부산대학교 도서관

Background: In Uganda, fertility rates and adult HIV prevalence are high, and many women conceive with partners living with HIV. Pre-exposure prophylaxis (PrEP) reduces HIV acquisition for women and, therefore, infants. We developed the Healthy Families-PrEP intervention to support PrEP use as part of HIV prevention during periconception and pregnancy periods. We conducted a longitudinal cohort study to evaluate oral PrEP use among women participating in the intervention. Methods and findings: We enrolled HIV–negative women with plans for pregnancy with a partner living, or thought to be living, with HIV (2017 to 2020) to evaluate PrEP use among women participating in the Healthy Families-PrEP intervention. Quarterly study visits through 9 months included HIV and pregnancy testing and HIV prevention counseling. PrEP was provided in electronic pillboxes, providing the primary adherence measure ("high" adherence when pillbox was opened ≥80% of days). Enrollment questionnaires assessed factors associated with PrEP use. Plasma tenofovir (TFV) and intraerythrocytic TFV-diphosphate (TFV-DP) concentrations were determined quarterly for women who acquired HIV and a randomly selected subset of those who did not; concentrations TFV ≥40 ng/mL and TFV-DP ≥600 fmol/punch were categorized as "high." Women who became pregnant were initially exited from the cohort by design; from April 2019, women with incident pregnancy remained in the study with quarterly follow-up until pregnancy outcome. Primary outcomes included (1) PrEP uptake (proportion who initiated PrEP); and (2) PrEP adherence (proportion of days with pillbox openings during the first 3 months following PrEP initiation). We used univariable and multivariable-adjusted linear regression to evaluate baseline predictors selected based on our conceptual framework of mean adherence over 3 months. We also assessed mean monthly adherence over 9 months of follow-up and during pregnancy. We enrolled 131 women with mean age 28.7 years (95% CI: 27.8 to 29.5). Ninety-seven (74%) reported a partner with HIV and 79 (60%) reported condomless sex. Most women (N = 118; 90%) initiated PrEP. Mean electronic adherence during the 3 months following initiation was 87% (95% CI: 83%, 90%). No covariates were associated with 3-month pill-taking behavior. Concentrations of plasma TFV and TFV-DP were high among 66% and 47%, 56% and 41%, and 45% and 45% at months 3, 6, and 9, respectively. We observed 53 pregnancies among 131 women (1-year cumulative incidence 53% [95% CI: 43%, 62%]) and 1 HIV-seroconversion in a non-pregnant woman. Mean pillcap adherence for PrEP users with pregnancy follow-up (N = 17) was 98% (95% CI: 97%, 99%). Study design limitations include lack of a control group. Conclusions: Women in Uganda with PrEP indications and planning for pregnancy chose to use PrEP. By electronic pillcap, most were able to sustain high adherence to daily oral PrEP prior to and during pregnancy. Differences in adherence measures highlight challenges with adherence assessment; serial measures of TFV-DP in whole blood suggest 41% to 47% of women took sufficient periconception PrEP to prevent HIV. These data suggest that women planning for and with pregnancy should be prioritized for PrEP implementation, particularly in settings with high fertility rates and generalized HIV epidemics. Future iterations of this work should compare the outcomes to current standard of care. Trial registration: ClinicalTrials.gov Identifier: NCT03832530https://clinicaltrials.gov/ct2/show/NCT03832530?term=lynn+matthews&cond=hiv&cntry=UG&draw=2&rank=1. Lynn T. Matthews and colleagues evaluate oral pre-exposure prophylaxis use among women participating in the Healthy-Families-PrEP intervention. Author summary: Why was this study done?: Tenofovir (TFV) disoproxil fumarate/emtricitabine as pre-exposure prophylaxis (PrEP) prevents HIV, is safe during pregnancy and breastfeeding, and is recommended by the WHO, CDC, and the Uganda Ministry of Health (MOH) for people exposed to HIV, including during periconception, pregnancy, and postpartum. Many women choose to conceive with partners who may be living with HIV but adherence to daily oral PrEP can be challenging. We designed and tested a 3-session Healthy Families-PrEP intervention in a rural Ugandan hospital HIV clinic and evaluated adherence to PrEP during periconception and pregnancy. What did the researchers do and find?: Women planning pregnancy were counseled on ways to have a child while avoiding HIV acquisition, offered PrEP, and, for those choosing PrEP, provided with quarterly adherence support. Approximately 131 women enrolled, 90% initiated PrEP and, among those, 85% took at least 80% of doses (measured via electronic pillcap) over 9 months. For women continuing PrEP in pregnancy, adherence persisted, by pillcap, over 9 months. Plasma TFV concentrations were high among 66%, 56%, and 45% at months 3, 6, and 9, respectively. TFV-DP concentrations were high among 47%, 41%, and 45% of women at months 3, 6, and 9, respectively. What do these findings mean?: Women in Uganda with PrEP indications and planning for pregnancy chose to use PrEP and most were able to sustain high adherence to daily oral PrEP prior to and during pregnancy. These findings suggest that women planning for and with pregnancy should be prioritized for PrEP implementation, particularly in settings with high fertility rates and generalized HIV epidemics. [ABSTRACT FROM AUTHOR]