Adherence to Periconception HIV Risk-reduction Among Uninfected Women in Rural Uganda
Phase: NA
Conditions: HIV Prevention
Sponsor: Massachusetts General Hospital

1 
 
Principal Investigator: Lynn T. Matthews, MD MPH  
 
Site PI:  Mwebesa Bosco Bwana, MBChB MPH  
 
 
Department/Division: MGH/ MUST 
Protocol Title: Adherence to periconception HIV risk-reduction among uninfected 
women in rural Uganda 
 
Protocol version date: 03 May 2018 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

2 
 
 
I. 
BACKGROUND AND SIGNIFICANCE 
Background 
Uganda has one of the highest total fertility rates in the world at 6.2 children per woman and 
HIV-prevalence among women attending antenatal care is ~ 11% [1, 2]. While services to 
prevent perinatal transmission are robust for HIV-infected pregnant woman, HIV prevention prior 
to a desired pregnancy is rarely addressed.  Yet, at least 30-50% of men living with HIV in 
Uganda desire children [3-7] and nearly half have a stable, uninfected partner [8]. Women risk 
condomless sex in order to meet important personal and sociocultural goals to have children [3, 
7, 9-11]. Integrating HIV prevention into reproductive health programs presents an opportunity 
to reduce HIV incidence among women in settings where fertility rates and HIV prevalence are 
high.  
Several effective strategies are available to women who want to conceive with an at-risk partner 
who is engaged in care including delaying condomless sex until the infected partner is on 
effective ART, treating STIs in both partners, limiting condomless sex to peak fertility, and 
sperm processing [12-14]. However, in a setting where gender power imbalances make it 
challenging for a woman to insist that her partner participate in strategies to reduce sexual 
transmission of HIV, pre-exposure prophylaxis (PrEP) may be a critical safer conception 
strategy. Understanding how women initiate and adhere to PrEP as periconception risk 
reduction is an important step towards developing safer conception programs [15, 16].    
Significance 
1.  Reducing periconception HIV-
acquisition risk is an efficient strategy to 
reduce HIV incidence among women 
and their children. Integrating HIV 
prevention into reproductive health 
programs may reduce HIV incidence, 
particularly in settings like Uganda 
where fertility rates (6.2 
children/woman) and HIV prevalence 
(7%) are high and HIV transmission 
within stable heterosexual relationships 
accounts for nearly half of new 
infections [26-28].  WHO and CDC 
guidelines emphasize that eliminating 
perinatal transmission requires pre-
conception counseling to reduce 
transmission to the mother and 
therefore the child [29, 30]. Programs to 
incorporate safer conception counseling 
have not been developed. 
 
2.  Safer conception tools are available.  
Data suggest that men and women living with HIV, their uninfected partners, and HIV care 
providers are eager for implementation of safer conception programs in sub-Saharan Africa [7, 
10, 11, 31].  Couples-based strategies such as ART for the infected partner, delaying 
Table 1. Safer conception methods for 
uninfected women with HIV-infected male 
partners.  
Adapted from Matthews et al. Curr Opinion HIV 
AIDS [12] 
Method                                                    Est. risk 
reduction 
Couples-based strategies 
 
ART for infected partner [17] 
96% 
STI treatment [18, 19] 
< 40% 
Sperm washing #[14, 20] 
~100% 
Condomless sex limited to peak 
fertility* [21] 
Unknown 
Couples-based HIV counseling and 
testing^[22] 
Unknown 
Female-controlled strategy 
 
Oral TDF/FTC PrEP for uninfected 
partner [23-25] 
63-75% 
* Risk reduction effected by reduced exposure.   
^ CHCT associated with decreased risk of HIV-
acquisition.  #Difficult to access.  

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condomless sex until HIV RNA is suppressed, and sperm washing can reduce HIV transmission 
to negligible levels. Couples-based HIV-counseling and testing and STI treatment may further 
reduce transmission (Table 1). Pre-exposure prophylaxis (PrEP), which does not require partner 
participation, is an additional safer conception strategy, that reduces HIV-acquisition risk by as 
much as 94%. 
3.  PrEP gives uninfected women a strategy to protect herself (and therefore her child) from 
HIV.  Women who partner with an HIV-infected man have limited power to negotiate safer sex 
or safer conception practices [3, 10, 32]. HIV-uninfected women partnered with men living with 
HIV describe obligations to meet childbearing expectations, irrespective of HIV risk [10].  In oral 
PrEP trials with high adherence, women experienced a reduction in HIV acquisition of 63-75% 
[23, 24]. Among women with plasma concentrations of tenofovir indicating recent dosing, 
protection was estimated at 94% [25]. While women who enrolled in PrEP trials without being in 
mutually-disclosed serodiscordant partnerships had particular challenges taking study drug [33, 
34], studies since PrEP efficacy has been proven suggest that this population is able and willing 
to take daily, oral PrEP [35].  Many of the barriers to adherence described by VOICE and Fem-
PrEP trial participants with low adherence related to lack of proven efficacy of study drug, low 
risk perceptions, and wanting study services without taking study drug [36, 37].  The current 
proposal avoids these pitfalls by communicating unequivocal PrEP efficacy to women who 
believe their partner is HIV-infected and plan to conceive a child. Furthermore, PrEP 
acceptance is not a requirement of the study, which minimizes incentives for initiating PrEP 
without intent to use PrEP. 
 
Given the limited prevention options for women who choose to conceive with HIV-positive men, 
WHO guidelines highlight serodiscordant couples considering conception are a priority group for 
PrEP[38]. The FDA labeling information and the U.S. Perinatal ART Guidelines support 
periconception PrEP use [16, 30, 39-42]. However, there are no data on feasibility and uptake of 
this strategy in settings with generalized epidemics.  
 
II. 
RESEARCH DESIGN AND SPECIFIC AIMS 
Table 2.  Conceptual framework for pregnancy-related PrEP adherence 
Domain 
Construct 
Measure(s) 
Individual 
HIV Knowledge 
HIV knowledge  [43] 
Safer conception knowledge[44] 
 
Risk  
Partner serostatus 
Risk perception [45] 
Risk behavior via diary 
Optimism 
PrEP optimism [46] 
Motivation 
Parenthood motivation [47] 
Medication side 
effects 
 
 
Socio-demographics 
e.g. asset index, substance use, reproductive history, 
partnership type 
Couple 
Partnership 
disclosure 
HIV disclosure [48, 49] 
Complete couples-based HIV counseling and testing 
Communication, 
gender norms 
Relationship power [50] 
Partner communication[51] 

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Research Design: In our mixed-methods research study we will offer comprehensive safer 
conception services to 150 HIV-uninfected women reporting an HIV-infected or high-risk partner 
and personal or partner plans for pregnancy in rural Uganda to evaluate prevalence and 
determinants of uptake and adherence (tenofovir plasma concentration >40ng/mL, opening pill 
device to take >80% of dispensed pills) to PrEP and other safer conceptions strategies among 
Ugandan women exposed to HIV. 
To evaluate factors that we believe may be experienced by our target study population at an 
individual, couple, and community-level that may influence PrEP initiation and adherence 
behaviors we have created a conceptual framework (Table 2), adapted from van der Stratenet 
al.[36, 54]. At the individual level, she may have excellent knowledge of safer conception 
strategies, be optimistic about PrEP efficacy, and perceive herself to be at risk for acquiring HIV. 
However, on the dyadic level, she and her partner do not communicate or trust one another, 
making it hard for her to adhere to a daily medication.  If she feels that being HIV-infected is 
highly stigmatized in the community, she may be more motivated to participate in periconception 
PrEP.  By collecting covariates that reflect constructs of this framework, our mixed methods 
data will allow us to develop this framework to inform an adherence intervention for women 
seeking periconception HIV-prevention.  
Specific Aims: Based on our conceptual framework for periconception risk reduction and 
adherence to periconception PrEP[36, 54] we propose the following specific aims: 
1. We will measure prevalence and factors associated with uptake of daily, oral TDF/FTC 
PrEP over 9 months.  We hypothesize that 70% of women will initiate PrEP as part of 
safer conception and that uptake will be associated with greater relationship power and 
social support.  Secondary outcomes include uptake of couples-based strategies 
including ART uptake by partners, limiting condomless sex to fertility, STI treatment, and 
couples-based HIV counseling and testing.   
2. We will objectively measure adherence to PrEP over up to 9 months. We hypothesize 
that 70% of women will have detectable plasma drug 3 months after PrEP initiation and 
that 70% of women will have >80% adherence by electronic Wisepill monitoring.  We 
hypothesize that women with greater relationship power and social support will be more 
likely to adhere. We will evaluate adherence to couples-based strategies including delay 
of condomless sex until partner taking ART for >3 months and limiting condomless sex 
to peak fertility.  We will measure HIV and pregnancy incidence. 
3. Based on a conceptual framework for PrEP adherence, we will conduct in-depth 
interviews with a subset of up to 45 women and their partners to explore barriers and 
promoters to use of PrEP and other safer conception strategies.  
4. We will offer objective sexually transmitted infection (STI) testing to all participants in 
order to measure the prevalence, incidence, and factors associated with STIs. We will 
compare incidence among women who choose and who do not choose PrEP.  
 
Offering women strategies to reduce HIV acquisition risk while meeting reproductive goals provides a 
unique approach to reducing HIV incidence among women of reproductive age and their children.      
 
Community 
Social support 
Functional Support [52] 
Stigma 
Attributed Stigma [53] 

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III. 
SUBJECT SELECTION 
Self-Report Inclusion Criteria 
1. Female 
2. Aged 18-35 
3. Likely to be fertile based on reproductive health history [55] 
4. Reported personal or partner desire to have a child in the next year [56-59] 
5. With a partner she reports as HIV-infected or likely to be HIV-infected (e.g. taking 
medicine daily, goes to clinic routinely, has HIV-infected partners, he has implied that he 
is “sick” but has not disclosed).   
6. Live within 60km of clinic.  Not planning on relocating to an area incompatible with ability 
to attend quarterly clinic over a 9-month follow-up period 
Objective Inclusion Criteria  
1. HIV-negative (onsite rapid testing) 
2. Not currently pregnant (onsite urine b-hcg testing) 
3. Fluent in English or local language 
4. Otherwise able to participate in the informed consent process  
Enrolment Criteria Male Partners 
We will enroll a subset of male partners to participate in in-depth interviews.  Inclusion criteria 
include: 
1. Partnered with female participant 
2. Fluent in English or local language 
3. Otherwise able to participate in the informed consent process  
Source of Subjects  
We will recruit and identify potential participants who may meet our selection criteria from: 
1. Our existing Healthy Families Program located at the Immune Suppression Syndrome 
(ISS) Clinic located in Mbarara town within the Mbarara District of Uganda.  This clinical 
program currently recruits HIV-affected individuals and couples for safer conception 
counseling and service provision (exclusive of PrEP which is not currently available in 
the public sector). 
2. MRRH HIV counseling and testing sites where > 300 women screen monthly and 
approximately 8% test HIV-positive 
3. Community partnerships and referrals from local healthcare providers 
4. Advertisement using flyers at our Safer Conception Clinic, local HIV counselling and 
testing sites,  appropriate community events, and informational radio spots. 
5. Male partners will be invited to participate by their female partners.  Female participants 
who are interested in including their partners in the study will be given an invitation letter 
which will offer contact details should their male partner choose to contact the research 
team.  He will also be invited to come to the clinic or research space alone or with his 
female partner.   
Sample Size: 

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We will enroll up to 150 women who meet the outlined inclusion/exclusion criteria and complete 
an informed consent process.  We will invite a subset (up to 45) of these women to participate in 
in-depth interviews.  We will invite these women to invite their pregnancy partner for an in-depth 
interview (up to 45 partners.)  We will enroll up to 150 women who meet the outlined 
inclusion/exclusion criteria to complete objective STI testing pending ethics approval for this 
amendment.  
 
IV. 
SUBJECT ENROLLMENT  
Informed Consent  
Upon completion of the screening questions, women who remain eligible will be asked to 
participate in an informed consent process before enrollment in the study. Women who screen 
positive for HIV and/or pregnancy during the initial screening process will not be invited to 
participate in the informed consent process for this study and will be referred to antenatal and/or 
HIV care.  They will still be eligible to participate in the clinical safer conception service.   
Research Assistants that are certified in Good Clinical Practice will use a written informed 
consent document as a guide to provide potential participants information on study procedures 
and study expectations of the research participant. The informed consent will take place orally in 
a one on one interview held in a private space to allow potential participants the opportunity to 
ask questions of the study staff. The informed consent document will be available to the 
participant in both English and the local language. Translation of the informed consent (and all 
other participant relevant study documents) will be subjected to translation, back translation and 
revision to ensure accuracy, clarity and ease of comprehension. During the informed consent 
interview the research assistant will remind the potential participants that participation in the 
research study is completely optional and deciding not to participate will have no effect on the 
clinical services they receive.  
The Informed Consent form will outline in detail: 
• 
Explanation of the consenting process in compliance with institutional policies: 
statement that participation is voluntary 
• 
Nature and purpose of study  
• 
Length of the study and number of participants  
• 
Explanation of procedures 
• 
Discomforts and risks, plans to protect participants from these risks 
• 
Benefits  
• 
Alternatives to participating  
• 
Rights as a participant of the study  
• 
Financial arrangements and reimbursements  
• 
Sources of additional information  
• 
Confidentiality, including how data will be used and how it will be kept private  
• 
Data storage and destruction.  
 
After each major section and any key points, the Research Assistant will pause and check for 
understanding and provide further clarification if necessary. All participants will be informed that 
the information they provide through the consent, interviews, lab work and questionnaires will be 

7 
 
treated as confidential (i.e., not shared with anyone outside of the research staff with linkage to 
identifying information) and voluntary (i.e., they are not obligated to answer any question).  If 
women prefer to take the screening and/or informed consent documents with them to further 
consider participation before completing informed consent for enrollment that will be presented 
as an option and study staff will check-in on their enrollment decision via the cell phone number 
provided by the women on their contact sheet.  
 
V. 
STUDY PROCEDURES  
Overview 
Upon completing the informed consent process, interested participants will be asked to sign or 
fingerprint a copy of the written informed consent to confirm that they understand the study and 
what is expected of them as a research participant. A copy of the signed consent form will be 
given to the participant for their records. After signing of the consent, participants will be 
considered enrolled as part of the sample goal of 150 uninfected women.  
Enrolled women will participate in the outlined mixed-method study to evaluate prevalence and 
determinants of uptake and adherence (tenofovir plasma concentration >40ng/mL, taking >80% 
of dispensed pills) to daily, oral TDF/FTC PrEP during periconception among HIV uninfected 
Ugandan women reporting HIV-infected or unknown serostatus partners. To accomplish this, 
women will participate in quarterly study visits, HIV and pregnancy testing, questionnaires and 
safer conception/adherence group counseling sessions. Participants will be eligible to initiate 
PrEP at any time during the first 6 months of the 9-month (maximum) study follow-up period. 
Participants will receive a PrEP referral form to bring to the clinic if they chose to initiate PrEP 
outside of a scheduled study follow up visit.   
Women who become pregnant or test positive for HIV during the 9-month follow-up period will 
complete exit activities (questionnaire and in-depth interview) and be referred to appropriate 
antenatal and/or HIV follow-up care.   
Counselling  
Comprehensive safer conception counselling: Enrolled women will be offered a package of 
safer conception counselling for uninfected women who want to conceive a child with an 
infected partner:   
• 
Encourage partner testing and serostatus disclosure within the partnership. 
• 
Encourage partner to initiate ART if he is eligible by national guidelines (CD4 cell 
count < 500 or in serodiscordant partnership),  
• 
Delay sex without condoms until he achieves HIV viral load suppression or is on ART 
x 6 months,  
• 
Consider contraception to delay pregnancy until safer conception strategies 
implemented 
• 
Limit sex without condoms to peak fertility, and / or 
• 
Consider sperm washing, donor sperm, and adoption as alternatives. 
Safer conception counselling will occur at baseline and then quarterly thereafter in non-pregnant 
women 

8 
 
Adherence support counselling: Brief adherence counselling and support sessions will be 
available at to all women at the time of enrollment and will cover PrEP education. Follow-up 
adherence counselling will be available during quarterly visits to all women who initiate PrEP.  
Counselling will be performed by trained study counsellors in a individual counselling sesion. 
These sessions will discuss barriers to and promoters of adherence.   Data Collection (Table 
3) 
Demographics: We will collect baseline demographic 
and reproductive health data (number of prior 
pregnancies, live births, living children) at enrollment. 
We will update demographic data at study exit to 
assess information that may change throughout the 
course of the study (e.g. employment, household 
income).   
Measures: Constructs will be assessed with a 
questionnaire administered at 0 months and study exit  
(Table 2). Other safer conception behaviors will also be 
assessed, including partner HIV status, delay of sex 
without condoms until partner on ART with viral load 
suppression, accessing additional services such as 
sperm washing.  
 
Sexual Behavior: Sexual behavior will be assessed 
through monthly diaries. The counsellor and the 
participant will fill in the first day of next anticipated 
menses on a monthly calendar and then participants 
will mark the number of condomless sex acts and bring 
this form back in for review at quarterly follow-up visits. 
We will use the sexual behavior data of woman who 
chose not to initiate PrEP to explore between group 
differences among individuals who chose to and who 
chose not to initiate PrEP.  In addition, we will be able 
to better understand the entire sample’s understanding 
and use of the alternative/additional safer conception 
strategy of timing sex to peak fertility by collecting this 
data regardless of PrEP initiation.  
 
Biologic tests; All participants: All participants will complete quarterly urine pregnancy tests, 
rapid HIV tests and syndromic screening for STIs. 
Beta hcg-urine pregnancy tests require approximately 4 drops of urine to test for 
human chorionic gonadotropin, a hormone that is produced once a woman becomes 
pregnant. Women who test positive for pregnancy after enrolment will be referred to 
appropriate antenatal care before being exited from the study.  
Rapid HIV testing will occur via the standard of care finger-prick blood sample. HIV 
finger-prick testing will entail the clinical study member pricking the tip of the participant’s 
 
Table 3.  Data collection procedures 
Months 
0 
i* 
3 
6 9/stud
exit 
Laboratory 
 
 
 
 
 
Urine pregnancy test 
x 
 
x 
x 
x 
HIV test 
x 
 
x 
x 
x 
STI screen  
x 
 
x 
x 
x 
STI Objective Testing 
x 
 
 
x 
 
STI Case Report Form 
x 
 
 
x 
 
Additional labs for women who initiate PrEP 
Creatinine  
 
x 
x 
x 
x 
HBV serology 
 
x 
 
 
 
Drug level adherence testing 
 
 
x 
x 
x 
Behavioral 
 
 
 
 
 
Safer conception counseling 
x 
 
x 
x 
x 
Full questionnaire (See 
Table 2) 
x 
 
 
 
x 
diary sexual behavior 
x 
 
x 
x 
x 
Wisepill adherence data 
x 
 
x 
x 
x 
In-depth interviews (See Aim 
3) 
 
 
 
x 
x 
Additional for women who initiate PrEP 
Adherence support 
x 
x 
x 
x 
x 
*i = PrEP initiation visit  
** Objective STI Testing will include:  gonorrhoeae, chlamydia, 
trichomonas vaginalis, herpes and syphilis at baseline and mont
6 for all participants and as needed based on screening at all 
other visits/exit 

9 
 
finger with a small, single-use lancet, squeezing a small amount of blood (approximately 
1-2 drops) into a sample collection pipette, transferring a drop of blood into a marked 
sample well and waiting approximately 10-20 minutes for results. Women who test 
positive will receive a second, confirmatory finger-pick test. Upon completion of 
confirmatory testing, women who were confirmed positive will receive post-test 
counselling and be referred for appropriate HIV care before being exited from the study. 
Syndromic STI screening: All women will be offered syndromic STI screening at each 
study visit. Syndromic STI screening will be conducted by asking participants if they 
have experienced any STI symptoms (e.g. discharge, ulcers, itching). For women who 
endorse STI symptoms a confirmatory test will be performed, and they will receive 
treatment medications dispensed by a licensed medical professional team member (see 
STI treatment below),   
Objective STI testing: Women who consent to participate in objective STI testing will 
complete objective STI screening tests at baseline, at the 6-month study visit or study 
exit (if exit occurs prior to the 6-month timepoint) independent of the syndromic STI 
screen (see above).   
Women who endorse symptoms of STI, as determined by syndromic STI screening, 
during interim visits or at the 3-month study visit will have additional objective STI 
testing.  
Objective STI tests include testing for Chlamydia trachomatis, Neisseria gonorrhoeae, 
Trichomonas vaginalis, Herpes Simplex Virus 2 (HSV2), and Syphilis. At each testing 
timepoint women will provide 2 vaginal swab specimens by either self-collection or nurse 
collection (based on participant preference). If self-collection is selected, participants will 
receive detailed instruction from the nurse to ensure the sample will be viable for testing.  
Self-collection of vulvo-vaginal swabs among women in Sub-Saharan Africa with and 
without pregnancy has been found to be safe, reliable, acceptable, and efficient [19, 60].  
Regardless of collection preference, all participants will be provided with a private 
environment for collection. Women will be asked to provide 2 plastic dacron swabs to 
facilitate objective testing for Chlamydia trachomatis, Neisseria gonorrhoeae, and 
Trichomonas vaginalis. The additional swab will be used to facilitate additional quality 
assurance testing as needed and stored for future testing by researchers involved with 
this study who, in the future, may think of other additional tests, related to our research 
questions pertaining to HIV risk, PrEP use and STIs, that they would like to perform on 
the additional swabs. Before we proceed with any future tests, we will submit the 
required proposals for ethics review by the university ethics review committee and the 
national council of science and technology. 
Women will also provide a blood sample (1 tube, ~10cc or 1 tablespoon) to test for 
HSV2 Ab and Syphilis testing with Treponemal Ab and Venereal Disease Research 
Laboratory (non-trep) tests. We anticipate that up to 150 women (depending on start 
date) will undergo objective STI testing at the enrollment visit.  
All biological tests including pregnancy testing, HIV testing, and STI syndromic 
screenings will be performed by clinical study staff in a private room located at the ISS 
clinic. 

10 
 
STI Treatment: Participants with positive STI testing will receive treatment at the study 
site dispensed by a licensed medical professional who is a member of the study team. 
All treatment regimens will be in accordance with standard Ugandan treatment 
guidelines. Study participants with positive STIs who receive treatment will also be given 
treatment medications to deliver to their partner(s) with the goal of preventing reinfection. 
This practice of patient-delivered partner medication has been shown to be efficacious in 
several settings, including Uganda [61]. 
 
Biologic tests; Women who initiate PrEP:  Women who initiate PrEP will complete creatinine at 
baseline and quarterly and hepatitis B safety monitoring at baseline to ensure that there are no 
contraindications to using PrEP.  A nurse will also assess for any symptoms experienced after 
initiating PrEP to evaluate for any medication side effects. Blood testing for renal function 
(Creatinine) and for hepatitis B infection will require 2 tubes of blood or approximately 10mL or 
<1 tablespoon of blood at baseline and 1 tube of blood or approximately 5mL quarterly.  As per 
WHO guidelines, women will be eligible to initiate PrEP immediately.  Women with abnormal 
renal function or active hepatitis B infection (HBV surface antigen positive) will be instructed to 
stop PrEP.  Abnormal renal function will be defined as: 
• 
Non pregnant women: serum Creatinine> 89 µmol/L and GFR < 60ml/min 
(Glomerular filtration will be estimated using the Cockcroft-Gault equation). 
Any woman who has abnormal safety lab results will be referred to appropriate clinical care.  
 
Adherence:  Adherence of PrEP will be assessed by biological sampling as well as electronic 
data capture monitoring. In addition to assessing adherence we will promote adherence through 
offering individual adherence counselling sessions to all women who initiate PrEP at their study 
visits using an adherence counselling tool developed specifically for PrEP adherence. 
Plasma tenofovir testing for plasma drug level will be collected at the first visit (3 
months) after PrEP initiation and at exit or incident pregnancy.  TFV concentration >40 
ng/mL indicates adherence in the prior 24 hours and is associated with HIV protective 
efficacy (1° outcome) [25, 62].  We will collect additional samples to test for 
phosphorylated tenofovir (TFV-DP) via dried blood spots, which are whole blood and 
provide longer-term exposure information (half-life 17 days).  DBS samples will be 
analyzed to adjudicate discrepancies between Wisepill and plasma TFV levels [63, 64]. 
In addition, a full blood count for hematocrit/hemoglobin testing will be taken at two 
instances: 
• At the first instance of DBS collection (for TFV levels) after the participant has 
initiated PrEP for the first time, 
• At the time of a positive pregnancy test if the participant is on PrEP and 
adherence DBS labs are indicated.  
This hematocrit/hemoglobin testing is a point of care test and will not require additional 
blood sample to be taken. The hematocrit is required to accurately interpret the TFV 
level in the dried blood spot which is a primary adherence outcome for the study.  
 
For participants who have already enrolled in the project we will test 
hematocrit/hemoglobin at their next study visit upon re-consenting them.  
 

11 
 
Wisepill device to monitor adherence. PrEP initiators will be given a Wisepill device to 
measure level and patterns of adherence in real-time. Wisepill uses wireless technology 
to monitor medication use. Device openings are recorded and transmitted via cellular 
networks in real-time to the Wisepill server. While not all device openings equate to 
ingestion, electronic adherence monitoring provides the best-available understanding of 
day-to-day adherence behavior. Flash memory maintains data for later transmission if 
connectivity is lost. We have collected Wisepill adherence data in Dr. Bangsberg’s 750-
person HIV cohort in Uganda (NCT01596322) and found a high degree of acceptability, 
reliability and validity with respect to predicting HIV RNA rebound [65].  Outcomes 
(median adherence >80%, median adherence, and number of interruptions >72 hours) 
will be calculated every 28 days and summarized quarterly.  
Interviews: We will conduct qualitative interviews to explore factors affecting periconception 
PrEP uptake and adherence.  We will sample from three groups of women (~15 per group):  (1) 
women who do not initiate PrEP, (2) women who initiate PrEP and have detectable plasma 
TFV, and (3) women who initiate PrEP and have undetectable plasma TFV. Interviews will 
target adherence experiences of participants and cover a range of relevant topics, including: (a) 
circumstances under which pills are taken (dosing behavior); (b) missed doses and why they 
happen; (c) what obstacles impede adherence; (d) who/what helps with adherence and how; (e) 
how pregnancy plans influence adherence behavior, and (f) reasons for changes in adherence 
patterns over time with a focus on constructs within our conceptual framework.  In addition, we 
will invite a subset of male pregnancy partners to participate in a similar in-depth interview to 
explore their experiences throughout the safer conception process.  
 
VI. 
SAMPLE COLLECTION, STORAGE, USE AND SHIPMENT 
Point of care testing: Urine pregnancy tests, rapid HIV tests and hematocrit testing will be 
performed at the MUST study clinic by study clinical staff.  These tests are considered point-of-
care tests and no samples will be stored or shipped. Sample specimens will be disposed of per 
the safety protocol of the study clinic in appropriately labelled biohazard waste receptacles.  
Tenofovir testing 
Number of samples:  We are enrolling 150 women with personal or partner pregnancy 
desire to participate in the research project and offering the entire sample the option to 
initiate daily, oral PrEP.  Based on enrolment and a maximum follow-up period of 9 
months with quarterly adherence testing we estimate the maximum number of stored 
plasma samples to be 600.  We anticipate collecting the DBS TNF-DP assay on the total 
number of samples for an estimated maximum of 600 DBS stored samples. The TNF-DP 
data will give a sense of longer-term adherence and help assess the “white coat” affect 
in this sample. Total temporarily-stored samples=1200.  
Use: Whole blood will be drawn and prepared plasma samples will be stored to test 
tenofovir (TNF) concentration levels in plasma samples of women who initiated PrEP. In 
addition, dried blood spots (DBS) will be collected and stored to test tenofovir 
diphosphate (TNF-DP) concentration levels for all women who initiate PrEP. TNF-DP is 
a more sensitive assay and will allow for more granular data analysis and interpretation 
of plasma TNF concentration results. 

12 
 
Collection and sample preparation: Our collaborating lab at the Johns Hopkins Medical 
Institute requires a 4 ml K3EDTA tube of blood drawn at each time point for testing of 
plasma TNF.  For plasma, the tube will be placed on ice after sampling and centrifuged 
down at 1500 g for ten minutes to separate the plasma. Immediate centrifugation 
negates the need for ice. Plasma will be stored in two aliquots at approximately -70°C 
within one hour of collection. Our collaborating lab at University of Colorado will perform 
DBS testing and requires, 50 uL of whole blood will be collected and spotted onto 
Whatman 903 protein saver cards using a calibrated research pipette. Spots will be dried 
completely at room temperature (2 hours out of direct sunlight) before sealing into a 
ziplock bag with a desiccant sachet and humidity indicator card. We will collect five spots 
(one card) per time point.  
Shipment and Storage: All plasma and dried blood spot samples will be temporarily 
stored at approximately -70°C to ensure long-term stability. Shipping will occur in 
batches and be sent on dry ice to our collaborating lab at the Johns Hopkins Medical 
Institute in Baltimore, Maryland, United States or to University of Colorado, Denver, 
Colorado, United States.  If extra samples are available, these materials may also be 
used by other researchers involved with this study who, in the future, may think of other 
additional tests, related to our research questions pertaining to HIV risk, PrEP use and 
STIs, that they would like to perform on the remaining samples within 10 years of 
collection. Before we proceed with any future tests, we will submit the required proposals 
for ethics review by the university ethics review committee and the national council of 
science and technology. 
STI Testing (General):  
All testing of vaginal swab samples for Gonorrhea, Chlamydia and Trichomonas will be 
processed at the MUST Microbiology lab via GeneXpert rapid nucleic acid amplification 
(NAAT) testing (see below.) 
Testing of phlebotomy samples for Syphilis Treponemal Ab and non-treponemal as well 
as the preprocessing and serum extraction for HSV2 Ab testing will be performed at the 
MUST Research lab. (see below) 
Serological testing for HSV2 (by ELISA) will be performed at Makerere University 
microbiology lab under Dr. Esther Joloba. Dr, Joloba’s lab has expertise in performing 
ELISA serology testing for HSV2 and has published on the sensitivity and specificity of 
this assay methodology among HIV-infected and uninfected Ugandans [66]. 
Turnaround time for all testing (with the exception of HSV2 Ab) will be approximately two 
hours, allowing women with positive STI test results to be seen for follow-up clinical 
evaluation and treatment as well as counselling around partner referral and treatment at 
the same study visit. Women with an active outbreak of suspected HSV2 based on 
clinical exam will be offered acyclovir prior to objective confirmatory results as per 
standard of care.  

13 
 
All biological tests including pregnancy testing, HIV testing, and STI syndromic 
screenings will be performed by clinical study staff in a private room located at the ISS 
clinic.  
STI Vaginal Swab Testing (MUST Microbiology Lab):  
The MUST Microbiology lab has been fully functional for over ten years. The lab has 
expertise in various lab modalities including GeneXpert and run over 800 samples via 
GeneXpert each month which include TB sputum, TB CSF, TB stool, HIV RNA, and HPV 
testing ([67]). The MUST Microbiology lab’s GeneXpert procedures have been externally 
validated by the Ugandan Ministry of Health as well as internally validated via Cepheid 
QA/QC procedures ([67]). GeneXpert testing will be utilized to test for CT, NG and TV.  
Number of samples: Objective STI testing will be offered to up to 150 women (this 
number will vary in light of our study currently in enrolment).  
All women will either self-collect or undergo nurse-collected vaginal swabs (2 swabs 
each) at study initiation, and either at 6 months or at the time of study exit prior to 6 
months. Women with STI symptoms at the 3 month study visit will also undergo 
additional vaginal swab testing, and given our knowledge of symptomatic STIs, we 
anticipate this to be no larger than 15% of our study population.[68] Therefore we 
anticipate collecting no more than 645 vaginal swabs in total. The second vaginal swab 
collected at each instance will be used for quality assurance or stored for future testing. 
Use: Vaginal swabs will be collected and analyzed at our corresponding laboratory to 
test for Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis via 
GeneXpert rapid nucleic acid amplification testing (NAAT).  
Collection and sample preparation: Vaginal swabs will be collected via 2 plastic dacron 
swab, placed in medium, and then stored at 2 to 8 degrees Celsius until the lab is able to 
perform testing. Samples can be frozen at -20 to -80 degrees for long-term storage. 
Shipment and Storage: Vaginal swab samples will be analyzed on-site at the MUST 
Microbiology Lab. Long-term storage of the secondary swab will be necessary for a 
proportion of these samples to undergo a secondary confirmatory test for validation of 
our a subset of the lab results. These materials may also be used by other researchers 
involved with this study who, in the future, may think of other additional tests, related to 
our research questions pertaining to HIV risk, PrEP use and STIs, that they would like to 
perform on the remaining vaginal swabs within 10 years of collection. Before we proceed 
with any future tests, we will submit the required proposals for ethics review by the 
university ethics review committee and the national council of science and technology. 
 
STI Blood Testing (MUST Research Lab):  
Number of samples: As stated above for vaginal swabbing, we will offer STI testing for 
up to 150 participants to undergo objective STI testing. If we assume 15% of patients will 

14 
 
have STI symptoms,[68] we would then anticipate having no more than 322 samples of 
blood.  
Use: 10cc of whole blood will be drawn from each study participant to test for HSV2 Ab 
and Syphilis Treponemal Ab. If the Syphilis Treponemal Ab is positive, this test will 
automatically reflex to a non-treponemal test to confirm the diagnosis and elucidate 
whether this is a new or old infection.  
 
Collection and sample preparation: Blood samples should be held for approximately 15 
minutes until a clot forms and should then be centrifuged to separate the serum from the 
blood clot. Samples can be stored at 2 to 8 degrees Celsius for up to five days or frozen 
at -20 to -80 degrees for long-term storage. 
 
Shipment and Storage: Blood samples for Syphilis will be analyzed on-site. Blood 
samples for HSV2 Ab will be preprocessed and temporarily stored at -80C for final 
testing at Makerere University in Kampala (see above). No long-term storage  is 
necessary for these samples. 
VII. 
REIMBURSEMENTS 
Participants will receive a transportation refund for all study visits. This reimbursement 
will be determined based on the distance from the participant’s home to the clinic, and 
can range from 10,000 UGX to 30,000 UGX.  Additionally, participants will receive an 
incentive of 20000 Ush to compensate them for their time.  
VIII. 
RISKS AND DISCOMFORTS: The potential risks incurred by participating in the studies 
include: 
1. Risk of acquisition of HIV: Based on inclusion criteria, all participants will be at risk for 
acquiring HIV.  It is therefore possible that some participants will become infected over 
the course of the follow-up study. All participants will be offered comprehensive 
counselling regarding HIV risks as well as safer conception risk.  Participants will be 
counselled about and able to access condoms in the clinic. Women who seroconvert will 
be offered comprehensive HIV care at the ISS clinic.  
2. Risk of developing resistant virus: Women who become acutely infected with HIV while 
incompletely taking TDF/FTC PrEP have an increased chance of developing resistant 
virus. Quarterly adherence counselling sessions will emphasize that women should 
come to the clinic for additional testing should she develop symptoms of acute HIV 
infection.  Furthermore, if women adhere well, the risk of getting HIV and therefore of 
getting resistant virus is low.  
3. Risk of partner related violence: We will promote serostatus disclosure between partners 
as part of our safer conception strategy. Discovery of HIV-serodiscordant status may be 
associated with harm to women.  In addition, women who do not disclose PrEP use, may 
be at risk for partner-related violence should her use of this drug be discovered, given 
the implications that she therefore perceives herself to be at risk for HIV acquisition.  In 
order to reduce the chance of partner violence we will facilitate referrals to couples-
based HIV counselling and testing in the same space as the research is conducted.  
4. Risk of Adverse effects related to taking TDF/FTC PrEP:  TDF/FTC is first-line therapy in 
the treatment of HIV. In patients taking TDF/FTC with other HIV medicines to treat HIV 
infection, common side effects include: diarrhea, nausea, tiredness, headache, 
dizziness, depression, problems sleeping, abnormal dreams, and rash.  In clinical trials 
of TDF/FTC as PrEP in which most people took study drug, side effects were reported 
by about 10% of participants (including those in the placebo group).  In the Partners 

15 
 
PrEP study group the most common reported symptoms was headache reported by 16% 
in each group (TDF, TDF/FTC, and placebo.)  Other risks reported with TDF/FTC 
exposure include: gastrointestinal intolerance, such as nausea, diarrhea or vomiting, and 
flatulence.  Rare but serious side effects (not reported in PrEP trials to date) include 
lactic acidosis/ severe hepatomegaly with steatosis, renal impairment, including cases of 
acute renal failure and Fanconi’s syndrome (renal tubular injury with severe 
hypophosphatemia), increase in bone metabolism leading to osteopenia, hypersensitivity 
reaction, acute exacerbation of hepatitis B infection, body fat redistribution, and risk of 
drug resistance in individuals with undiagnosed HIV. Women will be expressly 
counselled on the risks and benefits of PrEP during both the periconception and 
pregnancy period according to CDC and WHO guidelines. Women will be closely 
monitored in study visits and complete symptom logs.  A clinician will be a part of the 
study staff and PrEP will be held or discontinued for women experiencing adverse 
effects based on his/her clinical judgment.  Data on adverse events and side effects will 
be reported to the Antiretroviral in Pregnancy Registry. 
5. Risk of Stigma: There is a potential that enrolled participants will be stigmatized if they 
reveal their involvement with the study or become associated with the study in some 
other way.  
6. Social harms and psychological stress:   Social harm, including emotional distress (e.g., 
stigma, compromise of reproductive autonomy), is a potential risk for participants.  
Another potential risk for participants is psychological harm, where the participant may 
possibly behave in a manner indicating distress (crying, showing aggression) or verbally 
expresses anxiety, fear or anger regarding own and or a partner’s HIV serostatus or new 
STI diagnoses, interpersonal and or abuse issues within their partnership, pregnancy 
and or HIV serostatus disclosure concerns, as well as concerns with PrEP initiation and 
or adherence. Should this occur the protocol for managing participant distress will be 
implemented. The study team member will immediately stop the study procedures and 
talk with the participant about referral to a counsellor for support. Distressed participants 
will be referred to the local clinic for psychological counselling as per the routine 
standard of care at the clinic (please see Participant Distress Referral Form). After some 
time is allowed for recovery, the study team member will follow up with the participant to 
check their progress. 
7. Risk to confidentiality: Risk to confidentiality exist in all studies. To protect against 
breach of confidentiality, participants will be assigned a unique study identifier, 
participant names will not be used in any recorded interviews or paper forms, all 
documents will be kept in locked cabinets in the study site office in the ISS clinic in 
Mbarara.  All other study data will be associated with participants’ coded identification 
number only. A master list of participant names and their code numbers will be stored in 
a locked file cabinet separate from the rest of the data. Only Dr. Matthews, Dr, Bosco 
and the study coordinator will have access to the list, which will be destroyed within two 
years of publication of study findings, or if there is no publication, no later than six years 
after the study has ended.  All interviews will be conducted in private locations at the 
research site. Safer conception counselling and adherence counselling will occur in 
individual sessions with a trained counsellor.  All data will be kept confidential and stored 
in locked cabinets within restricted areas of MUST. All key drives and computers will be 
password protected. Sexual behaviour data collected by SMS will be protected in the 
servers and the messages themselves will be password protected.  
8. Risk of time inconvenience: There may be a time inconvenience to study participants but 
the study staff will work with participants to reduce study visit burden while still 
maintaining the integrity of the research aims.  

16 
 
9. Risk of discomfort: There is a risk that participants may feel uncomfortable discussing 
issues related to HIV status, STI history, fertility desires and other emotionally-charged 
or personal subjects during visits. However, we do not wish for this to happen, and 
participants may choose not to answer if talking about these issues makes them 
uncomfortable.  On-site counselling services will be made available for participants who 
express distress. In addition to psychological discomfort, participation in blood draws for 
testing may result in physical discomfort including but not limited to: faintness, 
inflammation of the vein, pain, bruising and/or bleeding at the puncture site. There is 
also a small possibility of infection. The physical discomfort from blood draw is unlikely to 
result in any serious adverse reaction but may cause irritation at the puncture site for 
several days. In order to best protect participants from potential discomforts phlebotomy 
procedures for biological and adherence testing will be performed by experienced 
personnel under sterile conditions. Vaginal swabs can also cause some discomfort both 
physically and potentially psychologically, but this will be minimized by encouraging all 
women to self-collect vaginal swabs. 
10. Unforeseen Risks: The study medicine is investigational for use as PrEP (but approved 
for treatment of HIV) in Uganda. It is approved for use as PrEP in the U.S. and Europe 
and recommended by the W.H.O. However, there may be unforeseen or unknown risks 
or side effects.  Women will be expressly counselled on the potential for unforeseen 
risks before initiating or continuing TDF/FTC as PrEP during periconception. In addition, 
women will be counselled on how and when to contact the study clinician if they 
experience any additional or potentially unforeseen side effects throughout their study 
participation. Given the data acquired to date in large clinical trials and demonstration 
projects of TDF/FTC as PrEP and the decades’ experience using TDF/FTC for the 
treatment of HIV, there is no reason to expect that the drug will not work as intended.   
 
IX. 
POTENTIAL BENEFITS 
Potential benefits to participants: The participant may benefit from the information gathered from 
this study by learning strategies for reducing periconception HIV transmission.  Participants who 
choose to initiate and adhere to safer conception strategies will also be engaging in HIV-risk 
reduction. PrEP and safer conception education are not routinely offered in the public health 
sector.  Women participating in the study may have a reduced risk of HIV transmission by virtue 
of their participation. Evaluating uptake of and adherence to antiretrovirals as pre-exposure 
prophylaxis in this population is crucial to understanding whether and how this prevention 
strategy should be incorporated into HIV-risk reduction packages for at-risk women planning or 
with pregnancy. Women will also benefit from receiving objective STI testing to achieve an 
accurate diagnosis and treatment for their STIs which will result in decreased morbidity for the 
participant and her potential children. In addition, participants will have access to regular testing 
and referrals to ongoing care.  
Potential benefits to society (e.g., increased understanding of disease processes): Women who 
choose to conceive with an infected or unknown serostatus partner in HIV-endemic settings 
need prevention strategies to reduce periconception HIV acquisition risk. Women at high risk for 
acquiring HIV during pregnancy also need risk reduction strategies to protect themselves and 
their babies. Evaluating uptake of and adherence to antiretrovirals as pre-exposure prophylaxis 
is crucial to understanding whether and how this prevention strategy should be incorporated into 
HIV risk reduction packages for at risk women planning or with pregnancy. Many PrEP studies 
focused on men who have sex with men (MSM) have shown that patients have an increase in 

17 
 
STIs.[69, 70] Understanding the STI risk among women, especially in the periconception period 
is a crucial first step in the process of designing PrEP programs and understanding patient risk 
in regards to HIV and STIs. 
 
X. 
ALTERNATIVES TO PARTICIPATION 
Participation is completely voluntary.  Deciding not to participate will not have any bearing on 
the participant’s ability to access clinical existing clinical services. 
XI. 
SOURCES OF ADDITIONAL INFORMATION 
 
For the duration of the study, enrolled women will be under the care of Dr. Mwebesa Bosco 
Bwana who is the clinician for the study. Women will be expressly counselled on when and how 
to contact Dr. Mwebesa Bosco Bwana throughout the duration of their participation. Dr. 
Mwebesa Bosco Bwana and other study staff will be available to participants between their 
study visits to discuss potential symptoms or problems.  
 
XII. 
MANAGEMENT OF ADVERSE EVENTS: 
 
Adverse events and serious adverse events will be assessed and logged by study staff at each 
study visit.  Unanticipated adverse events reported to the clinic staff or study clinician outside of 
normal study visits will be recorded and participants will be referred to appropriate care.  All 
adverse events will be reviewed by the Principal Investigators and other relevant study/clinical 
staff and reported to appropriate study ethics committees (MUST IRB, Partners Healthcare 
IRB). 
XIII. 
POST STUDY ACCESS TO TDF/FTC  
 
PrEP is not currently provided in the public sector in Uganda.  We will inform exiting participants 
about their options for accessing it in the private sector, or, should it become available, in the 
public sector. 
 
XIV. 
BIOSTATISTICAL ANALYSIS 
Analysis, Aim 1 
Hypothesis:  70% of women will initiate PrEP as part of a safer conception strategy. In the 
Partners PrEP demonstration project, 
PrEP uptake is ~90% among uninfected 
women in mutually-disclosed 
serodiscordant partnerships (JM Baeten, 
personal communication).  We expect 
uptake to be lower among women who 
are not in mutually-disclosed 
serodiscordant partnerships and who may 
worry about the effects of PrEP on 
pregnancy.  We hypothesize that PrEP 
uptake will be associated with relationship 
power and social support.   
Table 4. 95% CIs for range of uptake and 
adherence. 
% uptake 
or 
adherence 
Uptake, N = 
150 
95% CI 
Adherence1, N = 
105 
95% CI 
50 
42.5-57.5% 
40.4-59.6% 
60 
52.6-67.4% 
50.6-69.4% 
70 
63.1-76.9% 
61.2-78.8% 
80 
74.0-86.0% 
72.3-87.7% 
90 
85.5-94.5% 
84.3-95.7% 
1.  Detectable drug at visit 3 months after initiation 

18 
 
 
Estimates of PrEP uptake: PrEP uptake/initiation is defined as the proportion of enrolled women 
who collect at least one 3-month supply of PrEP.A target sample size of 150 women produces a 
95% CI width between 13% (when 70% initiate PrEP) and 15% (when 50% initiate PrEP) (Table 
4.) We will calculate the prevalence (and 95% CI) of PrEP initiation using an intercept-only 
logistic regression model to account for potential clustering within the two groups (women 
enrolled through partners, women enrolled as individuals).  We will describe, compare and test 
for differences between baseline characteristics of women who do and do not initiate PrEP. Log 
binomial regression with GEE will be used to estimate univariable and multivariable-adjusted 
risk ratios (RR) and 95% CIs for the associations between relationship power/social support and 
PrEP initiation. We will assess potential confounding factors individually; any factor with P≥0.20 
will be excluded from further consideration and the remaining covariates entered into a 
multivariable model.  
 
Analysis, Aim 2 
Hypothesis: 70% of 
women will have 
detectable drug 3 
months after PrEP 
initiation.  
Estimates of 
periconception PrEP 
adherence: 
Periconception 
PrEP adherence will 
be defined as PrEP 
initiators with 
plasma TFV 
concentration > 
40ng/mL three 
months after 
initiating PrEP.  A 
target sample size 
of 105 women 
initiating PrEP will 
provide 95% CI 
width of 18% when 
the percent of high adherers is 80% (Table 4).  Secondary adherence outcomes are based on 
Wisepill device monitoring.  We will determine the mean and median number of pills taken as 
well as patterns of adherence (gaps). We will consider Wisepill adherence as a binary outcome 
defined as taking > 80% of prescribed doses based on biologic plausibility and prior studies [23, 
65, 71, 72]. Monthly assessments of median (interquartile range) adherence and number of 72-
hour adherence gaps will be used to examine longitudinal trends in adherence.   
 
We will calculate prevalence (and 95%CI) of PrEP adherence using an intercept-only logistic 
regression model with GEE.  Log binomial regression with GEE will be used to estimate 
univariable and multivariable-adjusted risk ratios (RR) and 95% CIs for the associations 
between relationship power/social support and PrEP adherence.  
Table 5:  Minimal detectable RR at 80% power, alpha 0.5, 
comparing women with and without exposure characteristic, 
varying distribution of exposure, varying percentages of PrEP 
uptake / adherence. 
% with high 
relationship 
power 
% 
initiatingPrEP 
in unexposed 
group 
(n = 150) 
Min 
detectable 
RR 
% adherent 
in unexposed 
group 
(n = 105) 
Min 
detectable 
RR 
20% 
30% 
1.94 
30% 
2.14 
50% 
1.53 
50% 
1.63 
70% 
1.30 
70% 
1.35 
80% 
1.21 
80% 
1.24 
40% 
30% 
1.77 
80% 
1.24 
50% 
1.45 
30% 
1.94 
70% 
1.27 
50% 
1.54 
80% 
1.19 
80% 
1.22 
60% 
30% 
1.76 
70% 
1.32 
50% 
1.46 
80% 
1.22 
70% 
1.28 
30% 
1.94 
80% 
1.20 
80% 
1.23 

19 
 
 
We will assess potential confounding factors individually; any factor with P≥0.20 will be 
excluded from further consideration and the remaining covariates entered into a multivariable 
model. For continuous adherence outcomes, we will compare mean and median adherence 
levels across the periconception period according to levels of relationship power and social 
support. Depending on the adherence data distribution, we will fit univariable and multivariable 
linear or log-normal regression models with GEE. For the number of 72-hour adherence gaps, 
we will fit Poisson regression models with GEE. Table 5 shows the minimum differences we 
expect to detect with 80% power given a range of PrEP uptake/adherence and a range of 
distributions of exposures, where exposure to a certain characteristic elevates the prevalence of 
PrEP uptake/adherence. For example, to evaluate the association of relationship power on 
PrEP initiation, if the background prevalence of high relationship power is 20% the background 
prevalence of PrEP initiation among women with low relationship power is 50%, a sample size 
of 150 provides 80% power to detect a 53% increased likelihood of PrEP initiation (RR=1.53) 
among those with higher relationship power. 
 
We will describe uptake of and adherence to other safer conception strategies (e.g. proportion 
who time condomless sex to peak fertility, who delay condomless sex until partner is on ART), 
pregnancy incidence, and HIV seroconversion (and compare rates among those taking and 
adherent to PrEP with those who do not take or adhere to PrEP). All power and sample size 
calculations were calculated using Pass II software.   
Analysis, Aim 3 
We will use grounded theory methods to analyze interview data.  These methods lay out a 
systematic set of inductive procedures for developing categories of information, organizing data 
in terms of these categories through coding, connecting the categories, and deriving from these 
connections an empirically grounded theory[73].  
Analysis, Aim 4 
Aim 4.1. We will measure prevalence of STIs in up to 150 HIV-negative women who want to 
conceive a child while at risk for HIV exposure.  
Aim 4.2. We will measure six-month incidence of STIs in up to 150 HIV-negative women who 
conceive or want to conceive a child while at risk for HIV exposure.  
Hypothesis 4.2. We expect a higher incidence of condomless sex leading to a higher STI 
incidence among women who choose PrEP as part of a safer conception strategy compared to 
women who do not take PrEP. 
We intend to evaluate up to 150 HIV-negative women entering the study and estimate the 
prevalence of any STI and each of the specific STIs. Based on prior work, we anticipate the 
incidence of any STI will be approximately 35%[74] and that 2 out of 3 women[75] will want to 
start PrEP. We would have 82% power for a difference of 43% (PrEP group) vs 20% (no PrEP 
group) using a Chi-square test (alpha=0.05, two-sided).  
For Aim 4.1, we will use logistic regression first to test covariates as predictors of having a STI 
at baseline and then to develop an initial model predicting STI. This model will be applied to the 
STI incidence data through six months to assess operating characteristics.  For Aim 4.2, we will 
use a logistic regression model predicting incident STIs over six months including PrEP in all 
models and then adding the number of condomless sex acts to the model. If the number of 

20 
 
condomless sex acts is a significant predictor and there is a substantial reduction in the odds 
ratio (OR) for PrEP when the number of condomless sex acts is included in the model, then we 
will conclude that this is a mediator of the PrEP effect.   
 
XV. 
MONITORING AND QUALITY ASSURANCE  
The Ugandan PI will be responsible for continuous data and safety monitoring of all study 
participants and for alerting the US PI if unexpected concerns arise. Serious adverse events 
(e.g. physical or emotional injury) will be reported to all involved IRBs according to the 
guidelines of each IRB (i.e., within ten days for the Partners’ IRB) and to Gilead who will be 
providing study drug.  
Any protocol violations will be reported within the required timeframe (as per MUST IRB / 
Partners IRB requirements). 
All study-related information will be stored securely at the study site. All participant information 
will be stored in areas with limited access. Data collection will be labelled only by a participant 
identification number to maintain participant confidentiality. All records that contain names or 
other personal identifiers, such as locator forms and informed consent forms, will be stored 
separately from study records labelled with the participant identification number. All databases 
will be secured with password-protected access systems. The master list linking participant 
name to study identification number and other identifying information in study files will be 
retained for six years after the study is completed; after that time, the link will be destroyed. 
We will review the data bi-annually with particular attention to possible adverse events 
(including HIV acquisition, medication-related adverse events, adverse pregnancy outcomes, 
and social harms) among women participating in this study with a focus on: 
• 
Rate of HIV seroconversion, compared against the anticipated rate of incident HIV 
infection in the study population.  
• 
Serious adverse events and medication side effects.  
• 
Social harm, including emotional distress (e.g., stigma, compromise of reproductive 
autonomy).  
• 
Study execution, including enrolment rates, retention, PrEP initiation, and adherence.  
 
XVI. 
Budget for MUST  
  
Year 1 
Year 2 
Year 3 
  
7/1/16-6/30/17 
7/1/17-6/30/18 
7/1/18-6/30/19 
Personnel 
$74,766 
$74,766 
$74,766 
Consultants 
$0 
$0 
$0 
STI laboratory fees 
$0 
$2,000 
$12,714 
Equipment 
 n/a 
n/a 
n/a 
Supplies 
$850 
$150 
$0 
STI testing supplies 
$0 
$100 
$430 
STI shipping fees for 
confirmatory testing 
$0 
$200 
$800 

21 
 
STI treatment 
medications 
$0 
$50 
$295 
Travel 
$2,846 
$4,346 
$5,862 
Subject Costs 
$7,500 
$7,500 
$0 
Other 
$64,038 
$63,238 
$69,372 
Direct Costs 
$150,000 
$150,000 
$150,000 
Indirect Costs 
$15,000 
$15,000 
$15,000 
TOTAL 
$165,000 
$165,000 
$165,000 
 
 
 

22 
 
REFERENCES 
1. 
The_World_Bank. Fertility rate (total births per woman), Table. 2013  12 September 2013]; 
Word Development Indicators]. Available from: 
http://data.worldbank.org/indicator/SP.DYN.TFRT.IN. 
2. 
Ministry_of_Health, U. and UNAIDS, HIV and AIDS Uganda Country Progress Report 2014. 2015. 
3. 
Beyeza-Kashesya, J., et al., My partner wants a child: a cross-sectional study of the determinants 
of the desire for children among mutually disclosed sero-discordant couples receiving care in 
Uganda. BMC Public Health, 2010. 10: p. 247. 
4. 
Heys, J., et al., Fertility desires and infection with the HIV: results from a survey in rural Uganda. 
AIDS, 2009. 23 Suppl 1: p. S37-45. 
5. 
Nakayiwa, S., et al., Desire for children and pregnancy risk behavior among HIV-infected men and 
women in Uganda. AIDS Behav, 2006. 10(4 Suppl): p. S95-104. 
6. 
Wanyenze, R.K., et al., Fertility and contraceptive decision-making and support for HIV infected 
individuals: client and provider experiences and perceptions at two HIV clinics in Uganda. BMC 
Public Health, 2013. 13: p. 98. 
7. 
Wagner, G. and R.K. Wanyenze, Fertility desires and intentions and the relationship to consistent 
condom use and provider communication regarding childbearing among HIV clients in Uganda. 
ISRN Infectious Diseases, 2013. 
8. 
Case, K.K., et al., Understanding the modes of transmission model of new HIV infection and its 
use in prevention planning. Bull World Health Organ, 2012. 90(11): p. 831-838A. 
9. 
Beyeza-Kashesya, J., et al., The dilemma of safe sex and having children:  challenges facing HIV 
sero-discordant couples in Uganda. African Health Sciences, 2009. 9(1): p. 2-12. 
10. 
Kastner, J., et al., Antiretroviral Therapy Helps HIV-Positive Women Navigate Social Expectations 
for and Clinical Recommendations against Childbearing in Uganda. AIDS Res Treat, 2014. 2014: 
p. 626120. 
11. 
Matthews, L.T., et al., “I always worry about what might happen ahead”: Implementing safer 
conception services in the current environment of reproductive counseling for HIV-affected men 
and women in Uganda. BioMed Central: International Research, in press, 2015. 
12. 
Matthews, L.T., et al., Antiretrovirals and safer conception for HIV-serodiscordant couples. Curr 
Opin HIV AIDS, 2012. 7(6): p. 569-578. 
13. 
Bekker, L.G., et al., Guideline on safer conception in fertile HIV-infected individuals and couples. 
The Southern African Journal of HIV Medicine, 2011. 12(2): p. 31-44. 
14. 
Eke, A.C. and C. Oragwu, Sperm washing to prevent HIV transmission from HIV-infected men but 
allowing conception in sero-discordant couples. Cochrane Database Syst Rev, 2011(1): p. 
CD008498. 
15. 
Matthews, L.T., et al., Consistently high study medication adherence during periconception 
periods among HIV-1-uninfected women participating in a clinical trial of antiretroviral pre-
exposure prophylaxis. JAIDS, 2014. 67(1): p. 91-97. 
16. 
Matthews, L.T., et al., Periconception pre-exposure prophylaxis to prevent HIV transmission: 
benefits, risks, and challenges to implementation. AIDS, 2010. 24(13): p. 1975-1982. 
17. 
Cohen, M.S., et al., Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med, 
2011. 365(6): p. 493-505. 
18. 
Grosskurth, H., et al., Impact of improved treatment of sexually transmitted diseases on HIV 
infection in rural Tanzania: randomised controlled trial. Lancet, 1995. 346(8974): p. 530-6. 
19. 
Wawer, M.J., et al., A randomized, community trial of intensive sexually transmitted disease 
control for AIDS prevention, Rakai, Uganda. Aids, 1998. 12(10): p. 1211-25. 

23 
 
20. 
Semprini, A.E., et al., Insemination of HIV-negative women with processed semen of HIV-positive 
partners. Lancet, 1992. 340(8831): p. 1317-9. 
21. 
Weller, S. and K. Davis, Condom effectiveness in reducing heterosexual HIV transmission. 
Cochrane Database Syst Rev, 2002(1): p. CD003255. 
22. 
World_Health_Organization, Guidance on couples HIV testing and counselling including 
antiretroviral therapy for treatment and prevention in serodiscordant couples. 2012: Geneva. 
23. 
Baeten, J.M., et al., Antiretroviral Prophylaxis for HIV Prevention in Heterosexual Men and 
Women. N Engl J Med, 2012. 367(5): p. 399-410. 
24. 
Thigpen, M.C., et al., Antiretroviral Preexposure Prophylaxis for Heterosexual HIV Transmission in 
Botswana. N Engl J Med, 2012. 367(5): p. 423-34. 
25. 
Donnell, D., et al., HIV protective efficacy and correlates of tenofovir blood concentrations in a 
clinical trial of PrEP for HIV prevention. J Acquir Immune Defic Syndr, 2014. 66(3): p. 340-8. 
26. 
Ministry_of_Health, U. and UNAIDS, HIV and AIDS Uganda Country Progress Report. 2014. 
27. 
Uganda_Bureau_of_Statistics and ICF_International_Inc., Uganda Demographic and Health 
Survey 2011, M.I.I. UBOS and Calverton, Editor. 2012: Kampala, Uganda. 
28. 
Sauer, M.V., et al., Providing fertility care to men seropositive for human immunodeficiency 
virus: reviewing 10 years of experience and 420 consecutive cycles of in vitro fertilization and 
intracytoplasmic sperm injection. Fertil Steril, 2009. 91(6): p. 2455-60. 
29. 
Centers_for_Disease_Control. Elimination of Mother-to-Child Transmission (EMTCT) in the 
United States. 2014  [cited 2015 December 22, 2015]; Available from: 
http://www.cdc.gov/hiv/group/gender/pregnantwomen/emct.html. 
30. 
Panel_on_Treatment_of_HIV-
Infected_Pregnant_Women_and_Prevention_of_Perinatal_Transmission, Recommendations for 
use of antiretroviral drugs in pregnant HIV-1-infected women for maternal health and 
interventions to reduce perinatal HIV transmission in the United States. 2014. 
31. 
Schwartz, S.R., et al., Implementation of a safer conception service for HIV-affected couples in 
South Africa. AIDS, 2014. 28 Suppl 3: p. S277-85. 
32. 
Pintye, J., et al., Fertility Decision-Making Among Kenyan HIV-Serodiscordant Couples Who 
Recently Conceived: Implications for Safer Conception Planning. AIDS Patient Care STDS, 2015. 
29(9): p. 510-6. 
33. 
Marrazzo, J.M., et al., Tenofovir-based preexposure prophylaxis for HIV infection among African 
women. N Engl J Med, 2015. 372(6): p. 509-18. 
34. 
Van Damme, L., et al., Preexposure Prophylaxis for HIV Infection among African Women. N Engl J 
Med, 2012. 367(5): p. 411-22. 
35. 
Bekker, L.G., et al. HPTN 067/ADAPT Cape Town: A comparison of daily and nondaily  
PrEP dosing in African women, poster 978LB. in CROI. 2015. Seattle. 
36. 
van der Straten, A., et al., Women's experiences with oral and vaginal pre-exposure prophylaxis: 
the VOICE-C qualitative study in Johannesburg, South Africa. PLoS One, 2014. 9(2): p. e89118. 
37. 
Corneli, A., et al., Perception of HIV Risk and Adherence to a Daily, Investigational Pill for HIV 
Prevention in FEM-PrEP. J Acquir Immune Defic Syndr, 2014. 67(5): p. 555-63. 
38. 
World_Health_Organization, Guideline on when to start antiretroviral therapy and on pre-
exposure prophylaxis for HIV. 2015, W.H.O.: Geneva. 
39. 
Lampe, M.A., et al., Achieving safe conception in HIV-discordant couples: the potential role of 
oral preexposure prophylaxis (PrEP) in the United States. Am J Obstet Gynecol, 2011. 204(6): p. 
e1-e8. 
40. 
Whetham, J., et al., Pre-exposure prophylaxis for conception (PrEP-C) as a risk reduction strategy 
in HIV-positive men and HIV-negative women in the UK. AIDS Care, 2013. 

24 
 
41. 
Vernazza, P.L., et al., Preexposure prophylaxis and timed intercourse for HIV-discordant couples 
willing to conceive a child. AIDS, 2011. 25(16): p. 2005-8. 
42. 
U.S._Public_Health_Service, Centers_for_Disease_Control_and_Prevention, and U. 
Department_of_Health_and_Human_Services, Preexposure prophylaxis for the prevention of 
HIV infection in the United States - 2014.  Clinical Providers' Supplement. 2014. 
43. 
Carey, M.P. and K.E. Schroder, Development and psychometric evaluation of the brief HIV 
Knowledge Questionnaire. AIDS Educ Prev, 2002. 14(2): p. 172-82. 
44. 
Matthews, L.T., et al., Periconception HIV risk behavior among men and women reporting HIV-
serodiscordant partnesr in KwaZulu-Natal, South Africa. AIDS and Behavior, 2015. 
45. 
Napper, L.E., D.G. Fisher, and G.L. Reynolds, Development of the perceived risk of HIV scale. AIDS 
Behav, 2012. 16(4): p. 1075-83. 
46. 
Kalichman, S.C., Post-exposure prophylaxis for HIV infection in gay and bisexual men. 
Implications for the future of HIV prevention. Am J Prev Med, 1998. 15(2): p. 120-7. 
47. 
van Balen F, T.-K.T., Involuntarily childless couples: their desire to have children and their 
motives. . J Psychosom Obstet Gynaecol 1995. 16: p. 137-144. 
48. 
Tsai, A.C., et al., Internalized stigma, social distance, and disclosure of HIV seropositivity in rural 
Uganda. Ann Behav Med, 2013. 46(3): p. 285-94. 
49. 
Stirratt, M.J., et al., The role of HIV serostatus disclosure in antiretroviral medication adherence. 
AIDS Behav, 2006. 10(5): p. 483-493. 
50. 
Pulerwitz, J., S.L. Gortmaker, and W. DeJong, Measuring sexual relationship power in HIV/STD 
research. Sex Roles, 2000. 42(7/8): p. 637-620. 
51. 
Milhausen, R.R., Sales, J.M., Wingood, G.M., DiClemente, R.J., Salazar, L.F., & Crosby, R.A, 
Validation of a Partner Sexual Communication Scale for Use in HIV/AIDS Prevention 
Interventions. Journal of HIV/AIDS Prevention in Children & Youth, 2007. 8: p. 11 – 33. 
52. 
Broadhead, W.E., The Duke-UNC Functional Social Support Questionnaire. Measurement of 
social support in family medicine patients. . MEDICAL CARE, 1998. 26(7): p. 709-23. 
53. 
Visser, M.J., et al., Development of parallel scales to measure HIV-related stigma. AIDS Behav, 
2008. 12(5): p. 759-71. 
54. 
Crankshaw, T.L., et al., A conceptual framework for periconception HIV transmission risk 
reduction among HIV serodiscordant couples. Reproductive Health Matters, 2012. 20(39): p. 50-
60. 
55. 
Bunting, L. and J. Boivin, Development and preliminary validation of the fertility status 
awareness tool: FertiSTAT. Hum Reprod, 2010. 25(7): p. 1722-33. 
56. 
PRAMS model surveillance protocol. 2009  [cited 2009; Available from: 
http://www.cdc.gov/prams. 
57. 
Ahluwalia, I.B., et al., Pregnancy Risk Assessment Monitoring System (PRAMS): unintended 
pregnancy among women having a live birth. PRAMS Working Group. J Womens Health Gend 
Based Med, 1999. 8(5): p. 587-9. 
58. 
Klerman, L.V., The intendedness of pregnancy: a concept in transition. Matern Child Health J, 
2000. 4(3): p. 155-62. 
59. 
Rogers, M.M., I.B. Ahluwalia, and C.L. Melvin, The pregnancy risk assessment monitoring system 
(PRAMS). J Womens Health, 1998. 7(7): p. 799-801. 
60. 
Mudau, M., et al., High prevalence of asymptomatic sexually transmitted infections among 
human immunodeficiency virus-infected pregnant women in a low-income South African 
community. Int. J. STD AIDS, 2017: p. 956462417724908. 
61. 
Alam, N., et al., Partner notification for sexually transmitted infections in developing countries: a 
systematic review. BMC public health, 2010. 10(1): p. 19. 

25 
 
62. 
Hendrix, C.W., et al., Dose Frequency Ranging Pharmacokinetic Study of Tenofovir-Emtricitabine 
After Directly Observed Dosing in Healthy Volunteers to Establish Adherence Benchmarks (HPTN 
066). AIDS Res Hum Retroviruses, 2016. 32(1): p. 32-43. 
63. 
Castillo-Mancilla, J.R., et al., Short communication: Tenofovir diphosphate in dried blood spots as 
an objective measure of adherence in HIV-infected women. AIDS Res Hum Retroviruses, 2015. 
31(4): p. 428-32. 
64. 
Liu, A., et al., Patterns and correlates of PrEP drug detection among MSM and transgender 
women in the Global iPrEx Study. J Acquir Immune Defic Syndr, 2014. 67(5): p. 528-37. 
65. 
Haberer, J.E., et al., Adherence to Antiretroviral Prophylaxis for HIV Prevention: A Substudy 
Cohort within a Clinical Trial of Serodiscordant Couples in East Africa. PLoS Med, 2013. 10(9): p. 
e1001511. 
66. 
Lingappa, J., et al., Sensitivity and specificity of herpes simplex virus-2 serological assays among 
HIV-infected and uninfected urban Ugandans. International journal of STD & AIDS, 2010. 21(9): 
p. 611-616. 
67. 
Bahr, N.C., et al., Diagnostic accuracy of Xpert MTB/RIF Ultra for tuberculous meningitis in HIV-
infected adults: a prospective cohort study. Lancet Infect Dis, 2018. 18(1): p. 68-75. 
68. 
Mlisana, K., et al., Symptomatic vaginal discharge is a poor predictor of sexually transmitted 
infections and genital tract inflammation in high-risk women in South Africa. J. Infect. Dis., 2012. 
206(1): p. 6-14. 
69. 
Volk, J.E., et al., No New HIV Infections With Increasing Use of HIV Preexposure Prophylaxis in a 
Clinical Practice Setting. Clin. Infect. Dis., 2015. 61(10): p. 1601-1603. 
70. 
Liu, A.Y., et al., Preexposure Prophylaxis for HIV Infection Integrated With Municipal- and 
Community-Based Sexual Health Services. JAMA Intern. Med., 2016. 176(1): p. 75-84. 
71. 
Garcia-Lerma, J.G., et al., Prevention of rectal SHIV transmission in macaques by daily or 
intermittent prophylaxis with emtricitabine and tenofovir. PLoS Med, 2008. 5(2): p. e28. 
72. 
Grant, R.M., et al., Preexposure Chemoprophylaxis for HIV Prevention in Men Who Have Sex with 
Men. N Engl J Med, 2010. 363(27): p. 2587-99. 
73. 
Miles, M.B. and A.M. Huberman, Qualitative Data Analysis:  An expanded sourcebook. 2nd ed. 
1994, Thousand Oaks, CA: SAGE Publications, Inc. 
74. 
Kaida, A., et al. High burden of asymptomatic genital tract infections among sexually active 
South African youth: Considerations for HIV prevention programs. in Poster presented at: South 
African AIDS Conference. June 2017. Durban, South Africa. 
75. 
Matthews, L.T., et al., High Medication Adherence During Periconception Periods Among Hiv-1–
uninfected Women Participating in a Clinical Trial of Antiretroviral Pre-exposure Prophylaxis. 
Jaids Journal of Acquired Immune Deficiency Syndromes, 2014. 67(1): p. 91-97. 
XVII.