Offering pre-exposure prophylaxis for HIV prevention to pregnant and postpartum women: a clinical approach

Abstract

Introduction: HIV prevention during pregnancy and lactation is critical for both maternal and child health. Pregnancy provides a critical opportunity for clinicians to elicit women’s vulnerabilities to HIV and offer HIV testing, treatment and referral and/or comprehensive HIV prevention options for the current pregnancy, the postpartum period and safer conception options for future pregnancies. In this commentary, we review the safety of oral pre-exposure prophylaxis with tenofovir/emtricitabine in pregnant and lactating women and suggest opportunities to identify pregnant and postpartum women at substantial risk of HIV. We then describe a clinical approach to caring for women who both choose and decline pre-exposure prophylaxis during pregnancy and postpartum, highlighting areas for future research.Discussion: Evidence suggests that pre-exposure prophylaxis with tenofovir/emtricitabine is safe in pregnancy and lactation. Identifying women vulnerable to HIV and eligible for pre-exposure prophylaxis is challenging in light of the myriad of individual, community, and structural forces impacting HIV acquisition. Validated risk calculators exist for specific populations but have not been used to screen and offer HIV prevention methods. Partner testing and engagement of men living with HIV are additional means of reaching at-risk women. However, women’s vulnerabilities to HIV change over time. Combining screening for HIV vulnerability with HIV and/or STI testing at standard intervals during pregnancy is a practical way to prompt providers to incorporate HIV screening and prevention counselling. We suggest using shared decision-making to offer women pre-exposure prophylaxis as one of multiple HIV prevention strategies during pregnancy and postpartum, facilitating open conversations about HIV vulnerabilities, preferences about HIV prevention strategies, and choosing a method that best meets the needs of each woman.Conclusion: Growing evidence suggests that pre-exposure prophylaxis with tenofovir/emtricitabine during pregnancy and lactation is safe and effective. Shared decision-making provides one approach to identify at-risk women and offers pre-exposure prophylaxis but requires implementation research in diverse clinical settings. Including pregnant and breastfeeding women in future HIV prevention research is critical for the creation of evidence-driven public health policies and clinical guidelines.

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

“…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].…”

24‐Month HIV‐free survival among HIV‐exposed Infants in Lesotho: the PEAWIL cohort study

“…Altogether, 634 liveborn infants (328 (52.0%) male, 303 (48%) female, 3 missing) were HIV exposed. 24 Table 1). The proportion of women who disclosed their HIV status to someone was 74.4%, with 66.7% disclosing to their partner/spouse.…”

“…In addition, HIV-negative mothers who acquire infection during pregnancy risk transmitting the virus to their infants. Acute HIV infection during pregnancy or breastfeeding markedly increases the risk of MTCT of HIV [23][24][25][26]. We found that HIV transmission was four times higher in HIV-negative women who seroconverted compared to women who were HIV positive at delivery.…”

A Missed Opportunity for U.S. Perinatal Human Immunodeficiency Virus Elimination

“…Data suggest that pre-exposure prophylaxis is safe in pregnancy and breastfeeding 27 ; the Antiretroviral Pregnancy Registry finds no increased risk of birth defects from pre-exposure prophylaxis exposure 28 ; a substudy of women who became pregnant while on pre-exposure prophylaxis found no difference in pregnancy loss, preterm birth, birth defects, or 1-year growth anomalies 29 ; and a pharmacokinetic study found that pre-exposure prophylaxis was undetectable or negligible in breastfed infants’ serum. 13 These safety data should encourage health care providers to discuss and perhaps offer pre-exposure prophylaxis and other HIV prevention strategies during pregnancy with at-risk women who stand to reap tremendous benefits.…”