Early pre-exposure prophylaxis (PrEP) discontinuation among pregnant and postpartum women: Implications for maternal PrEP roll out in South Africa

Davey, Dvora Joseph; Mvududu, Rufaro; Mashele, Nyiko; Lesosky, Maia; Khadka, Nehaa; More, Judy; Bekker, Linda‐Gail; Gorbach, Pamina M.; Tj, Coates; Myer, Landon

doi:10.1101/2021.05.04.21256514

Cited by 7 publications

(2 citation statements)

References 30 publications

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“…Little is known about pharmacologic adherence measures during pregnancy and postpartum and about the factors related to optimal adherence during periods of sexual activity [8]. Prior studies demonstrated that pregnant and breastfeeding women (PBFW) using PrEP may struggle with daily use and continuation because of various personal, interpersonal or healthcare access barriers [9–11].…”

Section: Introductionmentioning

confidence: 99%

Adherence challenges with daily oral pre‐exposure prophylaxis during pregnancy and the postpartum period in South African women: a cohort study

et al. 2022

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Introduction Daily oral pre‐exposure prophylaxis (PrEP) can reduce HIV acquisition. However, prevention effectiveness requires daily adherence prior to and during periods of sexual activity. Little is known about pharmacologic measures of PrEP adherence during pregnancy and postpartum and the factors related to optimal adherence during periods of sexual activity in this population. Methods Between August 2019 and October 2021, we enrolled pregnant women without HIV at their first antenatal care visit followed‐up through 12 months postpartum. Eligible women ≥16 years old received HIV prevention counselling and were offered oral PrEP (TDF‐FTC). We quantified tenofovir‐diphosphate (TFV‐DP) in dried blood spots in women who reported taking PrEP in the past 30 days (at quarterly follow‐up visits). We used regression models with generalized estimating equations to evaluate correlates of TFV‐DP (any vs. none, and ≥2 vs. <2 doses/week), adjusting for maternal age and pregnancy status. Results and discussion In 382 women who started PrEP in pregnancy, returned for follow‐up and reported PrEP use in the past 30 days, the median age was 27 years (interquartile range [IQR] = 23–32), and the median time on PrEP was 168 days (IQR = 84–252 days). Half of the samples had quantifiable TFV‐DP at any time point (52%), declining from 67% of pregnant women 3 months post‐initiation to 31% of postpartum women by 12 months. Overall, 72% had concentrations corresponding to <2 doses/week; 25% ≥2 doses/week; 3% 7 doses/week. Concentrations were lower in postpartum versus pregnancy (age‐adjusted odds ratio [aOR] = 0.44; 95% confidence interval [CI] = 0.35–0.54). The correlation of self‐reported adherence and TFV‐DP ranged from –0.07 in pregnancy to 0.25 in postpartum women. Variables associated with having quantifiable TFV‐DP included partner living with HIV/unknown serostatus (aOR = 1.50; 95% CI = 1.01–2.22), and reported frequency of sexual activity in the past month (aOR sex >5/month vs. no sex or <5 times/month = 2.11; 95% CI = 1.58–2.82) adjusting for age and pregnancy versus postpartum status. TFV‐DP concentrations declined over follow‐up time (aOR for 6 vs. 3 months = 0.49; 95% CI = 0.36–0.67). Conclusions Objectively measured adherence to PrEP was low overall and did not correlate with self‐reported use. There is an urgent need for objective adherence measures to support clinical decision‐making as well as adherence support interventions as part of PrEP services for pregnant and postpartum women at risk of HIV.

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Section: Introductionmentioning

confidence: 99%

Adherence challenges with daily oral pre‐exposure prophylaxis during pregnancy and the postpartum period in South African women: a cohort study

et al. 2022

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“…For example, persons whose PrEP indication predominantly stems from living in a community with high HIV incidence rates would be likely to have sustained risk [10]. Although some people likely stop PrEP because of a change in indication and in consultation with their providers, many stop because of (accurate or inaccurate) change in risk perception [37–40], adverse effects that might be manageable [37,38,40–42,43 ▪ ], pressure from partners [41], the end of pregnancy [41], or problems with payment for PrEP and related medical services or problems with access to PrEP care [37,39,40,43 ▪ ,44].…”

Section: Addressing the Preexposure Prophylaxis Cliffmentioning

confidence: 99%

What will it take to meet UNAIDS targets for preexposure prophylaxis users?

Sullivan

2021

Current Opinion in Infectious Diseases

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Purpose of reviewPreexposure prophylaxis (PrEP) is a critical strategy to curb new HIV infections globally. National and global targets have been set for people starting PrEP. However, global PrEP initiations fell short of UNAIDS 2020 targets, and reflection is needed on how we set and meet targets for PrEP use. Recent findingsRecent literature documents challenges to meeting ambitious goals for PrEP coverage in multiple phases of PrEP: PrEP initiations are limited by gaps in the identification of those who might benefit from PrEP. Conversely, getting PrEP to those who need it most is threatened by inaccurate risk perception and HIV and PrEP stigma. Once people are on PrEP, a substantial number discontinue PrEP in the first year (the 'PrEP Cliff'), a finding that is robust across groups of PrEP users (e.g., women, men who have sex with men, transwomen) and across global prevention settings. Further, PrEP inequities -by which we refer to utilization of PrEP in a specific group that is not commensurate with their epidemic risk -threaten the overall population benefit of PrEP because those at highest risk of acquiring HIV are not adequately protected.

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Daily Oral Pre-exposure Prophylaxis (PrEP) Continuation Among Women from Durban, South Africa, Who Initiated PrEP as Standard of Care for HIV Prevention in a Clinical Trial

et al. 2022

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HIV incidence among women in Eastern and Southern Africa remains unacceptably high, highlighting the need for effective HIV prevention options, including pre-exposure prophylaxis (PrEP). The Evidence for Contraceptive Options and HIV Outcomes trial offered daily oral PrEP to participants during the latter part of the clinical trial as an additional HIV prevention choice. We explored daily oral PrEP continuation at trial exit among women enrolled from Durban, South Africa who initiated oral PrEP at the trial site. Of the 132 women initiating oral PrEP, 87% reported continuation of oral PrEP at month 1, 80% at month 3, and 75% continued using oral PrEP at their final trial visit and were referred to off-site facilities for ongoing oral PrEP access. The median duration of oral PrEP use in trial participants who used oral PrEP was 91 days (IQR 87 to 142 days). Women who disclosed their oral PrEP use to someone had increased odds of continuing oral PrEP at trial exit. Women who reported > 1 sex partner and those who felt they would probably or definitely get infected with HIV had reduced odds of continuing oral PrEP at trial exit. Of those discontinuing oral PrEP (n = 32), > 50% discontinued within the first month, and the most common reason for discontinuation was reporting side effects. The high rates of oral PrEP continuation in our study are encouraging and our findings can be utilized by other clinical trials providing oral PrEP as standard of care for HIV prevention and by oral PrEP implementation programmes.

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Early pre-exposure prophylaxis (PrEP) discontinuation among pregnant and postpartum women: Implications for maternal PrEP roll out in South Africa

Cited by 7 publications

References 30 publications

Adherence challenges with daily oral pre‐exposure prophylaxis during pregnancy and the postpartum period in South African women: a cohort study

Adherence challenges with daily oral pre‐exposure prophylaxis during pregnancy and the postpartum period in South African women: a cohort study

What will it take to meet UNAIDS targets for preexposure prophylaxis users?

Daily Oral Pre-exposure Prophylaxis (PrEP) Continuation Among Women from Durban, South Africa, Who Initiated PrEP as Standard of Care for HIV Prevention in a Clinical Trial

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