Moralisation, stigmatisation, and downstream interventions: How symbolic violence sustains geographic inequalities in deaths of despair in England.

Over half of global HIV infections occur among cisgender women, with notably high HIV incidence among women who are pregnant and postpartum. Increased risk of HIV acquisition during gestation due to biological and behavioural changes coupled with the potential for vertical transmission make HIV prevention among pregnant and lactating people (PLP) a unique and crucial global health priority. In the past 5 years, research efforts have prioritised understanding the effectiveness and acceptability of biomedical HIV prevention among PLP, including oral tenofovir disoproxil fumarate and emtricitabine pre-exposure prophylaxis (PrEP). These findings have provided valuable insights into the safety and efficacy of PrEP, informing both WHO recommendations and subsequent 2021 South African National Guidelines to include offering PrEP to PLP. However there are few data on how to provide and optimise PrEP use among PLP. The use of oral PrEP is increasing among PLP, with notable successes in Kenya, South Africa, and Zimbabwe. Despite growing availability and uptake, PrEP persistence and effective adherence (daily use before and during periods of sexual activity) are major challenges for effective use among pregnant women, and especially among breastfeeding women. As these elements of PrEP use are integral to prevention effectiveness, future research exploring the suitable delivery of PrEP and how to best optimise PrEP use among PLP is urgently needed. Previous studies have highlighted existing physical and social barriers contributing to suboptimal PrEP use among cisgender women, such as difficulties in clinical access, daily pill burden, side-effects, insufficient interpersonal support, and anticipated PrEP-related stigmas. In similar studies in Kenya and South Africa, PrEP discontinuation frequently occurred within the early months of use and was attributed to changes in HIV risk perception and side-effects experienced, which can worsen in early pregnancy. Another crucial point of PrEP discontinuation has been observed during the perinatal period and transition from antenatal to postnatal care, as women can perceive the infant risk of HIV acquisition to be significantly diminished following birth or have difficulty adhering to a daily pill regimen due to the demands of early parenthood. We aimed to evaluate PrEP initiation, continuation, and correlations of continued PrEP use among a cohort of South African PLP without HIV in antenatal care.