Randomized Trial of Dynamic Choice HIV Prevention at Antenatal and Postnatal Care Clinics in Rural Uganda and Kenya

Abstract

Background: Pregnant and postpartum women in Sub-Saharan Africa are at high risk of HIV acquisition. We evaluated a person-centered dynamic choice intervention for HIV prevention (DCP) among women attending antenatal and postnatal care. Setting: Rural Kenya and Uganda. Methods: Women (aged 15 years or older) at risk of HIV acquisition seen at antenatal and postnatal care clinics were individually randomized to DCP vs. standard of care (SEARCH; NCT04810650). The DCP intervention included structured client choice of product (daily oral pre-exposure prophylaxis or postexposure prophylaxis), service location (clinic or out of facility), and HIV testing modality (self-test or provider-administered), with option to switch over time and person-centered care (phone access to clinician, structured barrier assessment and counseling, and provider training). The primary outcome was biomedical prevention coverage—proportion of 48-week follow-up with self-reported pre-exposure prophylaxis or postexposure prophylaxis use, compared between arms using targeted maximum likelihood estimation. Results: Between April and July 2021, we enrolled 400 women (203 intervention and 197 control); 38% were pregnant, 52% were aged 15–24 years, and 94% reported no pre-exposure prophylaxis or postexposure prophylaxis use for ≥6 months before baseline. Among 384/400 participants (96%) with outcome ascertained, DCP increased biomedical prevention coverage 40% (95% CI: 34% to 47%; P < 0.001); the coverage was 70% in intervention vs. 29% in control. DCP also increased coverage during months at risk of HIV (81% in intervention, 43% in control; 38% absolute increase; 95% CI: 31% to 45%; P < 0.001). Conclusion: A person-centered dynamic choice intervention that provided flexibility in product, testing, and service location more than doubled biomedical HIV prevention coverage in a high-risk population already routinely offered access to biomedical prevention options.

Barriers and facilitators to uptake and use of oral pre-exposure prophylaxis in pregnant and postpartum women: a qualitative meta-synthesis

“…Pregnant and postpartum women faced the challenge of distinguishing between normal pregnancy symptoms and oral PrEP-related side effects. They were concerned that the observed side effects might be a danger sign for oral PrEP-exposed infants, which greatly reduced the willingness to use oral PrEP [46,47].Therefore, to alleviate maternal concerns about the side effects and safety of oral PrEP, medical providers should prioritize initiating early and frequent discussions with pregnant and postpartum women at high risk of HIV exposure, thoroughly explaining its safety profile, potential side effects, and providing informational support to enhance their awareness [48]. Furthermore, this review identified stigma against oral PrEP as a barrier to maternal oral PrEP implementation.…”

Client experiences with “Dynamic Choice Prevention,” a model for flexible patient‐centred HIV prevention delivery in rural Eastern Africa

“…The DCP trial testing facility‐based versus clinician‐supported CHW‐delivered services was found to increase biomedical prevention coverage by 27.5% among adult men and women at risk of HIV acquisition [ 15 ]. The trial testing DCP delivery among women seen at ante/postnatal care clinics increased prevention coverage by 40% [ 16 ].…”