Health system opportunities and challenges for PrEP implementation in Kenya: A qualitative framework analysis

Abstract

Background As pre-exposure prophylaxis (PrEP) scales up in sub-Saharan Africa, governments and implementers need to understand how to best manage national programs. Kenya’s national PrEP program offers an opportunity to review elements of program success within the health system and evaluate the utility of a national implementation framework. We explored health system considerations for PrEP implementation to understand how Kenya’s national PrEP implementation priorities align with those of PrEP service providers, peer educators, and program or county managers. Methods We conducted twelve key informant interviews (KII) and nine focus group discussions (FGDs) with PrEP program and county managers (n = 12), peer educators (n = 44), and PrEP service providers (n = 48). We recruited participants across a variety of cadres and experiences with PrEP programs. KIIs and FGDs focused on PrEP service delivery and program implementation. Data were collected by trained study staff, audio recorded, translated into English, and transcribed. We used framework analysis methods to systematically apply Kenya’s 2017 National PrEP Implementation Framework to the data and summarized findings according to the seven Implementation Framework domains. Results All respondents emphasized the important role of communication, coordination, training, and leadership in PrEP implementation. PrEP service providers and program and county managers highlighted the importance of efficient data collection and utilization, and improved resource allocation. Commodity security and research, while key elements of the PrEP Implementation Framework, were less commonly discussed, and research was less prioritized by respondents. Respondents highlighted the importance of coordinated PrEP service delivery across sites and programs to improve overall client experiences. Conclusion In the context of a nationally-scaled PrEP program, PrEP service providers, peer educators, and program and county managers value strong leadership, close coordination of services across sites, and expedient use of data to improve strategies and services. Kenya’s PrEP Implementation Framework aligns closely with the priorities of individuals involved in PrEP service delivery and management, and provides a comprehensive overview of health system considerations for effective implementation of a PrEP program at scale.

Structural influences on delivery and use of oral HIV PrEP among adolescent girls and young women seeking post abortion care in Kenya

“…As elicited in other studies, low proportions of trained providers and frequent staff turnover can yield inconsistency in the quality of care and sometimes leads to increased clinic wait times, delayed linkages to needed care, negative patient interactions with staff, and counselling that de-centers the patients’ needs and experiences. 24 , 25 , 26 , 27 In terms of material resources, health providers also cite availability of medications and HIV testing services as a critical component to creating and sustaining successful program and when deficient, programs can fail to provide services. 24 Strengthening HIV programs throughout the health sector requires investments in human resources and mobilizing systems to support long-term planning for commodities.…”

“…Key recommendations for challenges within health systems that stem from this work are echoed by other PrEP programs in Africa and include the need for robust supply chain management with coordination and prediction of stock demands for PrEP and HIV testing commodities, to better prevent bottlenecks and serve key populations for HIV prevention. 25 , 32 , 33 Sufficient staffing and PrEP training are fundamental factors to increase a facility’s ability to provide PrEP services to clients and avoid missed opportunities. 25 Lastly, administrative leadership support and involvement in promoting PrEP programming has significant bearing on day-to-day activities and potential to improve quality of services and reduce staff turnover.…”

“… 25 , 32 , 33 Sufficient staffing and PrEP training are fundamental factors to increase a facility’s ability to provide PrEP services to clients and avoid missed opportunities. 25 Lastly, administrative leadership support and involvement in promoting PrEP programming has significant bearing on day-to-day activities and potential to improve quality of services and reduce staff turnover. Individual facility leadership can be empowered to bring such data to higher levels within their health systems to effectuate supply chain system changes.…”

Awareness and Willingness to use Condoms and Preexposure Prophylaxis among Gay, Bisexual, and Other Cisgendered Men who Have sex with men in Slum Communities in Ghana. BSGH-004

“…The role of peer educators has been stressed in multiple studies in PrEP follow-ups and uptake among at-risk individuals. [119][120][121] Although no published work on PrEP and peer mentors in slums exist in Ghana, GBMSM peers have played a critical role in previous interventions that address HIV prevention and linkage to care GBMSM in Ghana. 9,48,49,67,88 Despite the favorable attitude toward PrEP uptake among our participants, we urge the training of more peer educators to strengthen use and adherence.…”