A Text Messaging-Based Support Intervention to Enhance Pre-exposure Prophylaxis for HIV Prevention Adherence During Pregnancy and Breastfeeding: Protocol for a Randomized Controlled Trial

"It gives me the strength and courage to take care of myself": a qualitative exploration of experiences with STI testing among women who initiated PrEP during pregnancy in Western Kenya

INTRODUCTION

Sexually transmitted infections (STIs) in pregnancy contribute to poor perinatal outcomes and increased HIV acquisition risk, underscoring the importance of delivering STI/HIV services within antenatal care. Few studies evaluate women's perspectives on the co-delivery of antenatal STI testing and HIV pre-exposure prophylaxis (PrEP). We sought to understand motivations for and experiences with STI testing among pregnant women who initiated HIV PrEP.

METHODS

We conducted semi-structured in-depth interviews (IDIs) among a subset of women enrolled in a randomized trial in Western Kenya (NCT04472884) who initiated PrEP within antenatal clinics and tested for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) in pregnancy and/or postpartum. As part of parent study procedures, IDIs were conducted between September 2023 and April 2024. Interviews were recorded, transcribed and thematically analysed using deductive and inductive methods. The Health Belief Model guided exploration of STI testing experiences, motivations for testing and the impact of testing on PrEP use.

RESULTS

Overall, 39 women who initiated PrEP during pregnancy and tested for CT/NG participated in IDIs; six tested positive for CT and/or NG. Median age was 26 years (IQR 21-29), 77% of participants had >8 years of education, 15% were employed and 72% were married. Most (86%) did not know their partner's HIV status, and 82% persisted with PrEP use at 9 months postpartum. Perceived vulnerability to STI/HIV acquisition, fear of adverse outcomes from untreated infections (e.g. pregnancy loss or harm to baby) and desire to alleviate symptoms (e.g. abnormal discharge) motivated STI testing uptake when offered during antenatal visits. Provision of STI-related education, availability of STI services (i.e. immediate treatment, expedited partner therapy) and supportive interactions with providers promoted positive experiences with STI testing. STI testing encouraged health-promoting behaviours, including sustained PrEP use, even when STI results were negative, as testing made women feel proactively involved in preventing HIV/STI complications for themselves and their infants.

CONCLUSIONS

In this qualitative evaluation among women who initiated PrEP in pregnancy, STI testing encouraged PrEP use, even when results were negative. Incorporating STI testing within PrEP delivery in antenatal care represents an opportunity for addressing HIV/STI in this priority population.

Postpartum women's prospective acceptability of long-acting HIV prevention approaches in Kenya: A qualitative study

Background

New long-acting pre-exposure prophylaxis (LA-PrEP) options offer an alternative to daily oral PrEP, which poses difficulties for adherence, especially during pregnancy and postpartum. Yet, limited data exist on LA-PrEP acceptability among pregnant and postpartum women. We aimed to evaluate its acceptability and identify strategies to enhance it.

Methods

We conducted an exploratory qualitative study with postpartum women in five public health facilities in Kisumu and Siaya Counties, Kenya. In-depth interviews (IDIs) were conducted with women expressing high, low, and mixed LA-PrEP interest throughout pregnancy and postpartum. Inductive and deductive content analysis was used, and themes of acceptability were explored using the Theoretical Framework of Acceptability (TFA).

Results

We conducted 70 IDIs with postpartum women between August 2023 and March 2024. The majority (62.9%) expressed consistently high interest in LA-PrEP. Most viewed LA-PrEP, especially every two-month injectables, as highly acceptable due to reduced pill burden, side effects, and dosing frequency. Concerns were raised regarding injectable PrEP safety for the baby during pregnancy and suitability of using the vaginal ring during delivery. Participants emphasized the importance of education on the safety of these methods during pregnancy and breastfeeding, and strategies for improving adherence, such as mobile reminders. Overall, women preferred LA-PrEP options over daily oral PrEP for convenience, effectiveness, and privacy, with healthcare provider education seen as crucial.

Discussion

We found high acceptability of LA-PrEP options among postpartum women with experience taking PrEP during pregnancy. The findings reveal diverse preferences and key factors influencing acceptability, including safety, discretion, and convenience.

Mobile solutions to Empower reproductive life planning for women living with HIV in Kenya (MWACh EMPOWER): Protocol for a cluster randomized controlled trial

BACKGROUND

Women living with HIV (WLWH) face unique reproductive health (RH) barriers which increase their risks of unmet need for contraception, contraceptive failure, unintended pregnancy, and pregnancy-related morbidity and mortality and may prevent them from achieving their reproductive goals. Patient-centered counseling interventions that support health care workers (HCWs) in providing high-quality RH counseling, tailored to the needs of WLWH, may improve reproductive health outcomes.

METHODS AND DESIGN

We are conducting a non-blinded cluster randomized controlled trial (cRCT) of a digital health intervention for WLWH (clinicaltrials.gov #NCT05285670). We will enroll 3,300 WLWH seeking care in 10 HIV care and treatment centers in Nairobi and Western Kenya. WLWH at intervention sites receive the Mobile WACh Empower intervention, a tablet-based RH decision-support counseling tool administered at baseline and SMS support during two years of follow-up. WLWH at control sites receive the standard of care FP counseling. The decision-support tool is a logic-based tool for family planning (FP) counseling that uses branching logic to guide RH questions based on participants' reproductive life plans, tailoring counseling based on the responses. Follow-up SMSs are based in the Information-Motivation-Behavioral (IMB) Skills model of behavioral change and are tailored to participant characteristics and reproductive needs through separate SMS "tracks". Follow-up visits are scheduled quarterly for 2 years to assess plans for pregnancy, pregnancy prevention, and contraceptive use. The primary outcome, FP discontinuation, will be compared using an intent-to-treat analysis. We will also assess the unmet need for FP, dual method use, viral load suppression at conception and unintended pregnancy.

DISCUSSION

The Mobile WACh Empower intervention is innovative as it combines a patient-centered counseling tool to support initial reproductive life decisions with longitudinal SMS for continued RH support and may help provide RH care within the context of provision of HIV care.