Background: HIV acquisition during pregnancy and lactation is associated with increased perinatal transmission. No studies report pre-exposure prophylaxis (PrEP) use after 7 weeks gestation or in lactation. We describe PrEP use in and around pregnancy to highlight implementation challenges and prompt future study.
Description: Two United States (U.S.) centers began offering PrEP during pregnancy in 2010 at specialty clinics for women living with HIV. Chart review was performed on women at high-risk for HIV acquisition pre-conception, during pregnancy and lactation at these centers from 2010-2015.
Lessons learned: 27 women and 30 referrals (3 repeat pregnancies) were identified. 26 women had an HIV-infected partner, 73% (19/26) of whom were on treatment, and 42% (11/26) of whom were virally suppressed. 39% (10/26) of partners had known detectable virus and 23% (6/26) had unknown viral loads.
The median time from identification to consultation was 30 days (IQR 2-62). Two women were lost to follow-up before consultation. One woman identified was not referred in the setting of multiple pregnancy complications. She remained in care and was HIV-negative at delivery, but was lost to follow-up until 10 months postpartum when she was diagnosed with HIV. Her infant was not infected. No other sero-conversions were identified.
In 70% (21/30) of referrals, women were pregnant at consultation; none received safer-conception counseling. Of referrals who were offered PrEP, 67% (18/27) chose to take PrEP. Median length of time on PrEP was 30 weeks (IQR 20-53). No PrEP-related pregnancy complications were identified. 57% (13/23) of women in care at delivery did not follow up postpartum.

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Conclusions/Next steps: When offered pre-conception, during pregnancy and lactation, U.S. women frequently chose to use PrEP. Further research and education are needed to close gaps in care linkage, offering women safe and effective HIV prevention methods in and around pregnancy. The postpartum period is particularly vulnerable to loss to follow-up.

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