“I had made the decision, and no one was going to stop me” —Facilitators of PrEP adherence during pregnancy and postpartum in Cape Town, South Africa

Introduction HIV incidence is high during pregnancy and postpartum in many settings. PrEP is safe and effective but requires adherence during potential HIV exposure, yet the facilitators of high maternal adherence are not well understood in high HIV burden settings. Methods We conducted semi-structured interviews with women who reported high adherence (PrEP use ≥ 25 days in last 30-days) within a PrEP service for pregnant and postpartum women located in a large primary care facility in a high-HIV burden township. Topics for interviews included: individual/interpersonal risk, disclosure, anticipated PrEP stigma, safety, side-effects, and facility-level factors effecting adherence. A thematic approach guided an iterative process of coding (reviewed to ensure intercoder reliability) and analysis using NVivo 12. Results We interviewed 25 postpartum women with high PrEP adherence who were on PrEP for a median of 9-months, median age 26-years, and median baseline gestational age 24-weeks. Themes identified as key drivers of optimal PrEP use were HIV risk perception – primarily due to partner’s perceived risky sexual behaviors and unknown serosatus—and a strong desire to have a baby free of HIV. Reported disclosure of PrEP use to family, partners and friends facilitated PrEP adherence. Women continued PrEP postpartum because they felt empowered by PrEP and did not want to “go backwards” and increase their HIV risk as before PrEP. Women who reported high adherence all discussed having community support and reminders to take PrEP on time. The primary barriers were anticipated or experienced stigma, which most overcame through education of partners/family about PrEP. Pregnant women experienced transient side effects, but found ways to continue, including taking PrEP at night. Women believed PrEP education and counselling were accessible when integrated into antenatal care which contributed to continued PrEP use. Conclusions Facilitators of optimal PrEP use through pregnancy and postpartum included fear of HIV acquisition for self and infant, mostly due to partner sexual behaviors and unknown serostatus, along with PrEP disclosure, and encouragement from partners and family. PrEP programs for pregnant and postpartum women should integrate strategies to assist women with realistic appraisals of risk and teach skills for securing support for significant others. ### Competing Interest Statement The authors have declared no competing interest. ### Clinical Trial NCT03902418 ### Clinical Protocols ### Funding Statement We would like to thank our study participants, PrEP-PP study staff and the City of Cape Town Department of Health staff. We received the study drug (Truvada) from Gilead (California, USA) and STI test kits from Cepheid (California, USA). DJD received funding from Fogarty International Center and National Institute of Health (K01TW011187), TC and LM received funding from National Institute of Mental Health (R01MH116771). ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The study was approved by the Human Research Ethics Committee at the University of Cape Town (#297/2018) and the University of California, Los Angeles Institutional Review Board (IRB#18-001622). All participants provided written informed consent during study enrolment. All necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable. Yes Data available upon request from PI.