Exploration of Pregnant and Breastfeeding Women's Acceptability of Rapid Point-of-Care Urine Testing Within Antenatal and Postnatal Care, and Its Perceived Impact on PrEP Adherence When Paired with PrEP Biofeedback Adherence Counselling in Cape Town, South Africa.

Pregnant and breastfeeding women (PBFW) on oral pre-exposure prophylaxis (PrEP) face barriers to adherence and persistence which may be improved by point-of-care adherence monitoring using urine tenofovir testing. We explored the acceptability of urine tenofovir testing for PrEP adherence monitoring among PBFW on oral PrEP, and how this, together with PrEP biofeedback adherence counselling, may have shaped PBFW's PrEP adherence and persistence. Between September 2022 and May 2024, we conducted a study among PBFW without HIV on oral PrEP in Cape Town, South Africa. Participants were randomized to intervention (urine tenofovir testing at each study visit with biofeedback adherence counselling) or standard-of-care arms (urine collected but not analyzed with participant, with standard PrEP adherence counselling). Participants, with consistent and inconsistent PrEP use, were purposively sampled from both study arms between October and December 2023 for qualitative interviews. Analysis was guided by the Theoretical Framework of Acceptability and Consolidated Framework for Implementation Research 2.0 using codebook thematic analysis. Among n = 39 women, who were pregnant (n = 16) or postpartum (n = 13); mean age was 29 years (SD = 7), and median time on PrEP was 11.9 weeks (IQR = 4.0,12.1). Acceptability of urine tenofovir testing was high, as it was perceived as familiar, appropriate and easy to use. Most felt that the limited perceived burden and opportunity costs were outweighed by the benefits, which included receiving feedback on their PrEP-taking behavior and if PrEP was present for HIV protection. Urine tenofovir testing with biofeedback counselling was seen as motivational to daily PrEP use. It positively reinforced PrEP-taking behaviors among those consistently using PrEP and allowed others the opportunity to reconsider their risk for HIV acquisition. Urine tenofovir testing facilitated more accurate self-reporting of PrEP adherence, although some reported restarting taking PrEP prior to visits. Participants' PrEP-taking was supported by non-judgmental and encouraging biofeedback counselling which included co-development of strategies to overcome pregnancy and postpartum related barriers to PrEP persistence. Confusion of urine tenofovir testing with other antenatal urine tests and perceptions of blood-based testing being more effective hindered application to motivating PrEP use. Addressing perceived efficacy and coherence related to urine tenofovir testing within counselling is key. Urine tenofovir testing with biofeedback counselling was perceived as acceptable and motivational to PrEP adherence among PBFW. Integration is further recommended, given that other urine tests are routinely utilized in antenatal care.