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Ntinga X, Isehunwa OO, Msimango LI, Smith PM, Matthews LT, Van Heerden A. Perceptions of Pre-exposure Prophylaxis (PrEP) for HIV prevention among men living with HIV in the context of reproductive goals in South Africa: a qualitative study. BMC Public Health 2024; 24:553. [PMID: 38389039 PMCID: PMC10882859 DOI: 10.1186/s12889-024-18118-4] [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: 11/14/2023] [Accepted: 02/15/2024] [Indexed: 02/24/2024] Open
Abstract
BACKGROUND Pre-exposure Prophylaxis (PrEP) and Treatment as Prevention (TasP) are effective strategies to prevent HIV transmission within serodifferent couples. However, limited usage of PrEP, knowledge and interest has been amongst the barriers for men, alongside testing and treatment adherence. We explored the perceptions of PreP for HIV prevention with Men living with HIV (MWH) who have reproductive goals, to understand awareness and experiences related to PrEP use in the context of HIV prevention with their partners. METHODS We undertook a qualitative study with 25 MWH aged 18 to 65 between April and September 2021 in South Africa. Potential participants were screened for eligibility and scheduled to participate in telephonic interviews. Interviews were audio recorded, transcribed, translated and thematically analysed. RESULTS Themes were organized into opportunities and barriers that men with HIV articulate as important for using PrEP to meet individual, couple, and community reproductive goals. At the individual level, some men were willing to discuss PrEP with their partners to protect their partners and babies from acquiring HIV. Lack of knowledge about PrEP among men was a potential barrier to promoting PrEP among their female partners. At the couple level, PrEP use was seen as a way to strengthen relationships between partners, signifying care, trust, and protection and was seen as a tool to help serodifferent couples meet their reproductive goals safely. At the community level, PrEP was viewed as a tool to promote HIV testing and prevention efforts, especially among men, but participants emphasized the need for more education and awareness. CONCLUSION Despite PrEP implementation in South Africa, awareness of PrEP among men with HIV in rural areas remains low. Engaging MWH to support their partners in accessing PrEP could be an innovative strategy to promote HIV prevention. Additionally, providing men with comprehensive reproductive health information can empower them to make more informed decisions, adopt safer sexual practices, and challenge societal norms and stigmas around HIV.
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Affiliation(s)
- Xolani Ntinga
- Centre for Community Based Research, Human Sciences Research Council, Old Bus Depot, Sweetwaters, Pietermaritzburg, 3201, South Africa.
| | - Oluwaseyi O Isehunwa
- Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Lindani I Msimango
- Centre for Community Based Research, Human Sciences Research Council, Old Bus Depot, Sweetwaters, Pietermaritzburg, 3201, South Africa
| | - Patricia M Smith
- Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Lynn T Matthews
- Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Alastair Van Heerden
- Centre for Community Based Research, Human Sciences Research Council, Old Bus Depot, Sweetwaters, Pietermaritzburg, 3201, South Africa
- SAMRC/WITS Developmental Pathways for Health Research Unit, Department of Pediatrics, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, South Africa
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Kefeni BT, Tesfaye S, Bayisa K, Negara E, Bati F. Determinants of long act reversible contraceptive utilization among HIV positive reproductive age women attending ART clinic in South West Ethiopia. Contracept Reprod Med 2023; 8:30. [PMID: 37143084 PMCID: PMC10158019 DOI: 10.1186/s40834-023-00227-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 04/15/2023] [Indexed: 05/06/2023] Open
Abstract
BACKGROUND Identifying the determinants of long-acting contraceptive utilization and managing the sexual and reproductive health of HIV-infected women is critical to reducing HIV transmission and maternal mortality. However, the determinants of long-acting contraceptive utilization have not been well understood in resource-limited settings like Ethiopia. The aim of this study was to identify determinants of long-acting reversible contraceptive utilization among HIV-positive women on ART in southwest Ethiopia. METHODS A facility-based, unmatched case control study was conducted from July 24 to August 28, 2021, in south-west Ethiopia. The study participants were HIV positive women, with a sample size of 109 cases and controls. An interviewer administered a questionnaire, and a check list was used for data collection. A systemic random sampling technique was used to collect data from cases and controls. Bivariate and multivariable logistic regressions were employed to determine the determinants of LARC utilization among HIV-positive women. To demonstrate the strength of the determinant, the odds ratio was calculated with 95% confidence intervals, and a P-value less than 0.05 was used to declare statistical significance. RESULT A total of 324 women (108 cases and 216 controls) of reproductive age who were HIV positive were interviewed, with a response rate of 99.0%. urban residence (AOR = 2.67, 95%CI: 1.23- 5.77), having formal education (AOR = 2.93, 95% CI:1.36, 6.34), being counseled by health care provider (AOR = 5.42,95% CI: 2.67-11.03), no future fertility intention (AOR = 2.87, 95% CI:1.44-5.70), having CD4 count less than 500 cell/mm3 (AOR = 4.18,95% CI:2.12-8.23), having information of HIV transmission from mother to child (AOR = 3.65,95% CI:1.49-8.95),not using condom during sexual intercourse (AOR = 4.86,95% CI:2.46-9.62),,having knowledge towards LARC (AOR = 2.38,95% CI:1.24-4.58) and attitude towards LARC (AOR = 6.41,95%CI:3.16-13.0) were independent determinants of LARC utilization among HIV positive women. CONCLUSION AND RECOMMENDATION Women being counseled by a health care provider, having no future fertility intention, and having a CD4 count less than 500 cells/mm3 were found to be determinants of long-acting contraceptive method utilization among HIV-positive reproductive-age women. Also, our study supports the WHO Strategic Concepts for Improving the Links between Family Planning and HIV/AIDS Policy, Programs, and Services. It is recommended that Health care providers should use these factors as base line during family planning counseling and service delivery.
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Affiliation(s)
| | - Sitota Tesfaye
- Department of Public Health, College of Health Sciences, Mettu University, Mettu, Ethiopia
| | - Kenbon Bayisa
- Department of Public Health, College of Health Sciences, Mettu University, Mettu, Ethiopia
| | - Ebissa Negara
- Department of Public Health, College of Health Sciences, Mettu University, Mettu, Ethiopia
| | - Feyiso Bati
- Department of Midwifery, College of Health Sciences, Dire Dawa University, Dire Dawa, Ethiopia
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Ramphisa MJ, Rasweswe MM, Mooa RS, Seretlo RJ. The support systems offered by the sexual partners of people living with HIV / AIDS: A qualitative study. INTERNATIONAL JOURNAL OF AFRICA NURSING SCIENCES 2023. [DOI: 10.1016/j.ijans.2023.100562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2023] Open
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Association between viral suppression during the third trimester of pregnancy and unintended pregnancy among women on antiretroviral therapy: Results from the 2019 antenatal HIV Sentinel Survey, South Africa. PLoS One 2022; 17:e0265124. [PMID: 35298503 PMCID: PMC8929576 DOI: 10.1371/journal.pone.0265124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 02/24/2022] [Indexed: 11/19/2022] Open
Abstract
Objectives About half of the pregnancies among women living with HIV (WLWH) receiving antiretroviral therapy (ART) in sub-Saharan African countries are reported to be unintended. Unintended pregnancy is associated with late initiation of antenatal care (ANC), and may delay provision of viral load monitoring services, antenatal adherence counselling and support, and other services that promote sustained viral suppression throughout pregnancy. This study examines the association between unsuppressed viral load during the third trimester of pregnancy and unintended pregnancy among women who initiated ART before pregnancy. Methods This was an analysis of data from a national antenatal survey conducted at 1 589 public health facilities in South Africa between 1 October and 15 November 2019. Consenting pregnant women aged 15–49 years attending ANC during the survey period were enrolled. Demographic and clinical data were collected through interview and medical record review. Pregnancy intention was assessed using two questions from the London Measure of Unplanned Pregnancy, and responses were categorized as “unintended,” “undecided,” and “intended.” Blood specimens were collected from all women and tested for HIV; and if positive, a viral load test was performed. A survey domain-based poisson regression model examined the association between unsuppressed viral load during the third trimester of pregnancy and unintended pregnancy among women who initiated ART before pregnancy. Viral suppression was defined as viral load <50 copies/mL. Results Of 10 901 WLWH with viral load data available, 63.3% (95% confidence interval (CI): 62.4%-64.1%) were virally suppressed. Among the 2 681 women (representing 24.1% of all WLWH with viral load data) who initiated ART before pregnancy and were in their third trimester at the time of enrolment, 74.4% (95% CI: 73.0%-75.8%) were virally suppressed. In the same population, the proportion virally suppressed was lower among women whose current pregnancies were unintended (72.1%, 95% CI: 70.1%-74.1%) compared to women whose pregnancies were intended (78.3%, 95% CI: 75.9%-80.5%). In multivariable analyses adjusted for age, gravity, marital status, education, location of facility and syphilis status, unintended pregnancy was associated with unsuppressed viral load during the third trimester (adjusted relative risk: 1.3, 95% CI: 1.1–1.4) among women who initiated ART before pregnancy. Conclusion The identified association between unsuppressed viral load and unintended pregnancy among pregnant women who initiated ART before pregnancy highlights the need to strengthen routine assessment of fertility preferences and provision of contraceptive services to reproductive age WLWH receiving ART.
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Carroll K, Pottinger AM, Pinkney J, Christie LR, Hamilton PI, Thompson MS. Fertility care expectations: what do PLHIV and health care providers in Jamaica know about assisted reproduction services for safe conception? AIDS Care 2022; 35:1045-1054. [PMID: 34986729 DOI: 10.1080/09540121.2021.2023729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Increased life expectancy among persons living with HIV (PLHIV) has increased the desire for parenthood. It is therefore important that PLHIV and health care providers (HCPs) are aware of the available assisted reproduction services (ARS) for PLHIV facing infertility or unsuppressed viremia. Through secondary data analysis we identified PLHIV who were actively trying to conceive and their knowledge of ARS. As specialized fertility care for PLHIV is managed by Obstetrician/Gynecologists (Ob/Gyns), they were surveyed regarding their attitudes towards working with PLHIV and their awareness and knowledge of ARS with a self-administered questionnaire. In this cross-sectional study, 251 PLHIV and 102 Ob/Gyns were recruited and interviewed using a semi-structured questionnaire. Although most Ob/Gyns (81%) reported being supportive of PLHIV having children, 85% counseled against pregnancy, particularly persons in HIV serodifferent relationships. Significantly more PLHIV under 40 years compared to those over 40 years had heard about ARS (59% vs. 43%, p = .007). Ob/Gyns were more knowledgeable of expensive ARS, while PLHIV's knowledge was more restricted to cheaper more accessible ones. In conclusion Ob/Gyns knowledge gaps and underlying stereotypes may present barriers to PLHIV's uptake of ARS. Additionally, virologically unsuppresed persons in HIV serodifferent relationships may be vulnerable as Ob/Gyns were less supportive of them.
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Affiliation(s)
- Kamali Carroll
- The Hugh Wynter Fertility Management Unit, The University of the West Indies, Kingston, Jamaica
| | - Audrey M Pottinger
- Department of Child and Adolescent Health, The University of the West Indies, Kingston, Jamaica
| | - Jodian Pinkney
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
| | - Loxley R Christie
- The Hugh Wynter Fertility Management Unit, The University of the West Indies, Kingston, Jamaica
| | - Pansy I Hamilton
- The Hugh Wynter Fertility Management Unit, The University of the West Indies, Kingston, Jamaica
| | - Monique S Thompson
- Department of Obstetrics and Gynaecology, The University of the West Indies, Kingston, Jamaica
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Mathenjwa M, Khidir H, Milford C, Mosery N, Rambally Greener L, Pratt MC, O'Neil K, Harrison A, Bangsberg DR, Safren SA, Smit JA, Psaros C, Matthews LT. Acceptability of an Intervention to Promote Viral Suppression and Serostatus Disclosure for Men Living with HIV in South Africa: Qualitative Findings. AIDS Behav 2022; 26:1-12. [PMID: 34097209 PMCID: PMC8786780 DOI: 10.1007/s10461-021-03278-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2021] [Indexed: 01/15/2023]
Abstract
Men living with HIV (MLWH) often have reproductive goals that can increase HIV-transmission risks to their pregnancy partners. We developed a safer conception intervention for MLWH in South Africa employing cognitive behavioral skills to promote serostatus disclosure, ART uptake, and viral suppression. MLWH were recruited from an HIV clinic near Durban, South Africa, and encouraged to include partners in follow-up visits. Exit in-depth interviews were conducted with eleven men and one female partner. The emerging over-arching theme is that safer conception care mitigates internalized and community-level HIV-stigma among MLWH. Additional related sub-themes include: (1) safer conception care acceptability is high but structural barriers challenge participation; (2) communication skills trainings helped overcome barriers to disclose serostatus; (3) feasibility and perceived effectiveness of strategies informed safer conception method selection. Our findings suggest that offering safer conception care to MLWH is a novel stigma-reducing strategy for motivating HIV prevention and treatment and serostatus disclosure to partners.
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Affiliation(s)
- Mxolisi Mathenjwa
- MRU (MatCH Research Unit), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | | | - Cecilia Milford
- MRU (MatCH Research Unit), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | - Nzwakie Mosery
- MRU (MatCH Research Unit), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | - Letitia Rambally Greener
- MRU (MatCH Research Unit), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
- Population Services International, South Africa, Johannesburg, South Africa
| | - Madeline C Pratt
- University of Alabama at Birmingham (UAB), Division of Infectious Disease, Birmingham, Alabama, USA
| | | | | | | | | | - Jennifer A Smit
- MRU (MatCH Research Unit), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | | | - Lynn T Matthews
- University of Alabama at Birmingham (UAB), Division of Infectious Disease, Birmingham, Alabama, USA.
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The prevalence of unintended pregnancy and its association with HIV status among pregnant women in South Africa, a national antenatal survey, 2019. Sci Rep 2021; 11:23740. [PMID: 34887462 PMCID: PMC8660789 DOI: 10.1038/s41598-021-03096-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 11/29/2021] [Indexed: 12/26/2022] Open
Abstract
To describe the prevalence of unintended pregnancy and its association with HIV status among pregnant women in South Africa. A cross-sectional survey was conducted between October and mid-November 2019 among pregnant women aged 15–49 years in 1589 selected public antenatal care facilities. Pregnancy intention was assessed using two questions from the London Measure of Unplanned Pregnancy. Survey logistic regression examined factors associated with unintended pregnancy. Among 34,946 participants, 51.6% had an unintended pregnancy. On multivariable analysis, the odds of unintended pregnancy was higher among women who knew their HIV-positive status before pregnancy but initiated treatment after the first antenatal visit (adjusted odds ratio [aOR], 1.5 [95% confidence interval (CI):1.2–1.8]), women who initiated treatment before pregnancy (aOR, 1.3 [95% CI:1.2–1.3]), and women with a new HIV diagnosis during pregnancy (aOR, 1.2 [95% CI:1.1–1.3]) compared to HIV-negative women. Women who were single, in a non-cohabiting or a cohabiting relationship, and young women (15–24 years) had significantly higher risk of unintended pregnancy compared to married women and women aged 30–49 years, respectively. A comprehensive approach, including regular assessment of HIV clients’ pregnancy intention, and adolescent and youth-friendly reproductive health services could help prevent unintended pregnancy.
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Gutin SA, Harper GW, Moshashane N, Ramontshonyana K, Stephenson R, Shade SB, Harries J, Mmeje O, Ramogola-Masire D, Morroni C. Relationship, partner factors and stigma are associated with safer conception information, motivation, and behavioral skills among women living with HIV in Botswana. BMC Public Health 2021; 21:2231. [PMID: 34879845 PMCID: PMC8653588 DOI: 10.1186/s12889-021-12268-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 11/16/2021] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND A significant proportion (20-59%) of people living with HIV in sub-Saharan Africa desire childbearing, are of reproductive age, and are in sero-different relationships (~50%). Thus it is plausible that some portion of new HIV transmissions are due to attempts to become pregnant. Safer conception (SC) methods that effectively reduce the risk of HIV transmission exist and can be made available in resource-constrained settings. Few studies in the region, and none in Botswana, have quantitatively examined the correlates of information, motivation, and behavioral skills for SC uptake. METHODS We surveyed 356 women living with HIV from 6/2018 to 12/2018 at six public-sector health clinics in Gaborone, Botswana. Participants were 18-40 years old, not pregnant, and desired future children or were unsure about their childbearing plans. We examined correlates of SC information, motivation, and behavioral skills using nested linear regression models, adjusting for socio-demographic, interpersonal, and structural variables. RESULTS Knowledge of SC methods varied widely. While some SC methods were well known (medical male circumcision by 83%, antiretroviral therapy for viral suppression by 64%), most other methods were known by less than 40% of participants. Our final models reveal that stigma as well as relationship and partner factors affect SC information, motivation, and behavioral skills. Both internalized childbearing stigma (ß=-0.50, 95%CI:-0.17, -0.02) and perceived community childbearing stigma were negatively associated with SC information (ß=-0.09, 95%CI:-0.80, -0.21). Anticipated (ß=-0.06, 95%CI:-0.12, -0.003) and internalized stigma (ß=-0.27, 95%CI:-0.44; -0.10) were associated with decreased SC motivation, while perceived community childbearing stigma was associated with increased SC motivation (ß=0.07, 95%CI:0.02, 0.11). Finally, internalized childbearing stigma was associated with decreased SC behavioral skills (ß=-0.80, 95%CI: -1.12, -0.47) while SC information (ß=0.24, 95%CI:0.12, 0.36), motivation (ß=0.36, 95%CI:0.15, 0.58), and perceived partner willingness to use SC (ß=0.47, 95%CI:0.36, 0.57) were positively associated with behavioral skills CONCLUSIONS: Low SC method-specific information levels are concerning since almost half (47%) of the study participants reported they were in sero-different relationships and desired more children. Findings highlight the importance of addressing HIV stigma and partner dynamics in interventions to improve SC information, motivation, and behavioral skills.
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Affiliation(s)
- Sarah A Gutin
- Center for AIDS Prevention Studies, Division of Prevention Science, University of California, San Francisco, 550 16th Street, 3rd Floor, 94143, San Francisco, CA, USA.
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, 1415 Washington Heights, MI, 48109, Ann Arbor, USA.
- Women's Health Research Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, 7925, Observatory, Cape Town, South Africa.
| | - Gary W Harper
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, 1415 Washington Heights, MI, 48109, Ann Arbor, USA
| | - Neo Moshashane
- Botswana Harvard AIDS Institute Partnership Princess Marina Hospital, Private Bag BO 320, Gaborone, Botswana
| | - Kehumile Ramontshonyana
- Botswana Harvard AIDS Institute Partnership Princess Marina Hospital, Private Bag BO 320, Gaborone, Botswana
| | - Rob Stephenson
- Department of Systems, Population and Leadership, School of Nursing, University of Michigan, MI, Ann Arbor, USA
- The Center for Sexuality and Health Disparities, School of Nursing, University of Michigan, Ann Arbor, MI, USA
| | - Starley B Shade
- Department of Epidemiology & Biostatistics School of Medicine, University of California, San Francisco, CA, San Francisco, USA
| | - Jane Harries
- Women's Health Research Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, 7925, Observatory, Cape Town, South Africa
| | - Okeoma Mmeje
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, 1415 Washington Heights, MI, 48109, Ann Arbor, USA
- Department of Obstetrics and Gynecology, University of Michigan Medical School, MI, Ann Arbor, USA
| | - Doreen Ramogola-Masire
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Botswana, Gaborone, Botswana
| | - Chelsea Morroni
- Women's Health Research Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, 7925, Observatory, Cape Town, South Africa
- Botswana Harvard AIDS Institute Partnership Princess Marina Hospital, Private Bag BO 320, Gaborone, Botswana
- MRC Centre for Reproductive Health, University of Edinburgh, 47 Little France Crescent, EH16 4TJ, Edinburgh, United Kingdom
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Muchimba M, Zyambo C. Characteristics and Sexual Risk Behavior of Men Who Never Tested for HIV in Zambia. Am J Mens Health 2021; 15:15579883211063343. [PMID: 34859712 PMCID: PMC8646204 DOI: 10.1177/15579883211063343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 11/07/2021] [Accepted: 11/11/2021] [Indexed: 11/17/2022] Open
Abstract
Compared with women and girls, proportionately fewer men and boys in sub-Saharan Africa receive HIV testing, treatment, and other services. This study determined factors associated with never testing for HIV and examined never testing as a predictor of sexual risk behavior among men in Zambia. The sample included 2,609 men aged 15 to 24 from the 2018 Zambia Demographic and Health Survey. Logistic regression results revealed that compared with men who ever tested for HIV, men who never tested were more likely to be younger, have less education, have no children, be unemployed, and belong to the low wealth bracket. They also had a higher likelihood of not using a condom at last sex but were less likely to have more than five lifetime sexual partners. HIV prevention programs can use sociodemographic characteristics to identify those who have a lower likelihood of testing for HIV. Prevention programs can use sociodemographic characteristics to develop profiles of those who may especially need to be targeted by initiatives to promote HIV testing. Awareness does not always engender behavior change; therefore, in addition to knowledge of HIV status, risk reduction should also be emphasized.
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Affiliation(s)
- Maureen Muchimba
- Department of Health Science, Saginaw Valley State University, University Center, MI, USA
| | - Cosmas Zyambo
- School of Public Health, Department of Community and Family Medicine, University of Zambia, Lusaka, Zambia
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Smith P, Buttenheim A, Schmucker L, Bekker LG, Thirumurthy H, Davey DLJ. Undetectable = Untransmittable (U = U) Messaging Increases Uptake of HIV Testing Among Men: Results from a Pilot Cluster Randomized Trial. AIDS Behav 2021; 25:3128-3136. [PMID: 34057659 PMCID: PMC8165342 DOI: 10.1007/s10461-021-03284-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2021] [Indexed: 01/20/2023]
Abstract
HIV testing coverage in sub-Saharan Africa is lower among men than women. We investigated the impact of a peer-delivered U = U (undetectable equals untransmittable) message on men’s HIV testing uptake through a cluster randomised trial with individual mobile clinic days as unit of randomisation. On standard of care (SOC) days, peer promoters informed men about the availability of HIV testing at the mobile clinic. On intervention days, peer promoters delivered U = U messages. We used logistic regression adjusting for mobile clinic location, clustering by study day, to determine the percentage of invited men who tested for HIV at the mobile clinic. Peer promoters delivered 1048 invitations over 12 days. In the SOC group, 68 (13%) of 544 men invited tested for HIV (3, 4.4% HIV-positive). In the U = U group, 112 (22%) of 504 men invited tested for HIV (7, 6.3% HIV-positive). Men in the U = U group had greater odds of testing for HIV (adjusted odds ratio = 1.89, 95% CI 1.21–2.95; p = 0.01). Tailored, peer-delivered messages that explain the benefits of HIV treatment in reducing HIV transmission can increase men’s HIV testing uptake.
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Affiliation(s)
- Philip Smith
- The Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, Faculty of Health Science, University of Cape Town, Cape Town, South Africa.
| | - Alison Buttenheim
- Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Laura Schmucker
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Center for Health Incentives and Behavioral Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Linda-Gail Bekker
- The Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, Faculty of Health Science, University of Cape Town, Cape Town, South Africa
| | - Harsha Thirumurthy
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Center for Health Incentives and Behavioral Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Dvora L Joseph Davey
- Department of Epidemiology, Fielding School of Public Health, University of California Los Angeles, Los Angeles, CA, USA
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
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11
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Milford C, Beksinska M, Greener R, Pienaar J, Rambally Greener L, Mabude Z, Smit J. Fertility desires of people living with HIV: does the implementation of a sexual and reproductive health and HIV integration model change healthcare providers' attitudes and clients' desires? BMC Health Serv Res 2021; 21:509. [PMID: 34039312 PMCID: PMC8157636 DOI: 10.1186/s12913-021-06487-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Accepted: 05/06/2021] [Indexed: 11/23/2022] Open
Abstract
Background There is a need for information and healthcare support for the fertility desires and contraceptive needs of people living with HIV (PLHIV) in order to provide safer conception support for sero-discordant couples wanting to safely conceive. A model to integrate sexual and reproductive health and HIV services was developed and implemented in a district hospital and six clinics in the eThekwini District, South Africa. Methods To evaluate the model’s success, a cross-sectional survey was conducted before and after implementation of the model. As part of this evaluation, fertility desires of PLHIV (both male and female), and providers’ perspectives thereof were explored. Changes in desires and attitudes after integration of services were investigated. Results Forty-six healthcare providers and 269 clients (48 male, 221 female) were surveyed at baseline, and 44 providers and 300 clients (70 male, 230 female) at endline. Various factors including relationship status, parity and antiretroviral treatment (ART) access influenced PLHIVs’ desires for children. Concerns for their own and their child’s health negatively impacted on PLHIV’s fertility desires. These concerns declined after integration of services. Similarly, providers’ concerns about PLHIV having children decreased after the implementation of the model. Conclusions Integrated services are important to facilitate provision of information on contraceptive options as well as safer conception information for PLHIV who want to have children. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06487-0.
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Affiliation(s)
- Cecilia Milford
- MRU (MatCH Research Unit), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Commercial City Building, 40 Dr AB Xuma Street, Durban, 4001, South Africa.
| | - Mags Beksinska
- MRU (MatCH Research Unit), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Commercial City Building, 40 Dr AB Xuma Street, Durban, 4001, South Africa
| | - Ross Greener
- MRU (MatCH Research Unit), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Commercial City Building, 40 Dr AB Xuma Street, Durban, 4001, South Africa
| | - Jacqueline Pienaar
- The Aurum Institute, Johannesburg, South Africa.,The Centre for HIV-AIDS Prevention Studies, Johannesburg, South Africa
| | - Letitia Rambally Greener
- MRU (MatCH Research Unit), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Commercial City Building, 40 Dr AB Xuma Street, Durban, 4001, South Africa
| | - Zonke Mabude
- MRU (MatCH Research Unit), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Commercial City Building, 40 Dr AB Xuma Street, Durban, 4001, South Africa
| | - Jennifer Smit
- MRU (MatCH Research Unit), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Commercial City Building, 40 Dr AB Xuma Street, Durban, 4001, South Africa
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12
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Woldesenbet S, Kufa-Chakezha T, Lombard C, Manda S, Cheyip M, Ayalew K, Chirombo B, Barron P, Diallo K, Parekh B, Puren A. Recent HIV infection among pregnant women in the 2017 antenatal sentinel cross-sectional survey, South Africa: Assay-based incidence measurement. PLoS One 2021; 16:e0249953. [PMID: 33852629 PMCID: PMC8046194 DOI: 10.1371/journal.pone.0249953] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 03/27/2021] [Indexed: 11/30/2022] Open
Abstract
Introduction New HIV infection during pre-conception and pregnancy is a significant contributor of mother–to–child transmission of HIV in South Africa. This study estimated HIV incidence (defined as new infection within the last one year from the time of the survey which included both new infections occurred during pregnancy or just before pregnancy) among pregnant women and described the characteristics of recently infected pregnant women at national level. Methods Between 1 October and 15 November 2017, we conducted a national cross–sectional survey among pregnant women aged 15–49 years old attending antenatal care at 1,595 public facilities. Blood specimens were collected from pregnant women and tested for HIV in a centralised laboratory. Plasma viral load and Limiting Antigen Avidity Enzyme Immunosorbent Assay (LAg) tests were further performed on HIV positive specimens to differentiate between recent and long–term infections. Recent infection was defined as infection that occurred within one year from the date of collection of blood specimen for the survey. Data on age, age of partner, and marital status were collected through interviews. Women whose specimens were classified as recent by LAg assay and with viral loads >1,000 copies/mL were considered as recently infected. The calculated proportion of HIV positive women with recent infection was adjusted for assay–specific parameters to estimate annual incidence. Survey multinomial logistic regression was used to examine factors associated with being recently infected using HIV negative women as a reference group. Age–disparate relationship was defined as having a partner 5 or more years older. Results Of 10,049 HIV positive participants with LAg and viral load data, 1.4% (136) were identified as recently infected. The annual HIV incidence was 1.5% (95% confidence interval (CI): 1.2–1.7). In multivariable analyses, being single (adjusted odds ratio, aOR: 3.4, 95% CI: 1.8–6.2) or cohabiting (aOR: 3.8, 95% CI: 1.8–7.7), compared to being married as well as being in an age–disparate relationship among young women (aOR: 3.1, 95% CI: 2.0–4.7; reference group: young women (15–24years) whose partners were not 5 years or more older) were associated with higher odds of recent infection. Conclusions Compared to previous studies among pregnant women, the incidence estimated in this study was substantially lower. However, the UNAIDS target to reduce incidence by 75% by 2020 (which is equivalent to reducing incidence to <1%) has not been met. The implementation of HIV prevention and treatment interventions should be intensified, targeting young women engaged in age–disparate relationship and unmarried women to fast track progress towards the UNAIDS target.
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Affiliation(s)
- Selamawit Woldesenbet
- Center for HIV and STI, National Institute for Communicable Diseases, Johannesburg, South Africa
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- * E-mail:
| | - Tendesayi Kufa-Chakezha
- Center for HIV and STI, National Institute for Communicable Diseases, Johannesburg, South Africa
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Carl Lombard
- Biostatistics Unit, South African Medical Research Council, Cape Town, South Africa
| | - Samuel Manda
- Biostatistics Unit, South African Medical Research Council, Pretoria, South Africa
- Department of Statistics, University of Pretoria, Pretoria, South Africa
| | - Mireille Cheyip
- Strategic Information Unit, Center for Disease Control and Prevention, Pretoria, South Africa
| | - Kassahun Ayalew
- Strategic Information Unit, Center for Disease Control and Prevention, Pretoria, South Africa
| | - Brian Chirombo
- HIV and Hepatitis Program, World Health Organization, Pretoria, South Africa
| | - Peter Barron
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Karidia Diallo
- Laboratory Branch, Centers for Disease Control and Prevention South Africa, Pretoria, South Africa
| | - Bharat Parekh
- Division of Global HIV/AIDS, International Laboratory Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Adrian Puren
- Center for HIV and STI, National Institute for Communicable Diseases, Johannesburg, South Africa
- Division of Virology, School of Pathology University of the Witwatersrand, Johannesburg, South Africa
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13
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Mandell LN, Rodriguez VJ, Peltzer K, Weiss SM, Jones DL. Fertility intentions of women living with HIV and their male partners during the perinatal period in rural South Africa. Int J STD AIDS 2021; 32:740-750. [PMID: 33769899 DOI: 10.1177/0956462420987447] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Understanding the fertility intentions of people living with HIV can guide safer conception planning and prevention of mother-to-child transmission (PMTCT). Most research has addressed fertility intentions among women, rather than couples, at a single time point. This clinical trial of a PMTCT intervention in rural Mpumalanga province, South Africa, examined longitudinal fertility intentions among perinatal women living with HIV and their male partners. Study assessments and intervention and control sessions were conducted prenatally and postpartum. Longitudinal predictors of participants' (n = 360 men, n = 917 women) fertility intentions were similar between sexes. Younger age and male involvement in perinatal care were associated with reporting fertility intentions at both baseline and 12 months postpartum. Having an HIV-positive infant and discussing pregnancy plans with a healthcare provider by 12 months postpartum were associated with incident fertility intentions after reporting no plans for further children at baseline. Results highlight the important role of healthcare providers to educate men and women on issues surrounding conception, as well as the potential for incorporating PMTCT and safer conception education into HIV clinical services.
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Affiliation(s)
- Lissa N Mandell
- Department of Psychiatry and Behavioral Sciences, 5452University of Miami Miller School of Medicine, Miami, FL, USA
| | - Violeta J Rodriguez
- Department of Psychiatry and Behavioral Sciences, 5452University of Miami Miller School of Medicine, Miami, FL, USA.,Department of Psychology, University of Georgia, Athens, GA, USA
| | - Karl Peltzer
- HIV/AIDS/STIs and TB (HAST) Research Programme, 56867Human Sciences Research Council, Pretoria, South Africa.,Department of Research & Innovation, 37714University of Limpopo, Sovenga, South Africa
| | - Stephen M Weiss
- Department of Psychiatry and Behavioral Sciences, 5452University of Miami Miller School of Medicine, Miami, FL, USA
| | - Deborah L Jones
- Department of Psychiatry and Behavioral Sciences, 5452University of Miami Miller School of Medicine, Miami, FL, USA
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14
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Gutin SA, Harper GW, Moshashane N, Bitsang C, Harries J, Ramogola-Masire D, Morroni C. "What if they are pre-conception? What should we do?": Knowledge, practices, and preferences for safer conception among women living with HIV and healthcare providers in Gaborone, Botswana. Front Glob Womens Health 2021; 1. [PMID: 33693437 PMCID: PMC7943178 DOI: 10.3389/fgwh.2020.582463] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Safer conception interventions that address HIV care, treatment, and prevention for HIV-affected couples are increasingly available in sub-Saharan Africa. Botswana, an HIV endemic country, is yet to offer formal safer conception services although universal test-and-treat approaches mean that increasing numbers of young, sexually active people living with HIV will start treatment and likely desire childbearing. In order to advance the safer conception discussion in Botswana, it is necessary to understand the current safer conception knowledge, practices, and preferences of healthcare providers and women living with HIV (WLHIV). We conducted qualitative in-depth interviews with 10 HIV healthcare providers and 10 WLHIV in Gaborone. Interviews were analyzed using a phenomenological approach. Safer conception knowledge was limited and safer conception discussions were rare. Healthcare provider and WLHIV preferences were at odds, with providers preferring WLHIV to initiate safer conception discussions, and WLHIV desiring providers to initiate safer conception discussions. Quotes from women and providers highlight deeper issues about power dynamics, concerns about stigma among women, and provider fears about promoting pregnancy. Providers emphasized the need for guidelines and training in order to improve the provision of safer conception counseling. These findings point to areas where safer conception in Botswana can be improved. Both WLHIV and providers would benefit from having information about a range of safer conception methods and approaches. In addition, since WLHIV felt hesitant about initiating safer conception conversations and feared stigma, and because putting the onus for starting safer conception discussions on women is a reversal of normal roles and power structures, providers must take the lead and routinely initiate fertility desire and safer conception discussions. Assisting healthcare providers with clear safer conception guidelines and training would improve the provision of accurate safer conception counseling and facilitate reproductive choice.
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Affiliation(s)
- Sarah A Gutin
- Dept. of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, MI, USA.,Women's Health Research Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.,Center for AIDS Prevention Studies, Division of Prevention Science, University of California San Francisco, San Francisco, CA, USA
| | - Gary W Harper
- Dept. of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | | | - Christina Bitsang
- Career and Counseling Services, University of Botswana, Gaborone, Botswana
| | - Jane Harries
- Women's Health Research Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Doreen Ramogola-Masire
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Botswana, Gaborone, Botswana
| | - Chelsea Morroni
- Women's Health Research Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.,Botswana U-Penn Partnership, Gaborone, Botswana.,Liverpool School of Tropical Medicine, Liverpool, United Kingdom.,Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
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15
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Mandell LN, Rodriguez VJ, Jones DL. Safer Conception and Family Planning Knowledge, Attitudes, and Practices Among Postpartum Women with HIV in Rural South Africa. Open Access J Contracept 2021; 12:17-25. [PMID: 33603508 PMCID: PMC7882456 DOI: 10.2147/oajc.s288569] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Accepted: 12/23/2020] [Indexed: 01/01/2023] Open
Abstract
Introduction With the help of safer conception strategies (SCS), women with HIV (WHIV) can achieve their reproductive goals while minimizing the risk of transmission to their partners or infants. However, interpregnancy intervals of at least 24 months are recommended to optimize maternal and infant health outcomes, so postpartum WHIV need to use contraception to delay subsequent pregnancies. Understanding safer conception and family planning knowledge, attitudes, and practices among WHIV is key to tailoring family planning policy and intervention development in regions with high HIV prevalence. Methods This study described the safer conception and family planning knowledge, attitudes, and practices of postpartum WHIV (N = 956) in rural Mpumalanga province, South Africa, 12 months after delivery. Results Almost all women understood the importance of condom use, but most overestimated the risk of sexual transmission. A majority of women reported that their partner’s desires (53%) and the risk of perinatal transmission (58%) were very important factors when making childbearing decisions. Most women (81%) used condoms for HIV prevention and most (83%) used contraception for pregnancy prevention. Many women (33% of contraceptive users) used condoms for both HIV prevention and contraception without using another contraceptive method as well. Only 43% of contraceptive users endorsed dual method use of condoms with hormones, intrauterine devices, or sterilization. Discussion Results highlight the prominence of condom-based pregnancy and HIV transmission prevention, the influence of male partners in fertility decision-making, and the opportunity for further education and promotion of long acting methods in this setting.
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Affiliation(s)
- Lissa N Mandell
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Violeta J Rodriguez
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, FL, USA.,Department of Psychology, University of Georgia, Athens, GA, USA
| | - Deborah L Jones
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
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16
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Discussing Reproductive Plans with Healthcare Providers by Sexually Active Women Living with HIV in Western Ethiopia. AIDS Behav 2020; 24:2842-2855. [PMID: 32212068 DOI: 10.1007/s10461-020-02833-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Discussing reproductive plans with healthcare providers by women living with HIV (WLHIV) can assist in promoting safe reproductive health practices, but little research has been undertaken in this area. A cross-sectional survey was conducted in western Ethiopia in 2018 among 475 sexually active WLHIV. One hundred and twenty seven (26.8%) participants reported becoming pregnant in the last 5 years after being aware of their HIV-positive status; 33.6% reported their intention to have children in the future, and 26.9% were ambivalent about having children. WLHIV who reported general and personalized discussions of reproductive plans with healthcare providers were 30.7% and 16.8%, respectively. Unmarried sexually active women and WLHIV accessing health centers for antiretroviral therapy (ART) were less likely to report both general and personalized discussions than married women and women who accessed ART through hospitals, respectively. WLHIV are both having and intending to have children, highlighting discussions with healthcare providers can deliver support that reduces the risk of vertical and horizontal HIV transmission.
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17
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Gutin SA, Harper GW, Amico KR, Bitsang C, Moshashane N, Harries J, Ramogola-Masire D, Morroni C. 'I'm waiting for that': Interest in the use of PrEP for safer conception in Botswana. Glob Public Health 2020; 15:1200-1211. [PMID: 32175819 DOI: 10.1080/17441692.2020.1741663] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Safe and effective low-cost safer conception (SC) methods are increasingly available and being integrated into national guidelines in sub-Saharan African contexts. Sero-different couples of childbearing age can benefit from such services and the routine provision of SC counselling. Pre-exposure prophylaxis (PrEP) to prevent HIV acquisition to uninfected partners can reduce the chances of HIV transmission when trying to achieve pregnancy. Botswana has a strong commitment to reducing new HIV infections but PrEP is not yet widely available and little guidance has been offered on counselling sero-different couples. We conducted qualitative in-depth interviews in Gaborone, Botswana with 10 HIV healthcare providers and 10 women living with HIV of childbearing age because they act as a key conduit for reaching sero-different partners with information about PrEP. We examined knowledge and attitudes towards PrEP to assess the viability and develop a deeper understanding of this SC option. Interviews were analysed using an interpretive phenomenological approach. Three themes emerged: (1) awareness of PrEP is limited, (2) providers and women overwhelmingly showed interest in PrEP and (3) women living with HIV and providers have concerns about PrEP use. With the correct support, PrEP could be a useful SC option for sero-different couples in Botswana and other sub-Saharan contexts.
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Affiliation(s)
- Sarah A Gutin
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, MI, USA.,Women's Health Research Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.,Center for AIDS Prevention Studies, Division of Prevention Science, University of California, San Francisco, San Francisco, CA, USA
| | - Gary W Harper
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - K Rivet Amico
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Christina Bitsang
- Career and Counseling Services, University of Botswana, Gaborone, Botswana
| | | | - Jane Harries
- Women's Health Research Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Doreen Ramogola-Masire
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Department of Obstetrics and Gynecology, Faculty of Medicine, University of Botswana, Gaborone, Botswana
| | - Chelsea Morroni
- Women's Health Research Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.,Botswana U-Penn Partnership, Gaborone, Botswana.,Liverpool School of Tropical Medicine, Liverpool, UK
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18
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Woldesenbet S, Kufa T, Cheyip M, Ayalew K, Lombard C, Manda S, Nadol P, Barron P, Chirombo B, Igumbor E, Pillay Y, Puren A. Awareness of HIV-positive status and linkage to treatment prior to pregnancy in the "test and treat" era: A national antenatal sentinel survey, 2017, South Africa. PLoS One 2020; 15:e0229874. [PMID: 32168356 PMCID: PMC7069609 DOI: 10.1371/journal.pone.0229874] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 02/15/2020] [Indexed: 02/07/2023] Open
Abstract
Introduction Knowledge of HIV status in South Africa (SA) is reported to be 90% among people living with HIV. National level estimates could mask population-specific levels, which are critical to monitor program coverage and potential impact. Using data from the 2017 national antenatal sentinel survey, we assessed knowledge of HIV-positive status, initiation of antiretroviral therapy (ART), and socio-demographic characteristics associated with knowledge of HIV-positive status prior to the current pregnancy among women attending antenatal care. Methods Between 1 October and 15 November 2017, a nationally representative sample of 32,716 pregnant women were enrolled from 1,595 public health facilities selected from all districts of SA. Data on age, gravidity, knowledge of HIV-positive status and ART initiation prior to pregnancy were extracted from medical records. A blood sample was collected from each woman regardless of prior knowledge of HIV status or ART history, and tested for HIV in the laboratory. All HIV-positive pregnant women enrolled in the survey were eligible for inclusion in the analysis. Multivariable survey logistic regression was used to examine factors associated with knowledge of HIV-positive status prior to the current pregnancy. Results Of 10,065 eligible HIV-positive women, 60.8% (95% confidence interval (CI):59.9%–61.7%) knew their HIV status prior to the current pregnancy, of whom 91.1% (95% CI: 90.4%–91.7%) initiated ART prior to the current pregnancy. Knowledge of HIV-positive status was lower among adolescent girls and young women (15–24 years) (38.9%) and primigravid women (40.5%) compared with older women (35–49 years) (75.5%) and multigravid women (64.7%). In a multivariable analysis, significant effect modification was found between gravidity and age (P value = 0.047). Being in the age group 15–24 years compared to the age group 35–49 years decreased the odds of knowing HIV-positive status by 80% (adjusted odds ratio (AOR): 0.2, 95% CI:0.1–0.4) among primigravid women and by 60%(AOR: 0.4, 95% CI:0.3–0.4) among multigravid women. Conclusion Knowledge of HIV-positive status prior to the current pregnancy fell short of the target of 90% among pregnant women living with HIV. This was especially low among adolescent girls and young women, highlighting the gap in youth friendly reproductive health and HIV testing services.
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Affiliation(s)
- Selamawit Woldesenbet
- Center for HIV and STI, National Institute for Communicable Diseases, Johannesburg, South Africa
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- * E-mail:
| | - Tendesayi Kufa
- Center for HIV and STI, National Institute for Communicable Diseases, Johannesburg, South Africa
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Mireille Cheyip
- Strategic Information Unit, Center for Disease Control and Prevention, Pretoria, South Africa
| | - Kassahun Ayalew
- Strategic Information Unit, Center for Disease Control and Prevention, Pretoria, South Africa
| | - Carl Lombard
- Biostatistics Unit, South African Medical Research Council, Cape Town, South Africa
| | - Samuel Manda
- Biostatistics Unit, South African Medical Research Council, Pretoria, South Africa
| | - Patrick Nadol
- Strategic Information Unit, Center for Disease Control and Prevention, Pretoria, South Africa
| | - Peter Barron
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Brian Chirombo
- HIV and Hepatitis Program, World Health Organization, Pretoria, South Africa
| | - Ehi Igumbor
- Strategic Information Unit, Center for Disease Control and Prevention, Pretoria, South Africa
- School of Public Health, University of the Western Cape, Bellville, Cape Town, South Africa
| | - Yogan Pillay
- HIV & AIDS, TB and Maternal, Child and Women’s Health (MCWH), National Department of Health, Pretoria, South Africa
| | - Adrian Puren
- Center for HIV and STI, National Institute for Communicable Diseases, Johannesburg, South Africa
- Virology Department, University of the Witwatersrand, Johannesburg, South Africa
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19
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Khidir H, Mosery N, Greener R, Milford C, Bennett K, Kaida A, Psaros C, Safren SA, Bangsberg DR, Smit JA, Matthews LT. Sexual Relationship Power and Periconception HIV-Risk Behavior Among HIV-Infected Men in Serodifferent Relationships. AIDS Behav 2020; 24:881-890. [PMID: 31165395 PMCID: PMC6891132 DOI: 10.1007/s10461-019-02536-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Gender norms affect HIV risk within serodifferent partnerships. We assessed how the sexual relationship power described by men living with HIV (MLWH) associates with periconception HIV-transmission risk behavior. Quantitative surveys were conducted with 82 MLWH reporting a recent pregnancy with an HIV-negative or unknown-serostatus partner in KwaZulu-Natal, South Africa. Surveys assessed decision-making dominance (DMD) using the Pulerwitz et al. sexual relationship power scale; partnership characteristics; and HIV-risk behaviors. Multivariable logistic regression models evaluated associations between DMD score and HIV-risk behaviors. Higher male decision-making dominance was associated with non-disclosure of HIV-serostatus to pregnancy partner (aRR 2.00, 95% CI 1.52, 2.64), not knowing partner's HIV-serostatus (aRR 1.64, 95% CI 1.27, 2.13), condomless sex since pregnancy (aRR 1.92, 95% CI 1.08, 3.43), and concurrent relationships (aRR 1.50, 95% CI 1.20, 1.88). Efforts to minimize periconception HIV-risk behavior must address gender norms and power inequities.
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Affiliation(s)
| | - Nzwakie Mosery
- Maternal Adolescent and Child Health Research Unit (MRU), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, KZN, South Africa
| | - Ross Greener
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, GT, South Africa
| | - Cecilia Milford
- Maternal Adolescent and Child Health Research Unit (MRU), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, KZN, South Africa
| | - Kara Bennett
- Bennett Statistical Consulting Inc., Ballston Lake, NY, USA
| | - Angela Kaida
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
| | - Christina Psaros
- Harvard Medical School, Boston, MA, USA
- Behavioral Medicine Program, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Steve A Safren
- Department of Psychology, University of Miami, Miami, FL, USA
| | - David R Bangsberg
- Oregon Health & Science University-Portland State University School of Public Health, Portland, OR, USA
| | - Jennifer A Smit
- Maternal Adolescent and Child Health Research Unit (MRU), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, KZN, South Africa
| | - Lynn T Matthews
- Harvard Medical School, Boston, MA, USA.
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA.
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, AL, USA.
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20
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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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21
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Kaida A, Kabakyenga J, Bwana M, Bajunirwe F, Muyindike W, Bennett K, Kembabazi A, Haberer JE, Boum Y, Martin JN, Hunt PW, Bangsberg DR, Matthews LT. High Incidence of Intended Partner Pregnancy Among Men Living With HIV in Rural Uganda: Implications for Safer Conception Services. J Acquir Immune Defic Syndr 2019; 81:497-507. [PMID: 30973545 PMCID: PMC6625849 DOI: 10.1097/qai.0000000000002053] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Many men with HIV express fertility intentions and nearly half have HIV-uninfected sexual partners. We measured partner pregnancy among a cohort of men accessing antiretroviral therapy in Uganda. METHODS Self-reported partner pregnancy incidence and bloodwork (CD4, HIV-RNA) were collected quarterly. Interviewer-administered questionnaires assessed men's sexual and reproductive health annually and repeated at time of reported pregnancy (2011-2015). We measured partner pregnancy incidence overall, by pregnancy intention and by reported partner HIV serostatus. We assessed viral suppression (≤400 copies/mL) during the periconception period. Cox proportional hazard regression with repeated events identified predictors of partner pregnancy. RESULTS Among 189 men, the baseline median age was 39.9 years (interquartile range: 34.7-47.0), years on antiretroviral therapy was 3.9 (interquartile range: 0.0-5.1), and 51% were virally suppressed. Over 530.2 person-years of follow-up, 63 men reported 85 partner pregnancies (incidence = 16.0/100 person-years); 45% with HIV-serodifferent partners. By 3 years of follow-up, 30% of men reported a partner pregnancy, with no difference by partner HIV serostatus (P = 0.75). Sixty-nine percent of pregnancies were intended, 18% wanted but mistimed, and 8% unwanted. Seventy-eight percent of men were virally suppressed before pregnancy report. Men who were younger [adjusted hazard ratio (aHR): 0.94/yr; 95% confidence interval (CI): 0.89 to 0.99], had incomplete primary education (aHR: 2.95; 95% CI: 1.36 to 6.40), and reported fertility desires (aHR: 2.25; 95% CI: 1.04 to 4.85) had higher probability of partner pregnancy. CONCLUSIONS A high incidence of intended partner pregnancy highlights the need to address men's reproductive goals within HIV care. Nearly half of pregnancy partners were at-risk for HIV, and one-quarter of men were not virally suppressed during periconception. Safer conception care provides opportunity to support men's health and reproductive goals, while preventing HIV transmission to women and infants.
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Affiliation(s)
- Angela Kaida
- Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada
| | - Jerome Kabakyenga
- Faculty of Medicine, Mbarara University of Science and Technology (MUST), Mbarara, Uganda
| | - Mwebesa Bwana
- Faculty of Medicine, Mbarara University of Science and Technology (MUST), Mbarara, Uganda
- Department of Medicine, Mbarara Regional Referral Hospital, Mbarara, Uganda
| | - Francis Bajunirwe
- Faculty of Medicine, Mbarara University of Science and Technology (MUST), Mbarara, Uganda
| | - Winnie Muyindike
- Faculty of Medicine, Mbarara University of Science and Technology (MUST), Mbarara, Uganda
- Department of Medicine, Mbarara Regional Referral Hospital, Mbarara, Uganda
| | - Kara Bennett
- Bennett Statistical Consulting, Ballston Lake, New York, USA
| | - Annet Kembabazi
- Faculty of Medicine, Mbarara University of Science and Technology (MUST), Mbarara, Uganda
| | - Jessica E. Haberer
- Massachusetts General Hospital (MGH) Global Health and Department of General Medicine, Boston, USA
| | - Yap Boum
- Faculty of Medicine, Mbarara University of Science and Technology (MUST), Mbarara, Uganda
- Epicentre, Médicins sans Frontières (MSF), Yaoundé, Cameroon
| | - Jeffrey N. Martin
- Department of Medicine, University of California at San Francisco (UCSF), San Francisco, USA
| | - Peter W. Hunt
- Department of Medicine, University of California at San Francisco (UCSF), San Francisco, USA
| | - David R. Bangsberg
- Faculty of Medicine, Mbarara University of Science and Technology (MUST), Mbarara, Uganda
- School of Public Health, Oregon Health Sciences University, Portland, USA
| | - Lynn T. Matthews
- MGH Global Health and Division of Infectious Diseases, Boston, USA
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22
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Matthews LT, Kiarie JN. Safer conception care to eliminate transmission of HIV. Lancet HIV 2019; 6:e413-e414. [PMID: 31160267 DOI: 10.1016/s2352-3018(19)30178-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 05/15/2019] [Indexed: 12/25/2022]
Affiliation(s)
- Lynn T Matthews
- University of Alabama at Birmingham, Division of Infectious Diseases, Birmingham, AL 35294, USA.
| | - James N Kiarie
- Human Reproduction Unit, WHO, Geneva, Switzerland; University of Nairobi, Division of Obstetrics and Gynecology, Nairobi, Kenya
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23
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Patwa MC, Bassett J, Holmes L, Mutunga L, Mudavanhu M, Makhomboti T, Van Rie A, Schwartz SR. Integrating safer conception services into primary care: providers' perspectives. BMC Public Health 2019; 19:532. [PMID: 31072352 PMCID: PMC6507034 DOI: 10.1186/s12889-019-6904-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 04/26/2019] [Indexed: 11/17/2022] Open
Abstract
Background In 2012, South Africa adopted the Contraception and Fertility Planning guidelines to incorporate safer conception services into care for HIV-affected couples trying to conceive. These guidelines lacked clear implementation and training recommendations. The objective of this study was to investigate factors influencing integration of safer conception services in a clinical setting. Methods Twenty in-depth interviews were conducted between October–November 2017 with providers and staff at Witkoppen Clinic in Johannesburg, where the Sakh’umndeni safer conception demonstration project had enrolled patients from July 2013–July 2017. Semi-structured interview guides engaged providers on their perspectives following the Sakh’umndeni project and possible integration plans to inform the translation of the stand-alone Sakh’umndeni services into a routine service. A grounded theory approach was used to code interviews and an adaptation of the Atun et al. (2010) ‘Integration of Targeted Interventions into Health Systems’ conceptual framework was applied as an analysis tool. Results Five themes emerged: (1) The need for safer conception training; (2) The importance of messaging and demand generation; (3) A spectrum of views around the extent of integration of safer conception services; (4) Limitations of family planning services as an integration focal point; and (5) Benefits and challenges of a “couples-based” intervention. In-depth interviews suggested that counselors, as the first point of contact, should inform patients about safer conceptions services, followed by targeted reinforcement of safer conception messaging by all clinicians, and referral to more intensively trained safer conception providers. Conclusion A safer conception counseling guide would facilitate consultations. While many providers felt that the services belonged in family planning, lack of HIV management skills, men and women trying to conceive within family planning may pose barriers.
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Affiliation(s)
- Mariya C Patwa
- Johns Hopkins Bloomber School of Public Health, 615 N Wolfe St. E7136, Baltimore, MD, USA
| | - Jean Bassett
- Witkoppen Health and Welfare Centre, Johannesburg, South Africa
| | - Leah Holmes
- Johns Hopkins Bloomber School of Public Health, 615 N Wolfe St. E7136, Baltimore, MD, USA
| | - Lillian Mutunga
- Witkoppen Health and Welfare Centre, Johannesburg, South Africa
| | - Mutsa Mudavanhu
- Witkoppen Health and Welfare Centre, Johannesburg, South Africa
| | | | - Annelies Van Rie
- Department of Epidemiology and Social Medicine, University of Antwerp, Antwerpen, Belgium
| | - Sheree R Schwartz
- Johns Hopkins Bloomber School of Public Health, 615 N Wolfe St. E7136, Baltimore, MD, USA.
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Davies N, Heffron R. Global and national guidance for the use of pre-exposure prophylaxis during peri-conception, pregnancy and breastfeeding. Sex Health 2018; 15:501-512. [PMID: 30447703 PMCID: PMC6790372 DOI: 10.1071/sh18067] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 09/15/2018] [Indexed: 12/30/2022]
Abstract
Pre-exposure prophylaxis (PrEP) is a well-established biomedical HIV prevention strategy and recommended to reduce HIV risk during peri-conception, pregnancy and breastfeeding. Efforts are needed to translate global recommendations into national guidelines and implementation strategies. This article presents the current status of policy guidance for the use of PrEP during peri-conception, pregnancy and breastfeeding, with a particular focus on high prevalence countries, including those in sub-Saharan Africa. PrEP clinical guidelines released by ministries of health or other national-level health bodies, with a particular focus on recommendations for PrEP use during peri-conception, pregnancy and breastfeeding, were reviewed and summarised. Among countries with PrEP guidelines and/or policy, pregnancy is recognised as a period with increased HIV vulnerability, and some recommend PrEP use specifically during pregnancy. Only one country notes that PrEP is contraindicated during pregnancy, recognising a gap in complete safety data from women using PrEP throughout pregnancy. PrEP is not contraindicated as a peri-conception HIV prevention strategy in any country, but only three countries have specific guidance for peri-conception HIV prevention. Multiple barriers to the implementation of PrEP during pregnancy and breastfeeding are discussed, including barriers at the policy, health systems, social and personal levels. Although pregnancy is a period of heightened risk and fertility rates are high in many settings with high HIV burden, few PrEP policies have included guidance for PrEP use specific to peri-conception, pregnancy and breastfeeding periods. This gap can be overcome by the development or adoption of national clinical guidelines and implementation strategies from exemplary countries.
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