Understanding the Influence of PrEP Motivations and Concerns on PrEP Use Among Pregnant Women in Lilongwe, Malawi: A Mixed-Methods Study.

Patient-centered PrEP choice in antenatal care may promote effective use of PrEP to reduce the risk of maternal HIV acquisition. To inform patient-centered counseling, we sought to understand values that pregnant women considered in their PrEP decision-making and their relationship with PrEP use in the context of an adherence support trial in Lilongwe, Malawi. 200 women completed an enrollment survey reporting values (motivations and concerns) they considered when deciding to use PrEP. We examined the associations of these values with study retention and adherence to PrEP (pharmacologic assessment), at 3 and 6 months after enrollment by estimating probability differences (PD). Thirty women and 10 study staff also completed in-depth interviews on the influence of women's values on PrEP adherence. We thematically analyzed interview transcripts through topical coding and summary matrices. Quantitatively, women reporting concerns related to PrEP disclosure and stigma were less likely to be retained. At 6 months, women concerned about partner disclosure (65.0% vs. 87.8%; PD: -22.8%, 95% CI: -44.2%, -1.3%) and family disclosure (68.2% vs. 87.6%; PD: -19.5%, 95% CI: -39.5%, -0.1%), and those who worried they would be perceived as living with HIV (74.5% vs. 88.9%; PD: -14.4%, 95% CI: -27.8%, -1.0%) were less likely to be retained than women without these concerns. Qualitatively, stigma-related concerns led women to avoid PrEP disclosure and conceal their PrEP use which made adherence difficult. Many missed early doses due to concerns about side effects and safety. Some who enrolled with an STI perceived less need for PrEP after their STI resolved. To address adherence barriers, counseling should address the difference between PrEP, ART, and STI treatments. Disclosure support and follow-up counseling to address side effects may also promote PrEP adherence.