Bundling PrEP With Family Planning May Be Key to HIV Prevention

While much attention is paid to the risks of HIV in men who have sex with men—the most heavily impacted demographic in the United States —in less developed nations such as those in Africa, there exists an outsize risk of HIV infection in young women.

Reaching this population is a priority for infectious disease specialists, who are working to increase the use of pre-exposure prophylaxis (PrEP) in this vulnerable group. One way to do that may be to bundle PrEP with birth control offerings in family planning clinics so as to increase uptake.

Investigators at the University of Washington in Seattle, working with colleagues at Kenyatta National Hospital in Nairobi, Kenya, designed an implementation program to assess how well PrEP could be integrated into family planning for at-risk young women and adolescents in the African nation. From November 2017 to June 2018, 8 public health clinics in the Kisumu region screened nearly 1300 women aged 15 to 45 years for HIV risk factors. Women who came to the clinics for birth control and were deemed to be at HIV-free but at risk of infection were given the opportunity to meet with nurses whose sole focus was to educate the participants about PrEP and provide them with same-day access to PrEP.

Risk of contracting HIV was defined by positive answers to questions on topics such as whether condoms had been used consistently—or at all—in the past 6 months, whether sexual partners were at high risk or of unknown HIV status, whether sex had been conducted in exchange for money or something else, whether there was a history of intimate partner violence, and whether there was a recent history of sexual activity under the influence of alcohol or other substances. Women who were at risk of HIV and were amenable to beginning PrEP were instructed to return monthly for clinical visits and to receive PrEP refills.

Twenty-two percent of the women in the program agreed to initiate PrEP, with a higher percentage of those 24 years and older. Almost all of the women (94%) whose partners had been diagnosed with HIV initiated PrEP, while 35% of women who did not know their partners’ status and 8% of women whose partners were HIV negative were willing to take PrEP. Women who had at least 1 risk factor but were unwilling to begin PrEP frequently claimed that their risk of HIV was low (43%) or cited their partners’ current HIV-negative status (47%). More than 1 in 5 participants wanted to consult with their partner before starting PrEP.

“Complex and multifactorial factors perpetuate HIV vulnerabilities for...many African women, including social, structural, and economic disparities,” Kenneth Mugwanya, PhD, a physician-epidemiologist at the University of Washington and lead author of the study, told Contagion®. “Furthermore, financial disparities and intimate partner violence often hinder a woman’s ability to negotiate condom use and protect herself from HIV.”

None of the women who adhered to the PrEP regimen and completed at least 1 follow-up visit were diagnosed with HIV during the study period. PrEP continuation at the 1-month mark was highest among women whose partners had HIV and among older women. At this point, women whose partners were HIV negative or of unknown HIV status and younger women more likely to discontinue PrEP. Condom-use history didn’t seem to have much of an impact on whether a woman continued PrEP.

The fact that more than 40% of all women in this study adhered to their PrEP regimens for at least 1 month points to the success of bundling PrEP education and dissemination with birth-control services. “Women want HIV prevention and family planning services in the same room, same provider, and same moment,” said Mugwanya. “Clinicians need to initiate conversations about sexual history during consultations as an entry point to identify women who may be at an elevated risk for HIV and could benefit from PrEP.” Although this study was conducted in Africa, Mugwanya said that its findings are applicable to heterosexual women in other nations who may be at risk of HIV.

Mugwanya’s team acknowledged that the study did not delve into the reasons why women choose to begin or opt out of PrEP or why they may continue or discontinue it, Additionally, it did not explore beliefs and experiences that shape these choices. However, their report mentioned that “an ongoing sister qualitative project that will include women and nurses who participated in this program will provide this contextual information.”