Abstract
BACKGROUND: Self-perceived HIV risk influences pre-exposure prophylaxis (PrEP) use, although few data on risk perception are available among pregnant women. We evaluated HIV risk perception and PrEP uptake among pregnant women in Kenya. METHODS: We used data from a randomized trial evaluating universal versus risk-based PrEP delivery models at 20 antenatal clinics in Kenya (NCT03070600). Pregnant women enrolled were offered PrEP at any gestational age. A validated risk score for predicting HIV acquisition among perinatal women defined high HIV risk. HIV risk perception was assessed by asking "What is your gut feeling about how likely you are to get infected with HIV?" without a specified timeframe and dichotomized as low ("extremely/very unlikely") versus high ("extremely/somewhat likely/very likely"). All women in the universal PrEP offer arm were included in the analysis. RESULTS: Among 2250 pregnant women, the median age was 24 years (interquartile range 21-28), 81% were married, and 22% did not know their partner's HIV status. Overall, 27% of women had high HIV risk scores of whom 61% self-perceived high risk. Among women with high HIV risk scores (n = 617), 69% declined PrEP; those who self-perceived low risk were more likely to decline than those with high risk perception (82% vs. 60%, adjusted prevalence ratio = 1.35, 95% confidence interval: 1.17-1.55, P < 0.001). Declining PrEP was associated with late gestational age at PrEP offer and with monogamous marriage among women with high HIV risk scores ( P < 0.05). CONCLUSIONS: Declining PrEP was common among pregnant women with high HIV risk, especially those who self-perceived low HIV risk. Refining risk perception may encourage PrEP uptake.