A one‐stop shop model for improved efficiency of pre‐exposure prophylaxis delivery in public clinics in western Kenya: a mixed methods implementation science study

Abstract

Introduction In public clinics in Kenya, separate, sequential delivery of the component services of pre‐exposure prophylaxis (PrEP) (e.g. HIV testing, counselling, and dispensing) creates long wait times that hinder clients’ ability and desire to access and continue PrEP. We conducted a mixed methods study in four public clinics in western Kenya to identify strategies for operationalizing a one‐stop shop (OSS) model and evaluate whether this model could improve client wait time and care acceptability among clients and providers without negatively impacting uptake or continuation. Methods From January 2020 through November 2020, we collected and analysed 47 time‐and‐motion observations using Mann–Whitney U tests, 29 provider and client interviews, 68 technical assistance reports, and clinic flow maps from intervention clinics. We used controlled interrupted time series (cITS) to compare trends in PrEP initiation and on‐time returns from a 12‐month pre‐intervention period (January–December 2019) to an 8‐month post‐period (January–November 2020, excluding a 3‐month COVID‐19 wash‐out period) at intervention and control clinics. Results From the pre‐ to post‐period, median client wait time at intervention clinics dropped significantly from 31 to 6 minutes (p = 0.02), while median provider contact time remained around 23 minutes (p = 0.4). Intervention clinics achieved efficiency gains by moving PrEP delivery to lower volume departments, moving steps closer together (e.g. relocating supplies; cross‐training and task‐shifting), and differentiating clients based on the subset of services needed. Clients and providers found the OSS model highly acceptable and additionally identified increased privacy, reduced stigma, and higher quality client–provider interactions as benefits of the model. From the pre‐ to post‐period, average monthly initiations at intervention and control clinics increased by 6 and 2.3, respectively, and percent of expected follow‐up visits occurring on time decreased by 18% and 26%, respectively; cITS analysis of PrEP initiations (n = 1227) and follow‐up visits (n = 2696) revealed no significant difference between intervention and control clinics in terms of trends in PrEP initiation and on‐time returns (all p>0.05). Conclusions An OSS model significantly improved client wait time and care acceptability without negatively impacting initiations or continuations, thus highlighting opportunities to improve the efficiency of PrEP delivery efficiency and client‐centredness.

Characterizing the Impact of the COVID-19 Pandemic on HIV PrEP care: A Review and Synthesis of the Literature

“…A full description and details of included studies’ characteristics are summarized (see Table 1 ) . These studies were conducted in the United States ( n = 18)[ 21 , 29 – 45 ], United Kingdom ( n = 6)[ 22 , 46 – 50 ], Australia ( n = 4)[ 23 , 51 – 53 ], Brazil ( n = 4)[ 54 – 57 ], Portugal ( n = 3)[ 54 , 56 , 58 ], Kenya ( n = 2)[ 59 , 60 ], Belgium ( n = 2)[ 24 , 26 ], South Africa ( n = 2)[ 25 , 27 ]. The rest of the studies were conducted in Canada[ 61 ], Croatia[ 62 ], Ireland[ 63 ], Zimbabwe[ 64 ], Netherlands[ 65 ], the Philippines[ 66 ], France[ 67 ].…”

“…One study included data from 20 different countries[ 68 ]. Most studies (n = 42) utilized quantitative methods, with 2 qualitative studies[ 29 , 43 ] and 2 mixed-method designs [ 39 , 60 ]. A majority of studies (n = 27) were comprised of MSM, three of which explicitly focused on young MSM[ 21 , 29 , 30 ].…”

Human resource needs and costs for HIV pre-exposure prophylaxis provision in nurse-led primary care in Eswatini and opportunities for task sharing

“…Time-and-motion studies have been previously applied to assess the human resource needs for providing PrEP, for instance, to HIV-discordant couples in Kenya, Uganda, and Zimbabwe [ 13 – 16 ]; to adolescent girls and young women in Kenya and South Africa [ 17 – 19 ]; to women attending ante- or postnatal care in Kenya [ 20 ]; or to men who have sex with men in the US [ 21 ]. The recorded duration for PrEP initiation ranged from a median time of 13.6 min to a mean time of 51 min.…”

Scaling up preexposure prophylaxis to maximize HIV prevention impact

“…PrEP initiations in communitybased clinics are also performed in San Francisco [34]. In settings with a high HIV prevalence in adolescent girls and young women, it is important to integrate PrEP services with family planning clinics In Kenya, a one-stop same-day PrEP model was shown to reduce clinic times and improve patient acceptability compared with the traditional model requiring different visits for HIV testing, counselling, clinical assessment and dispensing [36]. Using telemedicine linked with home or community-based HIV and STI testing may reduce the burden of clinic visits [31], particularly for patients living in nonurban settings.…”