PrEPception: Expanding Assisted Reproductive Options for Serodiscordant Couples

The purpose of this study is to observe patient response to current clinical practice utilizing TRUVADA (emtricitabine and tenofovir disoproxil fumarate) for Pre-Exposure Prophylaxis (PrEP) amongst HIV serodiscordant couples desiring to conceive across four U.S. cities that are currently offering this method as standard of care. This study is an observational cohort study, which will test the feasibility and acceptability of PrEP for conception, while examining the challenges and generalizability of this current medical practice. The CDC recently released formal clinical practice guidelines for the use of PrEP in the United States. For high-risk serodiscordant heterosexual couples using PrEP during conception, the guidelines state, "PrEP use periconception and during pregnancy by the uninfected partner may offer an additional tool to reduce the risk of sexual HIV acquisition. Both the FDA labeling information and the perinatal antiretroviral treatment guidelines permit this use" (CDC 2014).

Study Overview

• Status: Completed
• Conditions: PrEP for Conception Purposes

Detailed Description

Based on CDC's guidance on PrEP as well as results of randomized controlled trials, the U.S. Food and Drug Administration (FDA) approved this daily medication (comprised of one pill) to reduce the risk of sexually acquired HIV in adults at high risk. Other medical practices to avoid transmission within this population include assisted reproductive technologies such as sperm washing (or donated sperm) coupled with in vitro fertilization, intracytoplasmic sperm injection (an in vitro procedure where a single sperm is injected directly into an egg), and intrauterine insemination (placing the sperm directly into the uterus). However, these methods are costly and often regionally scarce. PrEP is more accessible and a less expensive option for couples. When used consistently and as prescribed, PrEP has shown to significantly reduce the risk of HIV infection among adult men and women. However, risk reduction counseling and clinical monitoring are necessary for its effective implementation. Therefore, beyond efficacy trials, it is important to conduct additional studies of pre-exposure prophylaxis to observe what factors make PrEP feasible and acceptable to couples, as well as identify other factors that impact level of adherence. The study will take place in four U.S. cities: Boston, Baltimore, Philadelphia, and San Francisco and will involve couples who have chosen to begin PrEP for conception as part of their clinical care after receiving preconception counseling and reviewing their options with their health care provider.

• Study Type: Observational
• Enrollment (Actual): 50

Contacts and Locations

Study Locations

• United States
  • Illinois
    • Chicago, Illinois, United States, 60201
      • Northwestern University
  • Maryland
    • Baltimore, Maryland, United States, 21287
      • The Johns Hopkins University School of Medicine
  • Massachusetts
    • Boston, Massachusetts, United States, 02118
      • Boston University Medical Center
  • Pennsylvania
    • Philadelphia, Pennsylvania, United States, 19102
      • Drexel University

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: Yes
• Genders Eligible for Study: All

• Sampling Method: Non-Probability Sample

Study Population

The study will take place in teaching hospitals in four U.S. cities: Boston, Baltimore, Philadelphia, and San Francisco and will involve couples who have chosen to begin PrEP for conception as part of their clinical care after receiving preconception counseling and reviewing their options with their health care provider.

Description

Inclusion Criteria:

• Between the ages of 18 to 40 years
• In relationship with HIV-positive male
• Chosen to take PrEP for conception after completing counseling with health care provider

Exclusion Criteria:

• HIV-positive
• In relationship with HIV-negative female
• Partner has chosen to take PrEP for conception after completing counseling with health care provider

Study Plan

How is the study designed?

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in PrEP adherence levels throughout regimen	Adherence will be measured in two ways: (1) Dried blood spots (DBS) to measure drug level two times, once after the woman has been taking the drug for one month and once when pregnancy is confirmed. We will perform unadjusted, bivariate analyses comparing participants below and equal to the drug level threshold for daily dosing using a one sample t-test for normally distributed continuous or ordinal variables on adherence. We will also perform a paired t-test for measuring the difference, if any, between the two adherence tests at the different time points for each individual. Adherence will also be measured through (2) participant self-report via a continuous variable of number of doses missed in the past month. We will perform unadjusted, bivariate analyses comparing the observed participant self-reported adherence levels to the gold standard of ≥95% self-reported adherence using a one-sample t test of means for normally distributed continuous or ordinal variables.	Monthly; participants will be followed for the duration of trying to conceive, an expected average of 1 year
Change in condom use and sexual practice over time	Condom use will be measured through participant self-report on number of times a condom was used during the past month compared to the number of times the participant had sexual intercourse with his/her partner or other individuals in the past month. We will perform unadjusted bivariate analyses comparing the observed participants in a one-sample student's t-test for normally distributed variables on condom use or a paired t-test for measuring the difference between two variables at different time points for the same subject (i.e. at baseline and at end-line evaluation). For a non-normal distribution, we will use the non-parametric equivalent such as Sign or Wilcoxon Signed rank test for a symmetric distribution.	Participants will be followed for the duration of trying to conceive, an expected average of 1 year
Change in number of couples who complete a clinical protocol for PrEP compared to the total number of couples that initiate PrEP	We will quantify this outcome measure by examining the number of couples who complete a clinical protocol for PrEP compared to the total number of couples that initiate PrEP, while examining other variables that could make the two groups statistically different. We will perform unadjusted bivariate analyses comparing the number of couples that complete the clinical protocol and those who withdraw or become ineligible throughout the duration of the study. We will use a one-way ANOVA or Kruskal-Wallis non-parametric test for continuous variables with two or more categories such as those that complete the protocol versus those that withdraw from PrEP versus those that become ineligible. We will perform a two-sample test of means to compare the overall categories of those that complete the protocol versus those that do not complete the protocol and create cross-tabulations with chi-square and Fisher's exact tests.	Monthly; participants will be followed for the duration of trying to conceive, an expected average of 1 year
Change in beliefs and sexual behavior at different time points for the same subject	For this outcome measure, we will perform unadjusted bivariate analyses in a paired t-test for measuring the difference in beliefs and sexual behavior at different time points for the same subject. For a non-normal distribution, we will use the non-parametric equivalent such as Sign or Wilcoxon Signed rank test for a symmetric distribution.	Monthly; participants will be followed for the duration of trying to conceive, an expected average of 1 year

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Changes in creatinine clearance from the baseline compared to creatinine clearance at the conclusion of PrEP for the same subject	To assess renal toxicities, we will perform unadjusted bivariate analyses in a paired t-test for measuring the difference of creatinine clearance from the baseline compared to creatinine clearance at the conclusion of PrEP for the same subject. For a non-normal distribution, we will use the non-parametric equivalent such as Sign or Wilcoxon Signed rank test for a symmetric distribution. We will also report on basic drug side effects, while summarizing other self-reported effects of PrEP.	Participants will be followed for the duration of trying to conceive, an expected average of 1 year
Measuring the rates of teratogenicity as compared to the general population as determined by medical record review	We will perform unadjusted bivariate analyses in a two-sample test of means to compare rates of teratogenicity of newborns with HIV-negative females using PrEP as compared to rates of birth defects within the general population in similar age group women.	1 year
HIV transmission rates	For this outcome measure, we will report descriptively on whether there is a transmission or not within the observed participants taking PrEP for conception purposes.	Participants will be followed for the duration of trying to conceive, an expected average of 1 year

Collaborators and Investigators

• Sponsor: Boston Medical Center
• Collaborators: Gilead Sciences
• Investigators: Principal Investigator: Margaret Sullivan, MD, Boston University Medical Campus

Study record dates

Study Major Dates

• Study Start (Actual): July 1, 2014
• Primary Completion (Actual): June 15, 2017
• Study Completion (Actual): June 15, 2017

Study Registration Dates

• First Submitted: August 19, 2014
• First Submitted That Met QC Criteria: September 2, 2014
• First Posted (Estimate): September 8, 2014

Study Record Updates

• Last Update Posted (Actual): July 7, 2017
• Last Update Submitted That Met QC Criteria: July 5, 2017
• Last Verified: July 1, 2017

More Information

Terms related to this study

• Keywords: HIV; PrEP; conception; serodiscordant
• Other Study ID Numbers: H-33071

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No