UNCPMZ 41901 - An Integrated Strategy to Support Antiretroviral Therapy and Pre-exposure Prophylaxis Adherence for HIV Prevention in Pregnant and Breastfeeding Women: a Pilot Study
Phase: NA
Conditions: HIV-1-infection, Antenatal Care
Sponsor: University of North Carolina, Chapel Hill

 
Title:  
An Integrated Strategy to Support Antiretroviral Therapy and Pre-exposure Prophylaxis Adherence for 
HIV Prevention in Pregnant and Breastfeeding Women 
 
 
NCT number:  
NCT04330989 
 
 
Document date: 
April 14, 2019 

 
Protocol v1.0 | 14 April, 2019 
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An integrated strategy to support antiretroviral therapy and pre-exposure prophylaxis 
adherence for HIV prevention in pregnant and breastfeeding women: a pilot study 
 
 
 
  
Protocol version 1.0 
April 14, 2019 
 
 
 
 
Funded by: 
US National Institutes of Health  
R01 AI131060 
A dyad approach to combination HIV prevention in pregnancy for Zambia and Malawi 
 
 
 Protocol Co-Chairs:  
Wilbroad Mutale MBChB, PhD 
Benjamin H. Chi, MD, MSc 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
Protocol v1.0 | 14 April, 2019 
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INVESTIGATORS AND SCIENTIFIC TEAM 
 
Protocol Chairs: 
Dr. Wilbroad Mutale MPhil, PhD 
Department of Health Policy 
University of Zambia School of Public Health,  
Box 50110, Lusaka, Zambia 
Email: wmutale@yahoo.com 
 
Benjamin H. Chi, MD, MSc 
Division of Global Women’s Health 
Department of Obstetrics and Gynecology 
University of North Carolina at Chapel Hill 
111 Mason Farm Rd; CB 7577, 4300 MBRB 
Chapel Hill, NC 27599 
Email: bchi@med.unc.edu  
 
Investigator of Record (IOR) Zambia 
Kellie Freeborn, RN, NP-BC, MSc., PhD 
UNC Global Projects - Zambia  
348 Independence Avenue 
Lusaka, Zambia 
Email: kellie.freeborn@med.unc.edu 
 
Investigator of Record (IOR) Malawi 
Friday Saidi, MBBS, MMed 
University of North Carolina (UNC) Project –Malawi 
100 Mzimba Road  
Kamuzu Central Hospital 
P. Bag A-104  
Lilongwe, Malawi 
Email: fsaidi@unclilongwe.org 
 
Co-Investigators: 
Margaret Kasaro, MBChB, MS 
 
 
 
 
 
UNC Global Projects - Zambia  
348 Independence Avenue 
Lusaka, Zambia 
Email: margaret.kasaro@unclusaka.org  
 
Andrew Kumwenda, MBChB, MPhil, MPH, MMed 
Department of Obstetrics and Gynaecology 
University of Zambia School of Medicine  
P.O. Box 50110 
Lusaka, Zambia.  
Email: andrew.kumwenda@unza.zm  
 
Oliver Mweemba, MPhil, PhD 
Department of Health Promotion and Education 
University of Zambia School of Public Health  
P.O. Box 50110 
Lusaka, Zambia 
Email: mweemba2@yahoo.com 
 
 

 
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Twaambo Hamoonga-Nkweendenda MPH  
Department of Community and Family Medicine, 
University of Zambia School of Public Health 
P.O. Box 50110 
Lusaka, Zambia. 
Email: tehams24@gmail.com 
 
Suzanne Maman, PhD 
Department of Health Behavior 
Gillings School of Global Public Health 
University of North Carolina at Chapel Hill 
135 Dauer Drive  
Chapel Hill, NC 27599 
Email: maman@email.unc.edu 
 
Kimberly Powers, PhD 
Department of Epidemiology  
Gillings School of Global Public Health 
University of North Carolina at Chapel Hill  
135 Dauer Drive  
Chapel Hill, NC 27599 
Email: powersk@email.unc.edu 
 
Nora Rosenberg, MSPH, PhD 
Department of Health Behavior 
Gillings School of Global Public Health 
University of North Carolina at Chapel Hill 
302 Rosenau Hall Campus Box 7440  
Chapel Hill, NC 27599 
Email: nrosenbe@email.unc.edu 
 
 
 
 
 
Katie Mollan, MS 
UNC Center for AIDS Research – Biostatistics Core 
School of Medicine 
University of North Carolina at Chapel Hill  
135 Dauer Drive  
Chapel Hill, NC 27599 
Email: kmollan@unc.edu 
 
Cassidy Claassen, MD, MPH 
Center for International Health, Education, and Biosecurity 
Institute for Human Virology at University of Maryland School of Medicine 
MGIC-Zambia, 6392 Dunduza Chisidza Crescent 
Lusaka, Zambia 
Email: cclaassen@ihv.umaryland.edu 
 
 
 

 
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PROTOCOL SUMMARY 
 
Background: If the anticipated gains for the prevention of mother-to-child HIV transmission (PMTCT) programs 
are to be realized, adherence to antiretroviral regimens will be critical. To date, however, there are few evidence-
based approaches that are scalable and sustainable in busy, programmatic settings where HIV burden is high. 
Based on our formative work, we developed a combination approach that includes patient-centered counseling 
and adherence supporter training. We seek to implement the intervention for both HIV-positive (for antiretroviral 
therapy, or ART) and HIV-negative (for pre-exposure prophylaxis, or PrEP) pregnant and breastfeeding women, 
thus providing a universal approach to support PMTCT programs holistically.  
 
Objective: We seek to obtain preliminary data about the effectiveness and implementation of a multi-
component adherence support strategy for HIV treatment and prevention among pregnant and breastfeeding 
women. 
 
Design: We propose two parallel, pilot randomized trials among women seeking antenatal clinic (ANC) services 
in Lusaka, Zambia and Lilongwe, Malawi. In Trial 1, we will evaluate the proposed multi-component intervention 
in the context of ART support for HIV-positive women. In Trial 2, we will assess the same strategy applied to 
PrEP adherence among HIV-negative women at elevated risk for HIV acquisition.  
 
Proposed intervention: We propose a multi-component strategy to support both ART and PrEP adherence in 
the context of antenatal care settings. The principal components include: 
 
 
Patient-centered counseling: Integrated next step counseling (iNSC) is a structured, patient-centered 
approach informed by motivational interviewing techniques. The goal of iNSC is to foster an environment for 
joint-problem solving in order that the participant may identify their individual needs to increase or sustain 
sexual health through biomedical and non-biomedical approaches.  iNSC frames the counselling sessions 
as a non-judgmental discussion to explore the facilitators and challenges to sexual health and medication 
adherence.  Through this process the participant is able to identify needs to optimize sexual health protection 
and medication adherence.    
 
 
Adherence supporter training: There is broad body of knowledge showing that peer or partner support can 
help to enhance adherence and retention in antenatal and HIV programs. We propose an adherence 
supporter intervention. Participants will be asked to identify a partner, family member, or friend to whom they 
are willing to disclose their HIV status (for HIV-positive women) or their intent to initiate PrEP (for HIV-
negative women). Participants may also select a clinic-based peer to serve in this adherence supporter role. 
The emphasis of these trainings will be basic HIV knowledge, importance of antiretroviral adherence, 
potential drug side effects, and practical strategies for supporting adherence. Based on our formative 
research, we believe the addition of this adherence supporter intervention to iNSC will help to reinforce 
behaviors discussed during patient-centered counseling.  
 
Study Arms: Participants randomly assigned to the control arm will receive supplemental counseling in safe 
obstetrics and newborn care, based on World Health Organization guidelines. Women randomly assigned to the 
intervention arm will receive a multi-component support strategy comprising iNSC and adherence supporter 
training.  
 
Population: We will enroll pregnant women 18 years of age or older receiving antenatal care services at our 
designated study facilities. In Trial 1, we will enroll 100 HIV-positive women who started (or re-started, after a 6 
months or longer treatment interruption) a first-line ART regimen within the past 30 days. In Trial 2, we will enroll 
200 HIV-negative women willing to initiate and continue oral PrEP, in the form of tenofovir disoproxil fumarate 
and emtricitabine (TDF-FTC), and who report factors that place them at elevated risk for HIV acquisition.  
 
Study Site: Chipata First Level Hospital (Lusaka, Zambia) and Bwaila District Hospital (Lilongwe, Malawi)  
 
Duration and Follow up: The duration of recruitment is expected to be six months. The length of participant 
follow-up is six months from enrollment.  

 
Protocol v1.0 | 14 April, 2019 
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Study Outcomes: For Trial 1 (ART adherence support), the primary outcome is to be retained in care with HIV 
viral suppression at six months following study enrollment. Secondary outcomes include: adherence to ART as 
measured by self-report and pharmacy measures; acceptability, feasibility, and fidelity of adherence support 
components; and incidence of social harms and other adverse events associated with the study intervention. For 
Trial 2 (PrEP adherence support), the primary outcome is retained in care with adherence to PrEP as 
measured by plasma and intracellular tenofovir drug concentrations at six months following study 
enrollment. Secondary outcomes include: adherence to PrEP as measured by self-report and pharmacy 
measures; acceptability, feasibility, and fidelity of adherence support components; incidence of social harms and 
other adverse events associated with the study intervention; and incidence of maternal HIV infection. 
 
Relevance: To achieve the goal of eliminating mother-to-child transmission of HIV in sub-Saharan Africa by 
2030 and to meet the ambitious 95-95-95 target set forth by UNAIDS, new approaches are needed to support 
proven biomedical interventions during pregnancy and breastfeeding. Antiretroviral regimens for ART and PrEP 
have been shown to be highly efficacious in clinical trials; however, barriers to adherence in public health settings 
may mitigate their otherwise broad population impact. New, resource-appropriate, and scalable approaches are 
urgently needed to support the implementation of these evidence-based practices. 
 
 

 
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1.0 INTRODUCTION 
 
Services to prevent mother-to-child transmission of HIV (PMTCT) have expanded rapidly and dramatically 
reduced pediatric HIV in sub-Saharan Africa. A rapid progression of scientific, programmatic, and policy 
advances have led to calls for the “virtual elimination” of pediatric HIV.1 However, two sets of challenges remain.  
 
First, despite policies supporting lifelong antiretroviral therapy (ART) for all HIV-infected pregnant and 
breastfeeding women (i.e., the Option B+ strategy), uptake is not universal2 and a significant proportion drop out 
of care over time, nearly 20% in the first six months on treatment.3-6 In addition, without adequate support, 
adherence to ART may be suboptimal, which may in turn lead to antiretroviral drug resistance, treatment failure, 
and subsequent horizontal or vertical transmission.7 While interventions have been shown to improve adherence 
and retention during pregnancy and breastfeeding,3 there is need for scalable models that can be integrated into 
existing health systems.  
 
Second, existing antenatal services leave large gaps in primary HIV prevention. Women in sub-Saharan Africa 
face an unacceptably high risk of acquiring HIV during pregnancy and breastfeeding. In a meta-analysis of 19 
studies, Drake and colleagues reported a pooled incidence rate of 4.7/100 person-years (95% confidence 
interval [CI]: 3.3–6.1) during pregnancy and 2.9/100 person-years (95%CI: 1.8–4.0) while breastfeeding.8 
Women who become acutely infected during pregnancy and breastfeeding have much higher rates of mother-
to-child HIV transmission (MTCT).9-12 Unfortunately, for the majority of pregnant women who test HIV-negative, 
services end with post-test counseling; few—if any—structured interventions are offered.  
 
We propose a multi-component adherence support strategy to support HIV treatment and prevention in the 
context of pregnancy and breastfeeding. Our intervention combines both biomedical and behavioral components; 
it is also cross-cutting in nature, designed to support both HIV treatment (i.e., ART) and prevention (i.e., PrEP) 
in antenatal settings to reduce vertical and horizontal HIV transmission. We consider the HIV status of all 
pregnant and breastfeeding women and offer interventions tailored to those circumstances. It contrasts the 
typical PMTCT approach, which segments the antenatal population based on HIV status and provides targeted 
interventions to only select (i.e., HIV-positive) groups. If proven effective, this cross-cutting model could have a 
transformative effect on how HIV prevention, care, and treatment are integrated within antenatal care in African 
settings. 
 
 
2.0 STATEMENT OF THE PROBLEM 
 
To achieve the goal of eliminating mother-to-child transmission of HIV (EMTCT) in sub-Saharan Africa by 2030 
and to meet the ambitious 95-95-95 target set forth by UNAIDS,13 new approaches are needed to support proven 
biomedical interventions during pregnancy and breastfeeding. Antiretroviral regimens for ART and PrEP have 
been shown to be highly efficacious in clinical trials. However, barriers to adherence in public health settings 
may mitigate their otherwise broad population impact. New, resource-appropriate, and scalable approaches are 
urgently needed to support the implementation of these evidence-based practices. 
 
 
3.0 RATIONALE 
 
In this pilot study, we evaluate a cross-cutting approach to support antiretroviral adherence, one that can be 
applied to ART and PrEP. Our study intervention comprises two parts: patient-centered counseling and 
adherence supporter training. These components are informed by the current medical literature, as well as our 
own formative work. We focus on the antenatal and postnatal periods because they represent periods of elevated 
HIV risk—both for mother and infant—and windows of increased healthcare access. By evaluating the 
intervention’s effectiveness, acceptability, and feasibility, we will obtain the necessary preliminary data to inform 
larger definitive studies for PMTCT.  
  
 

 
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4.0 LITERATURE REVIEW 
 
4.1 Reduction of pediatric HIV in global settings 
 
An estimated 1.6 million new HIV infections among children were prevented globally in the past two decades, 
due in large part to the availability of antiretroviral drugs to HIV-positive pregnant and breastfeeding women.13 
The majority of these prevented infections—approximately 1.3 million—have occurred since 2010.14-16 These 
remarkable gains have been made through important scientific advancements, forward-thinking policy changes, 
and renewed investments from local governments and international donors.17,18 Driven by global campaigns—
including the Global Plan Towards the Elimination of New HIV Infections among Children by 2015 and Keeping 
Their Mothers Alive19—national programs in sub-Saharan Africa have reduced new pediatric HIV infections by 
60% and reduced AIDS-related pediatric mortality under 5 years by 62%. The proportion of children living with 
HIV who received antiretroviral therapy (ART) increased from 15% to 51% globally in six years (2009-2015).14-16 
Despite this tremendous progress, however, challenges remain. The majority of pediatric HIV infections continue 
to be via MTCT and occur mainly in sub-Saharan Africa.15,20 Although universal ART is routinely available during 
pregnancy and breastfeeding (i.e., Option B+),21 uptake and adherence present ongoing challenges.4,6,22 In 
addition, there is growing recognition that current programs, which emphasize HIV treatment for HIV-positive 
women alone, may overlook pregnant and breastfeeding women who acquire HIV during pregnancy, but are 
missed through existing PMTCT services.23 
 
 
4.2. Evolution of PMTCT regimens and the continued need for ART adherence  
 
Significant progress has been made globally to prevent mother-to-child HIV transmission in the past two 
decades.18,24 In most African settings, recommended antiretroviral regimens have evolved from short-course 
regimens, including short-course zidovudine25 and intrapartum nevirapine,26,27 to lengthier combination regimens 
that covered the longer span of pregnancy and breastfeeding.28 With the expansion of HIV services in the 
region—and driven by effective global campaigns—there has been a rapid move towards universal antiretroviral 
therapy (ART) for all HIV-positive pregnant and breastfeeding women. Initially introduced in Malawi, the so-called 
“Option B+” strategy was soon incorporated into World Health Organization HIV guidelines and adopted by 
countries in sub-Saharan Africa and worldwide.29 Subsequent studies of this regimen have demonstrated the 
efficacy of its various components, including the PROMISE 1077BF/FF studies conducted in multiple African 
sites and in India.30-32 
 
The evolution of PMTCT policy has led to significant reductions in pediatric HIV in sub-Saharan Africa. However, 
while coverage of services has improved across the region, there is growing concern about achievement and 
sustainment of virologic suppression during pregnancy and breastfeeding—the key determinant of successful 
PMTCT.33,34 In one meta-analysis, the pooled proportion of antenatal mothers with adequate ART adherence 
(defined as >80%) was only 72%.33 In Malawi, another study reported adequate adherence in only 73% of 
pregnant women, with a significant drop in the first three months after delivery.35 As national programs seek to 
meet the new 95-95-95 targets set forth by UNAIDS, it is clear that new interventions are needed to support ART 
adherence during pregnancy and breastfeeding. There appears to be a growing armamentarium of evidence-
based practices available to program managers and policymakers. Strategies include integrated HIV care within 
antenatal settings,36-38 peer adherence supporters,39 text messages and other mHealth interventions,40 and 
cognitive behavioral interventions.41   
 
 
4.3 PrEP in pregnancy and breastfeeding: new opportunities and challenges 
 
In randomized trials, oral pre-exposure prophylaxis (PrEP), in the form of daily tenofovir disoproxil fumarate and 
emtricitabine (TDF-FTC), has been shown to be effective for prevention of HIV acquisition,42-46 including in 
women.47,48 This intervention may be particularly well-suited for pregnancy and breastfeeding. Not only are HIV 
incidence rates exceedingly high during pregnancy in many African settings,8 features that characterize this 
period may lead to greater PrEP adherence: high levels of institutional healthcare,49,50 altruistic motivations 
towards the unborn fetus,51-53 a tradition of male partner engagement,54 and a window of concentrated risk. In 

 
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order to be effective, however, adherence is critical. In studies where adherence was high, the risk for new HIV 
infections dropped by as much as 85%;47 when adherence was low, results were equivocal.55 
 
TDF-FTC has been used in the context of pregnancy for both HIV and hepatitis B therapy, and has a strong track 
record for maternal and infant safety.57  Data from PrEP trials have shown that TDF-FTC in the first trimester did 
not result in adverse outcomes at birth or in infant growth.58 A smaller, open-label study—where women were 
given the option of continuing PrEP once they became pregnant—demonstrated similarly encouraging 
outcomes.59 Studies in Kenya and Uganda suggest that PrEP can be safely used during breastfeeding with 
minimal infant drug exposure.60 In settings with high HIV incidence during pregnancy (i.e., greater than 3.0 
infections per 100 person-years), PrEP has been shown to be highly cost-effective across a range of modeling 
assumptions.61 
 
Early studies suggest that pregnant and 
breastfeeding women will initiate PrEP. In a 
pilot program in Kenya, a large proportion of 
HIV-negative women in serodiscordant 
relationships continued PrEP even after the 
diagnosis of pregnancy.59 The decision to 
remain on the regimens was driven by the 
desire to prevent horizontal and vertical HIV 
transmission, the latter in the case of 
undiagnosed new HIV acquisition.62 PrEP 
also appears acceptable in the general 
antenatal population. As part of the PrEP 
Implementation for Young Women and 
Adolescents (PrIYA) project, for example, 
1008 pregnant women were approached 
across 10 health facilities in western Kenya. 
Overall, 347 (34%) agreed to PrEP 
counseling. Of these, 252 (73%) were found 
eligible for PrEP and agreed to initiate it the 
same day.63 Few studies, however, have 
evaluated approaches to support PrEP 
adherence and there appear to be multi-
level barriers to its continued use over time 
(Figure 1).56 This represents an important 
gap in the current PrEP cascade in these 
settings. 
 
 
4.4 Our formative work 
 
During our formative phase, we completed a 
new systematic review and meta-analysis to 
estimate the risk of HIV acquisition during 
pregnancy and breastfeeding in sub-
Saharan Africa. Overall, 41 studies met our 
inclusion criteria. These represented 35 
independent cohorts that contributed over 
100,000 PY of follow-up. The pooled HIV 
incidence 
during 
pregnancy 
and 
breastfeeding was 3.7/100 PY (95% CI: 3.0-
4.5), a rate consistent with cohort studies of 
female sex workers, men who have sex with 
men, and HIV serodiscordant couples.44,64-67 
Figure 1: Barriers to PrEP adherence identified in a systematic review 
of the literature 56 
 
Figure 2: HIV incidence during pregnancy and breastfeeding in sub-
Saharan Africa: a meta-analysis 

 
Protocol v1.0 | 14 April, 2019 
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We also found recent declines in estimated HIV incidence over time (Figure 2), coinciding with the expansion of 
combination prevention services in much of sub-Saharan Africa. While such trends are encouraging, the number 
of new HIV infections remains unacceptably high among pregnant and breastfeeding women. 
 
We have developed a framework for HIV prevention during pregnancy and breastfeeding. In our framework 
(Figure 3), partner HIV status is used to stratify the population into six distinct groups (A-F). To optimally reduce 
horizontal and vertical HIV transmission during pregnancy, we argue that tailored interventions are needed. We 
hypothesized that three specific points along this dyad-based framework could have important downstream 
impact: (1) male partner HIV testing, (2) support for ART adherence, and (3) support for PrEP during pregnancy. 
 
Figure 3: Proposed framework for HIV prevention during pregnancy and breastfeeding68 
 
To test this hypothesis, we developed a mathematical model describing horizontal and vertical HIV transmission 
during pregnancy within patient-partner and patient-infant dyads, respectively.69 The model was based on 
biological and behavioral inputs from the medical literature and from ANC program data from Malawi and Zambia. 
The downstream impact of three main HIV prevention strategies, alone and in combination, was assessed by 
varying: (1) male partner HIV testing from a base-case value of 15% to a target of 35%; (2) suppressive ART for 
HIV-positive ANC patients and partners from a base-case of 70% to a target of 90%; and (3) adherent PrEP use 
for HIV-uninfected female ANC patients from a base-case of 0% to a target of 20%. Using this model, the 
percentage of horizontal and vertical HIV infections that could be averted relative to the current (base-case) 
scenario (see Table 1) were estimated as follows: 
 
 
Increasing male partner testing to 35% coverage was predicted to reduce horizontal and vertical 
transmissions by 16.7% and 15.1%, respectively (scenario 2); corresponding reductions with 20% female 
PrEP use were 13.4% and 12.1% (scenario 4). 
 
Jointly increasing coverage of both male partner testing and female PrEP use by 20 percentage points 
was predicted to reduce horizontal and vertical transmissions by ~one-quarter (scenario 7); this reduction 
increased to ~one-third with a combination of these two interventions plus increasing suppressive ART 
(scenario 8). 
 
Across scenarios, a 20-percentage-point increase in suppressive ART for HIV-positive patients and 
partners had only a modest incremental impact (scenarios 3 vs. 1, 5 vs. 2, 6 vs. 4, 8 vs. 7).  
 

 
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The modeling suggests that combination HIV prevention in ANC settings, particularly approaches that increase 
male partner testing and female PrEP use, could substantially reduce HIV incidence among pregnant women, 
their partners, and their newborns in sub-Saharan Africa. 
 
Table 1: Percentage of potential horizontal and vertical HIV infections averted 
Scenario 
% male partners 
tested for HIV 
% HIV+ ANC 
patients & partners 
on suppressive ART 
% HIV− female 
ANC patients on 
PrEP 
% Horizontal 
transmissions* 
averted 
% Vertical 
transmissions 
averted 
1 
Current (15%) 
Current (70%) 
Current (0%) 
--- (Base case) 
--- (Base case) 
2 
↑ to 35% 
Current (70%) 
Current (0%) 
16.7% 
15.1% 
3 
Current (15%) 
↑ to 90% 
Current (0%) 
1.1% 
1.8% 
4 
Current (15%) 
Current (70%) 
↑ to 20% 
13.4% 
12.1% 
5 
↑ to 35% 
↑ to 90% 
Current (0%) 
21.5% 
19.9% 
6 
Current (15%) 
↑ to 90% 
↑ to 20% 
16.3% 
13.9% 
7 
↑ to 35% 
Current (70%) 
↑ to 20% 
27.8% 
25.1% 
8 
↑ to 35% 
↑ to 90% 
↑ to 20% 
32.1% 
29.2% 
* both female-to-male and male-to-female 
 
Based on this formative work, we propose an approach 
strategy to support HIV treatment and prevention in the 
context 
of 
pregnancy 
and 
breastfeeding. 
Our 
intervention is integrated because it combines both 
biomedical and behavioral components that could be 
operationalized in a routine health system. It is also 
cross-cutting in nature, designed to support both HIV 
treatment (ART) and prevention (PrEP) in antenatal 
settings to reduce vertical and horizontal HIV 
transmission. A strength of our approach is that we 
consider the HIV status of all pregnant and 
breastfeeding women and offer interventions tailored to 
those circumstances. It contrasts the typical PMTCT 
approach, which segments the antenatal population 
based 
on 
HIV 
status 
and 
provides 
targeted 
interventions to only select (i.e., HIV-positive) groups.  
 
Our intervention comprises two parts: (1) patient-
centered counseling and (2) adherence supporter 
training. These two components were selected 
because of their adaptability and their ability to address 
a wide range of barriers at the individual, relationship, 
and structural level. We also emphasize patient-
centered approaches based on recommendations from 
four PrEP clinical trials teams.70 We show a list of 
common 
obstacles 
faced 
by 
pregnant 
and 
breastfeeding women, informed by our formative qualitative research and via expert opinion at our technical 
stakeholder meeting in September 2018 (Table 2). Each factor is mapped to our proposed intervention, showing 
how the component parts may address common issues faced by our population. 
 
 
5.0 RESEARCH QUESTIONS 
 
Does the addition of a multi-component adherence support strategy increase retention in care and HIV viral 
suppression (as a composite outcome), compared to the standard clinical care for ART adherence for HIV-
positive pregnant and breastfeeding women in the antenatal setting?  
 
Table 2: Barriers to HIV prevention during pregnancy 
and breastfeeding, mapped to our proposed intervention 
components 
Individual level barriers 
 
Lack of knowledge about PrEP 
PCC, AS 
Low perceived risk, feeling healthy 
PCC, AS 
Fear of stigma, incl. perceived infidelity 
PCC, AS 
Conflicting demands and responsibilities 
PCC, AS 
Traditional and spiritual beliefs 
PCC 
Substance use 
PCC, AS 
Mental health 
PCC, AS 
Relationship level barriers 
 
Powers dynamics – social, cultural 
PCC, AS 
Partner violence 
PCC, AS 
Fear of disclosure 
PCC, AS 
Poor social support 
PCC, AS 
Structural level barriers 
 
Poor treatment by healthcare providers 
PCC 
Transportation 
PCC, AS 
Discreet storage of medications 
PCC, AS 
Food requirements for medications 
PCC 
Clinic wait times 
PCC, AS 
Quality of counseling 
PCC 
Human resource constraints in clinics 
AS 
Lack of motivation for healthcare workers 
AS 
PCC=patient-centered counseling 
AS=adherence support 

 
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Does the addition of a multi-component adherence support strategy increase retention in care and functional 
pharmacologically measured adherence to TDF-FTC for PrEP (as a composite outcome), compared to the 
standard clinical adherence education for HIV-negative pregnant and breastfeeding women in the antenatal 
setting?  
 
 
6.0 OBJECTIVES AND OUTCOMES 
 
The overall objective of this study is to obtain preliminary data about the effectiveness and implementation of 
a multi-component adherence support strategy for HIV treatment and prevention among pregnant and 
breastfeeding women.  
 
 
6.1 Primary and secondary objectives 
 
Our primary objective is: 
 
To obtain preliminary data about the effectiveness of a multi-component adherence support strategy to 
increase both ART and PrEP adherence during pregnancy and breastfeeding 
 
Our secondary objectives are: 
 
To measure acceptability, feasibility, and fidelity of the separate components of the adherence support 
strategy in a “real world” setting 
 
To compare social harms between the intervention and control arms in the contexts of ART and PrEP 
 
To identify factors associated with successful ART and PrEP adherence among pregnant and 
breastfeeding women 
 
Our exploratory objective is: 
 
To measure the incidence of maternal HIV infection among HIV-negative women on PrEP 
 
6.2 Study Outcomes 
 
6.2.1 Primary outcome for Trial 1 (ART adherence support) 
 
For Trial 1, the primary outcome is retention in care with HIV viral suppression, defined as <40 copies/mL, at six 
months following study enrollment. 
 
6.2.2 Secondary outcomes for Trial 1 (ART adherence support) 
 
For Trial 1, secondary outcomes include:  
 
Retention in care with HIV viral suppression, defined as <1,000 copies/mL 
 
Adherence to ART as measured by self-report and pharmacy measures (e.g., pill count, medication 
possession ratio) 
 
Acceptability, feasibility, and fidelity of adherence support components (intervention arm only) 
 
Incidence of social harms and other adverse events (both arms) 
 
6.2.3 Primary outcome for Trial 2 (PrEP adherence support) 
 
For Trial 2, the primary outcome is retention in care with functional adherence to PrEP as measured 
categorically according to plasma and intracellular tenofovir drug concentrations at six months following 
study enrollment.  
 
6.2.4 Secondary outcomes for Trial 2 (PrEP adherence support) 
 

 
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For Trial 2, secondary outcomes include: 
 
Adherence to PrEP as measured by self-report and pharmacy measures (e.g., pill count, medication 
possession ratio) 
 
Acceptability, feasibility, and fidelity of adherence support components (intervention arm only) 
 
Incidence of social harms and other adverse events (both arms) 
 
Incidence of maternal HIV infection 
 
 
7.0 HYPOTHESES 
 
The implementation of a multi-component adherence support strategy will increase retention in care with viral 
suppression among HIV-positive pregnant women on ART. 
The implementation of a multi-component adherence support strategy will increase retention in care with 
functional PrEP adherence among HIV-negative pregnant women. 
 
 
8.0 METHODOLOGY  
 
8.1 Study design  
 
We propose two parallel, pilot randomized trials to evaluate an integrated antiretroviral adherence support 
strategy for pregnant and breastfeeding women. In Trial 1, we evaluate the proposed multi-component 
intervention in the context of ART support for HIV-positive women. In Trial 2, we assess the efficacy of the same 
strategy applied to PrEP adherence among HIV-negative women at elevated risk for HIV acquisition. These pilot 
trials are designed to obtain preliminary data about the intervention’s efficacy and its feasibility and 
implementation.  
 
 
8.2 Study intervention 
 
We propose a multi-component strategy to support both ART and PrEP adherence in the context of antenatal 
care settings. The principal components include: 
 
8.2.1 Integrated Next Step Counseling 
 
Integrated next step counseling (iNSC) is a structured, patient-centered approach informed by motivational 
interviewing techniques.71,72 The goal of iNSC is to foster an environment for joint-problem solving in order that 
the participant may identify their individual needs to increase or sustain sexual health through biomedical and 
non-biomedical approaches.  iNSC frames the counselling sessions as a non-judgmental discussion to explore 
the facilitators and challenges to sexual health and medication adherence.  Through this process the participant 
is able to identify needs to optimize sexual health protection and medication adherence.    
 
Study staff will be trained to provide iNSC to participants randomized to the intervention arm. iNSC uses eight 
distinct stages to guide the counselor and patient through a semi-structured discussion: introduce, review, 
explore, tailor, identify, strategize, plan, and document. Within each, the counselor guides the patient through 
motivational interviewing and other patient-centered strategies. iNSC will be provided at each scheduled study 
visit by trained study personnel. A standard case report form is used to document steps included in the 
discussion, as well as important content emerging from exploration of facilitators, challenges, needs and 
strategies.  
 
8.2.2 Adherence supporter training 
 

 
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There is a broad body of knowledge showing that peer or partner support can help to enhance adherence and 
retention in antenatal and HIV programs.40 We propose an adherence supporter intervention. Participants will be 
asked to identify a partner, family member, or friend to whom they are willing to disclose their HIV status (for 
HIV-positive women) or their intent to initiate PrEP (for HIV-negative women). Participants may also select a 
clinic-based peer to serve in this adherence supporter role. Study staff will provide training for this adherence 
supporter in the month following enrollment, using materials adapted from similar interventions. A second 
“refresher” session will be provided the following month as well. The emphasis of these trainings will be basic 
HIV knowledge, importance of antiretroviral adherence, potential drug side effects, and practical strategies for 
supporting adherence. Based on our formative research, we believe the addition of this adherence supporter 
intervention to iNSC will help to reinforce behaviors discussed during patient-centered counseling.  
 
8.2.3 Standard of care (control arm) 
 
Participants randomized to the control arm will receive a similar level of engagement—compared to those in the 
intervention arm—when visiting the health facility, based on the current standard of care. This will include 
supplemental information in safe obstetrics and newborn care, based on World Health Organization and local 
guidelines for safe motherhood and delivered via usual practice.  
 
 
8.3 Eligibility criteria  
 
Below, we separately list the eligibility criteria for our two parallel trials. Trial 1 focuses on ART adherence support 
for HIV-positive pregnant women. Trial 2 focuses on PrEP adherence support for at-risk HIV-negative pregnant 
women. Women who have previously enrolled in the study will not be permitted to enroll again. Following 
informed consent, participants will be enrolled into one of two parallel randomized trials based on their HIV 
status. 
 
8.3.1 Eligibility criteria for enrollment in Trial 1 (HIV-positive women) 
 
Trial 1 inclusion criteria 
 
Documented pregnancy by urine pregnancy test or physical exam 
 
Documented positive HIV status 
 
Initiated on first-line ART within the past 30 days, either for the first time or after treatment interruption 
of 6 months or longer (if previously started but stopped ART)  
 
Willingness to remain in the study site’s catchment area over the course of study follow-up and to 
comply with visit schedule 
 
Ability and willingness to provide informed consent 
 
Trial 1 exclusion criteria 
 
Risk for intimate partner violence or social harms as a result of participation, in the judgement of the 
study personnel  
 
Other conditions that, in the judgment of the study personnel, would make participation in the study 
inappropriate 
 
8.3.2 Eligibility criteria for enrollment in Trial 2 (HIV-negative women) 
 
Trial 2 inclusion criteria 
 
Documented pregnancy by urine pregnancy test or physical exam 
 
Documented negative HIV status within the past three months 
 
Identified factor(s) for elevated risk for HIV acquisition, such as known positive or unknown partner 
HIV status; report of secondary sexual partners over the past 12 months; diagnosis of STI over the 
past 12 months; use of post-exposure prophylaxis in the past 12 months; reported use of shared 
injection material or equipment; and/or unspecified concern about HIV acquisition during pregnancy 
and breastfeeding 
 
Willingness to initiate and continue PrEP over the course of study follow-up 

 
Protocol v1.0 | 14 April, 2019 
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 
Willingness to remain in the study site’s catchment area over the course of study follow-up and to 
comply with visit schedule 
 
Ability and willingness to provide informed consent 
 
Trial 2 exclusion criteria 
 
Positive HIV test at time of screening 
 
Positive hepatitis B surface antigen test at time of screening 
 
Renal insufficiency, defined as creatinine clearance <90 mL/min, history of known renal parenchymal 
disease, or known single kidney at time of screening 
 
Risk for intimate partner violence or social harms as a result of participation, in the judgement of 
the study personnel  
 
Other conditions that, in the judgment of the study personnel, would make participation in the study 
inappropriate 
 
8.4 Study site and study population 
 
8.4.1 Study site in Zambia  
 
Chipata First Level Hospital is a busy, health facility run by the Lusaka District Health Office serving a population 
of over 100,000. Chipata averages 400-450 new antenatal patients attending ANC clinic each month with an 
additional 900-1000 return ANC visits. Similar to other facilities in Lusaka the HIV prevalence in ANC clinic is 
10-15%.  
 
8.4.2 Study site in Malawi 
 
Bwaila District Hospital is a high-volume district facility run by the Malawi Ministry of Health. Approximately 1,500 
babies are delivered each month at the facility and approximately 500 women present each month for infant 
immunization visits. Bwaila Hospital has been providing PMTCT services since April 2002. Similar to many parts 
of Lilongwe, the antenatal HIV prevalence is estimated as high as 13%.  
 
 
8.5 Recruitment and enrollment procedures 
 
Staff will provide interested participants with additional information and referral to the study. Potential participants 
will be identified at any point in their pregnancy. All women attending the ANC clinic at enrolling study facilities 
who meet the eligibility criteria (section 8.3) will be invited to participate in the study. All participants will undergo 
an informed consent procedure to ensure they are well-informed about the study, its objectives, and its 
requirements (section 9.2)  
 
8.5.1 Enrollment procedures for Trial 1 
 
Following informed consent, HIV-positive pregnant women eligible for Trial 1 will be enrolled at the same visit. 
We will collect social, demographic, medical, and behavioral information from all participants.  We will obtain 
from the locator information from the participant, including phone numbers, addresses, and directions. 
Participants will be randomly assigned to one of two study arms (control or intervention). Statistical software will 
be used to generate a list of random assignments with a 1:1 ratio, balanced for each site. The randomly 
generated numbers will be placed in opaque sealed envelopes and sequentially numbered with participant 
identification numbers.73 
 
8.5.2 Enrollment procedures for Trial 2 
 
Following informed consent, HIV-negative pregnant women eligible for Trial 2 will first undergo screening for HIV 
and hepatitis B surface antigen (HBsAg). Specimens will be drawn; participants will be asked to return in 1-2 
weeks to confirm their eligibility to initiate PrEP. During that return visit, candidates who remain eligible (i.e., do 

 
Protocol v1.0 | 14 April, 2019 
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not meet any exclusion criteria) will be formally enrolled at this visit. Similar to Trial 1, we will then collect social, 
demographic, medical, and behavioral information from all participants.  We will obtain locator information from 
the participant, including phone numbers, addresses, and directions. Participants will be randomly assigned to 
one of two study arms (control or intervention). Statistical software will be used to generate a list of random 
assignments with a 1:1 ratio, balanced for each site. The randomly generated numbers will be placed in opaque 
sealed envelopes and sequentially numbered with participant identification numbers.73 
 
 
8.6 Study follow-up 
 
8.6.1 Study procedures for Trial 1 
 
In Trial 1, we plan study visits at enrollment, month 1, month 3, and month 6. The study procedures at each visit 
are listed in Appendix 1.  
 
Participants will collect ART from the local PMTCT program. At each visit, we will obtain information about 
adherence, regardless of the randomization arm. Study visits and pharmacy visits will be scheduled to minimize 
the number of trips needed at the clinic.  
 
At six weeks postpartum, we will collect information about delivery and neonatal outcomes, including HIV status 
of HIV-exposed infants. For most women, this will occur over the course of their 6-month follow-up; for those 
who have not yet delivered by the time they reach their primary study endpoint, we will schedule an additional 
follow-up visit accordingly.  
 
For those in the intervention arm, we will also collect data about the iNSC and adherence supporter strategies 
 
8.6.2 Study procedures for Trial 2 
 
In Trial 2, we have included a screening phase to further assess eligibility. We plan study visits at enrollment, 
month 1, month 3, and month 6. The study procedures at each visit are listed in Appendix 1.  
 
Because PrEP programs are only beginning to roll-out in Malawi and Zambia, we plan to dispense TDF-FTC on 
a monthly basis. At these pharmacy visits, we will obtain information about adherence, regardless of the 
randomization arm. Study visits and pharmacy visits will be scheduled to minimize the number of trips needed 
at the clinic.  
 
At six weeks postpartum, we will collect information about delivery and neonatal outcomes, including HIV status 
of HIV-exposed infants. For most women, this will occur over the course of their 6-month follow-up; for those 
who have not yet delivered by the time they reach their primary study endpoint, we will schedule an additional 
follow-up visit accordingly.  
 
For those in the intervention arm, we will also collect data about the iNSC and adherence supporter strategies.  
 
For HIV-negative women who test positive for HIV over the course of the study, TDF-FTC will be stopped while 
the diagnosis is confirmed. We will collect a specimen for HIV RNA concentration (i.e., viral load) and storage 
for HIV resistance testing. If the HIV diagnosis is confirmed, the participant will complete exit study procedures 
(i.e., analogous to month 6 visit) and receive a guided referral to the HIV care and treatment clinic at the study 
clinic site. 
 
 
8.7 Implementation assessment 
 
8.7.1 Quantitative assessment of iNSC implementation 
 

 
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A core component of our adherence support intervention is iNSC, a patient-centered counseling approach that 
uses distinct stages to guide the counselor and patient through a semi-structured discussion. Within each, the 
counselor guides the patient through motivational interviewing and other patient-centered strategies. A standard 
case report form is used to document steps included in the discussion, as well as important content emerging 
from exploration of facilitators, challenges, needs and strategies. These instruments are adapted from other 
large network studies, including IMPAACT 2009 (pregnant and breastfeeding women in sub-Saharan Africa) and 
ATN 110/113 (men who have sex with men in the US).  
 
While iNSC case report forms have been used to retrospectively assess fidelity, including in ATN 110/113,72 this 
approach has important limitations, including improper, missing, and single reporter (i.e., counselor) 
documentation. In contrast, we propose to code recorded interviews to assess fidelity. This approach has been 
used to assess motivational interviewing interventions in numerous settings,74,75 including for ART adherence in 
the US.76 However, despite the similarities in the counseling techniques, such methodologies have not been 
applied to iNSC to date. 
 
We will conduct detailed audits of iNSC sessions for all participants randomized to the intervention arm, in either 
Trial 1 or Trial 2 (n=150 total). As part of informed consent, we will seek permission to audio-record the 
discussions to be later reviewed by trained audit nurses. Two reviewers will independently rate the iNSC session 
according to key domains, providing both objective and subjective measures about the quality of the counseling. 
Through this process, our audit staff will also assess the appropriateness of documentation in the primary case 
report forms, including misinformation and missing data. It will also provide important feedback loops to improve 
counseling over time. 
 
8.7.2 Quantitative assessment of adherence supporter implementation 
 
A second component of our intervention is training for designated adherence supporters. At enrollment, we will 
ask what key attributes participants look for in an adherence supporter and then collect detailed information 
about the identified candidate. In most cases, this will be a close friend or family member, including the 
participant’s primary male partner. We will document details about the adherence supporter training itself—the 
selected venue, preferences for format (e.g., one-on-one vs. group sessions), and completion of key curriculum 
modules. At each follow-up visit, we will administer a standard questionnaire to all participants (i.e., the index 
pregnant woman) regarding the adherence support provided by this designated individual. This will include 
ratings about the adherence supporter intervention along three primary domains: level of engagement of the 
adherence supporter, relationship dynamics (including trust and confidentiality), and satisfaction with the support 
provided. 
 
8.7.3 Qualitative assessment of multi-component study intervention 
 
We will conduct semi-structured interviews (SSIs) to explore the acceptability of the multi-component adherence 
support strategy through the experiences of participants and adherence supporters. We are interested in 
individual-level engagement with the intervention (including satisfaction with the different components), as well 
as barriers and facilitators to participation.  
 
We will conduct serial SSIs to gain insight about the study intervention over time. We propose a sample size of 
up to 40 study participants between the two sites, all randomized to the intervention arm: 20 from Trial 1 and 20 
from Trial 2 (Table 3). Three interviews are planned—within four weeks each of the enrollment, 3-month, and 6-
month study visits. For individuals who are lost to follow-up or formally withdraw from the study, we will make 
efforts to trace them and conduct a final exit interview.   
 
Table 3: Sample size for qualitative evaluation 
 
Participants in Zambia 
(total interviews) 
Participants in Malawi 
(total interviews) 
Trial 1 participants in intervention arm 
10 (30) 
10 (30) 
Trial 2 participants in intervention arm 
10 (30) 
10 (30) 
Total 
20 (60) 
20 (60) 

 
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We will use SSI guides, developed and piloted by our teams in the field, to provide a framework for the discussion. 
The SSIs will be conducted in rooms at or near the clinic that provide sufficient privacy to ensure confidentiality 
of information and are quiet enough to enable audio recording of the interviews. Each SSI is expected to last 30-
60 minutes. Based on our past experiences in Malawi and Zambia, including from the formative phase of the 
parent study, the proposed sample size should allow us to reach thematic saturation. 
 
 
8.8 Study drug 
 
8.8.1 Study drug for Trial 1 
 
In accordance to the eligibility criteria, all HIV-positive participants in Trial 1 will be on first-line ART according to 
local HIV guidelines. Dispensation of ART will be managed by the local PMTCT/ART program at the study facility. 
We will collect information about prescribed ART drugs, pharmacy dispensations, and adherence evaluations at 
short visits on a monthly basis, timed with routine clinic visits.  
 
8.8.2 Study drug for Trial 2 
 
To ensure a consistent medication supply over the 6-month follow-up period, we will provide TDF-FTC for PrEP 
to all study participants in Trial 2. Packaged product will be dispensed by an on-site study staff. Participants will 
begin daily administration of TDF-FTC from the day of randomization to 6 months after randomization. The drug 
will be dispensed on a monthly basis.  
 
Tenofovir disoproxil fumarate (TDF) and emtricitabine (FTC) are antiretroviral agents, indicated and used in 
combination to reduce the risk of sexually acquired HIV in adults at high risk. Each dose contains 300 mg of TDF 
and 200 mg of FTC, to be dosed on a daily basis. 
 
TDF is a fumaric acid salt of the bis-isopropoxycarbonyloxymethyl ester derivative of tenofovir. The chemical 
name is 9-[(R)-2 [[bis[[(isopropoxycarbonyl)oxy] methoxy]phosphinyl]methoxy]propyl]adenine fumarate (1:1). It 
has a molecular formula of C19H30N5O10P • C4H4O4 and a molecular weight of 635.52. TDF is an acyclic 
nucleoside phosphonate diester analog of adenosine monophosphate. TDF requires initial diester hydrolysis for 
conversion to tenofovir and subsequent phosphorylations by cellular enzymes to form tenofovir diphosphate. 
Tenofovir diphosphate inhibits the activity of HIV-1 RT by competing with the natural substrate deoxyadenosine 
5′-triphosphate and, after incorporation into DNA, by DNA chain termination. Tenofovir diphosphate is a weak 
inhibitor of mammalian DNA polymerases α, β, and mitochondrial DNA polymerase γ. 
 
The chemical name of FTC is 5-fluoro-1-(2R,5S)-[2 (hydroxymethyl)-1,3-oxathiolan-5-yl]cytosine. FTC is the (-) 
enantiomer of a thio analog of cytidine, which differs from other cytidine analogs in that it has a fluorine in the 5-
position. It has a molecular formula of C8H10FN3O3S and a molecular weight of 247.24. It has the following 
structural formula: FTC is a white to off-white crystalline powder with a solubility of approximately 112 mg/mL in 
water at 25 °C. The partition coefficient (log p) for emtricitabine is -0.43 and the pKa is 2.65. FTC, a synthetic 
nucleoside analog of cytidine, is phosphorylated by cellular enzymes to form emtricitabine 5'-triphosphate. 
Emtricitabine 5'-triphosphate inhibits the activity of the HIV-1 reverse transcriptase (RT) by competing with the 
natural substrate deoxycytidine 5'-triphosphate and by being incorporated into nascent viral DNA which results 
in chain termination. Emtricitabine 5′-triphosphate is a weak inhibitor of mammalian DNA polymerase α, β, ε and 
mitochondrial DNA polymerase γ.  
 
 
8.9 Retention  
 
Once participants are enrolled in the trial, the study team will make efforts to retain them in follow-up to minimize 
bias associated with loss to follow-up. The study team will closely monitor retention rates and address any issues 
prospectively. Strategies to minimize attrition include:  
 

 
Protocol v1.0 | 14 April, 2019 
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 
Thorough explanation of the study visit schedule and procedures during informed consent.  
 
Collection of detailed locator information at enrollment.  
 
Use of appropriate and timely visit reminder mechanisms (including phone calls and text messages, if 
participants specifically agree).  
 
Follow-up after missed visits, including home or alternative, off-site visits where possible. 
 
Mobilization of trained outreach workers to complete in-person contact with participants at their homes 
and/or other locations. 
 
If participants elect to discontinue their involvement in the study, we will document their stated reason(s). These 
will be reported in any reports about the study cohort. 
 
 
8.10 Safety Monitoring  
 
At each study visit, study staff will evaluate participants for social harms and adverse events (AEs). A social 
harm will be defined as a non-medical untoward consequence of study participation, including: difficulties in 
personal relationships, stigma, or discrimination from family or community. An AE will be defined as any untoward 
medical occurrence in a study participant including any abnormal sign (e.g., abnormal physical exam or 
laboratory finding), symptom, or disease, temporally associated with the individual’s participation in the research, 
whether or not considered related to participation in the research. In addition to events related to study 
procedures we can expect that this population of pregnant and postpartum women to experience adverse events 
unrelated to study procedures, including opportunistic infections, side effects from antiretroviral therapy or other 
medications, hospitalization, and death.  
 
All adverse events and social harms will be documented, assessed for seriousness / severity, expectedness, 
and relatedness, and carefully monitored. The severity of events will be graded using the National Institute of 
Health’s Division of AIDS Table for Grading the Severity of Adult and Pediatric Adverse Events. We will also 
record information on all serious adverse events (SAEs) occurring in participants whether or not they are related 
to study participation or the study drug, including AEs that: 
 
1. Result in hospital admission (unless hospitalization is preplanned, i.e. for delivery) or prolongation of 
existing hospitalization  
2. Are immediately life-threatening, including drug reactions that necessitate discontinuation of study 
participation,  
3. Cause significant, persistent, or permanent harm or disability, either physical or psychological,  
4. Result in death to mother or infant, or 
5. Are congenital anomalies or birth defects 
 
 
8.11 Biological specimen collection and testing  
 
All samples will be obtained from study participants by trained study staff according to approved standard 
operating procedures. All samples will be processed according to the assay manufacturers’ specifications. Some 
specimens collected from patients in this protocol will be analyzed immediately per standard antenatal care 
guidelines. Others will be transported, processed, and temporarily housed at the University Teaching Hospital 
(Lusaka, Zambia) and the UNC Project Malawi (Lilongwe, Malawi). Use of stored specimens for testing that is 
not specifically designated in this protocol will require additional regulatory approval. All laboratory testing will be 
performed by trained staff using standard operating procedures and according to specific assay manufacturers’ 
specifications. 
 
 
8.12 Quality control and quality assurance procedures 
 
Standard Operating Procedures (SOPs) following manufacturer’s protocols and detailing technical procedures 
involved (e.g. sample collection, processing and storage, assay procedures and how to interpret test results) will 

 
Protocol v1.0 | 14 April, 2019 
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be developed and used by the study team. Tests will only be performed by certified laboratory personnel. Site 
coordinators will complete annual recertification. The certification process is an opportunity to ensure the highest 
specimen quality and standardize collection techniques. 
 
 
8.13. Data Management and Storage  
 
Data collected from each participant will include sociodemographic information, relevant HIV and obstetrical 
history, and results of HIV testing.  Study data management (e.g., data transmission, query resolution, etc.) will 
follow site data management standard operating procedures. Study identification numbers will be used on all 
forms and communications related to the study. A separate confidential register will link study identification 
numbers and participant names. All data instruments and registers will be securely stored. Data will be entered 
into a custom-built database and, where possible, will be validated via double entry.  Computers and tablets will 
be encrypted and password protected and their access restricted to authorized study personnel. Backups of the 
data will be made on a weekly basis. Data may be transmitted electronically to the study investigators through 
secure cloud-based servers. Study information will not be released without written permission of the participant, 
except when necessary for monitoring by the relevant ethical committees or their designees. Data will be 
disposed of after completion of the study per country guidelines. At that time, electronic records, including linkage 
codes and identifiers, will be deleted. Paper records will be shredded prior to disposal. 
 
 
8.14 Sample Size 
 
The two parallel randomized trials in this protocol are each designed as pilot studies, so that we may obtain the 
necessarily preliminary data about outcomes and implementation to inform future, larger studies. As such, the 
sample sizes are based on feasibility considerations. Despite this general approach, we provide estimated power 
and precision of each trial for large differences between the intervention and control arms.  
 
8.14.1 Sample size for Trial 1 
 
We will enroll 100 HIV-positive pregnant women in 
Trial 1, randomized 1:1 between the intervention and 
control arms (n=50 each), with randomization 
balanced (stratified) by site. The primary endpoint for 
Trial 1 is the proportion of participants retained and in 
care with viral suppression at 6-month follow-up. This 
composite outcome is calculated based on the entire 
randomized sample, with the approximately 10% of 
women lost to follow-up included in the denominator.  
 
Figure 4 presents anticipated statistical power for the 
Trial 1 primary analysis over a range of scenarios. 
Control arm probabilities of the primary outcome 
(retained in care with viral suppression <40 
copies/mL) are shown ranging from 0.70 to 0.85.[ref] 
Effect sizes (risk differences) are shown ranging from 
0.10 to 0.25. Assuming alpha=0.05 and the 
probability of being retained and in care with viral 
suppression in the control arm is 0.75, we anticipate 
approximately 82% power to detect an increase in 
viral 
suppression 
probability 
of 
0.20 
in 
the 
intervention arm (i.e., 75% vs. 95% retained with viral suppression in the control and intervention arms, 
respectively). For lower control arm probabilities of being retained in care with viral suppression (e.g., 0.70) there 
will be ≥80% statistical power to detect a risk difference of 0.22 or larger. Power calculations were based on a 
two-sided likelihood ratio chi-square test for two proportions. 
Figure 4: Statistical power in Trial 1 by effect size and 
control arm probability of retained in care with viral 
suppression (VS) at 6 months 
  

 
Protocol v1.0 | 14 April, 2019 
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The anticipated statistical precision for the Trial 1 and Trial 2 comparisons are presented in Table 4. For control 
and intervention probabilities of being retained and in care with viral suppression of 0.75 and 0.95, respectively, 
the anticipated 95% CI for the risk difference has length 0.263. This trial will provide preliminary data on the 
effectiveness of the intervention which can be leveraged in planning a larger, future trial.   
 
 
Table 4: Anticipated statistical power and precision for Trial 1 and Trial 2 
 
 
Assumed true probability of 
outcome* 
 
Example results in expectation 
n tested / n evaluable (%) 
 
Population 
N 
enrolled 
per arm 
Control 
Intervention 
Power† 
Intervention 
Control 
Difference in 
probabilities  
(95% CI) 
CI Width 
Trial 1  
 
50 
75% 
85% 
24% 
43/50 (86%) 
38/50 (76%) 
10 (-5.4, 25.4%) 
30.8% 
 
 
 
90% 
52% 
45/50 (90%) 
38/50 (76%) 
14 (-0.6, 28.6%) 
29.2% 
 
 
 
95% 
83% 
48/50 (96%) 
38/50 (76%) 
20 (6.8, 33.2%) 
26.3% 
 
 
 
 
 
 
 
 
 
Trial 2  
 
100 
30% 
45% 
59% 
45/100 (45%) 
30/100 (30%) 
15 (1.7, 28.3%) 
26.6% 
 
 
 
50% 
83% 
50/100 (50%) 
30/100 (30%) 
20 (6.6, 33.4%) 
26.7% 
 
 
 
55% 
95% 
55/100 (55%) 
30/100 (30%) 
25 (11.7, 38.3%) 
26.6% 
 
* For Trial 1 (HIV-positive women), the outcome is retained and in care with viral suppression at 6 months. For Trial 2 (HIV-negative 
women), the outcome is retained and in care on PrEP at 6 months 
† Using a likelihood ratio Chi-square test for two proportions, alpha=0.05 
 
8.14.2 Sample size for Trial 2 
 
We will enroll 200 HIV-negative pregnant women in Trial 
2, randomized 1:1 between the intervention and control 
arms (n=100 each), balanced (stratified) by site. The 
primary endpoint for Trial 2 is the proportion of 
participants retained and in care with functional PrEP 
use at 6 months. This composite outcome is calculated 
based on the entire randomized sample, with the 
anticipated 10% of women lost to follow-up included in 
the denominator.  
 
Figure 5 presents the anticipated statistical power for the 
Trial 2 primary analysis for a range of scenarios. The 
control arm probabilities of retained and in care with 
functional PrEP adherence at six months are shown 
ranging from 0.20 to 0.35; and effect sizes (risk 
differences) are shown ranging from 0.15 to 0.35. Trial 2 
is powered to detect large increases in being retained in 
care with functional PrEP adherence between study 
arms. Assuming the probability of being retained in care 
with functional PrEP adherence in the control arm is 
0.30, we anticipate approximately 82% power to detect 
an increase in the probability of functional PrEP adherence of 0.20 in the intervention arm (i.e., 30% vs. 50% in 
the control and intervention arms, respectively). For lower control arm probabilities of being retained in care with 
 
Figure 5: Statistical power in Trial 2 by effect size and 
control arm probability of retained in care with 
pharmacologically measured functional PrEP at 6 
months  
 

 
Protocol v1.0 | 14 April, 2019 
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functional PrEP adherence (e.g., 0.20) there will be ≥80% statistical power to detect a risk difference of 0.18 or 
larger. Power calculations were based on a two-sided likelihood ratio chi-square test for two proportions and 
alpha=0.05. The anticipated statistical precision for the Trial 2 comparisons are presented in Table 4. For control 
and intervention probabilities of being retained and in care with functional PrEP of 0.30 and 0.50, respectively, 
the anticipated 95% CI has length 0.267. Like Trial 1, the primary objective of Trial 2 is to obtain preliminary data 
regarding the efficacy of the intervention which can support future trials. 
 
 
8.15 Data Analysis Plan 
 
8.15.1 General Approach 
 
The two randomized pilot trials will be conducted in parallel for HIV-positive (Trial 1) and HIV-negative (Trial 2) 
pregnant women. All primary and secondary endpoints will be evaluated separately for each trial. In order to 
evaluate effectiveness, analyses will be conducted using an intention-to-treat approach, with women analyzed 
according to the arm they were randomly assigned. Appropriate descriptive statistics will be used throughout, n 
(%) for categorical data and median (25th, 75th percentile), mean (SD) and min-max for continuous measures.  
 
Given the pilot nature of these studies, emphasis will be put on estimation and precision of measured effects, 
rather than null hypothesis testing. An alpha=0.05 will be used throughout to compute 95% confidence intervals 
(CIs), with no adjustment for multiplicity. In the case of small cell counts or analyses of continuous data with 
n<30, 95% CI coverage properties of large-sample methods will be evaluated in simulation studies or existing 
exact statistical methods (e.g., exact CI for a risk difference) will be used. Given potential for precision loss with 
exact CI methods and the pilot nature of these studies, we will use large-sample methods (e.g., Wald CIs) when 
the nominal CI coverage level is tenable. 
 
Missing (unevaluable) data are anticipated to be uncommon (≤10%). The primary analyses are based on a 
composite endpoint of being retained in care with either viral suppression (Trial 1) or functional PrEP use (Trial 
2), and thus complete case analyses will be conducted (i.e., missing viral load data = excluded). Women who 
are not retained in care will be counted in the denominator for the primary analysis. Sensitivity analyses will 
exclude women who were not retained in care. 
 
8.15.2 Primary endpoint analysis of Trial 1 (ART adherence)  
 
We will assess ART adherence by evaluating the viral suppression status of each study participant 6 months 
after study enrollment. Participants not lost to follow-up will be classified as either virally suppressed (<40 
copies/mL) or not virally suppressed (≥40 copies/mL). Women who are not retained for 6-month follow-up will be 
counted as failures and will contribute to the analysis denominator. The proportion of women who are retained 
and in care with viral suppression will be compared between randomization arms based on a linear-binomial 
model. To control for any site-specific effects, site (country) will be included as a covariate in the model. From 
the linear-binomial model, the site-adjusted risk difference of being retained and in care with viral suppression 
for the intervention arm versus the control arm will be calculated, along with a corresponding 95% CI. Results 
will also be described separately by country (Malawi and Zambia). 
 
8.15.3 Primary endpoint analysis of Trial 2 (PrEP adherence) 
 
We will assess PrEP adherence via drug concentrations of plasma tenofovir (TFV) and intracellular tenofovir 
diphosphate (TFVdp). Using published algorithms,77 results from the plasma and upper layer of packed cells 
(ULPC) assays will be combined to develop a composite adherence score. The scale ranges from 0 to 5 and 
each category represents a distinct adherence pattern (Table 5). Our primary outcome for this analysis will be 
functional adherence, which we define as 4-5 or more doses per week (scores of 4 or 5). In sensitivity analysis, 
we will also consider a rigorous outcome of optimal adherence (score of 5, representing consistent daily dosing). 
Future published improvements upon this algorithm will be taken into consideration for sensitivity analyses prior 
to the final analysis. 
 

 
Protocol v1.0 | 14 April, 2019 
Page 22 of 31 
 
 
 
Table 5: Adherence composite scores based on TFV and TVFdp concentrations, with doses estimated per interval 77 
Score 
TFV in plasma 
TVFdp in ULPC 
Estimates doses per interval 
0 
None detectable 
<10,000 fmol/mL 
Low number or no doses in the interval 
1 
Detectable 
<10,000 fmol/mL 
A few doses in the entire interval 
2 
Any level 
10,000 to 100,000 fmol/mL 
1-2 doses per week 
3 
<10 ng/mL 
>100,000 fmol/mL 
Several doses early in the interval, followed by a 
stop in the 1-2 weeks leading up to sampling visit 
4 
>10 ng/mL 
100,000 to 1,000,000 fmol/mL 
4-5 doses per week 
5 
>10 ng/mL 
>1,000,000 fmol/mL 
Approximately daily dosing 
 
In our primary analysis, we will compare the proportion of the sample retained in care with functional PrEP 
adherence at 6-month follow-up between the two randomization arms using a linear-binomial model. As with 
Trial 1, site (country) will be included as a covariate in the model. Women who are not retained for 6-month 
follow-up will be counted as failures and will contribute to the analysis denominator. From the linear-binomial 
model, the site-adjusted risk difference of being retained and in care with functional PrEP for the intervention 
arm versus the control arm will be calculated, along with a corresponding 95% CI. Results will also be described 
separately by country (Malawi and Zambia). 
 
In addition to the primary analysis, assessing functional PrEP adherence as binary outcome, secondary analyses 
will compare the adherence composite scores between the study arms using a Wilcoxon rank-sum test. This 
analysis will be restricted to women with an evaluable adherence composite score. 
 
8.15.4 Secondary endpoints analyses of Trial 1 and Trial 2 
 
For both trials, incidence of social harms and other adverse events will be estimated by study arm, and individual 
events will be described using listings. Retention in the study will be described using frequency tables, and 
reasons for study drop-out will be tabulated. Participant deaths will be recorded along with the contributing 
cause(s) of death. 
 
Adherence to ART and PrEP will be measured both by self-report and pharmacy measures. A medication 
possession ratio (MPR) will be estimated within study arm, and the difference in means between study arms will 
be compared using a 95% CI. An MPR of 80% or greater will be categorized as good adherence; this threshold 
will be used for additional analyses of a dichotomized endpoint (retained in care with MPR ≥ 80% at 6-month 
follow-up). Analyzed risk difference will be estimated using the same approach as in the primary endpoints 
described above. Data visualizations will display individual-level data points and box-plots of adherence 
measures (e.g., MPR, pill counts). Self-reported adherence responses will be described within study arm. In Trial 
2, incidence of maternal HIV infection will be estimated with a corresponding exact Poisson 95% CI. Additionally, 
detailed statistical analysis plans will be finalized prior to analysis of each trial. 
 
8.15.5 Implementation assessment: quantitative (intervention arm only) 
 
For the iNSC and adherence supporter components, we will quantify implementation fidelity in separate 100-
point scales that consider objective and subjective measures. We will describe their overall distribution and 
investigate how these differ when stratified by type of study visit, staff member providing iNSC, and calendar 
time (e.g., in biweekly increments). These assessments will help to characterize the quality of implementation 
over the course of study participation.  
 
Because of the structure of the intervention, fidelity scoring for the adherence supporter will be summarized over 
the course of study follow-up for each study participant receiving the intervention. However, we will investigate 
associations with each of the component domains (i.e., engagement, relationship dynamics, and satisfaction) 
over follow-up time. We will also conduct stratified analyses based on key characteristics, such as the 

 
Protocol v1.0 | 14 April, 2019 
Page 23 of 31 
relationship with the identified adherence supporter (e.g., male partner, other family member, close friend) and 
venue of training.  
 
8.15.6 Implementation assessment: qualitative (intervention arm only) 
 
The SSI audio recordings will be transcribed and translated for analysis. All identifiers will be redacted from the 
interview transcripts prior to analysis. Although we propose sample sizes for each group based on prior 
experience, the final number interviewed will be determined by theoretical saturation. Data will be analyzed using 
techniques that include coding, memoing, and matrices to summarize and interpret key patterns in the data. 
Comparative and thematic analyses will be used to provide an in-depth understanding of the experiences related 
to HIV testing. The interviews will be audiotaped and transcribed by the interviewers. Analysis of textual data will 
consist of 5 steps: 1) Reading for Content: Our analysis will begin with data reading until content becomes 
intimately familiar. As data are reviewed, emergent themes will be noted. Topics that the research has not 
adequately addressed and ones that emerge unexpectedly will be explored in continued fieldwork. 2) Coding: A 
list of codes will be created based on identified themes and assigned to specific sections of text so that the text 
can be easily searched. Code definitions will be documented in a code book. Qualitative interviewers will be 
trained to apply the codes using Nvivo to ensure inter-coder reliability, 10% of data will be double-coded. 3) Data 
reduction: Once transcripts have been coded, we will work within each code to identify principal sub-themes that 
reflect finer distinctions in the data. This entails taking an inventory of what is related to the given code, capturing 
the variation or richness of each theme and noting differences between individuals or among subgroup. 4) Data 
display: Matrices and tables that categorize and display data will be used to help facilitate comparisons. 
5) Interpretation: Once text has been read and coded, and central ideas extracted, we will identify and explain 
the core meanings of the data. We will search for relationships among themes identified and develop diagrams 
in order to map out relationships in the data. 
 
 
9.0 ETHICAL CONSIDERATIONS 
 
9.1 Ethical approval 
 
All study participants will be fully informed of the study procedures described above. Prior to study activation, for 
each participating site, ethical approval will be sought from the relevant institutional review boards / research 
ethics committees, national authorities, and other regulatory authorities.  
 
 
9.2 Informed consent 
 
All participants will be consented prior to participation and during the consent process they will be reminded that 
their participation is voluntary. Discussions with prospective participants and informed consent procedures will 
be conducted in private to protect patient confidentiality. We will obtain written informed consent from all 
participants. The study procedures, risks, and benefits will be discussed and we will answer all questions prior 
to obtaining consent. The consent forms will be translated into relevant local languages and back-translated into 
English to assure accurate translation. For illiterate participants, a literate impartial witness will be present during 
the entire consent process to ensure that all of the relevant information has been provided and the participant 
voluntarily gives consent. Eligible women who do not wish to participate in this study will continue to receive HIV 
and ANC care according to local clinical standards. We will obtain signed permission from the pregnant woman 
to collect locator information, including phone numbers, addresses, and directions. Permission for collection of 
locator information and contract tracing will be per usual practice at the clinic. 
 
 
9.3 Data storage  
 
The confidentiality of all study records will be safeguarded to the extent legally possible. To maintain participant 
confidentiality, all laboratory specimens, reports, study data and administrative forms will be identified by a coded 
number only. All databases will be secured with password-protected access systems, and computer entries will 

 
Protocol v1.0 | 14 April, 2019 
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be identified by coded number only. Forms, lists, logbooks, appointment books, and any other listings or data 
forms that link participant ID numbers to other identifying information will be stored in a separate, locked fireproof 
safe cabinet in a locked local office. For the data collected through audio recordings, all audio files will be deleted 
from the recorders after data are transferred into a computer. Study-related computers, tablets, audio tapes, field 
notes, and other study materials will be kept in a locked cabinet in a locked local office. All data analysis will be 
performed using datasets which have only study ID numbers as unique identifiers.  
 
 
9.4 Confidentiality  
 
Measures will be taken to ensure safety of data and confidentiality of all our study participants. All participants 
will be assigned a unique study ID number. The interview guides will not capture names of the participants but 
only their ID number. No study participant will be identified in any report or publication about this study. However, 
for quality control and safety purposes, data that we collect may be reviewed by the sponsor of this study (i.e. 
United States National Institute of Allergy and Infectious Diseases), the ethical and regulatory committees in 
Zambia, Malawi, and at the University of North Carolina at Chapel Hill. Clinical information with individual 
identifiers will not be released without the written permission of the participant. We expect these procedures to 
adequately protect participant confidentiality. 
 
 
9.5 Potential risks of proposed research to study participants  
 
Risks to participants in this study are not expected to differ significantly from the risks inherent in the local 
standard of care for pregnant women. Investigators will make efforts to minimize risks to participants. We do not 
expect any risks from the one-on-one interviews or counselling sessions. Participants may feel uncomfortable 
when being interviewed, but may decide to skip or refuse to answer any questions that they do not want to 
answer. It is expected that this study will expose subjects to minimal risks.  
 
Side effects and serious adverse events with TDF-FTC administration are rare. In HIV-uninfected individuals in 
PrEP trials, adverse reactions that were reported by more than 2% of TDF-FTC users and more frequently than 
by placebo subjects were headache, abdominal pain and weight decrease78. Side effects of daily TDF-FTC use 
may include diarrhea, nausea, fatigue, headache, dizziness, depression, problems sleeping, abnormal dreams, 
and rash. These symptoms may be additive to normal changes associated with pregnancy; however, drug- 
typically decrease over time on medication. All antiretroviral regimens included in this study have been approved 
for use for ART and PrEP by the Malawian and Zambian Ministries of Health. 
 
Physical risks also include the risk of discomfort, bruising or swelling from venipuncture. The risks that are 
associated with venipuncture are infrequent and minimized with the use of proper technique. Such risks include 
(1) bleeding, (2) bruising, or (3) rarely infection at the site of needle insertion. Individuals may also rarely become 
faint, in which case symptoms abate after several minutes in a recumbent position. Blood volumes for the study 
have been calculated to ensure safety. Collection of vaginal and rectal samples may also be associated with 
some discomfort and mild bleeding. Participants will be reassured in all cases that such feelings are transient. 
 
Participation in clinical research includes the risks of loss of confidentiality and discomfort with the personal 
nature of questions, particularly when discussing HIV infection or sexual behaviors. At each step in the study, 
we will protect participant privacy and confidentiality to reduce these risks (e.g., consenting participants in a 
private setting, not including names on case report forms, etc.). Although investigators will make every effort to 
protect participant privacy and confidentiality, it is possible that participant involvement in the study could become 
known to others, and that social harms may result (i.e., as participants could become known as HIV-positive). 
Participants will be given a phone number they can call at any time if they need assistance or feel they are at 
risk of harm.  
 
 
9.6 Potential benefits of proposed research to study participants and others  
 

 
Protocol v1.0 | 14 April, 2019 
Page 25 of 31 
The benefits to participants include: (1) increased adherence to ART, which will decrease HIV viral load and 
prevent transmission to both infant and partner(s); or (2) increased adherence to PrEP, which will prevent HIV 
infection; and (3) general improvement in sexual health through the development of individual strategies to 
overcome barriers to healthcare. Study findings may also inform local strategies to improve existing national HIV 
programs in Malawi and Zambia, promoting adherence to antiretroviral regimens for HIV-positive and HIV-
negative pregnant women in the context of ANC. 
 
 
9.7 Inclusion of children, sub-populations, and vulnerable populations  
 
This study focuses on the outcomes of pregnant and breastfeeding women; as such, they must be included in 
our study population. Prisoners will be excluded as they receive care at separate facilities. 
 
 
9.8 Reimbursement/compensation 
 
There is no cost to participating in the study. Participants will be provided transport reimbursement for each study 
visit, according to local research standards.  
 
 
9.9 Dissemination of findings 
 
Study findings will be disseminated through appropriate local channels, including academic and public health 
research symposia. We will report findings to relevant local authorities in Malawi and Zambia. One or more 
publications will also be submitted to a peer-reviewed journal. Our study team plans to publish the study results 
whether positive or negative. The study participants’ privacy and confidentiality will be strictly maintained in all 
results dissemination or publication activities. 
 
 
10.0 TIME FRAME  
 
In Table 6, we show our proposed timeline for the study activities.  
 
Table 6: Study timeline 
Objective 
Month 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
1
8 
Site preparation 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Data systems programming 
x 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Site training 
x 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Enrollment 
 
 
x 
x 
x 
x 
x 
x 
 
 
 
 
 
 
 
 
 
 
Follow-up 
 
 
 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
 
 
 
 
Data entry and management 
 
 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
 
 
 
Statistical analysis 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
x 
x 
x 
 
Publication and dissemination 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
x 
x 
 
 
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12.0 APPENDICES  
  
1. Schedule of evaluations – Trials 1 and 2 
 
2. Informed consent forms 
 
Trial 1 – adherence support for ART 
 
Trial 2 – adherence support for PrEP 
 
Qualitative interviews 
 
 
 

 
Protocol v1.0 | 14 April, 2019 
Page 30 of 31 
APPENDIX 1: 
 
Schedule of evaluations for Trial 1 – adherence support for ART 
 
 
Clinic 
visits 
Pharmacy  
visit 
Pregnancy 
outcome 
 
Enrollment 
Month 1 
Month 3 
Month 6 
Monthly 
6 weeks 
postpartum 
Laboratory studies 
     HIV RNA (viral load) 
6 mL  
 
6 mL 
6 mL 
 
 
     Hemoglobin 
2 mL 
 
 
 
 
 
     Syphilis screening 
2 mL* 
 
 
 
 
 
     Urine dipstick 
X 
 
X 
X 
 
 
     Vaginal microbiome  
X 
X 
 
 
 
 
     Storage for HIV resistance testing 
6 mL** 
 
 
6 mL ** 
 
 
Medical exam 
     Medical history 
X 
 
 
 
 
 
     Obstetric exam 
X 
X 
X 
X 
 
 
Questionnaires 
     Demographic information 
X 
 
 
 
 
 
     Sexual history 
X 
 
 
X 
 
 
     Partner information 
X 
 
X 
X 
 
 
     Social harms (including IPV) 
X 
X 
X 
X 
 
 
     Stigma 
X 
 
 
X 
 
 
     Self-efficacy 
X 
 
 
X 
 
 
     Depression  
X 
 
 
X 
 
 
     HIV risk behaviors 
X 
X 
X 
X 
 
 
     Delivery information 
 
 
 
 
 
X 
Study drug 
     ART dispensed at PMTCT clinic 
 
 
 
 
X 
 
     Pill counts 
 
 
 
 
X 
 
     Self-report adherence 
 
 
 
 
X 
 
Intervention assessment (intervention arm only) 
     Integrated next step counseling (iNSC) 
X 
X 
X 
X 
 
 
     Adherence supporter  
X 
 
 
 
 
 
     Qualitative interviews (subset) 
X*** 
 
X*** 
X*** 
 
 
 
* will perform test if no results available in the medical record 
** storage of leftover specimen for HIV resistance testing 
*** schedule additional procedures within 30 days of visit for subset of participants enrolled in this component 
 
 
 

 
Protocol v1.0 | 14 April, 2019 
Page 31 of 31 
Schedule of evaluations for Trial 2 – adherence support for PrEP 
 
 
Screening 
 
Clinical 
visits 
Pharmacy 
visit 
Pregnancy 
outcome 
HIV confirmatory 
testing 
 
 
Enrollment 
Month 1  
Month 3 
Month 6 
Monthly 
6 weeks 
postpartum 
(if rapid HIV test is 
positive) 
Laboratory studies 
 
     Rapid HIV antibody test 
X 
X 
 
X 
X 
 
 
 
     Hepatitis B Antigen 
4 mL 
 
 
 
 
 
 
 
     ALT  
 
2 mL 
 
 
 
 
 
 
     Creatinine 
 
2 mL 
 
2 mL 
2mL 
 
 
 
     Syphilis screening 
 
2mL * 
 
 
 
 
 
 
     Urine dipstick 
 
X 
X 
X 
X 
 
 
 
     Tenofovir concentration  
 
 
 
4 mL 
4 mL 
 
 
 
     Vaginal microbiome 
 
X 
X 
 
 
 
 
 
     HIV RNA (viral load) 
 
 
 
 
 
 
 
4 mL 
     Storage for HIV resistance testing 
 
 
 
 
 
 
 
6 mL 
Medical exam 
 
     Medical history  
X 
 
 
 
 
 
 
 
     Obstetric exam 
X 
X 
X 
X 
X 
 
 
 
Questionnaires 
 
     Demographic information 
 
X 
 
 
 
 
 
 
     Sexual history  
 
X 
 
 
X 
 
 
 
     Partner information 
 
X 
 
X 
X 
 
 
 
     Social harms (including IPV) 
 
X 
X 
X 
X 
 
 
 
     Stigma  
 
X 
 
 
X 
 
 
 
     Self-efficacy 
 
X 
 
 
X 
 
 
 
     Depression 
 
X 
 
 
X 
 
 
 
     HIV risk behaviors  
 
X 
X 
X 
X 
 
 
 
     Delivery information 
 
 
 
 
 
 
X 
 
Drug dispensation and adherence assessment 
 
     PrEP dispensation 
 
 
 
 
 
X 
 
 
     Pill counts 
 
 
 
 
 
X 
 
 
     Self-report adherence 
 
 
 
 
 
X 
 
 
Intervention assessment (intervention arm only) 
 
     Integrated next step counseling  
     (iNSC) 
 
X 
X 
X 
X 
 
 
 
     Adherence supporter 
 
X 
 
 
 
 
 
 
     Qualitative interviews 
 
X*** 
 
X*** 
X*** 
 
 
 
 
* will perform test if no results available in the medical record 
** storage of leftover specimen for HIV resistance testing 
*** schedule additional procedures within 30 days of visit for subset of participants enrolled in this component