High PrEP uptake and objective longitudinal adherence among HIV-exposed women with personal or partner plans for pregnancy in rural Uganda: A cohort study

Performance of Adherence Measures for Oral, Tenofovir-Based HIV Pre-Exposure Prophylaxis: A Systematic Review

Accurate adherence measures to HIV pre-exposure prophylaxis (PrEP) are essential for identifying individuals with low adherence and providing tailored support. This systematic review summarizes evidence on the performance of PrEP indirect adherence measures and explores their potential use in clinical practice. Following a registered protocol (PROSPERO: CRD42020144733) we searched PubMed, Embase, LILACS and Web of Science until December 2024. We included studies that assessed PrEP adherence among individuals using daily oral PrEP with tenofovir disoproxil fumarate plus emtricitabine (TDF/FTC). The reference standard involved quantifying PrEP in dried blood spots or plasma, and index tests included self-reported adherence, pill counts, pharmacy records, electronic monitoring, or composite measures. We used QUADAS-2 to assess the risk of bias and applicability concerns. Twenty-three studies, which included 6649 individuals, fulfilled the inclusion criteria. Most were observational studies (n = 17, 73.9%), and the most common measure was self-report (n = 18, 78.3%). The performance of indirect measures was reported through accuracy statistics in 12 studies (52.2%), concordance in two (8.7%), correlation in eight (34.8%), and proportions in one (4.3%). The risk of bias and applicability concerns were generally low or unclear due to unclear reporting. This review underscores the wide heterogeneity of indirect measures used to assess PrEP adherence, with self-reports being the most frequently utilized. Despite some correlation with direct measures, these methods showed mixed evidence of accuracy, with studies reporting moderate discriminatory capacity for identifying high protective levels of TFV-DP. This finding limits the broader applicability of the measures and underscores the need for further research.

"You're in an Image of a Man but Not a Man": A Qualitative Analysis of Intersectional Stigma Among Men with HIV Experiencing Subfertility in Rural Southwestern Uganda

Many men with HIV (MWH) want to have children and may encounter HIV- and infertility-related stigma experiences. Integration of reproductive health and HIV care for men is rare. When available, safer conception care focuses on HIV prevention but lacks fertility support. We conducted qualitative in-depth interviews in Uganda with 30 MWH who desired more children and self-reported no partner pregnancy after 12 or more months of conception attempts. We separately interviewed 10 female partners. Interviews explored stigma experiences and factors impacting engagement in HIV and reproductive care. We used vignettes to elicit responses to stories of couples experiencing challenges of HIV and subfertility. The study team discussed, coded, and analyzed data from individual participant interview transcripts, inductively identifying emergent themes. The following overarching themes emerged: (1) Reproductive goals often take priority over HIV prevention among HIV-affected couples in this context, influenced by multi-level subfertility stigma in society. (2) MWH may pursue behaviors that increase risk of HIV transmission to meet their reproductive goals. (3) Men and women are eager to maintain their primary partnerships, prevent HIV transmission, and meet their reproductive goals with guidance from healthcare providers. Further research is needed on the causes of subfertility and infertility among HIV-affected couples in East Africa to better support their conception goals. Additionally, studies on the intersection of HIV and infertility stigma in high-fertility, high-HIV prevalence areas are essential for designing interventions that meet couples' social, emotional, and medical needs.

Use of tenofovir-based preexposure prophylaxis among pregnant women in South Africa

OBJECTIVE

We developed Healthy Families-PrEP to support perinatal women to use HIV prevention strategies.

DESIGN

Single-arm study to evaluate PrEP use among pregnant women exposed to the intervention.

METHODS

We offered safer conception counselling, including TDF/FTC as PrEP with adherence support (Healthy Families-PrEP) for women planning for pregnancy in South Africa with a partner with HIV or unknown serostatus. Women completed pregnancy and HIV testing quarterly and were followed for 1 year or until pregnancy end. For those initiating PrEP, electronic pillcap data and plasma were collected. We described PrEP adherence by proportion of days with pillcap openings and proportion of women with detected (≥10ng/ml) plasma tenofovir.

RESULTS

From November 2017 to January 2020, 326 women with median age 24 years [interquartile range (IQR) 22-27] enrolled. Partner HIV-serostatus was unknown by 316 (97%). Over 3204 person-months of follow-up, 56 women became pregnant. Twenty-six women used PrEP during pregnancy and opened pillcaps on a mean of 53.1% [95% confidence interval (CI) 46.9-59.3%] of days. Plasma tenofovir was detected among 25, 15.4, and 12.5% of women providing samples during months 0-3, 4-6, and 7-9. No HIV seroconversions were observed.

CONCLUSION

We observed low-pregnancy incidence. Counselling may have encouraged delayed pregnancy plans; some women may have exaggerated pregnancy plans to enroll. About half of pregnant women used PrEP and took over half of doses by pillcap. Fewer than 25% had tenofovir detected, likely reflecting pregnancy-related pharmacokinetics and adherence challenges. High interest in pregnancy PrEP use highlights the need to optimize adherence support and prevention choice.

Associations with HIV preexposure prophylaxis use by cisgender female sex workers in two Ugandan cities

BACKGROUND

Sex workers of all genders have a high risk of HIV acquisition and are a priority population for HIV pre-exposure prophylaxis (PrEP). We aimed to assess current oral PrEP use and associated factors among cisgender female sex workers (FSW) in two Ugandan cities.

METHODS

We administered a survey questionnaire to 236 HIV-negative FSW in the cities of Mbale and Mbarara from January to March 2020. The survey was nested in a quasi-experimental study to assess the effect of peer education and text message reminders on the uptake of regular sexually transmitted infection (STI) and HIV testing. Using interviewer-administered questionnaires, we obtained data on current self-reported tenofovir-based oral PrEP use. We used modified Poisson regression with robust standard errors to evaluate the factors associated with current oral PrEP usage.

RESULTS

Nearly 70% of FSWs reported taking an HIV test during the past three months. Among the respondents, 33% (33/100) in Mbale and 67% (91/136) in Mbarara reported having ever heard of PrEP. However, only 9.7% (23/236) self-reported currently taking oral-PrEP. In Mbarara, FSWs were twice as likely to be aware of or use oral PrEP than those in Mbale (adjusted prevalence ratio [aPR] 2.33; 95% confidence interval (CI) 1.19-3.97; p = 0.01). Additionally, current use was positively associated with attainment of secondary (aPR 2.50; 95% CI: 1.14-5.45; p = 0.02) or tertiary education (aPR 3.12; 95% CI: 1.09-8.96; p = 0.03).

CONCLUSION

PrEP use in this cohort of FSWs was low and was associated with location and level of education. To increase PrEP uptake among FSWs, targeted educational campaigns and implementation studies are needed, particularly for those with lower levels of education.

Prenatal exposure to HIV pre-exposure prophylaxis and birth, growth, and social-emotional developmental outcomes throughout early childhood in Kenya: a prospective cohort study

BACKGROUND

As pre-exposure prophylaxis (PrEP) implementation continues to scale up among pregnant people, accruing safety data following prenatal PrEP exposure remains important. In this study, we aimed to evaluate the relationship between prenatal PrEP exposure and birth and infant or child outcomes.

METHODS

This prospective cohort study analysed data from the PrEP Implementation for Mothers in Antenatal Care study (NCT03070600). Participants were eligible for inclusion if they were currently pregnant, not currently using PrEP, were aged 15 years or older, planned to remain in the study area, were not enrolled in other studies, and did not have HIV or tuberculosis. Participants enrolled during pregnancy at 20 maternal and child health clinics in western Kenya and were followed up until 9 months postpartum. Those who reported taking PrEP at any antenatal visits were identified as prenatally PrEP exposed. In an extension cohort, participants and their children were followed up until 36 months postpartum. Infant anthropometry and social-emotional development using the Ages and Stages Questionnaire (ASQ-SE), second edition were assessed by trained study nurses. Among a subset of participants, we confirmed prenatal PrEP exposure using tenofovir diphosphate concentrations in dried blood spots. Perinatal outcomes (birth, growth, and neurodevelopment) were the primary outcomes assessed.

FINDINGS

Between Jan 15, 2018, and Jul 31, 2019, 4063 female individuals were enrolled and included in the analysis, of whom 558 (13·7%) used PrEP during pregnancy, initiating at a median of 26 weeks' gestation (IQR 22-31) for a median duration of 9·6 weeks in pregnancy (5·7-15·0). Compared with PrEP-unexposed pregnancies, there was no difference in pregnancy loss (ie, miscarriage), stillbirth, preterm birth, or neonatal death among PrEP exposed pregnancies (all p>0·05). There were no differences in infant length or weight at 6 weeks, 6 months, and 9 months (all p>0·05) between children with and without prenatal PrEP exposure, including underweight, stunting, and wasting. Results were similar when analysed separately by trimester of PrEP initiation and duration on PrEP, and in a subset at 24 months, 30 months, and 36 months. Prenatal PrEP exposure was not associated with ASQ-SE scores at 24-months (p=0·12), 30-months (p=0·75), or 36-months (p=0·81). No differences in adverse perinatal and infant outcomes were found among Kenyan individuals with quantifiable prenatal tenofovir diphosphate exposure.

INTERPRETATION

We found no significant differences in adverse birth or infant or child outcomes for 3 years of follow-up by prenatal PrEP exposure status. These data support findings from previous studies that demonstrate the safety of oral PrEP use during pregnancy.

FUNDING

The National Institutes of Health, National Institute of Allergy and Infectious Disease; Eunice Kennedy Shriver National Institute of Child Health and Human Development; the National Institute of Nursing Research; the University of Washington's Center for AIDS Research Behavioral Sciences Core and Biometrics Core; and the Global Center for the Integrated Health of Women, Adolescents, and Children.

TRANSLATION

For the Swahili translation of the abstract see Supplementary Materials section.

Awareness, willingness, and uptake of pre-exposure prophylaxis (PrEP) among men who have sex with men in Ghana

BACKGROUND

HIV prevalence among men who have sex with men (MSM) in Ghana is 18.1% as compared to 1.6% in the general population. Pre-exposure Prophylaxis (PrEP) is recommended by the World Health Organization (WHO) for people who are HIV-negative and at high risk of acquiring HIV. Since PrEP introduction in Ghana in 2020, little is known nationally about the level of awareness, uptake, and willingness to take PrEP among MSM. This study aims to generate estimates on PrEP awareness, uptake and willingness to use among MSM in Ghana.

METHODS

We conducted a bio-behavioral survey among MSM aged 18 years and above in all the 10 traditional regions in Ghana from August 2022 to July 2023 using respondent-driven sampling (RDS). RDS-Analyst was used to compute weights based on the participants' network. Data analysis was restricted to MSM who were HIV-negative and sexually active to estimate the prevalence of awareness, willingness, and uptake of PrEP. A multivariable logistic regression model was used to assess the factors influencing these outcomes.

RESULTS

Out of the 3,420 total MSM surveyed, 2,627 were HIV negative and were included in the analysis, Out of which 44.5% (95% CI: 42.0-47.0) were aware of PrEP, 90.4% (95% CI: 88.0-92.3) were willing to take PrEP and 17.8% (95% CI: 16.0 - 19.8) had ever taken PrEP. In the regression analyses, PrEP awareness was 5-fold higher among those who completed tertiary education (aOR: 5.56, 95% CI: 2.87-10.78, p < 0.001) and 4-fold among those who interacted with peer educators (aOR: 3.78, 95% CI: 2.52-5.67, p < 0.001). In terms of uptake, the odds were almost 9 times among those who had experienced forced sex (aOR: 8.88, 95% CI: 1.42-55.47, p = 0.02). MSM aged 25-34 were less willing to take PrEP (aOR:0.21, 95% CI 0.07-0.65, p = 0.006) and PrEP use was also less likely among those who consumed high alcohol (aOR:0.42, 95% CI 0.19-0.92, p = 0.03) and never tested for HIV (aOR: 0.44, 95% CI" 0.25-0.88, p = 0.017).

CONCLUSION

In Ghana, awareness and willingness to take PrEP to prevent HIV is high, but uptake is low. These results highlight the need for interventions to improve the overall uptake of PrEP among MSM in Ghana, especially among those aged 25-34, high alcohol consumers and those who have never screened for HV. Effective implementation of these findings into the national policies can enhance access and encourage PrEP use, ultimately reducing HIV incidence in Ghana among MSM.

An Open Letter on Advancing HIV prevention: Augmenting an ecosystem-based approach to understand prevention decision-making

In the last two decades, HIV programs have been able to avert millions of AIDS-related deaths and reduce HIV incidence. However, the 1.3 million new HIV infections in 2022 remain significantly above the UNAIDS target of fewer than 370,000 new infections by 2025. HIV programs worldwide also did not achieve the UN's 90-90-90 target for testing and treatment set for 2020. Within this broader picture, HIV continues to disproportionately affect key and at-risk populations, including gay men and other men who have sex with men, female sex workers, and adolescent girls and young women. As HIV incidence declines and biomedical advances continue, it will become critical for public-health practitioners to reach key and at-risk populations with prevention services and limit primary transmission. In this Open Letter, we focus on factors that influence uptake of HIV prevention products and thereby demand for HIV prevention products and services. These factors exist at three levels of the decision-making ecosystem - the individual level, interaction level and systemic level. We argue that approaching HIV prevention solely through the lens of these levels creates a static view of prevention decision-making. There is a need instead for a dynamic viewpoint that can mirror the changing contexts in which users find themselves and make prevention decisions. We demonstrate that the current ecosystem viewpoint is useful to understand the gaps that exist in program implementation, but does not provide adequate insights into the underlying behaviors that contribute to these gaps. To address this, we suggest an approach to include dynamic aspects of decision-making with factors that influence the individual's assessment of risk, their evaluation of the opportunities to use HIV prevention, and their effective use of prevention products.

Transforming HIV prevention: the promise of long-acting preexposure prophylaxis in high HIV burden settings

PURPOSE OF REVIEW

Recent research on efficacy and safety of long-acting preexposure prophylaxis (PrEP) holds the promise to transform HIV prevention in high HIV burden settings. We review emerging findings regarding early end-user acceptability of long-acting PrEP modalities, feasibility of integrating long-acting PrEP into health systems, and considerations regarding drug resistance and cost.

RECENT FINDINGS

Long-acting PrEP, particularly injectables, was found to be highly acceptable among individuals across key populations in high HIV burden settings. Concerns around use of long-acting PrEP highlight the importance of choice and ability to switch methods. Existing provider-level barriers to oral PrEP implementation (e.g., overburdened staff, training gaps) may impact long-acting PrEP rollout - however, utilization of PrEP implementation strategies such as task-shifting, timely PrEP training for all providers, differentiated service delivery, and integration with sexual health services, may mitigate barriers. Studies modeling injectable PrEP scale-up demonstrate substantial benefits in HIV mortality reduction, outweighing risks of increased integrase inhibitor resistance, but also highlight the urgency of pricing long-acting PrEP to ensure access and affordability.

SUMMARY

Long-acting PrEP could be a game changer in HIV prevention in high burden settings. There is an urgent need for rapid scale production and price reductions to ensure access in high HIV burden settings. Implementation strategies are needed to address individual and provider-level barriers.

Uptake and Persistence of Safer Conception Strategies Among South African Women Planning for Pregnancy

Safer conception strategies can minimize HIV acquisition during periconception periods among women living in HIV-endemic areas. We examined uptake and predictors of persistent use of the same safer conception strategy among a cohort of HIV-uninfected South African women ages 18-35 years planning for pregnancy with a partner living with HIV or of unknown HIV-serostatus. The safer conception strategies we evaluated included oral PrEP, condomless sex limited to peak fertility, and waiting for a better time to have a child (until, for example, the risks of HIV acquisition are reduced and/or the individual is prepared to care for a child); persistence was defined as using the same safer conception strategy from the first visit through 9 months follow-up. Modified Poisson regression models were used to examine predictors of persistent use of the same strategy. The average age of 227 women in our cohort was 24.6 (range: 18.0, 35.7) years. In this cohort, 121 (74.2%) women reported persisting in the same strategy through 9 months. Employment and HIV knowledge were associated with the persistent use of any strategy. Our results highlight the need to provide safer conception services to women exposed to HIV during periconception periods. Findings also offer some insights into factors that might influence persistent use. Further research is needed to better understand how to involve male partners and how their involvement might influence women's consistent use of safer conception strategies during periconception periods.

Assessment of acceptance and associated factors of HIV pre-exposure prophylaxis among commercial female sex workers in drop-in centers selected sub-cities of Addis Ababa, Ethiopia

Background

Globally, female sex workers (FSWs) face high risk of HIV, particularly in regions like sub-Saharan Africa. In Ethiopia and Addis Ababa, the impact is significant. Implementing WHO-recommended measures, such as pre-exposure prophylaxis (PrEP), is crucial to reducing new HIV infections and addressing service access disparities among FSWs. Thus this study aimed to assess the acceptance of Pre-Exposure Prophylaxis (PrEP) among commercial female sex workers in selected sub-cities of Addis Ababa, Ethiopia, 2022.

Method

Institution-based cross-sectional study design was conducted on three randomly selected sub-cities of Addis Ababa from June 20 to July 30, 2022. All (358) commercial sex workers available during the study period were included. A structured, pretested, and interviewer-administered questionnaire was used to collect the data. Logistic regression was used to identify factors associated with acceptance of pre-exposure prophylaxis and statistical significance was determined at p-value <0.05. An odds ratio with a 95% confidence interval was used to measure association estimates.

Result

A total of 358 female sex workers responded, 67.9% (95% CI: 63.7, 73.2%) were willing to take pre-exposure prophylaxis. Acceptability of pre-exposure prophylaxis was significantly associated with the accessibility of pre-exposure prophylaxis at easily reachable areas (AOR3.786; 95%CI: 1.449, 9.894) and knowledge about pre-exposure prophylaxis (AOR 3.270; 95%CI: 1.336, 8.001).

Conclusion

Acceptability of pre-exposure prophylaxis among female sex workers was 67.9% which is low. Accessibility of pre-exposure prophylaxis is an easily reachable area and knowledge of about it could significantly affect its acceptability.

Preventing perinatal HIV acquisition; current gaps and future perspectives

PURPOSE OF REVIEW

Although current treatment could eradicate vertical transmission, in 2022, 130 000 infants acquired HIV globally. HIV suppression with antiretroviral therapy (ART) transforms survival for people living with HIV (PLWH), and prevents transmission, including vertical. International guidelines recommend lifelong ART for PLWH, consequently perinatal HIV acquisition reflects implementation gaps in the HIV care cascade. We summarize these gaps, exploring potential novel approaches and therapeutic innovations towards eliminating vertical HIV transmission.

RECENT FINDINGS

Multifactorial challenges continue to underpin gaps in the HIV care cascade, including accessibility, availability and sustainability of HIV testing, prevention and treatment, alongside stigma, gender-based violence and poverty. Long-acting ART may be important in preventing perinatal HIV acquisition, with early data demonstrating tolerability and efficacy of injectable ART throughout pregnancy, both as HIV treatment and prevention. Carefully selected long-acting broadly neutralizing antibodies (bNAbs) matching circulating, exposing viral envelope sequences have demonstrated safety, clinical trials are ongoing to demonstrate efficacy.

SUMMARY

Emerging clinical studies should prioritize pregnant/lactating people and infants to ensure such therapies are well tolerated and efficacious. Alongside therapeutic innovation, programmatic strategies must address social and economic challenges, ensuring sustainable HIV treatment/prevention programmes and facilitating global elimination of blood-borne viruses.

Oral preexposure prophylaxis uptake, adherence, and persistence during periconception periods among women in South Africa

OBJECTIVE

We developed the Healthy Families-PrEP intervention to support HIV-prevention during periconception and pregnancy. We evaluated preexposure prophylaxis (PrEP) use with three objective measures.

DESIGN

This single-arm intervention study enrolled women in KwaZulu-Natal, South Africa, who were HIV-uninfected, not pregnant, in a relationship with a partner with HIV or unknown-serostatus, and with pregnancy plans. PrEP was offered as part of a comprehensive HIV prevention intervention. Participants were followed for 12 months.

METHODS

We evaluated periconception PrEP uptake and adherence using quarterly plasma tenofovir concentrations. We modeled factors associated with PrEP uptake and high plasma tenofovir (past day dosing). Patterns of use were analyzed using electronic pillcap data. Dried blood spots to measure intracellular tenofovir product (past 2 months dosing) were analyzed for a subset of women.

RESULTS

Three hundred thirty women with median age 24 (IQR: 22-27) years enrolled. Partner HIV-serostatus was unknown by 96% ( N  = 316); 60% (195) initiated PrEP. High plasma tenofovir concentrations were seen in 35, 25, 22, and 20% of samples at 3, 6, 9, and 12 months, respectively. Similar adherence was measured by pillcap and dried blood spots. In adjusted models, lower income, alcohol use, and higher HIV stigma were associated with high plasma tenofovir. Eleven HIV-seroconversions were observed (incidence rate: 4.04/100 person-years [95% confidence interval: 2.24-7.30]). None had detectable plasma tenofovir.

CONCLUSION

The Healthy Families-PrEP intervention supported women in PrEP use. We observed high interest in periconception PrEP and over one-third adhered to PrEP in the first quarter; one-fifth were adherent over a year. High HIV incidence highlights the importance of strategies to reduce HIV incidence among periconception women.

CLINICAL TRIAL NUMBER

NCT03194308.

Sexually Transmitted Infection Prevalence, Partner Notification, and Human Immunodeficiency Virus Risk Perception in a Cohort of Women Completing Sexually Transmitted Infection Screening as Part of a Safer Conception Study

BACKGROUND

Integrating sexually transmitted infection (STI) and preexposure prophylaxis (PrEP) care may optimize sexual and reproductive health.

METHODS

We nested an STI substudy within a human immunodeficiency virus (HIV) prevention cohort (parent study) of 18- to 35-year-old women from South Africa, planning pregnancy with a partner with HIV or of unknown serostatus. Parent-study women completed annual surveys regarding HIV-risk perceptions and were offered oral PrEP. Preexposure prophylaxis initiators completed quarterly plasma tenofovir (TFV) testing. Substudy women completed STI screening at enrollment, 6 months, onset of pregnancy, and in the third trimester via examination, vaginal swabs tested via PCR for Chlamydia trachomatis , Neisseria gonorrhoeae , Trichomonas vaginalis , Mycoplasma genitalium , and blood tested for Treponema pallidum . Follow-up was 6 months. Women with STIs were treated, offered partner notification (PN) cards, and surveyed regarding PN practices. We describe STI prevalence and incidence, and model factors associated with prevalent infection. Sexually transmitted infection substudy and parent study-only participants were matched on age and number of days on study to assess HIV-risk perception scores between the 2 groups and the proportion with detectable TFV.

RESULTS

Among 50 substudy participants, 15 (30%) had prevalent STI. All 13 completing follow-up reported PN. Most did not prefer assisted PN. Mean HIV risk perception scores and proportion with detected plasma TFV were similar across groups.

CONCLUSIONS

High STI prevalence supports the importance of laboratory screening to optimize sexual health for women planning pregnancy. Rates of self-reported PN are reassuring; low interest in assisted PN suggests the need for alternative approaches. Enhanced STI care did not affect HIV-risk perception or PrEP adherence, however both were relatively high in this cohort.

HIV Preexposure Prophylaxis With Emtricitabine and Tenofovir Disoproxil Fumarate Among Cisgender Women

Importance

Emtricitabine and tenofovir disoproxil fumarate (F/TDF) for HIV preexposure prophylaxis (PrEP) is highly effective in cisgender men who have sex with men (MSM) when adherence is high (>4 doses/week). Real-world effectiveness and adherence with F/TDF for PrEP in cisgender women is less well characterized.

Objective

To characterize the effectiveness of F/TDF for PrEP and its relationship with adherence in cisgender women.

Design, Setting, and Participants

Data were pooled from 11 F/TDF PrEP postapproval studies conducted in 6 countries that included 6296 cisgender women aged 15 to 69 years conducted from 2012 to 2020. HIV incidence was evaluated according to adherence level measured objectively (tenofovir diphosphate concentration in dried blood spots or tenofovir concentration in plasma; n = 288) and subjectively (electronic pill cap monitoring, pill counts, self-report, and study-reported adherence scale; n = 2954) using group-based trajectory modeling.

Exposures

F/TDF prescribed orally once a day. HIV incidence was analyzed in subgroups based on adherence trajectory.

Main Outcomes and Measures

HIV incidence.

Results

Of the 6296 participants, 46% were from Kenya, 28% were from South Africa, 21% were from India, 2.9% were from Uganda, 1.6% were from Botswana, and 0.8% were from the US. The mean (SD) age at PrEP initiation across all studies was 25 (7) years, with 61% of participants being younger than 25 years. The overall HIV incidence was 0.72 per 100 person-years (95% CI, 0.51-1.01; 32 incident HIV diagnoses among 6296 participants). Four distinct groups of adherence trajectories were identified: consistently daily (7 doses/week), consistently high (4-6 doses/week), high but declining (from a mean of 4-6 doses/week and then declining), and consistently low (less than 2 doses/week). None of the 498 women with consistently daily adherence acquired HIV. Only 1 of the 658 women with consistently high adherence acquired HIV (incidence rate, 0.13/100 person-years [95% CI, 0.02-0.92]). The incidence rate was 0.49 per 100 person-years (95% CI, 0.22-1.08) in the high but declining adherence group (n = 1166) and 1.27 per 100 person-years (95% CI, 0.53-3.04) in the consistently low adherence group (n = 632).

Conclusions and Relevance

In a pooled analysis of 11 postapproval studies of F/TDF for PrEP among cisgender women, overall HIV incidence was 0.72 per 100 person-years; individuals with consistently daily or consistently high adherence (4-6 doses/week) to PrEP experienced very low HIV incidence.

Piloting Gain and Loss-Framed PrEP and Childbearing Messaging to Promote HIV Testing in Uganda: Perspectives from Couples and Providers

Fears of relationship dissolution and the inability to bear healthy children remain barriers to HIV testing in sub-Saharan Africa. Pre-exposure prophylaxis (PrEP) carries both clinical and symbolic benefits that counter these fears. We conducted a pilot messaging intervention through Uganda's assisted partner notification (APN) program, where providers assist HIV-positive index clients in notifying sexual partners and encourage testing. We randomized providers at three clinics to implement phone scripts over two months with (1) gain-framed or (2) loss-framed information about PrEP and childbearing; or (3) usual care. In 23 in-depth interviews with providers, index clients, and partners, five major themes emerged on intervention acceptability and feasibility: (1) value of PrEP and childbearing messaging in APN; (2) value of this messaging coming earlier in APN; (3) overall preference for gain-framed messages; (4) need to tailor timing of messaging; and (5) need for messaging outside of APN. Register data (109 index clients, 145 partners) indicated most index clients (95%) wanted their potential conception partners informed about PrEP. Preliminary trends suggest the intervention sites outperformed usual care in testing rates among potential conception partners. Messaging that highlights PrEP and safe childbearing may be a promising new communication strategy to promote HIV testing.

Implementation determinants and strategies in integration of PrEP into maternal and child health and family planning services: experiences of frontline healthcare workers in Kenya

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.