Women with limited power over decisions could benefit from PrEP

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A study among pregnant women in South Africa has found many lack control over condom use – and would be willing to use pre-exposure prophylaxis (PrEP) to protect themselves and their babies from HIV.

In-depth interviews with 26 South African women who were either pregnant or recently post-partum, revealed high levels of interest in PrEP. Many of the interviewees reported feeling that they did not have a say in whether they used a condom with their partner.

In the study, researchers led by Dvora Joseph Davey at the School of Public Health and Family Medicine, University of Cape Town, the Fielding School of Public Health, and the David Geffen School of Medicine, University of California Los Angeles, conducted qualitative interviews with the women, all of whom were HIV negative with a positive partner or a partner with an unknown status. They all reported having condomless sex and using alcohol while pregnant.

While they expressed a clear desire to protect themselves and their baby from HIV, the vast majority of participants felt they did not have a say in the matter of condom use, and many described times when their partners showed firm resistance to condoms. Some also said their use of drugs and/or alcohol reduced their sense of risk, which further increased the likelihood of condomless sex.

In addition to this, many of the women believed that condomless sex during pregnancy played an important role in the baby’s development. One woman stated “(I believe) that my baby will grow when I have sex, as the sperm is good for the baby.” Others believed that sex during pregnancy prevented tearing during labour. Beliefs such as these leave women and their children more vulnerable to infection during pregnancy.

Furthermore, unequal power relations led to participants feeling unable to ask whether their partner was HIV positive or negative. Many said they struggled to get their partner to test for HIV, and that their partner determined their own status based on the HIV tests they had undergone. Some also reported being blamed for their partner’s HIV positive status, despite being negative themselves.

Researchers found participants were aware they were at an increased risk of acquiring HIV, although the women’s sense of risk changed after giving birth. Many linked their increased risk to having a partner who engaged in multiple sexual partnerships during their pregnancy but felt unable to challenge their partner over this, use condoms or abstain from sex.

Although most had not heard of PrEP before the study, all except one said they would be interested in using it. However, some were concerned about the harmful impact PrEP could have on their unborn child, expressing the worry that “because it’s a pill… I would not be sure how it would affect the baby”.

In this context of women’s limited power over decisions surrounding sex and condom use, the study suggests pregnant women and new mothers in South Africa would benefit from PrEP. However, it also has important implications for the design of programmes that seek to deliver PrEP to pregnant women. This includes the need for counselling to address the potential risks to babies and infants whose mothers are taking PrEP, and how best to take PrEP when sexual activity is constantly changing during pregnancy and post-birth periods.

The study also reinforces the urgent need for HIV prevention interventions that address unequal gender relations, such as couples’ counselling and testing for HIV and interventions that prevent gender-based violence.

HIV acquisition during pregnancy and breastfeeding significantly contributes toward paediatric HIV infection; however, little is known about risk behaviours in HIV-uninfected pregnant and postpartum women. We conducted twenty-six in-depth-interviews between July and December 2016 using a semi-structured interview guide among HIV-uninfected pregnant and recently postpartum women at-risk of HIV acquisition (defined as reporting ≥1 of the following: partner’s serostatus unknown or HIV-infected, recent condomless sex in pregnancy, and/or alcohol use during pregnancy) who attended primary healthcare services. Our study contextualizes factors related to risky sexual behaviours during pregnancy and postpartum periods and assesses knowledge and hypothetical acceptability of pre-exposure prophylaxis (PrEP) in pregnancy. Translated and transcribed data were coded and analysed by three researchers using a thematic analysis approach. In interviews with HIV-uninfected pregnant/postpartum women at-risk of HIV acquisition, we identified common themes associated with sexual risk behaviours during pregnancy, including: lack of control over decisions in sex and condom use in pregnancy, low perceived risk (e.g. beliefs that their partner has the same HIV-negative serostatus), and socio-cultural beliefs around condom use during pregnancy (e.g. contact with sperm is essential for baby’s development). PrEP knowledge was low among HIV-uninfected pregnant and breastfeeding women, and potential acceptability was good, though primary concerns were around the potential impact on the infant. While mothers presented a clear desire to protect themselves from HIV acquisition once pregnant, they also reported lack of control, and socio-cultural beliefs, like sex is good for the baby, that increased their risk of seroconversion. Mothers had limited PrEP awareness but reported hypothetical willingness to use PrEP because of concerns over HIV acquisition and onward mother to child transmission.

Dvora Joseph Davey, Elise Farley,Catriona Towriss, Yolanda Gomba, Linda-Gail Bekker, Pamina Gorbach, Steven Shoptaw, Thomas Coates, Landon Myer

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