Delivering preexposure prophylaxis to pregnant and breastfeeding women in Sub-Saharan Africa

Davey, Dvora Joseph; Bekker, Linda‐Gail; Gorbach, Pamina M.; Coates, Thomas J.; Myer, Landon

doi:10.1097/qad.0000000000001604

Cited by 35 publications

(31 citation statements)

References 36 publications

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“…Data from studies like ours, which point to specific period of high risk and patterns of high-risk behaviors, are important for informing who and when should women get PrEP during pregnancy. Future research, including operation research, must evaluate how best to ensure access to this powerful prevention intervention in this vulnerable group [ 29 ]. Now is the time to evaluate how best to provide PrEP to vulnerable pregnant and breastfeeding women as there are few data on acceptability, initiation, and adherence in pregnant and breastfeeding women in Africa where the burden of HIV is greatest.…”

Section: Discussionmentioning

confidence: 99%

Sexual risk during pregnancy and postpartum periods among HIV-infected and –uninfected South African women: Implications for primary and secondary HIV prevention interventions

et al. 2018

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BackgroundHIV acquisition in pregnancy and breastfeeding contributes significantly toward pediatric HIV infection. However, little is known about how sexual behavior changes during pregnancy and postpartum periods which will help develop targeted HIV prevention and transmission interventions, including pre-exposure prophylaxis (PrEP).MethodsCross-sectional study in HIV-infected and uninfected pregnant and postpartum women in Cape Town, South Africa. Interviewers collected survey data on demographic, sexual behaviors, and alcohol use among pregnant and post-partum women. We report descriptive results of sexual behavior by trimester and postpartum period, and results of multivariable logistic regression stratified by pregnancy status.ResultsWe enrolled 377 pregnant and postpartum women (56% pregnant, 40% HIV-infected). During pregnancy, 98% of women reported vaginal sex (8% anal sex, 44% oral sex) vs. 35% and 88% during the periods 0–6 and 7–12 months postpartum, respectively (p<0.05). More pregnant women reported having >1 partner in the past 12-months compared to postpartum women (18% vs. 13%, respectively, p<0.05). Sex frequency varied by trimester with greatest mean sex acts occurring during first trimester and >6-months postpartum (13 mean sex acts in first trimester; 17 mean sex acts >6-months postpartum). Pregnant women had increased odds of reporting condomless sex at last sex (aOR = 2.96;95%CI = 1.84–4.78) and ever having condomless sex in past 3-months (aOR = 2.65;95%CI = 1.30–5.44) adjusting for age, HIV status, and sex frequency compared to postpartum women.ConclusionWe identified that sexual behaviors and risk behaviors were high and changing during pregnancy and postpartum periods, presenting challenges to primary and secondary HIV prevention efforts, including PrEP delivery to pregnant and breastfeeding women.

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Section: Discussionmentioning

confidence: 99%

Sexual risk during pregnancy and postpartum periods among HIV-infected and –uninfected South African women: Implications for primary and secondary HIV prevention interventions

et al. 2018

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“…Our review did not include summarization of social science and qualitative studies related to PrEP use among pregnant and breastfeeding women. This is an important dimension that complements clinical trial evidence .…”

Section: Resultsmentioning

confidence: 99%

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?

et al. 2020

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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 http://www.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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“…PrEP has an important role in HIV prevention, including for pregnant and breastfeeding women [22‐25]. When adherence is maintained, PrEP – formulated as once daily tenofovir disoproxil fumarate and emtricitabine (TDF‐FTC) – has been shown to be highly effective across numerous randomized trials in women [26].…”

Section: Resultsmentioning

confidence: 99%

Accelerating progress towards the elimination of mother‐to‐child transmission of HIV: a narrative review

et al. 2020

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Introduction Findings from biomedical, behavioural and implementation studies provide a rich foundation to guide programmatic efforts for the prevention of mother‐to‐child HIV transmission (PMTCT). Methods We summarized the current evidence base to support policy makers, programme managers, funding agencies and other stakeholders in designing and optimizing PMTCT programmes. We searched the scientific literature for PMTCT interventions in the era of universal antiretroviral therapy for pregnant and breastfeeding women (i.e. 2013 onward). Where evidence was sparse, relevant studies from the general HIV treatment literature or from prior eras of PMTCT programme implementation were also considered. Studies were organized into six categories: HIV prevention services for women, timely access to HIV testing, timely access to ART, programme retention and adherence support, timely engagement in antenatal care and services for infants at highest risk of HIV acquisition. These were mapped to specific missed opportunities identified by the UNAIDS Spectrum model and embedded in UNICEF operational guidance to optimize PMTCT services. Results and discussion From May to November 2019, we identified numerous promising, evidence‐based strategies that, properly tailored and adopted, could contribute to population reductions in vertical HIV transmission. These spanned the HIV and maternal and child health literature, emphasizing the importance of continued alignment and integration of services. We observed overlap between several intervention domains, suggesting potential for synergies and increased downstream impact. Common themes included integration of facility‐based healthcare; decentralization of health services from facilities to communities; and engagement of partners, peers and lay workers for social support. Approaches to ensure early HIV diagnosis and treatment prior to pregnancy would strengthen care across the maternal lifespan and should be promoted in the context of PMTCT. Conclusions A wide range of effective strategies exist to improve PMTCT access, uptake and retention. Programmes should carefully consider, prioritize and plan those that are most appropriate for the local setting and best address existing gaps in PMTCT health services.

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Delivering preexposure prophylaxis to pregnant and breastfeeding women in Sub-Saharan Africa

Cited by 35 publications

References 36 publications

Sexual risk during pregnancy and postpartum periods among HIV-infected and –uninfected South African women: Implications for primary and secondary HIV prevention interventions

Sexual risk during pregnancy and postpartum periods among HIV-infected and –uninfected South African women: Implications for primary and secondary HIV prevention interventions

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?

Accelerating progress towards the elimination of mother‐to‐child transmission of HIV: a narrative review

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