HIVST acceptance and PrEP initiation among pregnant women at high risk of HIV in Homa Bay and Siaya counties, Kenya

Thesis (Master's)--University of Washington, 2021Background: Sub-Saharan Africa has the highest incidence of HIV worldwide with women having a higher incidence than men. Pregnancy increases risk for HIV acquisition which can increase the risk of vertical HIV transmission. Low rates of HIV testing in male partners is an important driver of incident HIV infection among pregnant women. Distribution of HIV self-tests (HIVST) for male partners can facilitate male partner HIV testing and help women make informed decisions about PrEP. This study aims to understand how acceptance of HIVST for male partner testing influences PrEP acceptance among pregnant women, identify cofactors of HIVST, PrEP, and of combined HIVST and PrEP, and influence of HIVST on knowledge of partner HIV status. Methods: This study utilized longitudinal data from the targeted arm of the PrEP Implementation of Mothers in Antenatal care study, a cluster-randomized clinical trial evaluating two models of PrEP delivery in pregnant women conducted in Homa Bay and Siaya counties. Within the targeted arm, pregnant women were assessed using an objective HIV risk assessment tool. Women at high risk of HIV acquisition were systematically offered PrEP and were included in this analysis. Additionally, women in this arm were offered HIVST for their male partners and were asked to report on the HIVST results of their partners at their next visit. Data including HIVST acceptance, PrEP acceptance, PrEP discontinuation, male partner HIVST acceptance and HIVST reported by the participants was captured. Presence of intimate partner violence (IPV) was assessed using the Hurt-Insult-Threaten-Scream (HITS) screening tool. Depression was assessed using the Patient Health Questionnaire-2 (PHQ2) while social support was evaluated using the 18-item Medical Outcomes Study Social Support Survey (MOS-SSS). Chi-squared tests were utilized to compare the association between HIVST acceptance for male partner and PrEP acceptance. Univariate logistic regression was used to compare participant demographics, pregnancy characteristics and male partner characteristics between women who accepted either intervention or accepted both interventions compared to those who declined both HIVST and PrEP (reference group). Results: Of 2,197 women in the targeted arm, 1,008 (46%) women were determine to be at high risk of HIV acquisition and were included in the analysis. Median age of women was 25 years and 88.4% were married. Approximately 46.7% perceived themselves to be at high risk of HIV acquisition, 51.1% reported high social support, 12.8% reported experiencing IPV and 16.9% reported signs of depression. Male partners had a median age of 31 years, with 16.4% being >10 years older. Overall, 86.1% of women reported that they did not know their partner’s HIV status. Of 1,008 high-risk pregnant women, 50% accepted HIVST only, 13.9% accepted both HIVST and PrEP and 10.2% accepted PrEP only. Overall, 63.9% accepted HIVST, of whom 80.9% offered them to their male partners; 69.1% used the HIVST kits and 67.2% of the women tested together with their male partners. Overall, 68.7% of women became newly aware of their partners HIV status by 9 months postpartum with 1.9% of these partners having a positive HIVST. Cofactors for accepting either PrEP or HIVST included HIV risk perception, social support, parity, male partner HIV status and marital status/type of partnership. Cofactors for accepting PrEP alone included the woman’s age, the male partner’s age and presence of IPV. Cofactors for accepting HIVST alone included the woman’s level of education. Cofactors for accepting both HIVST and PrEP included social support, presence of IPV, depression and suspicion of male partners’ having other sexual partners. Unawareness of male partner HIV status and high HIV risk perception were the facilitators of uptake of PrEP. The major barrier of accepting both HIVST and PrEP was need to consult the male partner. Other barriers of accepting PrEP included their need for more time to think, pill burden and low HIV risk perception Conclusion: Distribution of HIVST for male partner testing was acceptable and useful to help high risk pregnant women navigate decisions about PrEP. Understanding the factors that foster high risk pregnant women to accept HIVST only, PrEP only or accept both HIVST and PrEP is key in informing and scaling up HIVST programming and PrEP counselling for pregnant women