PrEP retention and prescriptions for pregnant women during COVID-19 lockdown in South Africa

In sub-Saharan Africa, HIV risk is high during pregnancy and breastfeeding and could increase during the COVID-19 pandemic because of reduced access to HIV prevention and treatment services.1, 2 Pre-exposure prophylaxis (PrEP) is an essential and effective prevention intervention during pregnancy and the post-partum period.³

PrEP in Pregnant and Postpartum Women (PrEP-PP) is a cohort study of HIV-negative pregnant and post-partum women in antenatal care at a primary care clinic that remained open and operational during the COVID-19 lockdown in a community with high antenatal HIV prevalence in Cape Town, South Africa. HIV-uninfected pregnant women are screened for eligibility to the PrEP-PP study at their first antenatal visit to the primary care clinic, then they complete an interviewer-delivered survey. Women choose whether to take PrEP at each study visit and are followed up until 12 months post partum. Enrolment to the study began in August, 2019, and is ongoing.

We evaluated the effect of the national COVID-19 lockdown in South Africa on study visits and PrEP prescriptions among pregnant women in antenatal care. We compared missed study visits and PrEP prescription refill visits at the 1-month and 3-month follow-up visits between August, 2019, and March 27, 2020 (before the national lockdown because of COVID-19), and during lockdown (from March 28 to June 1, 2020) in women who started PrEP at enrolment.

From August, 2019, to June, 2020, we recruited and enrolled 455 HIV-uninfected pregnant women (aged ≥16 years) at their first antenatal visit (median gestation 21 weeks [IQR 14–28]; median age 25 years [IQR 22–31]). Sexual activity before versus during lockdown was similar (94% vs 93% reporting sex in the past 30 days). Overall, 414 (91%) of 455 women opted to start PrEP at their first antenatal visit; preventing infant HIV (90%) and unknown or positive partner serostatus (10%) were the most common reasons given. Before lockdown, 29% participants on PrEP missed their 1-month visit and 41% missed their 3-month visit. During the nationwide lockdown, missed PrEP visits increased significantly to 63% at the 1-month visit and 55% at the 3-month visit. Overall, 34% of women missed visits before lockdown and 57% during lockdown (appendix). The relative risk of missing a study visit increased during lockdown compared with before lockdown (odds ratio 2·36, 95% CI 1·73–3·16).

These data indicate the profound effect that the South African response to the COVID-19 pandemic might have on HIV prevention efforts in this setting. Study visits were scheduled at the same time as antenatal or postnatal visits; missed visits have implications for maternal and infant health. Pregnant and post-partum women who are on PrEP cited fear of COVID-19 and contact with the health facility as common barriers. Community-based PrEP delivery and telephone interviews are needed to address barriers to attending facility-based PrEP prescription and study visits.