal HIV infections with no difference in maternal HIV incidence between arms: 0.31/100 p-yr (95% CI: 0.15, 0.65) Targeted and 0.38/100p-yr (95% CI: 0.20, 0.73) Universal (adjusted relative risk [aRR]: 0.85 [CI: 0.28, 2.55]). There was no significant difference in the frequency of appropriate PrEP use between the arms (68.2% vs. 59.1% in Targeted vs. Universal, respectively) (aRR: 1.03 [CI: 0.96, 1.10]). CONCLUSIONS Given comparable maternal HIV incidence and PrEP uptake in Universal and Targeted approaches, and the simplicity that universal PrEP offers, our findings suggest that universal PrEP counselling is optimal for integrating PrEP in MCH systems.
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Affiliation(s)
- John Kinuthia
- Department of Research and ProgramsKenyatta National HospitalNairobiKenya
| | | | - Joshua Stern
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
| | - Nancy Ngumbau
- Department of Research and ProgramsKenyatta National HospitalNairobiKenya
| | - Ben Ochieng
- Department of Research and ProgramsKenyatta National HospitalNairobiKenya
| | - Laurén Gómez
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
| | - Felix Abuna
- Department of Research and ProgramsKenyatta National HospitalNairobiKenya
| | - Salphine Watoyi
- Department of Research and ProgramsKenyatta National HospitalNairobiKenya
| | - Mary Marwa
- Department of Research and ProgramsKenyatta National HospitalNairobiKenya
| | - Daniel Odinga
- Department of Research and ProgramsKenyatta National HospitalNairobiKenya
| | - Anjuli D. Wagner
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
| | - Barbra A. Richardson
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
- Department of BiostatisticsUniversity of WashingtonSeattleWashingtonUSA
- Division of Allergy and Infectious DiseasesUniversity of WashingtonSeattleWashingtonUSA
- Vaccine and Infectious Disease DivisionFred Hutchinson Cancer Research CenterSeattleWashingtonUSA
| | - Jillian Pintye
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
- Department of Behavioral Nursing & Health InformaticsUniversity of WashingtonSeattleWashingtonUSA
| | - Jared M. Baeten
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
- Department of EpidemiologyUniversity of WashingtonSeattleWashingtonUSA
- Department of MedicineUniversity of WashingtonSeattleWashingtonUSA
- Gilead SciencesFoster CityCaliforniaUSA
| | - Grace John‐Stewart
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
- Department of EpidemiologyUniversity of WashingtonSeattleWashingtonUSA
- Department of MedicineUniversity of WashingtonSeattleWashingtonUSA
- Department of PediatricsUniversity of WashingtonSeattleWashingtonUSA
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Sekhon M, van der Straten A. 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. PLoS One 2021; 16:e0259779. [PMID: 34784355 PMCID: PMC8594804 DOI: 10.1371/journal.pone.0259779] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 10/26/2021] [Indexed: 11/19/2022] Open
Abstract
HIV infection during pregnancy and breastfeeding has implications for maternal health. Between May- November 2018, we explored prospective acceptability of two novel HIV Pre-exposure Prophylaxis (PrEP) products, oral pills and vaginal rings, through focus group discussions with 65 pregnant and breastfeeding women in Malawi, South Africa, Uganda, Zimbabwe. Qualitative analysis was completed, guided by the Theoretical Framework of Acceptability (TFA). First, a deductive thematic analysis was applied to relevant coded data, into the seven TFA constructs (Affective Attitude; Burden; Ethicality, Intervention Coherence; Opportunity Costs; Perceived Effectiveness; Self-efficacy). Next, an iterative analysis was completed to generate themes within each of the TFA constructs. Women’s positive attitudes towards daily oral PrEP highlighted the familiarity of taking pills, understanding the purpose of taking pills, and the perception that it is an effective method to protect mothers and babies from HIV during pregnancy and breastfeeding. Women emphasized the ease of using the ring given its monthly duration that lowers burden on the user, its discreetness and invisibility once in place. The TFA analysis highlighted how acceptability of both methods could be enhanced by focusing on perceptions of the end users (i.e. the women) and not just the products themselves. This approach provided insights into how to refine the intervention materials and plans for implementation.
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Affiliation(s)
- Mandeep Sekhon
- Department of Population Health Sciences, School of Population Health and Environmental Sciences, Faculty of Life Sciences & Medicine, King’s College London, London, United Kingdom
- * E-mail:
| | - Ariane van der Straten
- Center for AIDS prevention studies, University of California San Francisco, CA, United States of America
- Women’s Global Health imperative, RTI International, Berkeley, CA, United States of America
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Stalter RM, Pintye J, Mugwanya KK. Safety review of tenofovir disoproxil fumarate/emtricitabine pre-exposure prophylaxis for pregnant women at risk of HIV infection. Expert Opin Drug Saf 2021; 20:1367-1373. [PMID: 33998936 PMCID: PMC9010110 DOI: 10.1080/14740338.2021.1931680] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 05/14/2021] [Indexed: 02/07/2023]
Abstract
Introduction: Pregnancy is a period of elevated HIV risk in high-burden settings, motivating the need for prevention tools that are both safe for use and effective during pregnancy. Oral pre-exposure prophylaxis (PrEP) containing tenofovir disoproxil fumarate (TDF) is recommended by the World Health Organization, including for pregnant and postpartum women at substantial risk of HIV infection. Although TDF use during pregnancy appears generally safe, data on PrEP use during pregnancy remain limited.Areas covered: We provide an overview of the clinical pharmacology and efficacy of daily TDF-based PrEP and summarize current evidence on the safety of PrEP use by pregnant HIV-uninfected women. We synthesize relevant studies assessing pregnancy outcomes among pregnant women who are living with HIV (WLHIV) and using TDF-based therapy. Finally, we make comparison to the safety profiles of other emerging HIV prevention options.Expert opinion: The current evidence indicates that TDF/FTC PrEP use is not associated with increased risk of adverse pregnancy and early infant growth outcomes. While safety data are generally reassuring, there is need for continued accrual of data on growth and pregnancy outcomes in PrEP research, implementation projects, and controlled pharmacokinetic studies to support current evidence and to understand concentration-efficacy relationship in pregnant women.
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Affiliation(s)
- Randy M. Stalter
- Epidemiology Department, University of Washington, Seattle, WA, USA
| | - Jillian Pintye
- School of Nursing, University of Washington, Seattle, WA, USA
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Were DK, Musau A, Atkins K, Shrestha P, Reed J, Curran K, Mohan D. Health system adaptations and considerations to facilitate optimal oral pre-exposure prophylaxis scale-up in sub-Saharan Africa. Lancet HIV 2021; 8:e511-e520. [PMID: 34265282 DOI: 10.1016/s2352-3018(21)00129-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 06/06/2021] [Accepted: 06/08/2021] [Indexed: 12/26/2022]
Abstract
Following WHO's 2015 recommendation, countries in sub-Saharan Africa have progressively scaled up oral pre-exposure prophylaxis (PrEP) as part of combination HIV prevention. PrEP has potential to significantly reduce new HIV infections in sub-Saharan Africa if it is widely available, accessible, and effectively used. Initial scale-up efforts have generated progress, drawing lessons from existing HIV interventions, such as antiretroviral therapy and biomedical prevention. However, beset by unprepared health systems, scale-up has been slow, resulting in suboptimal coverage among priority groups at higher risk of HIV acqusition. Using the WHO health system building blocks framework, this Review synthesises literature on essential considerations for PrEP scale-up in sub-Saharan Africa, highlighting the importance of health system adaptability and responsiveness.
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Affiliation(s)
| | | | - Kaitlyn Atkins
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Prakriti Shrestha
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | | | - Diwakar Mohan
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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van der Straten A, Ryan JH, Reddy K, Etima J, Taulo F, Mutero P, Taylor J, Piper J, Musara P. Influences on willingness to use vaginal or oral HIV PrEP during pregnancy and breastfeeding in Africa: the multisite MAMMA study. J Int AIDS Soc 2021; 23:e25536. [PMID: 32524700 PMCID: PMC7287313 DOI: 10.1002/jia2.25536] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 03/25/2020] [Accepted: 04/15/2020] [Indexed: 12/15/2022] Open
Abstract
Introduction Women 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. Methods In 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. Results Of 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. Conclusions Participants 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.
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Affiliation(s)
- Ariane van der Straten
- Women's Global Health Imperative (WGHI), RTI International, Berkeley, CA, USA.,Center for AIDS Prevention Studies (CAPS), University of California San Francisco, San Francisco, CA, USA
| | - Julia H Ryan
- Women's Global Health Imperative (WGHI), RTI International, Berkeley, CA, USA
| | - Krishnaveni Reddy
- Wits Reproductive Health and HIV Institute (Wits RHI), University of the Witwatersrand, Johannesburg, South Africa
| | - Juliane Etima
- Makerere University - Johns Hopkins University Research Collaboration, Kampala, Uganda
| | - Frank Taulo
- Johns Hopkins Project-College of Medicine, University of Malawi, Blantyre, Malawi
| | - Prisca Mutero
- University of Zimbabwe College of Health Sciences Clinical Trials Research Centre, Harare, Zimbabwe
| | | | | | - Petina Musara
- University of Zimbabwe College of Health Sciences Clinical Trials Research Centre, Harare, Zimbabwe
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Chi BH, Mbori‐Ngacha D, Essajee S, Mofenson LM, Tsiouris F, Mahy M, Luo C. Accelerating progress towards the elimination of mother-to-child transmission of HIV: a narrative review. J Int AIDS Soc 2020; 23:e25571. [PMID: 32820609 PMCID: PMC7440973 DOI: 10.1002/jia2.25571] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 05/28/2020] [Accepted: 06/08/2020] [Indexed: 01/16/2023] Open
Abstract
INTRODUCTION Findings from biomedical, behavioural and implementation studies provide a rich foundation to guide programmatic efforts for the prevention of mother-to-child HIV transmission (PMTCT). METHODS We summarized the current evidence base to support policy makers, programme managers, funding agencies and other stakeholders in designing and optimizing PMTCT programmes. We searched the scientific literature for PMTCT interventions in the era of universal antiretroviral therapy for pregnant and breastfeeding women (i.e. 2013 onward). Where evidence was sparse, relevant studies from the general HIV treatment literature or from prior eras of PMTCT programme implementation were also considered. Studies were organized into six categories: HIV prevention services for women, timely access to HIV testing, timely access to ART, programme retention and adherence support, timely engagement in antenatal care and services for infants at highest risk of HIV acquisition. These were mapped to specific missed opportunities identified by the UNAIDS Spectrum model and embedded in UNICEF operational guidance to optimize PMTCT services. RESULTS AND DISCUSSION From May to November 2019, we identified numerous promising, evidence-based strategies that, properly tailored and adopted, could contribute to population reductions in vertical HIV transmission. These spanned the HIV and maternal and child health literature, emphasizing the importance of continued alignment and integration of services. We observed overlap between several intervention domains, suggesting potential for synergies and increased downstream impact. Common themes included integration of facility-based healthcare; decentralization of health services from facilities to communities; and engagement of partners, peers and lay workers for social support. Approaches to ensure early HIV diagnosis and treatment prior to pregnancy would strengthen care across the maternal lifespan and should be promoted in the context of PMTCT. CONCLUSIONS A wide range of effective strategies exist to improve PMTCT access, uptake and retention. Programmes should carefully consider, prioritize and plan those that are most appropriate for the local setting and best address existing gaps in PMTCT health services.
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Affiliation(s)
- Benjamin H Chi
- University of North Carolina at Chapel HillChapel HillNCUSA
| | | | | | | | | | - Mary Mahy
- Joint United Nations Programme on HIV/AIDS (UNAIDS)GenevaSwitzerland
| | - Chewe Luo
- United Nations Children’s Fund (UNICEF)New YorkNYUSA
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Joseph Davey DL, Daniels J, Beard C, Mashele N, Bekker LG, Dovel K, Ncayiyana J, Coates TJ, Myer L. Healthcare provider knowledge and attitudes about pre-exposure prophylaxis (PrEP) in pregnancy in Cape Town, South Africa. AIDS Care 2020; 32:1290-1294. [PMID: 32576023 DOI: 10.1080/09540121.2020.1782328] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Pre-exposure prophylaxis (PrEP) in pregnancy can reduce HIV incidence and vertical transmission. Healthcare providers (HCPs) play a critical role in delivering PrEP in antenatal care but little is known about HCP knowledge and attitudes about PrEP in pregnancy. We conducted a qualitative study in two healthcare facilities to assess HCPs' PrEP knowledge and perspectives relating to HIV prevention in pregnant women. Between January-March'19, we administered in-depth interviews among antenatal HCPs. We utilized a constant comparison approach to identify major qualitative findings. We enrolled 35 female HCPs (median age=43yrs. Fewer than half of HCPs had heard of PrEP before. Of those who had heard of PrEP, most felt that it was safe to take during pregnancy. Most HCPs described inaccurate PrEP knowledge regarding effectiveness, and most who knew about PrEP lacked clinical detail. HCPs highlighted important potential barriers to maternal PrEP use including: fear that PrEP may be unsafe, or belief that women must talk to partners/parents before initiating PrEP. Facilitators include good knowledge about serodiscordancy and vulnerability to seroconversion in pregnancy and desire to help women gain control overHIV prevention. We recommend integrating PrEP training into HIV testing and PMTCT nurse training to improve counseling and maternal PrEP delivery.
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Affiliation(s)
- Dvora L Joseph Davey
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, CA, USA.,Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Joseph Daniels
- Department of Psychiatry and Human Behaviors, Charles R. Drew University of Medicine and Science, Los Angeles, CA, USA
| | - Cindy Beard
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, CA, USA
| | - Nyiko Mashele
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Kathryn Dovel
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Jabulani Ncayiyana
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Thomas J Coates
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Landon Myer
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
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Joseph Davey DL, Pintye J, Baeten JM, Aldrovandi G, Baggaley R, Bekker L, Celum C, Chi BH, Coates TJ, Haberer JE, Heffron R, Kinuthia J, Matthews LT, McIntyre J, Moodley D, Mofenson LM, Mugo N, Myer L, Mujugira A, Shoptaw S, Stranix‐Chibanda L, John‐Stewart G. Emerging evidence from a systematic review of safety of pre-exposure prophylaxis for pregnant and postpartum women: where are we now and where are we heading? J Int AIDS Soc 2020; 23:e25426. [PMID: 31912985 PMCID: PMC6948023 DOI: 10.1002/jia2.25426] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Accepted: 11/20/2019] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION HIV incidence is high during pregnancy and breastfeeding with HIV acquisition risk more than doubling during pregnancy and the postpartum period compared to when women are not pregnant. The World Health Organization recommends offering pre-exposure prophylaxis (PrEP) to pregnant and postpartum women at substantial risk of HIV infection. However, maternal PrEP national guidelines differ and most countries with high maternal HIV incidence are not offering PrEP. We conducted a systematic review of recent research on PrEP safety in pregnancy to inform national policy and rollout. METHODS We used a standard Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) approach to conduct a systematic review by searching for completed, ongoing, or planned PrEP in pregnancy projects or studies from clinicaltrials.gov, PubMed and NIH RePORTER from 2014 to March 2019. We performed a systematic review of studies that assess tenofovir disoproxil fumarate (TDF)-based oral PrEP safety in pregnant and breastfeeding HIV-uninfected women. RESULTS AND DISCUSSION We identified 14 completed (n = 5) and ongoing/planned (n = 9) studies that evaluate maternal and/or infant outcomes following PrEP exposure during pregnancy or breastfeeding. None of the completed studies found differences in pregnancy or perinatal outcomes associated with PrEP exposure. Nine ongoing studies, to be completed by 2022, will provide data on >6200 additional PrEP-exposed pregnancies and assess perinatal, infant growth and bone health outcomes, expanding by sixfold the data on PrEP safety in pregnancy. Research gaps include limited data on (1) accurately measured PrEP exposure within maternal and infant populations including drug levels needed for maternal protection; (2) uncommon perinatal outcomes (e.g. congenital anomalies); (3) infant outcomes such as bone growth beyond one year following PrEP exposure; (4) outcomes in HIV-uninfected women who use PrEP during pregnancy and/or lactation. CONCLUSIONS Expanding delivery of PrEP is an essential strategy to reduce HIV incidence in pregnancy and breastfeeding women. Early safety studies of PrEP among pregnant women without HIV infection are reassuring and ongoing/planned studies will contribute extensive new data to bolster the safety profile of PrEP use in pregnancy. However, addressing research gaps is essential to expanding PrEP delivery for women in the context of pregnancy.
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Affiliation(s)
- Dvora L Joseph Davey
- Department of EpidemiologyFielding School of Public HealthUniversity of CaliforniaLos AngelesCAUSA
- Division of Epidemiology and BiostatisticsSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
| | - Jillian Pintye
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
| | - Jared M Baeten
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
- Department of EpidemiologyUniversity of WashingtonSeattleWAUSA
- Department of MedicineUniversity of WashingtonSeattleWAUSA
| | - Grace Aldrovandi
- Geffen School of MedicineUniversity of CaliforniaLos AngelesCAUSA
| | | | - Linda‐Gail Bekker
- Faculty of Health SciencesDesmond Tutu HIV CentreInstitute of Infectious Disease and Molecular MedicineUniversity of Cape TownCape TownNCSouth Africa
| | - Connie Celum
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
| | - Benjamin H Chi
- Department of Obstetrics and GynecologyUniversity of North Carolina at Chapel HillChapel HillNCUSA
| | - Thomas J Coates
- Geffen School of MedicineUniversity of CaliforniaLos AngelesCAUSA
| | | | - Renee Heffron
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
- Department of EpidemiologyUniversity of WashingtonSeattleWAUSA
| | - John Kinuthia
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
- Department of Research and ProgramsKenyatta National HospitalNairobiKenya
| | | | - James McIntyre
- Division of Epidemiology and BiostatisticsSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
- ANOVAJohannesburgSouth Africa
| | - Dhayendre Moodley
- Department of Obstetrics and GynaecologyUniversity of KwaZulu‐NatalDurbanSouth Africa
- Centre for AIDS Research in South AfricaDurbanSouth Africa
| | | | - Nelly Mugo
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
- Center for Clinical ResearchKenya Medical Research Institute (KEMRI)NairobiKenya
| | - Landon Myer
- Division of Epidemiology and BiostatisticsSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
| | - Andrew Mujugira
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
- Infectious Diseases InstituteMakerere UniversityKampalaUganda
| | - Steven Shoptaw
- Geffen School of MedicineUniversity of CaliforniaLos AngelesCAUSA
- Department of Family MedicineUniversity of CaliforniaLos AngelesCAUSA
| | | | - Grace John‐Stewart
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
- Department of EpidemiologyUniversity of WashingtonSeattleWAUSA
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Slogrove AL. Being prepared to evaluate pregnancy PrEP. J Int AIDS Soc 2019; 22:e25435. [PMID: 31851419 PMCID: PMC6918507 DOI: 10.1002/jia2.25435] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 11/27/2019] [Indexed: 11/20/2022] Open
Affiliation(s)
- Amy L Slogrove
- Department of Paediatrics and Child HealthFaculty of Medicine and Health SciencesStellenbosch UniversityWorcesterSouth Africa
- Ukwanda Centre for Rural HealthDepartment of Global HealthFaculty of Medicine and Health SciencesStellenbosch UniversityWorcesterSouth Africa
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Dettinger JC, Kinuthia J, Pintye J, Baeten JM, John‐Stewart G. Response to "Being prepared to evaluate pregnancy PrEP". J Int AIDS Soc 2019; 22:e25440. [PMID: 31872948 PMCID: PMC6929148 DOI: 10.1002/jia2.25440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 12/04/2019] [Indexed: 11/11/2022] Open
Affiliation(s)
| | - John Kinuthia
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
- Department of Obstetrics/GynecologyKenyatta National HospitalNairobiKenya
| | - Jillian Pintye
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
| | - Jared M Baeten
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
- Department of EpidemiologyUniversity of WashingtonSeattleWAUSA
- Department of MedicineUniversity of WashingtonSeattleWAUSA
| | - Grace John‐Stewart
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
- Department of EpidemiologyUniversity of WashingtonSeattleWAUSA
- Department of MedicineUniversity of WashingtonSeattleWAUSA
- Department of PediatricsUniversity of WashingtonSeattleWAUSA
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