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Anna Leone is a resident in the UNC Department of Obstetrics and Gynecology after graduating from the University of Pittsburgh School of Medicine in 2021. Her research while in medical school focused on barriers to contraceptive access, and the use of ketamine as a sole anesthetic agent in resource-limited settings. As a global health scholar, Anna is looking at trends in HIV exposure risk during pregnancy and postpartum and using a prevention-effective PrEP adherence strategy during that time to prevent new maternal HIV infections to improve both maternal and child outcomes. This will use data from previous and ongoing studies by mentor Dr. Benjamin Chi, who is a Professor of Obstetrics and Gynecology in the Division of Global Women’s Health at the UNC School of Medicine and who lived in Lusaka, Zambia from 2003 to 2015.

Abstract: Daily PrEP adherence is challenging, especially among pregnant and lactating women (PLW). Newer concepts about prevention-effective PrEP adherence emphasize aligning PrEP use with periods of elevated HIV infection risk; however, little data exists about this adherence strategy among PLW. The purpose of this study was to characterize HIV exposure risk during pregnancy and postpartum, assess whether periods of PrEP adherence aligned with elevated HIV risk, and evaluate whether the pilot PrEP adherence support intervention enhanced alignment of PrEP use with HIV risk.

Methods: We used data from a pilot randomized trial of a PrEP adherence support intervention to perform the secondary analysis. HIV exposure risk and adherence to PrEP were measured at the three- and six-month visits. HIV exposure risk was categorized as higher risk or low risk using an algorithm of risk factors from the pilot study. PrEP use was measured using two assays and a published algorithm to determine adherence scores. Alignment of HIV risk and PrEP use was defined as either higher HIV risk and adherent to PrEP or low HIV risk and non-adherent to PrEP. Tornado and Sankey plots were used to descriptively analyze HIV exposure risk, PrEP adherence, and alignment. Risk difference and corresponding Wald confidence interval were used to estimate the effect of the pilot combination adherence intervention on aligned PrEP use.

Results: Of 200 participants in the trial, 164 met inclusion criteria for this analysis. HIV exposure risk appeared high and increased from month 3 to 6. PrEP adherence was low among participants: 34% at month 3 and 29% at month 6.  Only 55% of participants aligned their PrEP use with their HIV exposure risk at month 3 and 51% at month 6; these relationships were dynamic, and many participants changed between groups over the course of the study. We found a risk difference of 15.7% at month 3 and 4.7% at month 6 when comparing alignment between intervention and control groups of the pilot study.

Conclusion: PLW have difficulty with daily PrEP adherence, and HIV exposure risk can change over the course of pregnancy and postpartum; thus, prevention-effective PrEP adherence needs to be studied in this patient population. Targeted counseling approaches such as those in the pilot study may positively impact alignment of PrEP use with HIV exposure risk and future studies should investigate this role.

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