Understanding PrEP decision making among pregnant women in Lilongwe, Malawi: A mixed‐methods study

Abstract

Introduction Pre‐exposure prophylaxis (PrEP) is a promising tool for HIV prevention during pregnancy. With increasing rollout in antenatal settings, counselling strategies to help pregnant women make appropriate decisions about PrEP use are needed. Understanding women's motivations and concerns for PrEP use—and how these inform their decision making and feelings about the decision to start PrEP—are critical to inform these strategies. Methods We conducted a convergent mixed‐methods study from June 2020 to June 2021 in the context of a PrEP adherence support trial among HIV‐negative pregnant women in Lilongwe, Malawi. Two hundred women completed a survey reporting their motivations and concerns about PrEP use, and their feelings about the decision to start PrEP (Decisional Regret Scale). Thirty women completed in‐depth interviews to better understand the decision‐making process, including motivations and concerns weighed in women's decision to use PrEP. Analyses comprised descriptive and bivariate statistics, thematic qualitative analysis, and integration of quantitative and qualitative results. Results Women initiating PrEP during pregnancy were highly motivated to obtain HIV protection for themselves and their unborn child, often due to perceived HIV risk connoted by a recent sexually transmitted infection and/or concerns about partner non‐monogamy. These motivations prevailed despite some concerns about safety and side effects, anticipated stigmatization, and concerns about adherence burden and pill attributes. Many women had informed their partner of their decision to use PrEP yet few felt their decision was contingent upon partner approval. Most women felt positively about the decision to start PrEP (mean decisional regret = 1.2 out of 5), but those with a greater number of concerns reported greater decisional regret (B = 0.036; p = 0.005). Furthermore, women who were specifically concerned about partner disclosure, who disliked pills or who had no perceived HIV risk reported greater decisional regret. Conclusions Pregnant women were strongly motivated by the promise of HIV protection offered by PrEP and accepted it despite diverse concerns. A shared decision‐making approach that centres pregnant women and offers partner involvement may help identify and address initial concerns about PrEP use and support prevention‐effective use of PrEP during this important period.

A Patient-Centered, Combination Intervention to Support Adherence to HIV Pre-exposure Prophylaxis During Pregnancy and Breastfeeding: A Randomized Pilot Study in Malawi

“…Uncertainty , on the other hand, can lead to an oscillation between PrEP use and nonuse and thus variable persistence in PrEP use. Such themes emerged in an ancillary, mixed-methods study of trial participants, 30 lending further support to these alternate dynamics. Correctly matching outcomes with the local context, as described by the Mutuality Framework, is essential in future research.…”

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 perceive the protective effects of oral PrEP for both pregnant and postpartum women and newborns which is a strong motivation to use oral PrEP, especially in serodiscordant couples [ 16 – 18 , 25 – 27 , 29 , 31 ]. The experience of taking oral PrEP during pregnancy and in the postpartum period and remaining HIV-free makes pregnant and postpartum women personally aware of the benefits of oral PrEP, which greatly facilitates the implementation of oral PrEP [ 34 ].…”

Awareness of and willingness to use oral pre-exposure prophylaxis (PrEP) for HIV prevention among sexually active adults in Malawi: results from the 2020 Malawi population-based HIV impact assessment

“…Those who reported having sex with more than one partner were more willing to use PrEP. Both perceived risk and actual risk have been previously shown to increase willingness to use PrEP in previous studies [ 10 , 18 – 20 ]. This specific willingness to take PrEP by those with a perceived high risk may support the need to improve access to PrEP to all persons.…”