Background: Pregnant women in South Africa (SA) are at high risk of HIV acquisition. Pre-exposure prophylaxis (PrEP) use during pregnancy is both safe and effective in preventing HIV. However, posttraumatic stress (associated with intimate partner violence and/or other traumas) and depression negatively impact PrEP adherence among women in SA. 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. The overarching 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 the postpartum transition. Candidate: I am a clinical psychologist and a postdoctoral fellow at Massachusetts General Hospital/Harvard Medical School. I am applying for a five-year K23 Career Development Award to obtain the training, mentorship, and research experience that will enable me to become (1) an independent investigator at the R01 level and (2) an expert in reducing the psychological barriers to HIV prevention among women in low- resource settings. Mentoring: Dr. Conall O’Cleirigh will serve as my primary mentor; he brings expertise in the psychosocial aspects of HIV prevention and intervention development for global contexts. Drs. Christina Psaros and Jessica Haberer, both co-mentors, will offer guidance on qualitative data analysis as it applies to intervention development and implementation science frameworks for low- and middle-income settings. Drs. Landon Myer, John Joska, and Lucia Knight, my SA-based co-mentors, will provide mentorship on biomedical HIV prevention strategies for use during pregnancy/postpartum, intervention development for the South African context, and intervention sustainability within the antenatal clinic setting. 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 intensive direct mentorship, coursework, workshops, and primary research in SA. This training and research experience will enable me to support the mental and sexual health of women at risk for acquiring HIV. 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 via qualitative interviews; (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. We will use this formative research to apply for an R01-level grant to evaluate the efficacy and effectiveness of the intervention.

In South Africa, pregnant and breastfeeding women are at elevated risk of acquiring HIV, and pre-exposure prophylaxis (PrEP) is a safe and effective HIV prevention strategy; however, posttraumatic stress and depression, which are prevalent in this population, negatively impact PrEP adherence and persistence. This study will (1) explore the mechanisms by which posttraumatic stress and depression impact PrEP use during pregnancy and the postpartum transition; (2) develop a brief intervention that addresses common underlying factors of posttraumatic stress and depression to improve PrEP adherence and persistence; and (3) evaluate the feasibility and acceptability of the intervention when delivered in a community-based antenatal care setting. If feasibility, acceptability, and preliminary efficacy are demonstrated, then the intervention will be ready for large- scale efficacy/effectiveness testing.