Reducing psychological barriers to PrEP persistence among pregnant and postpartum women in Cape Town, South Africa - Background: Pre-exposure prophylaxis (PrEP) use during pregnancy is both safe and effective in preventing HIV. However, posttraumatic stress and depression negatively impact PrEP adherence among women. Addressing posttraumatic stress and depression will likely improve PrEP adherence and persistence (i.e., sustained PrEP adherence over time) during pregnancy and breastfeeding, which are periods of dramatically increased HIV risk. South Africa (SA) provides a uniquely informative and efficient setting for this work because HIV incidence during pregnancy and breastfeeding remain high and PrEP is routinely delivered in antenatal care. In contrast, lower HIV incidence and less widespread PrEP implementation in the United States (US) would require recruitment across many more clinics, substantially longer enrollment periods, and considerably greater resources to study these mechanisms. The goal of this proposal is to develop and test the feasibility and acceptability of a cognitive behavioral intervention that targets common underlying factors of posttraumatic stress and depression to improve PrEP adherence and persistence during pregnancy and postpartum. Candidate: I am a clinical psychologist and a postdoctoral fellow at Massachusetts General Hospital/Harvard Medical School. I seek to obtain the training, mentorship, and research experience that will enable me to become (1) an independent investigator and (2) an expert in reducing psychological barriers to HIV prevention among women. Mentoring: Dr. Conall O’Cleirigh, my primary mentor, brings expertise in the psychosocial aspects of HIV prevention and intervention development. Drs. Christina Psaros and Jessica Haberer, both co-mentors, will offer guidance on qualitative data analysis and implementation science frameworks. Drs. Landon Myer, John Joska, and Lucia Knight, my SA-based co-mentors, will provide mentorship on biomedical HIV prevention strategies for pregnancy/postpartum, intervention development for the South African context, and intervention sustainability within antenatal care. Dr. Robert Parker, a biostatistician, will serve as a consultant. Training: Specific training in qualitative analysis for intervention development and implementation, HIV prevention during pregnancy, and psychosocial treatment development for resource-limited settings will be achieved through direct mentorship, coursework, workshops, and primary research in SA. Research: The specific aims of the project are to (1) explore the mechanisms by which posttraumatic stress and depression impact PrEP adherence and persistence during pregnancy; (2) develop and conduct a proof-of-concept test of a brief PrEP adherence and persistence intervention that reduces the negative impact of psychological mechanisms common to posttraumatic stress and depression on PrEP use, and builds behavioral skills to improve self-care; and (3) evaluate the feasibility and acceptability of the intervention, which will be integrated into antenatal care, in a pilot randomized controlled trial. Findings will inform efforts to improve PrEP adherence among pregnant and postpartum women in the US and other settings where trauma, depression, and related psychological barriers undermine HIV prevention.
