A Review of HIV Pre-Exposure Prophylaxis: The Female Perspective

Examining the Role of Posttraumatic Stress and Depressive Symptoms in HIV Pre-exposure Prophylaxis (PrEP) Motivation Among Women Survivors of Intimate Partner Violence

Post-traumatic stress disorder (PTSD) and major depressive disorder (MDD) are associated with functional impairments, yet little is known about their influence on HIV pre-exposure prophylaxis (PrEP) motivation among women survivors of intimate partner violence (IPV). Understanding how PTSD and MDD symptoms influence PrEP motivation is particularly important given survivors of IPV have an increased risk for HIV acquisition. The present study assessed the association between PrEP motivation with latent profiles of PTSD and MDD symptoms among women survivors of IPV. Data were collected from a sample of 285 women from Baltimore, MD, and New Haven, CT. Latent profile analysis (LPA) was performed to identify distinct patterns of depressive and PTSD symptoms among women survivors of IPV. Binary logistic regression was performed to examine the association of profile membership on PrEP motivation. A six-profile solution was determined to best fit the data. Profiles were characterized by: Profile 1, very low depressive and very low PTSD symptoms (28.07%); Profile 2, average depressive symptoms and low (below the mean) PTSD symptoms (21.05%); Profile 3, high depressive symptoms and low (below the mean) PTSD symptoms (9.8%); Profile 4, moderate depressive symptoms and high PTSD symptoms (15.78%); Profile 5, high PTSD avoidance and average depressive symptoms (17.1%); Profile 6, high depressive and high PTSD symptoms (8%). We found that, the odds of being in Stage 3 of the PrEP Motivational Cascade (PrEParation; defined by having access to a medical provider to prescribe PrEP, be willing to take PrEP, and self-identifying as an appropriate candidate for PrEP) compared to Stage 1 of the PrEP Motivational Cascade (Precontemplation; defined by being eligible for PrEP, but not willing to take PrEP and/or not self-identifying as an appropriate candidate for PrEP) were lower for women assigned to the low depressive symptoms and low PTSD symptoms profile (Profile 1 of the LPA) compared to women in the high depressive symptoms and High PTSD symptoms profile (Profile 6 of the LPA, OR = 0.22, 95% CI = 0.06-0.76, p = 0.02). Women assigned to the low PTSD symptoms and average depressive symptoms profile (Profile 2 of the LPA) had lower odds of being in Stage 3 (PrEParation) compared to Stage 1 (Precontemplation) compared to women assigned to the high depressive symptoms and High PTSD symptoms profile (Profile 6 of the LPA, OR = 0.25, 95% CI = 0.07-0.92, p = 0.037). Women survivors of IPV with higher PTSD and MDD symptoms expressed greater motivation to engage in PrEP compared to women survivors with low PTSD and low MDD symptoms. Findings support the CDC's clinical PrEP recommendations to integrate depression screening into PrEP services, but there is a critical need to also include PTSD screening. Further, MDD and PTSD symptoms may present differential barriers to PrEP motivation among women survivors of IPV. Precision care could synchronize trauma-informed practices and mental health treatment to engage survivors in PrEP services.

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

BACKGROUND

The World Health Organization recommends Pre-Exposure Prophylaxis (PrEP) for all populations at substantial risk of HIV infection. Understanding PrEP awareness and interest is crucial for designing PrEP programs; however, data are lacking in sub-Saharan Africa. In Malawi, oral PrEP was introduced in 2018. We analyzed data from the 2020 Malawi Population-based HIV Impact Assessment (MPHIA) to assess PrEP awareness and factors associated with PrEP interest in Malawi.

METHODS

MPHIA 2020 was a national cross-sectional household-based survey targeting adults aged 15 + years. Oral PrEP was first described to the survey participants as taking a daily pill to reduce the chance of getting HIV. To assess awareness, participants were asked if they had ever heard of PrEP and to assess interest, were asked if they would take PrEP to prevent HIV, regardless of previous PrEP knowledge. Only sexually active HIV-negative participants are included in this analysis. We used multivariable logistic regression to assess sociodemographic factors and behaviors associated with PrEP interest. All results were weighted.

RESULTS

We included 13,995 HIV-negative sexually active participants; median age was 29 years old. Overall, 15.0%, 95% confidence interval (CI): 14.2-15.9% of participants were aware of PrEP. More males (adjusted odds ratio (aOR): 1.3, 95% CI: 1.2-1.5), those with secondary (aOR: 1.5, 95% CI: 1.2-2.0) or post-secondary (aOR: 3.4, 95% CI: 2.4-4.9) education and the wealthiest (aOR: 1.6, 95% CI: 1.2-2.0) were aware of PrEP than female, those without education and least wealthy participants, respectively. Overall, 73.0% (95% CI: 71.8-74.1%) of participants were willing to use PrEP. Being male (aOR: 1.2; 95% CI: 1.1-1.3) and having more than one sexual partner (aOR: 1.7 95% CI: 1.4-1.9), were associated higher willingness to use PrEP.

CONCLUSIONS

In this survey, prior PrEP knowledge and use were low while PrEP interest was high. High risk sexual behavior was associated with willingness to use PrEP. Strategies to increase PrEP awareness and universal access, may reduce HIV transmission.

Viral dissemination and immune activation modulate antiretroviral drug levels in lymph nodes of SIV-infected rhesus macaques

Introduction and methods

To understand the relationship between immunovirological factors and antiretroviral (ARV) drug levels in lymph nodes (LN) in HIV therapy, we analyzed drug levels in twenty-one SIV-infected rhesus macaques subcutaneously treated with daily tenofovir (TFV) and emtricitabine (FTC) for three months.

Results

The intracellular active drug-metabolite (IADM) levels (TFV-dp and FTC-tp) in lymph node mononuclear cells (LNMC) were significantly lower than in peripheral blood mononuclear cells (PBMC) (P≤0.005). Between Month 1 and Month 3, IADM levels increased in both LNMC (P≤0.001) and PBMC (P≤0.01), with a steeper increase in LNMC (P≤0.01). The viral dissemination in plasma, LN, and rectal tissue at ART initiation correlated negatively with IADM levels at Month 1. Physiologically-based pharmacokinetic model simulations suggest that, following subcutaneous ARV administration, ART-induced reduction of immune activation improves the formation of active drug-metabolites through modulation of kinase activity and/or through improved parent drug accessibility to LN cellular compartments.

Conclusion

These observations have broad implications for drugs that need to phosphorylate to exert their pharmacological activity, especially in the settings of the pre-/post-exposure prophylaxis and efficacy of antiviral therapies targeting pathogenic viruses such as HIV or SARS-CoV-2 replicating in highly inflammatory anatomic compartments.

Single-nucleotide polymorphisms in ABC drug transporters alter expression and circulating tenofovir in healthy South African women exposed to pre-exposure prophylaxis

Aim: We investigated if single-nucleotide polymorphisms (SNPs) in ATP-binding cassette (ABC) drug transporters alter gene expression and tenofovir disposition in South African women taking Truvada® for HIV prevention. Materials & methods: In 393 women, real-time PCR was used to determine the associations between six SNPs in ABC transporter genes, mRNA expression and circulating-tenofovir. Results: Univariable and multivariable analyses showed that CT and TT relative to CC genotypes for the ABCC4(3463C/T) SNP had significantly higher tenofovir levels. In contrast, the AA genotype for the ABCC4(4976A/G) SNP showed significantly less tenofovir, while mRNA expression was increased. Conclusion: SNPs in the ABCC4 gene may differentially affect gene expression and circulating tenofovir. Their impact may inform on low pre-exposure prophylaxis efficacy and discern effective drugs in clinical trials of African women enriched for certain genotypes.

Enzyme-Triggered l-α/d-Peptide Hydrogels as a Long-Acting Injectable Platform for Systemic Delivery of HIV/AIDS Drugs

Eradicating HIV/AIDS by 2030 is a central goal of the World Health Organization. Patient adherence to complicated dosage regimens remains a key barrier. There is a need for convenient long-acting formulations that deliver drugs over sustained periods. This paper presents an alternative platform, an injectable in situ forming hydrogel implant to deliver a model antiretroviral drug (zidovudine [AZT]) over 28 days. The formulation is a self-assembling ultrashort d or l-α peptide hydrogelator, namely phosphorylated (naphthalene-2-ly)-acetyl-diphenylalanine-lysine-tyrosine-OH (NapFFKY[p]-OH), covalently conjugated to zidovudine via an ester linkage. Rheological analysis demonstrates phosphatase enzyme instructed self-assembly, with hydrogels forming within minutes. Small angle neutron scattering data suggest hydrogels form narrow radius (≈2 nm), large length fibers closely fitting the flexible cylinder elliptical model. d-Peptides are particularly promising for long-acting delivery, displaying protease resistance for 28 days. Drug release, via hydrolysis of the ester linkage, progress under physiological conditions (37 °C, pH 7.4, H2 O). Subcutaneous administration of Napffk(AZT)Y[p]G-OH in Sprague Dawley rats demonstrate zidovudine blood plasma concentrations within the half maximal inhibitory concentration (IC50 ) range (30-130 ng mL-1 ) for 35 days. This work is a proof-of-concept for the development of a long-acting combined injectable in situ forming peptide hydrogel implant. These products are imperative given their potential impact on society.

A qualitative study to explore daily versus on-demand oral pre-exposure prophylaxis (PrEP) in young people from South Africa, Uganda and Zimbabwe

BACKGROUND

Adolescents in sub-Saharan Africa (SSA) remain vulnerable to HIV infection. While pre-exposure prophylaxis (PrEP) is highly effective in preventing HIV transmission as a daily or on-demand regimen, tailored approaches are necessary. The Combined HIV Adolescent PrEP and Prevention Study (CHAPS) is a mixed-methods research program investigating the acceptability and feasibility of implementing daily and on-demand PrEP among young people in SSA. It also aims to determine an on-demand dosing schedule for insertive sex. For this paper, we explored preferences for daily versus on-demand PrEP amongst adolescents as part of CHAPS.

METHODS

Purposive sampling was used to recruit participants from Soweto and Cape Town (South Africa), Wakiso district (Uganda) and Chitungwiza (Zimbabwe). At the time of the study in 2018/2019, Uganda had not rolled out PrEP to the general population; in Zimbabwe, PrEP for young people was only available at selected sites with one located within the study recruitment area. In South Africa, PrEP was made available to selected high-risk groups. We conducted 60 in-depth interviews and 24 group discussions amongst young people aged 13-24 without HIV in South Africa, Uganda, and Zimbabwe. All in-depth interviews and group discussions were audio-recorded, transcribed verbatim and translated to English. Data were analysed using framework analysis. The main themes were centered around preferences for daily and on-demand PrEP.

RESULTS

Reasons for on-demand preferences included stigma, pill fatigue, adherence and side effects. Reasons for daily PrEP preferences included factors related to sexual risk behaviour, continuous protection against incidents of unintentional exposure, and the increased efficacy of a daily dose. Participants at all sites preferring daily PrEP identified the same reasons, with more males than females citing inadvertent blood contact or perceived increased efficacy. Similarly, participants at all sites preferring on-demand PrEP gave the same reasons for their preferences for on-demand PrEP; the exception was South Africans who did not mention the hope of having fewer side effects by not taking daily PrEP. Additionally, more males than females cited intermittent sex as a reason for opting for on-demand PrEP.

CONCLUSIONS

Our study is the first known to explore and describe youth preferences for daily versus on-demand PrEP. While the choice is clear-cut, the reasons cited in the different options provide invaluable insights into their decisions, and the actual and perceived facilitators and barriers to access to PrEP. Further education is needed amongst young people, not only about PrEP but also in other areas of comprehensive sexuality education. Exploring all options of HIV prevention is crucial to provide a tailored, one-size-does-not-fit-all approach to adolescent care in SSA to reduce and, the continued and increasing risk of this preventable infection.

Using qualitative comparative analysis to understand the conditions that produce successful PrEP implementation in family planning clinics

BACKGROUND

Title X-funded family planning clinics have been identified as optimal sites for delivery of pre-exposure prophylaxis (PrEP) for HIV prevention to U.S. women. However, PrEP has not been widely integrated into family planning services, especially in the Southern U.S., and data suggest there may be significant implementation challenges in this setting.

METHODS

To understand contextual factors that are key to successful PrEP implementation in family planning clinics, we conducted in-depth qualitative interviews with key informants from 38 family planning clinics (11 clinics prescribed PrEP and 27 did not). Interviews were guided by constructs from the Consolidated Framework for Implementation Research (CFIR), and qualitative comparative analysis (QCA) was used to uncover the configurations of CFIR factors that led to PrEP implementation.

RESULTS

We identified 3 distinct construct configurations, or pathways, that led to successful PrEP implementation: (1) high "Leadership Engagement" AND high "Available Resources"; OR (2) high "Leadership Engagement" AND NOT located in the Southeast region; OR (3) high "Access to Knowledge and Information" AND NOT located in the Southeast region. Additionally, there were 2 solution paths that led to absence of PrEP implementation: (1) low "Access to Knowledge and Information" AND low "Leadership Engagement"; OR (2) low "Available Resources" AND high "External Partnerships".

DISCUSSION

We identified the most salient combinations of co-occurring organizational barriers or facilitators associated with PrEP implementation across Title X clinics in the Southern U.S. We discuss implementation strategies to promote pathways that led to implementation success, as well as strategies to overcome pathways to implementation failure. Notably, we identified regional differences in the pathways that led to PrEP implementation, with Southeastern clinics facing the most obstacles to implementation, specifically substantial resource constraints. Identifying implementation pathways is an important first step for packaging multiple implementation strategies that could be employed by state-level Title X grantees to help scale up PrEP.

Knowledgeable, aware / interested: Young black women's perceptions of pre-exposure prophylaxis

Purpose

HIV in the United States disproportionately affects young Black women. Pre-exposure prophylaxis (PrEP) is an effective HIV prevention option that has the potential to reduce HIV incidence among HIV-vulnerable populations. However, data regarding women's awareness, interest in starting, and feelings of acceptability or stigma about PrEP remains limited, particularly among adolescent and young Black women.

Materials and methods

A cross-sectional survey was conducted with 100 sexually active young Black women ages 13–24 years attending women's health clinics in Chicago, IL. Descriptive statistics were used to characterize the sample and determine more about what the PrEP needs and barriers are in this community. Associations were modeled using logistic regression and 95% confidence intervals for both bivariate and multivariable models.

Results

In our survey (N = 100), half of study participants (50%) expressed interest in starting PrEP in the next three months and a majority (80%) of young women were confident they could obtain PrEP. Pregnant young women were significantly more interested in starting PrEP than non-pregnant women [OR 2.3 95% CI (1.0, 5.4)], p = 0.05), however, this association did not remain significant in adjusted models.

Conclusions

This study provides a more complete understanding of awareness, interest in, and acceptability of PrEP among adolescent and young Black women attending women's health clinics. Findings indicate sustained interest in starting PrEP, reduced stigma, and increased awareness of PrEP among young Black women. These findings suggest that integrating PrEP into women's health clinics is a promising strategy to increase awareness and utilization of PrEP and decrease HIV transmission among youth at highest risk.

Low incidence of HIV infection and decreasing incidence of sexually transmitted infections among PrEP users in 2020 in Germany

Introduction

Objectives of this study, as part of a nation-wide HIV pre-exposure prophylaxis (PrEP) evaluation project, were to determine the incidence of infections with HIV, chlamydia, gonorrhea, syphilis, hepatitis A/B/C in persons using PrEP, and to describe the health care funded PrEP use in Germany. Additionally, factors associated with chlamydia/gonorrhea and syphilis infections were assessed.

Methods

Anonymous data of PrEP users were collected at 47 HIV-specialty centers from 09/2019–12/2020. Incidence rates were calculated per 100 person years (py). Using longitudinal mixed models, we analyzed risk factors associated with sexually transmitted infections (STIs).

Results

4620 PrEP users were included: 99.2% male, median age 38 years (IQR 32–45), 98.6% men who have sex with men (MSM). The median duration of PrEP exposure was 451 days (IQR 357–488), totaling 5132 py. Four HIV infections were diagnosed, incidence rate 0,078/100py (95% CI 0.029–0.208). For two, suboptimal adherence was reported and in the third case, suboptimal adherence and resistance to emtricitabine were observed. One infection was likely acquired before PrEP start. Incidence rates were 21.6/100py for chlamydia, 23.7/100py for gonorrhea, 10.1/100py for syphilis and 55.4/100py for any STI and decreased significantly during the observation period. 65.5% of syphilis, 55.6% of chlamydia and 50.1% of gonorrhea cases were detected by screening of asymptomatic individuals. In a multivariable analysis among MSM younger age, PrEP start before health insurance coverage and daily PrEP were associated with greater risk for chlamydia/gonorrhea. Symptom triggered testing and a history of STI were associated with a higher risk for chlamydia/gonorrhea and syphilis. A significantly lower risk for chlamydia/gonorrhea and syphilis was found for observations during the COVID-19 pandemic period.

Conclusions

We found that HIV-PrEP is almost exclusively used by MSM in Germany. A very low incidence of HIV infection and decreasing incidence rates of STIs were found in this cohort of PrEP users. The results were influenced by the SARS-CoV-2 pandemic. Rollout of PrEP covered by health insurance should be continued to prevent HIV infections. Increased PrEP availability to people at risk of HIV infection through the elimination of barriers requires further attention. Investigation and monitoring with a longer follow-up would be of value.

Supplementary Information

The online version contains supplementary material available at 10.1007/s15010-022-01919-3.

Determinants of Implementation for HIV Pre-exposure Prophylaxis Based on an Updated Consolidated Framework for Implementation Research: A Systematic Review

BACKGROUND

Delivery and use of HIV pre-exposure prophylaxis (PrEP) are suboptimal in the United States. Previous reviews of barriers and facilitators have not used an implementation science lens, limiting comprehensiveness and the link to implementation strategies. To summarize the state of the science, we systematically reviewed determinants of PrEP implementation using the updated Consolidated Framework for Implementation Research (CFIR 2.0).

SETTING

PrEP-eligible communities and delivery settings in the United States.

METHODS

In January 2021, we searched Ovid MEDLINE, PsycINFO, and Web of Science for peer-reviewed articles related to HIV/AIDS, interventions, implementation, and determinants or strategies. We identified 286 primary research articles published after 1999 about US-based PrEP implementation. Team members extracted discrete "mentioned" and "measured" determinants, coding each by setting, population, valence, measurement, and CFIR 2.0 construct.

RESULTS

We identified 1776 mentioned and 1952 measured determinants from 254 to 239 articles, respectively. Two-thirds of measured determinants were of PrEP use by patients as opposed to delivery by providers. Articles contained few determinants in the inner setting or process domains (ie, related to the delivery context), even among studies of specific settings. Determinants across priority populations also focused on individual patients and providers rather than structural or logistical factors.

CONCLUSION

Our findings suggest substantial knowledge in the literature about general patient-level barriers to PrEP use and thus limited need for additional universal studies. Instead, future research should prioritize identifying determinants, especially facilitators, unique to understudied populations and focus on structural and logistical features within current and promising settings (eg, pharmacies) that support integration of PrEP into clinical practice.

Exploring the Role of Provider–Patient Communication in Women’s Sexual Health and Pre-Exposure Prophylaxis Care in the Primary Care Settings in New York State of the United States

Background: Women shoulder a disproportionate burden of HIV infection in the United States and worldwide. Pre-exposure prophylaxis (PrEP) is an effective tool for HIV prevention, but its use is suboptimal. Primary care providers (PCP) are considered the ideal PrEP caregivers, but they generally underperform in PrEP care implementation. Methods: From 2020 to 2022, we employed semi-structured in-depth interviews to collect information about barriers and facilitators in PrEP care and beliefs and opinions regarding sexual wellness among 18 PCP and 29 PrEP-eligible women. We employed content analysis and thematic analysis to explore the transcribed narrative data. Results: The current study was guided by the “Communication Pathways” Framework. We studied how communication functions affect PrEP care and women’s sexual wellness on the pathways. We identified several specific pathways between communication and PrEP care implementation in primary care settings, including patient knowledge, linkage to care, therapeutic alliance, and decision making on PrEP care. A paradox regarding who should initiate the discussion regarding sexual history and PrEP care was identified. Conclusions: Findings suggested that a navigation and assistance system for PrEP care in patients and providers is urgently needed. Future studies should facilitate PrEP discussion, engagement, and monitoring in primary care settings.

Let Me Prep You to PREP Me: Amplifying the Voices of Black Women and Their Providers to Consider PrEP as an HIV Prevention Option

Despite the high efficacy of pre-exposure prophylaxis (PrEP) in preventing HIV acquisition, PrEP uptake among Black cisgender women remains low. Our qualitative study assessed Black cisgender women's perspectives, attitudes, and acceptability towards PrEP, in addition to exploring PrEP-related attitudes, facilitators, and barriers to PrEP access among health care staff. This study was conducted to ascertain data to inform the development of our HIV prevention app-Savvy HER-which is being designed for Black cisgender women. Our findings indicated that Black women had low levels of PrEP acceptability and high levels of misconceptions, inaccurate knowledge, and stigma towards PrEP. Health care providers in our sample confirmed barriers of stigma, misconceptions, and knowledge among their patients coupled with difficulty accessing PrEP due to structural barriers. Our study indicated that there is a critical need to heighten Black cisgender women's PrEP knowledge and HIV risk perception in order to increase PrEP acceptability and uptake.

Psychosocial health in pregnancy and postpartum among women living with - and without HIV and non-pregnant women living with HIV living in the Nordic countries - Results from a longitudinal survey study

BACKGROUND

The success of antiretroviral therapy has normalized pregnancy among women living with HIV (WWH) with a very low risk of perinatal transmission of HIV. Despite these advances, WWH still face complex medical and psychosocial issues during pregnancy and postpartum. The aim of this study was to assess differences in psychosocial health outcomes between pregnant WWH, non-pregnant WWH, and pregnant women without HIV, and further identify factors associated with probable depression in the third trimester and postpartum.

METHODS

In a longitudinal survey study, participants were included from sites in Denmark, Finland, and Sweden during 2019-2020. Data was collected in the 3rd trimester, 3 and 6 months postpartum using standardized questionnaires assessing depression, perceived stress, loneliness, and social support. Mixed regression models were used to assess changes over time within and between groups. Logistic regression models were used to identify factors associated with depression in pregnancy and postpartum.

RESULTS

A total of 47 pregnant WWH, 75 non-pregnant WWH, and 147 pregnant women without HIV were included. The prevalence of depression was high among both pregnant and non-pregnant WWH. There was no significant difference between pregnant and non-pregnant WWH in depression scores, perceived stress scores, or social support scores at any time point. Compared to pregnant women without HIV, pregnant WWH reported worse outcomes on all psychosocial scales. Social support and loneliness were associated with an increased odds of depressive symptoms in the adjusted analysis.

CONCLUSIONS

A high burden of adverse psychosocial outcomes was observed in both pregnant and non-pregnant women living with HIV compared to pregnant women without HIV. Loneliness and inadequate social support were associated with increased odds of depression in pregnancy and should be a focus in future support interventions.

A Comparison of Tenofovir Predose Concentrations in Generic Pre-exposure Prophylaxis Formulations: A Short Communication

BACKGROUND

There is extensive evidence to show that pre-exposure prophylaxis (PrEP) using tenofovir disoproxil fumarate (TDF)-based formulations dramatically reduces the risk of HIV acquisition among individuals without HIV infection. Here, the authors aim to compare tenofovir plasma predose concentrations in subjects taking PrEP daily versus on demand and using different TDF-based generic formulations.

METHODS

Subjects providing informed signed consent for the measurement of tenofovir plasma levels were included in the study. Predose drug concentrations were stratified according to PrEP administration and the type of TDF-based formulation. The control group consisted of patients with HIV infection who were matched for renal function and were administered branded TDF that was not combined with boosted-antiretroviral drugs.

RESULTS

The study consisted of 100 subjects (mean age, 39 ± 10 years; body weight, 77 ± 11 kg). A wide distribution in tenofovir predose concentrations was observed, with values ranging from 17 to 297 ng/mL (coefficient of variation 77%). No significant differences were noted in tenofovir predose concentrations between subjects who were administered PrEP daily (n = 75) or on demand (n = 25) [94 (35-255) versus 104 (37-287) ng/mL; P = 0.476]. Comparable tenofovir predose concentrations were found between patients with HIV infection (n = 220) who were administered branded TDF and those without HIV infection who were treated with 5 different generic TDF-based formulations with generics-to-branded ratios. These were always within the range of 80%-125% and were used to define bioequivalence.

CONCLUSIONS

The marketed generic formulations of TDF delivered tenofovir plasma predose concentrations comparable with those delivered by branded formulations.

Initial implementation of PrEP in Zambia: health policy development and service delivery scale-up

INTRODUCTION

Daily pre-exposure prophylaxis (PrEP) for HIV prevention is highly effective, but not yet widely deployed in sub-Saharan Africa. We describe how Zambia developed PrEP health policy and then successfully implemented national PrEP service delivery.

POLICY DEVELOPMENT

Zambia introduced PrEP as a key strategy for HIV prevention in 2016, and established a National PrEP Task Force to lead policy advocacy and development. The Task Force was composed of government representatives, regulatory agencies, international donors, implementation partners and civil society organisations. Following an implementation pilot, PrEP was rolled out nationally using risk-based criteria alongside a national HIV prevention campaign.

NATIONAL SCALE-UP

In the first year of implementation, ending September 2018, 3626 persons initiated PrEP. By September 2019, the number of people starting PrEP increased by over sixfold to 23 327 persons at 728 sites across all ten Zambian provinces. In the first 2 years, 26 953 clients initiated PrEP in Zambia, of whom 31% were from key and priority populations. Continuation remains low at 25% and 11% at 6 and 12 months, respectively.

LESSONS LEARNT

Risk-based criteria for PrEP ensures access to those most in need of HIV prevention. Healthcare worker training in PrEP service delivery and health needs of key and priority populations is crucial. PrEP expansion into primary healthcare clinics and community education is required to reach full potential. Additional work is needed to understand and address low PrEP continuation. Finally, a task force of key stakeholders can rapidly develop and implement health policy, which may serve as a model for countries seeking to implement PrEP.

Missed Opportunities for HIV Prevention in Perinatal Care Settings in the United States

Universal opt-out HIV screening in pregnancy is an essential intervention toward eliminating perinatal HIV transmission in the US. However, it fails to identify pregnant people who are HIV negative at the time of testing but are at ongoing risk for HIV acquisition. Those of us involved in caring for women living with HIV are acutely aware of the many diagnoses of HIV that might have been prevented if only a partner had been tested for HIV or preexposure prophylaxis (PrEP) had been offered to a patient. This perspective article will review current recommendations and evidence-based interventions to evaluate missed opportunities for HIV prevention in US perinatal care settings. We identified three barriers to implementation of HIV prevention strategies during pregnancy and breastfeeding: (1) HIV risk for women is underestimated and poorly defined in clinical practice; (2) Partner testing is challenging and implementation studies in the US are lacking; and (3) PrEP remains underutilized. In March 2020, the National Perinatal HIV Hotline convened a group of clinicians and researchers specializing in perinatal HIV care to a case-based discussion of missed opportunities in perinatal HIV prevention. From our review of the literature via PubMed search as well as expert opinions gathered in this discussion, we make recommendations for addressing these barriers.

Pre-Exposure Prophylaxis (PrEP) for HIV Infection in Cisgender and Transgender Women in the U.S.: A Narrative Review of the Literature

Using a socioecological approach, this review describes the peer-reviewed literature on oral pre-exposure prophylaxis (PrEP) among both cisgender (cis women) and transgender women (trans women) in the U.S. A search of the PubMed database and HIV-related conference abstracts generated over 2,200 articles and abstracts. Of these, 103 fulfilled review inclusion criteria. Most of the existing research presents findings on individual-level factors associated with PrEP use such as willingness and perceived barriers. There was far less investigation of factors related to PrEP at more distal ecological levels. Though trans women are at greater risk of HIV infection than cisgender women, less is known about this population group with respect to PrEP despite their inclusion in many major clinical trials. Further, the literature is characterized by a persistent conflation of sex and gender which makes it difficult to accurately assess the reviewed research on HIV prevention and PrEP apart from risk group. Informed by these findings, we highlight specific opportunities to improve access to PrEP and reduce socioecological barriers to PrEP care engagement for cisgender and transgender women.

Results from a PrEP Demonstration Project for At-Risk Cisgender Women in the United States

BACKGROUND

Daily oral tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) is effective for reducing HIV acquisition among cisgender women. We report results from the first United States observational open-label demonstration project of PrEP among at-risk cisgender women.

METHODS

Adherence Enhancement Guided by Individualized Texting and Drug Levels (AEGiS) was a 48-week single-arm open-label demonstration study of daily oral TDF/FTC in cisgender women ≥18 years old at-risk for HIV. Adherence was supported using two-way text messaging and titrated adherence counseling based on rapid-turnaround tenofovir diphosphate concentrations from dried blood spots. Study visits occurred at baseline, and at weeks 4, 12, and quarterly through week 48. Outcomes included TDF/FTC adherence, retention and persistence.

RESULTS

From June 2016 to October 2018, 136 cisgender women enrolled [mean age 40 (SD 11); 38% non-Hispanic (NH) Black and 19% Latina]. At 48 weeks, 84 (62%) participants were retained and 62 (46%) remained on PrEP. Over one-third (12/31) of those on study but off PrEP throughout study discontinued TDF/FTC due to side effects, and one adverse event led to study discontinuation. Of 120 participants with drug concentrations measured, 67 (56%) had at least one concentration consistent with ≥6 doses/week (d/w); 22 (18%) had consistent ≥6 d/w across all study visits attended. There were no incident HIV infections and 4 incident bacterial STIs.

CONCLUSION

Adequate PrEP adherence for protective drug concentrations was not achieved for most study participants. More work needs to be done to fully explicate the reasons for non-adherence and low retention in cisgender women.

PrEP reminds me that I am the one to take responsibility of my life: a qualitative study exploring experiences of and attitudes towards pre-exposure prophylaxis use by women in Eswatini

BACKGROUND

Pre-exposure-prophylaxis (PrEP) has been heralded for its potential to put women in control of preventing HIV infection, but uptake and continuation rates have been disappointing in high-incidence settings in sub-Saharan Africa. We explored structural and social factors that influenced PrEP use among young women and pregnant or breastfeeding women in rural Eswatini.

METHODS

We conducted two in-depth interviews with ten women on PrEP, and one-time in-depth interviews with fourteen women who declined or discontinued PrEP. Interviews covered decision-making processes around PrEP initiation and experiences with pill-taking. In-depth interviews were conducted with nine health workers, covering experiences in delivering PrEP services, and two focus group discussions were held with men to elicit their perceptions of PrEP. Interviews and discussions were audio-recorded, translated, transcribed and analysed thematically, using an inductive approach.

RESULTS

PrEP initiation and use were experienced by many women as empowering them to take control of their health and well-being, and stay HIV free, facilitating them to realise their aspirations relating to motherhood and educational attainment. However, the social norms that defined relationship dynamics with partners or family members either undermined or promoted this empowerment potential. In particular, young women were rarely supported by family members to take PrEP unless it was perceived to be for protecting an unborn child. Stigmatisation of pill-taking through its associations with HIV and the burden of daily pill-taking also contributed to PrEP discontinuation.

CONCLUSIONS

Unlike many prevention tools, PrEP enabled women to achieve a sense of control over their lives. Nevertheless, women's agency to continue and adhere to PrEP was influenced by social and structural factors including gender norms, family expectations of young women, relationship dynamics and stigma related to HIV. Future interventions should address these barriers to promote PrEP use among sexually-active women.

"PrEP just isn't my priority": Adherence challenges among women who inject drugs participating in a pre-exposure prophylaxis (PrEP) demonstration project in Philadelphia, PA USA

Pre-exposure prophylaxis (PrEP) has the ability to curb HIV transmission among women if they are highly adherent (e.g. 6/7 weekly doses). In a recent PrEP demonstration project with 95 women who inject drugs (WWID) in Philadelphia, PA, USA, PrEP uptake was high but adherence was low. This qualitative study draws upon the Behavioral Model for Vulnerable Populations (BMVP) to describe how the context of 23 WWID's lives challenged PrEP adherence using narrative data from in-depth interviews. Content analysis suggests that women's need to organize their day around predisposing survival needs made it difficult to prioritize PrEP. Adherence was further challenged by dis-enabling structural forces such as entry into institutions that do not provide PrEP (e.g., drug treatment and correctional facilities) and medication diversion to illicit marketplaces. Overtime, women's perceived need for PrEP was dynamic: in periods they characterized as risky, women considered PrEP highly beneficial and described enhanced motivation to adhere. In periods of low perceived risk, women were less committed to continuing daily PrEP in the context of their competing survival needs. In sum, WWID faced challenges to PrEP adherence that correspond to all of the BMVP domains. To optimize PrEP for WWID, multi-level programs are needed that address the determinants that both increase HIV susceptibility and undermine adherence.

"Yes, I'm interested in taking PrEP!": PrEP interest among women respondents to the European community-based survey "Flash! PrEP in Europe"

The World Health Organization recommends pre-exposure prophylaxis (PrEP) for all populations at substantial risk of HIV infection, including women. However, data regarding PrEP interest among women is lacking, particularly in Europe. Factors associated with interest in using PrEP were assessed among women respondents to the Flash! PrEP in Europe (FPIE) survey. This community-based cross-sectional study, conducted in 12 European countries, aimed to assess PrEP knowledge and interest. "High objective risk" (HOR) was assessed using established risk criteria following EACS and CDC guidelines. Factors associated with interest in using PrEP were assessed in univariable and multivariable logistic regression models. Among 678 women, 12.5% (n = 85) were considered at HOR, 46.8% (n = 317) indicated prior PrEP knowledge and 18.0% (n = 122) reported interest in using PrEP. Among women at HOR, 40.0% (n = 34) were interested in PrEP. Factors significantly associated with PrEP interest in the final multivariable model were: younger age (18-29 years) (aOR 1.91[95CI: 1.07; 3.41]), bad self-perceived financial status (1.84[1.09; 3.11]), migrant status (south to north) (2.87[1.05; 7.89]), single or dating relationship status (1.93[1.23; 3.03]), sexual abuse history (1.86[1.17; 2.97]), "rather high"/ "high" self-perceived HIV risk (3.21[1.32; 7.81]), and HOR (2.49[1.42; 4.35]). These results show that women at HOR and those who perceived themselves to be at high risk are interested in using PrEP. There is a critical need for targeted information and improved access to PrEP to increase uptake of this HIV prevention tool to meet PrEP interest among women.

A qualitative study to identify critical attributes and attribute-levels for a discrete choice experiment on oral pre-exposure prophylaxis (PrEP) delivery among young people in Cape Town and Johannesburg, South Africa

BACKGROUND

The uptake and adherence of daily oral PrEP has been poor in high-risk populations in South Africa including young people. We used qualitative research methods to explore user preferences for daily and on-demand oral PrEP use among young South Africans, and to inform the identification of critical attributes and attribute-levels for quantitative analysis of user preferences, i.e. a discrete choice experiment (DCE).

METHODS

Data were collected between September and November 2018 from eight group discussions and 20 in-depth interviews with young people 13 to 24 years in Cape Town and Johannesburg. Using a convenience sampling strategy, participants were stratified by sex and age. Interviewers used a semi-structured interview guide to discuss several attributes (dosing regimen, location, costs, side effects, and protection period) for PrEP access and use. Group discussions and in-depth interviews were audio-recorded, transcribed verbatim and translated to English. We used framework analysis to explore context-specific attributes and attribute-levels for delivering oral PrEP in South Africa. The adolescent community advisory board, expert and study team opinions were consulted for the final DCE attributes and levels.

RESULTS

We enrolled 74 participants who were 51% (n = 38/74) male, had a median age of 18.5 [Interquartile range = 16-21.25] years, 91% (n = 67/74) identified as heterosexual and 49% (n = 36/74) had not completed 12th grade education. Using the qualitative data, we identified five candidate attributes including (1) dosing regimen, (2) location to get PrEP, (3) cost, (4) route of administration and (5) frequency. After discussions with experts and the study team, we revised the DCE to include the following five attributes and levels: dosing regime: daily, and on-demand PrEP; location: private pharmacy, public clinic, mobile clinic, ATM); cost: free-of-charge, R50 (~2GBP), R265 (~12GBP); side effects: nausea, headache, rash; and duration of protection: fulltime protection versus when PrEP is used).

CONCLUSIONS

There is limited literature on qualitative research methods describing the step-by-step process of developing a DCE for PrEP in adolescents, especially in resource-constrained countries. We provide the process followed for the DCE technique to understand user preferences for daily and on-demand oral PrEP among young people in South Africa.

Achievements and gaps to provide pre-exposure prophylaxis (PrEP) for women across the European Region - Results from a European survey study

Introduction

The use of pre-exposure prophylaxis (PrEP) is a safe and effective prevention option to all people at substantial risk of HIV acquisition, irrespective of gender. However, in most European countries PrEP services focus on key populations, in particular men who have sex with men (MSM). This study aims to explore PrEP availability and implementation for women across the European region.

Methods

An online survey was sent to all members of Women Against Viruses in Europe (WAVE) from 50 countries in September 2019. It consisted of 19 questions, including both multiple choice and free text answers.

Results

In total, responses from 34 countries were included in the study (Western Europe n ​= ​12, Central Europe ​= ​12, Eastern Europe n ​= ​6). PrEP was accessible in 30 WHO European countries. More than half of them stated that PrEP was available for all groups at-risk of HIV acquisition (n ​= ​18), while in many countries PrEP was only available to MSM and transgender persons. Two-thirds of country respondents confirmed the availability of a national guideline for PrEP (n ​= ​23), of which six countries had specific recommendations for PrEP in women. The most cited obstacles for PrEP access were lack of information about PrEP, lack of political support, and high cost for the individual. Fifteen country respondents stated that there were specific obstacles for PrEP access for women, such as guidelines prioritizing MSM, women not being seen as a target population for PrEP, and lack of knowledge about which subgroup of women would benefit most from PrEP. Seven countries had made efforts to encourage women’s access to PrEP, most of which were individually based or initiated by local NGOs.

Conclusions

PrEP is an important addition to HIV combination prevention. Women’s access to PrEP in Europe remains limited. Women are often not included in the guidelines or targeted with education or information, resulting in a general lack of information about the use of PrEP for women.

Utilizing emergency departments for pre-exposure prophylaxis (PrEP)

HIV incidence and prevalence rates in emergency departments (EDs) around the nation warrant strategies to protect and sustain the HIV negative status of persons who are at risk for HIV. The ED provides a rare opportunity to serve as a vehicle for connecting pre-exposure prophylaxis (PrEP)-eligible patients with clinical settings such as an ED that are knowledgeable and well informed about PrEP. PrEP has established efficacy at preventing HIV acquisition. The greatest challenge is access to PrEP and uptake thereof among vulnerable populations. We propose recommendations to improve the functionality of EDs as access points for PrEP referrals as an HIV prevention strategy to increase PrEP availability and uptake.

Intimate Partner Violence and Pre-exposure Prophylaxis (PrEP): A Rapid Review of Current Evidence for Women's HIV Prevention

Pre-exposure prophylaxis (PrEP) is a valued component of HIV prevention and increasing attention is focusing on women's PrEP use. Common HIV prevention options (e.g., condoms) remain underused and fail to consider the context of intimate partner violence (IPV). PrEP presents an opportunity to expand viable options for women. A systematic rapid review using key word searches of PubMed and proceedings from six national and international conferences related to HIV, women's health, or interpersonal violence identified nine studies which met set inclusion criteria. Studies were coded using a structured abstraction form and summarized according to relevant themes. IPV was found to have implications on women's interest and willingness to use PrEP, partner interference or interruptions in PrEP use, and adherence. Findings indicate a dearth of research on women's PrEP use and IPV and highlight the urgency for research, public heath practice, and policy attention around the HIV risk context and needs of women who experience IPV.

The PrEP Care Continuum Among Cisgender Women Who Sell Sex and/or Use Drugs Globally: A Systematic Review

HIV prevalence among cisgender female sex workers (FSW) and/or women who use drugs (WWUD) is substantially higher compared to similarly aged women. Consistent with PRISMA guidelines, we conducted the first systematic review on the pre-exposure prophylaxis (PrEP) continuum among FSW and/or WWUD, searching PubMed, Embase, CINAHL, PsycInfo, and Sociological Abstracts. Eligibility criteria included: reporting a PrEP related result among FSW and/or WWUD aged 18 + ; peer-reviewed; and published in English between 2012 and 2018. Our search identified 1365 studies; 26 met eligibility requirements, across the following groups: FSW (n = 14), WWUD (n = 9) and FSW-WWUD (n = 3). Studies report on at least one PrEP outcome: awareness (n = 12), acceptability (n = 16), uptake (n = 4), and adherence (n = 8). Specific barriers span individual and structural levels and include challenges to daily adherence, cost, and stigma. Combining health services and long-acting PrEP formulas may facilitate better PrEP uptake and adherence. The limited number of studies indicates a need for more research.

HIV Pre-Exposure Prophylaxis Implementation Cascade Among Health Care Professionals in the United States: Implications from a Systematic Review and Meta-Analysis

Although pre-exposure prophylaxis (PrEP) has been approved for primary HIV prevention for individuals aged 18 years or older since 2012, PrEP utilization has been suboptimal. To understand trends in PrEP provision from the health care providers' perspective, we systematically assessed each specific stage along the PrEP implementation cascade (i.e., awareness, willingness, consultation, and prescription) among health care professionals (HCPs) in the United States. Between June and December 2018, we conducted a systematic review of published studies on this topic. A total of 36 eligible studies were identified and included in the analyses. Random-effect models were employed to examine the pooled prevalence of each key stage along the cascade. Time trend and subgroup analyses were conducted. A thematic analysis was used to identify barriers and facilitators along the PrEP cascade. In this study, a total of 18,265 HCPs representing diverse demographics were included. The pooled prevalence of PrEP awareness was 68% [95% confidence interval (CI) = 55-80%], willingness to prescribe PrEP was 66% (95% CI = 54-77%), PrEP consultation was 37% (95% CI = 25-51%), and prescription provision was 24% (95% CI = 17-32%). Subgroup analyses revealed that PrEP provision among HCPs was lowest in the south, but has been improving annually nationwide. Infectious disease specialists [odds ratio (OR) = 4.06, 95% CI = 3.12-5.28; compared with primary care providers] and advanced practice registered nurses/physician assistants (OR = 1.51, 95% CI = 1.09-2.09; compared with physicians) had higher odds of prescribing PrEP. Barriers and facilitators regarding optimal PrEP implementation were embedded within individual, dyadic, social, and structural levels. This meta-analysis has comprehensively examined the trend and pattern of PrEP implementation among HCPs. To achieve optimal implementation of the PrEP cascade in the United States, tailored training and programs need to be provided to HCPs.

Pre-Exposure Prophylaxis for HIV Prevention in Women: Current Status and Future Directions

Pre-exposure prophylaxis (PrEP) is a promising intervention to prevent HIV acquisition, with benefits both to the individual and to population-level health. PrEP is an opportunity to complement ongoing public health efforts to eliminate HIV. For women, PrEP can also serve as a gateway to access sexual and reproductive health (SRH) services. Clinical efficacy of PrEP was initially reported in women using a 1% tenofovir vaginal gel in 2010, followed by an efficacy trial of oral PrEP using TDF/FTC in men who have sex with men (MSM). Since then, further trials have reported efficacy in oral PrEP containing tenofovir in women and heterosexual men, while the subsequent trials for women using tenofovir gel reported no efficacy, stemming from difficulties in achieving adequate adherence. In an effort to offer women additional choices to oral PrEP, alternative modalities are being tested in clinical research, including long-acting injectable formulations and intra-vaginal rings. In 2015, a meta-analysis of clinic trials and open-label extension studies led to the World Health Organization (WHO) strongly recommending the provision of oral PrEP containing tenofovir for any person at substantial risk of HIV infection, irrespective of gender or population group. Currently, PrEP services for women around the world, including those who are either pregnant or breastfeeding, remain limited. Outside sub-Saharan Africa, most PrEP programmes are focused on MSM. South Africa, Kenya, and the USA have the greatest utilization of oral PrEP by women. Yet, since 2012, of the estimated > 300,000 people globally who have initiated PrEP, a minority are women. In this narrative review, we examine the most recent literature on clinical and implementation PrEP research among women. We highlight the high burden of disease related to common sexually transmitted infections (STIs) in women, and the opportunity to integrate PrEP and other HIV prevention services, STI case management, and family planning services, as part of a more robust package of SRH services. Raising awareness on PrEP amongst women and their healthcare providers, minimizing gaps in access, and ensuring adherence and persistence of PrEP during periods of risk are critical issues if PrEP can have a meaningful impact on reducing HIV incidence in women globally.

"We know this will be hard at the beginning, but better in the long term": understanding PrEP uptake in the general population in Eswatini

Information regarding HIV pre-exposure prophylaxis (PrEP) for the general population is largely lacking, because the majority of PrEP demonstration projects have focused on key populations. This qualitative study examines barriers and facilitators to PrEP uptake and adherence among the general population in Eswatini, where PrEP is offered through public-sector primary-care clinics. We analysed 106 semi-structured in-depth interviews with healthcare workers (n = 26), stakeholders (n = 30), and clients who initiated, continued, declined or discontinued PrEP (n = 50). Some healthcare workers and stakeholders feared that PrEP would reduce condom use and cause drug resistance, while some clients feared possible side effects and the reaction of family members when learning of PrEP use. At the same time, respondents across all groups valued that PrEP could be taken without partner knowledge or consent, and that PrEP was available via public sector clinics. Clients felt that PrEP relieved the fear of HIV infection and thus bolstered enjoyment during sex. Overall, respondents described the general population approach to PrEP delivery as enabling and life-improving, despite the above concerns. Respondents recommended to create community PrEP promotion and delivery, gain community leaders' approval and understanding of PrEP, shorten the PrEP initiation process, and target men and adolescent girls.

'This is mine, this is for me': preexposure prophylaxis as a source of resilience among women in Eswatini

OBJECTIVE

To understand the relationship between HIV preexposure prophylaxis (PrEP) and resilience among Emaswati women.

DESIGN

A qualitative study using semistructured in-depth interviews.

METHODS

We interviewed 24 women who recently initiated PrEP at one of six public-sector primary-care clinics participating in a government demonstration project for PrEP for the general population, as well as 30 PrEP stakeholders from HIV policy, implementation and donor sectors.

RESULTS

PrEP clients and stakeholders described an environment marked by high HIV risk. In this context, clients felt PrEP enhanced their resilience through feelings of protection, control over HIV acquisition, choice in relation to when to take PrEP, sexual pleasure and relief from the fear and consequences of HIV infection. Those in serodiscordant relationships described improved partner communication and a shared sense of responsibility for HIV prevention. Both PrEP clients and stakeholders asserted that PrEP marketing and communication should be Emaswati-led and community-owned.

CONCLUSION

PrEP helps women in Eswatini envision longer, healthier and more fulfilled lives. PrEP enhances resilience through several pathways, including self-efficacy, choice, control over HIV infection and relief from the fear of HIV infection. Social marketing and information campaigns should not only focus on PrEP as an HIV-prevention method but also emphasize how PrEP has expanded choice, enhanced control and facilitated sexual enjoyment among PrEP clients.

Perspectives of US women participating in a candidate PrEP study: adherence, acceptability and future use intentions

INTRODUCTION

Limited data exist on acceptability of candidate pre-exposure prophylaxis (PrEP) regimens among US women. We evaluated PrEP experiences, attitudes and future use intentions among sexually active women who completed the US-based HIV Prevention Trials Network 069/AIDS Clinical Trials Group 5305 study.

METHODS

Women participated in the study between March 2013 and November 2015. We analysed computer-assisted self-interview (CASI) surveys among 130 women and conducted in-depth interviews among a subset of 26 women from three sites. Interviews were conducted in mid/late-2015.

RESULTS

Most women (57%) reported very good/excellent PrEP adherence on CASI, although 21% acknowledged over-reporting adherence at least some of the time. Commitment to preventing HIV infection, a sense of ownership of the study, and keeping pills stored in a visible location facilitated adherence. Adherence barriers included "simply forgetting" and being away from home. Most women interviewed did not intend to use PrEP in the future because of lack of perceived need due to their own (as opposed to their partners') low-risk behaviour and concerns about affordability - but not because of side effects or other characteristics of the regimens.

DISCUSSION

Improving HIV prevention options for US women will require access to affordable PrEP as well as expanding women's understanding of relationship- and community-level factors that increase their risk of acquiring HIV.

Global and national guidance for the use of pre-exposure prophylaxis during peri-conception, pregnancy and breastfeeding

Pre-exposure prophylaxis (PrEP) is a well-established biomedical HIV prevention strategy and recommended to reduce HIV risk during peri-conception, pregnancy and breastfeeding. Efforts are needed to translate global recommendations into national guidelines and implementation strategies. This article presents the current status of policy guidance for the use of PrEP during peri-conception, pregnancy and breastfeeding, with a particular focus on high prevalence countries, including those in sub-Saharan Africa. PrEP clinical guidelines released by ministries of health or other national-level health bodies, with a particular focus on recommendations for PrEP use during peri-conception, pregnancy and breastfeeding, were reviewed and summarised. Among countries with PrEP guidelines and/or policy, pregnancy is recognised as a period with increased HIV vulnerability, and some recommend PrEP use specifically during pregnancy. Only one country notes that PrEP is contraindicated during pregnancy, recognising a gap in complete safety data from women using PrEP throughout pregnancy. PrEP is not contraindicated as a peri-conception HIV prevention strategy in any country, but only three countries have specific guidance for peri-conception HIV prevention. Multiple barriers to the implementation of PrEP during pregnancy and breastfeeding are discussed, including barriers at the policy, health systems, social and personal levels. Although pregnancy is a period of heightened risk and fertility rates are high in many settings with high HIV burden, few PrEP policies have included guidance for PrEP use specific to peri-conception, pregnancy and breastfeeding periods. This gap can be overcome by the development or adoption of national clinical guidelines and implementation strategies from exemplary countries.

Assessing Mozambicans' willingness and determinants to use pre-exposure prophylactic HIV medication

In anticipation of the introduction of the pre-exposure prophylaxis drugs as an additional HIV prevention tool, we mapped the different positions of Mozambicans' willingness to use it. Overall, 507 adults indicated willingness to use under different conditions varying as a function of perceived susceptibility to and severity of infection, side effects, administration protocol, and cost. Three qualitatively different positions were found: Unwillingness irrespective of conditions (4%), depend on circumstances (76%), and unconditional willingness (8%). A large majority of participants were willing to use pre-exposure prophylaxis drugs, provided that the administration is not too constraining, and the adverse side effects can be minimized.