PrEP during pregnancy: why universal delivery may be more effective

Research in Kenya suggests that screening pregnant women for HIV risk in order to offer them PrEP is no more effective than providing general counselling and trusting women to identify their own risk.

What is the research about?

How antenatal care services should provide PrEP to pregnant women.

Researchers did a randomized control trial with 4,500 women without HIV in Siaya and Homa Bay counties, where HIV prevalence is high.

Around half of the women had standard PrEP counselling. This outlined HIV risk factors and things to consider about using PrEP, then women decided whether or not to take PrEP. This is called universal delivery.

The other half of women had an HIV-risk assessment. This looked at things like their partner’s HIV status, number of sexual partners, and whether they recently had a sexually transmitted infection. Women in this group were offered an HIV self‐testing kit to give to their partner. Women identified as being at high risk of HIV were offered PrEP, women identified as low-risk were not (although if they asked for PrEP they were given it). This is called targeted delivery.

Why is this research important?

Providing PrEP for pregnant women and new mothers in maternal and child health clinics in Kenya is a proven HIV prevention strategy. But doing this means services have to be adapted, and this means more work for overstretched healthcare workers. So it is important to work out the most effective and efficient way that clinics can provide PrEP while also ensuring that the women who need it are reached.

What did they find out?

Overall, 42% of women were at high‐risk of HIV.

In the targeted group, 27% of women screened as high-risk accepted PrEP. This was slightly lower than the universal group, where 32% of women who met high-risk criteria accepted PrEP.

Among women considered to be at low risk of HIV, 7% in the targeted group and 13% in the universal group still wanted to take PrEP.

Overall, 69% of women made PrEP decisions in line with their HIV risk (70% in the targeted group and 68% in the universal group).

Women stayed in the study for nine months after giving birth. During this time, 16 women got HIV. Infection rates were similar between groups.

Half of the women who began PrEP used it throughout the nine-months. Adherence rates were similar between groups.

Around two-thirds (64%) of women who were offered an HIV self-test for their partner took one. Women were advised not to do so if they were concerned about partner violence or abuse. (Around 8% of participants experienced partner violence.)

Around 85% of partners who were offered an at-home HIV test took one, and 96% shared their results with their partner. The proportion of women in the targeted group who did not know their partner's HIV status fell from 40% to 19% due to the self-testing results.

Most self-tests screened partners as HIV-negative. This decreased the number of women classified as being at high risk for HIV.

What does this mean for HIV services?

That providing standard PrEP counselling is likely to be as effective as HIV-risk screening.

It is also the cheaper option. So these findings could be used to advocate that universal PrEP should be offered in maternal and child health clinics as a cost-effective way to increase pregnant women’s HIV prevention options. Rather than providing standard one-to-one counselling sessions, it may even be more possible to provide group counselling. This would reduce costs even further.

A universal approach might also help reduce stigma, as PrEP is being discussed generally rather than being targeted at certain women.

These findings can also be used to advocate that maternal and child health clinics should provide HIV self-testing kits for partners alongside PrEP for women. But more thought is needed on how to support women with violent or abusive partners to safely meet their HIV prevention needs.