AFJOG

REVIEW African Journal of Obstetrics and Gynaecology | Volume 2 | Issue 3 | 2024 | Pre-Exposure Prophylaxis to prevent HIV infection during Pregnancy and Breast-feeding: A South African Perspective Eligible individuals who choose to enter a PrEP programmust be screened for contraindications to PrEP (see Box 3 below) and counselled on other risk reducing strategies, for the prevention of sexually transmitted infections (STI) (see Box 4 below) (5,6,22,24) . HIV prevention programs are laborious, and require intense follow-up, monitoring and commitment (see Box 5 below) (22) . The program must be tailored to individual and community’s needs, and have a holistic approach (i.e. WHO differentiated approach) (6) . Below, Box 6 summarizes other services that must be provided in a PrEP program and Box 7 shows indications for PrEP discontinuation (22) . The oral fixed dose combination (FDC) pill containing tenofovir disoproxil fumerate and emtricitabine (TDF/FTC) was approved by the South African Medicine Control Council (MCC) for the prevention of newHIV infections in 2015 and is currently the standard of care in the country (22,25) . In 2019,WHOapproved another oral PrEP pill containing tenofovir alafenamide fumerate and emtricitabine (F/TAF), after favourable reports from clinical trials (21) . Oral F/TAF (Descovy) is only available in a handful of countries (pending generic availability) and is only recommended for use in cisgender males and transgender females (21) . Its use is also limited by cost and lack of safety data in cisgender females (21,26) . Tenofovir Disoproxil-based oral PrEP is the most widely used regimen for PrEP and has been shown to be highly effective (5,6,22,24,27) . Tenofovir disoproxil fumerate (TDF) and tenofovir alafenamide fumerate (TAF) are safe and well tolerated drugs. However, TAF has a better side-effect profile than TDF (28) . Initial minor side-effects including headache and gastrointestinal upset may be experienced in up to 10% of people taking oral PrEP. The symptoms typically resolve within 2–3 weeks (29) . A creatinine clearance (CrCl) test is recommended at initiation of oral PrEP, to exclude asymptomatic renal disease, as TDF may be nephrotoxic (22,24) . Renal function evaluation is not essential in individuals < 30 yrs and should not delay initiation of PrEP (22) . All pregnant women initiating oral PrEP must have renal function evaluation on the day of initiation. Serum creatinine levels must be evaluated at 3 months and again at 6 months after initiation of oral PrEP for pregnant women (22,24) . Creatinine clearance is not reliable for renal evaluation in pregnant women (22) . As a result of technological advancement, several other options for PrEP, that may appeal to individual preferences, are currently available or in development. Clinical trials continue to evaluate other novel PrEP agents and formulations. In 2021, WHO recommended the dapivirine ring (DVR) as an additional PrEP option for women at substantial risk of HIV acquisition (30,31) . A year later, WHO recommended cabotegravir (an injectable long-acting integrase strand inhibitor) as another additional PrEP option for all individuals who are at risk (30) . Box 1 INDICATIONS FOR ANTIRETROVIRAL THERAPY Pre-Exposure Prophylaxis (PrEP) ARV medication taken by an HIV-uninfected individual to prevent HIV infection Post-Exposure Prophylaxis (PEP) ARV medication taken within 72hrs after exposure to HIV and continued for 28 days to prevent HIV Anti-retroviral therapy (ART) Lifelong treatment with ARV medication for people living with HIV to improve quality of life Box 2 A. Risk Factors for HIV Infection Pregnant and breastfeeding women Adolescents, young women, and men Men who have sex with men Individuals with multiple sexual partners Recent history of STI People who inject drugs/ Sex or Migrant workers Serodiscordant couples not virally suppressed Any individual requesting PrEP B. Eligibility Criteria for PrEP HIV negative by routine test No symptoms of acute HIV infection Willing to take PrEP as prescribed Box 3: Contraindications to PrEP Acute HIV Infection Renal Impairment Contraindications to PrEP regimen Unwillingness to take oral PrEP as prescribed Box 4: Safer Sexual Practices Lubrication use Male/Female condom use Effective contraception use Syndromic STI management Voluntary medical male circumcision Treatment of HIV-positive partner Box 5: Baseline Tests and Follow-up HIV screening: ELISA/ Fourth generation rapid Renal function: eGFR > 60 mL/min(>30yrs/Risk factors) sCr < 85µmol/L (all pregnant women) Hepatitis B screen: HBsAg/ HBsAb Hepatitis C screen: Consider Ab test for MSM STI screen: Symptomatic screen Examination if indicated Urine dipstix for urethritis Syphilis screening: rapid/laboratory Full STI panel if resources allow Pregnancy test: Urine pregnancy test or bHCG 1 month review: - HIV & STI screening - Counselling: Risk reduction/ Adherence/ Contraception - Address Side-effects 3 Monthly Visits: Reassess as above Provide 3 month supply of oral PrEP African Journal of Obstetrics and Gynaecology | Volume 2 | Issue 3 | 2024 | 08