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High HIV incidence rates have been observed among pregnant and breastfeeding women in sub-Saharan Africa. Oral pre-exposure prophylaxis (PrEP) can effectively reduce HIV acquisition in women during these periods; however, understanding of its acceptability and feasibility in antenatal and postpartum populations remains limited. To address this gap, we conducted in-depth interviews with 90 study participants in Malawi and Zambia: 39 HIV-negative pregnant/breastfeeding women, 14 male partners, 19 healthcare workers, and 18 policymakers. Inductive and deductive approaches were used to identify themes related to PrEP. As a public health intervention, PrEP was not well-known among patients and healthcare workers; however, when it was described to participants, most expressed positive views. Concerns about safety and adherence were raised, highlighting two critical areas for community outreach. The feasibility of introducing PrEP into antenatal services was also a concern, especially if introduced within already strained health systems. Support for PrEP varied among policymakers in Malawi and Zambia, reflecting the ongoing policy discussions in their respective countries. Implementing PrEP during the pregnancy and breastfeeding periods will require addressing barriers at the individual, facility, and policy levels. Multilevel approaches should be considered in the design of new PrEP programs for antenatal and postpartum populations.
This qualitative study was part of a larger effort to design and evaluate a combination HIV prevention package for pregnant and breastfeeding women and their partners [3]. This formative work was conducted in Malawi and Zambia, where the parent study will be implemented. In both countries, population-based surveys have reported high rates of annual HIV incidence among women of reproductive age (0.46%, 95%CI: 0.18–0.75% in Malawi and 1.10%, 95%CI: 0.72–1.48% in Zambia) [18, 19]. Although data are not available to describe population-level HIV incidence during pregnancy and breastfeeding, prior studies from Malawi and Zambia indicate substantially higher rates during these periods [20–23]. In addition, estimates from the 2018 UNAIDS Spectrum model suggest that new maternal HIV infections—acquired during pregnancy and breastfeeding—may contribute to as high as 40–45% of new infant infections in these countries [2]. We used a qualitative descriptive approach in the design, data collection and analysis of this formative study [24, 25]. Our goal was to provide accurate accounting of events—and their meaning—from the individuals interviewed [24]. We drew from the basic tenets of naturalistic inquiry, with no specific commitment to a pre-defined theoretical framework [26]. We recruited participants from four populations: HIV-negative pregnant or breastfeeding women seeking care, their male partners, healthcare workers (HCWs), and policymakers. The first three groups were enrolled from Bwaila District Hospital (Lilongwe, Malawi), the University Teaching Hospital (Lusaka, Zambia), and Kamwala Health Centre (Lusaka, Zambia). Policymakers from both Malawi and Zambia were identified through existing governmental technical working groups. Female participants were recruited from maternal and child health care units (i.e., antenatal, postnatal, family planning, and well child clinics) at these hospitals via convenience sampling. All participants were aged 18 years or above and resided near the study sites. The inclusion criteria for pregnant/breastfeeding women were: confirmed pregnancy or reported delivery with continued breastfeeding, access of maternal-child health care services at one of the study sites, documented HIV-negative status, and report of a male sexual partner. Male partners of participating pregnant or breastfeeding women were eligible for this study. These individuals were only recruited after we received permission from the index pregnant or breastfeeding participant. HCWs were eligible to participate if they worked at the maternal and child health care units within the targeted study health facilities. Policymakers were recruited from the Ministries of Health, national AIDS commissions, partner implementing organizations, and donor agencies. All participated on governmental HIV technical working groups. Our target accrual was: 40 HIV-negative pregnant/breastfeeding women, 40 male partners, 20 HCWs, and 20 policymakers. This sample size was divided equally between the two countries. We conducted in-depth interviews to better understand the role of PrEP in HIV prevention among pregnant and breastfeeding women. Women, male partners, HCW, and policymakers were all asked about their knowledge of PrEP, overall opinion/acceptability of PrEP, and perceived challenges for implementing PrEP in pregnant/breastfeeding women in Malawi and Zambia. Sociodemographic data for pregnant/breastfeeding women and male partners were collected using a separate form. We did not collect analogous information from HCWs and policymakers for reasons of confidentiality. Researchers and research assistants trained in qualitative methods conducted the in-depth interviews to capture participant views on PrEP use during pregnancy and breastfeeding. All interviewers were local; they spoke the language of the participants and were familiar with the local context and culture. They used semi-structured interview guides developed by members of the study team. Prior to implementation, these interview guides were field tested at participating health facilities to assess content and ensure meaning. All interviews with pregnant/breastfeeding women, male partners, and HCWs were conducted in private rooms within study site facilities. Policymakers were typically interviewed at a private venue of their choosing. Interviews were conducted either in English or in local languages (e.g., Chichewa, Nyanja, or Bemba) depending on the participant’s choice. Each interview lasted approximately one hour. All in-depth interviews were audio-recorded, transcribed verbatim, and translated into English by bilingual study personnel. These were then verified for clarity and completeness by an independent reviewer who was part of the qualitative team but not involved in transcription and translation. Members of the study team developed a central codebook that was used in both countries. We used NVivo12 Version 10 (QSR International, Pty Ltd.; Doncaster, Victoria, Australia) to organize and code data. Initial inductive codes were derived from the interview guides and additional deductive codes were added as themes emerged. This information was then used to create summaries and matrices to compare participant views. We received ethical approval from the University of North Carolina at Chapel Hill Institutional Review Board (Chapel Hill, NC, USA), the National Health Science Research Committee of Malawi (Lilongwe, Malawi), and the University of Zambia Biomedical Research Ethics Committee (Lusaka, Zambia) to conduct this study. All participants provided written informed consent prior to initiating study activities.
