Preferences and Acceptability for Long-Acting PrEP Agents Among Pregnant and Postpartum Women with Experience Using Daily Oral PrEP in South Africa and Kenya

Abstract

Introduction: Long-acting pre-exposure prophylaxis (PrEP) options could overcome some barriers to oral PrEP persistence during pregnancy and postpartum. We evaluated long-acting PrEP preferences among oral PrEP-experienced pregnant and postpartum women in South Africa and Kenya, two countries with high coverage of oral PrEP and with pending regulatory approvals for long-acting injectable cabotegravir and the dapivirine vaginal ring (approved in South Africa, under review in Kenya). Methods: From September 2021 to February 2022, we surveyed pregnant and postpartum women enrolled in oral PrEP studies in South Africa and Kenya. We evaluated oral PrEP attitudes and preferences for existing and future long-acting PrEP methods. Results: We surveyed 190 women in South Africa (67% postpartum; median age 27 years [IQR 22-32]) and 204 women in Kenya (79% postpartum; median age 29 years [IQR 25-33]). 75% of participants reported oral PrEP use within the last 30 days. Overall, 49% of participants reported negative oral PrEP attributes, including side effects (21% South Africa, 30% Kenya) and pill burden (20% South Africa, 25% Kenya). Preferred PrEP attributes included long-acting method, effectiveness, safety while pregnant and breastfeeding, and free medication. Most participants (75%, South Africa and Kenya) preferred a potential long-acting injectable over oral PrEP, most frequently for longer duration of effectiveness in South Africa (87% South Africa, 42% Kenya) versus discretion in Kenya (5% South Africa, 49% Kenya). 87% of participants preferred oral PrEP over a potential long-acting vaginal ring, mostly due to concern about possible discomfort with vaginal insertion (82% South Africa, 48% Kenya). Significant predictors of long-acting PrEP preference included past use of injectable contraceptive (aOR 2.48, 95% CI: 1.34, 4.57), disliking at least one oral PrEP attribute (aOR 1.72, 95% CI: 1.05, 2.80), and preferring infrequent PrEP use (aOR 1.58, 95% CI: 0.94, 2.65). Conclusions: Oral PrEP-experienced pregnant and postpartum women expressed a theoretical preference for long-acting injectable PrEP over other modalities, demonstrating potential acceptability among a key population who must be at the forefront of injectable PrEP rollout. Reasons for PrEP preferences differed by country, emphasizing the importance of increasing context-specific options and choice of PrEP modalities for pregnant and postpartum women.

User Preferences on Long-Acting Pre-Exposure Prophylaxis for HIV Prevention in Sub-Saharan Africa: A Scoping Review

“…Product duration was the most important factor driving user preferences in many studies across demographics [7,10,12,23,28]. Oral PrEP-experienced pregnant and postpartum women most commonly cited product duration as a factor for switching to LAI [12].…”

“…Product duration was the most important factor driving user preferences in many studies across demographics [7,10,12,23,28]. Oral PrEP-experienced pregnant and postpartum women most commonly cited product duration as a factor for switching to LAI [12]. Oral PrEP-experienced men also frequently reported difficulty adhering to a daily dosing schedule, especially on weekends, as well as difficulty swallowing the pill itself [7].…”

“…Most or all individuals in 11 studies had prior experience with oral PrEP, while nine studies were conducted among exclusively PrEP-naïve participants (Table S2). 10 studies were conducted among individuals participating in randomized clinical trials for PrEP [5][6][7][8][9][10][11], cohort studies [12,13], or PrEP implementation projects [14].…”

“…In a study of pregnant and postpartum women participating in the PrEP-PP and PrIMA-X trials in South Africa and Kenya, respectively, many voiced safety concerns for the mother and infant during pregnancy and breastfeeding. These women, most of whom had recent experience with oral PrEP, tended to prefer long-acting products over daily oral for their longer duration (especially in South Africa) and increased discretion (especially in Kenya) [12]. All pregnant AGYW interviewed in a study in South Africa would not use the DVR on account of perceived side effects [16].…”

The potential benefits of long-acting injectable cabotegravir in pregnant and breastfeeding women and their infants

“…Our updated model has been parameterized using recent data from a PrEP cohort study conducted among pregnant and postpartum women in South Africa, which shows reasonable oral PrEP uptake but limited adherence and continuation [5,7,15]. In this context, CAB-LA could potentially be very important, reducing HIV incidence in PBW by around 40%, and reducing vertical transmission by around 24% -a reflection of both greater acceptability of injectable prevention methods [22][23][24] and superior efficacy [9]. Offering a choice of CAB-LA and oral PrEP would lead to the greatest PrEP uptake (consistent with the effect of choice in family planning [25]), but the impact on HIV transmission would not differ materially from offering CAB-LA alone.…”