PrEP stigma undermines PMTCT efforts in Zimbabwe

Zimbabwe is among 10 African countries chosen to roll out Lenacapavir. Lenacapvir is a once-a-year injectable Pre-Exposure Prophylaxis (PrEP) drug for HIV prevention. Lenacapavir adds to the growing list of PrEP options that Zimbabwe has approved. The approval is through the Ministry of Health and Child Care (MoHCC).

PrEP has been identified as a critical tool in reducing new HIV infections in newborn babies. There are other PrEP products now available in the country. These include the Dapivirine Vaginal Ring, approved in 2022, Oral PrEP, and the long-acting injectable Cabotegravir (CAB-LA).

However, the Dapivirine Ring is not approved for use during pregnancy. It is also not approved for use in the first six weeks after childbirth. On the other hand, CAB-LA cannot be started during pregnancy. However, women already using it can continue if they become pregnant.

The World Health Organization (WHO) has issued guidelines permitting the use of Lenacapavir and Oral PrEP during pregnancy. In Zimbabwe, the U.S. Embassy announced that the rollout will prioritise pregnant and breastfeeding women. This is a group at high risk of HIV infection.

Despite these scientific advances, PrEP uptake remains low in Zimbabwe. This has major implications for Prevention of Mother-to-Child Transmission (PMTCT) programs. Many women still acquire HIV during pregnancy or breastfeeding. This puts their babies at risk of infection.

Rising HIV infections during pregnancy

According to Dr. Angela Mushavi, the National PMTCT and Paediatric HIV Care and Treatment Coordinator at MoHCC, Zimbabwe is recording worrying new trends in maternal HIV infections. 

“The first half of this year, our treatment coverage for PMTCT is sitting at 91 percent. We are worried about that slight decline. We hope that it will be reversed." She said this during a recent National Validation Committee (NVC) meeting. The meeting was on the Triple Elimination of Mother-to-Child Transmission of HIV, Syphilis, and Hepatitis B.

Dr. Mushavi noted that many women enter antenatal care (ANC) clinics when they are HIV negative. However, they later test positive during pregnancy or breastfeeding.

Ministry of Health data for 2023 estimates that 3,652 new HIV infections occurred in children. Most of the infections happen during pregnancy, followed by infections during breastfeeding. The main contributing factors include late initiation of ART and treatment dropouts. Mothers not receiving ART during pregnancy or breastfeeding are also contributing factors. These statistics highlight gaps in PMTCT interventions, especially in relation to PrEP coverage.

Lived realities of women in rural Zimbabwe

While national data shows progress in PMTCT, the lived experiences of women in rural communities reveal the stigma and cultural barriers that continue to undermine PrEP uptake.

Dr. Joseph Murungu, one of Zimbabwe’s leading HIV researchers, led a study on how to boost PrEP use. It focused on HIV-negative pregnant and breastfeeding women and adolescents. The study found that there are some major barriers. These include stigma, misconceptions, and cultural beliefs. Gender-based violence also plays a big role. While lack of partner support makes it even harder for women to use PrEP.

For women like Kudzai Mangwiro (29), from Muchineripi Village in Gokwe North, taking PrEP is not simply a medical decision. Taking PrEP is a negotiation within her marriage.

“It will cause problems,” she said. “Imagine suddenly telling my husband, ‘I want to start PrEP.’ He would think I’m hiding something. Or maybe that I’m HIV-positive, unfaithful, or accusing him of cheating.

Kudzai knows PrEP can help protect her, but she feels it’s safer to wait until she talks to her husband.

“I trust my husband,” she said. “When I registered this pregnancy, he came with me to the ANC, and we both tested HIV negative. I believe we can keep it that way.”

Talent Sungisai (32) from Muchemwa Village, under Chief Chiromo, shared the same concerns. She is also receiving care at Gokwe North District Hospital.

“We want to protect ourselves and our children, but these conversations are not easy. Abruptly asking for PrEP can spark conflict.”

Misconceptions fuel low uptake

Health workers in rural Zimbabwe say stigma and false beliefs about PrEP make it hard for people to use it.

Caritas Mbombe, the District Nursing Officer in Gokwe North, said many people still misunderstand PrEP. Some think HIV-negative people should not use it because it contains ART medicines. Others take it from the clinic but throw it away at home if their partners or relatives disagree. Some even pass it on to family members who fear getting infected.

“Most communities believe PrEP should not be given to HIV-negative clients. This is mainly because they know it contains ART medicines. Some mothers take the medicine from the clinic but throw it away at home. Usually because their partners or relatives don’t approve," said Mbombe.

She believes it is impossible to attain the UNAIDS 2030 targets. And to end AIDS as a public health concern as long as PrEP uptake is still low

“This will affect our targets in eliminating HIV especially towards 2030. Why? Because if pregnant mothers are not taking PrEP, it means there is an increased risk of them becoming HIV positive. This is taking into consideration that they will be having unprotected sex. So the risks are high and they might transmit the HIV to the unborn baby.”

In Gokwe South, health workers say male resistance still hinders PrEP use in ANC settings. Sister Farisai Mlambo, the Nurse in Charge at Katema Clinic, said many husbands prevent their wives from taking PrEP.

“The problem is that few men come with their wives for ANC visits,” she said. “When women collect PrEP alone, many are told to stop using it because their husbands think it’s ARVs. Some even return to the clinic saying, ‘My husband told me to stop.’

This dynamic has contributed to delayed ANC bookings. It also leads to home deliveries, and lower PrEP uptake in the district.

Mr. Isaki Chiwara, the NAC District AIDS Coordinator for Gokwe South, said ANC booking rates are at 71 percent. The district is aiming to reach over 85 percent.

Late bookings mean women miss HIV testing and prevention early in pregnancy,” he said. “Some only come to the clinic to give birth, when it’s already too late to stop HIV transmission to the baby. 

Uneven Uptake Across Provinces

National data shows wide disparities in ANC PrEP initiations across Zimbabwe’s provinces. Mashonaland West recorded the highest uptake with 1,230 initiations. Manicaland East followed with 1,100, while Manicaland recorded 738. Harare recorded the lowest at 136, with Masvingo also low at 272. recorded the highest uptake with 1,230 initiations. Manicaland East followed with 1,100, while Manicaland recorded 738. Harare recorded the lowest at 136, with Masvingo also low at 272.

Data shows that most women start PrEP while pregnant, not after delivery. This means many breastfeeding mothers miss out on protection.

Commenting on Harare’s low uptake, Dr. Michael Vere, Harare City Health Deputy Director, said stigma remains a likely barrier.

“Even though Harare is not the worst, we need 100 percent uptake. For now, we can only assume stigma is the leading cause. We need a mini survey to better understand the reasons,” he said.