Process evaluation of PrEP implementation in Kenya: adaptation of practices and contextual modifications in public HIV care clinics

Abstract

Introduction In Africa, oral pre‐exposure prophylaxis (PrEP) is largely provided via over‐burdened public HIV care clinics. Successfully incorporating PrEP services into these clinics may require adaptations to practices outlined in national implementation guidelines and modifications to routine existing service delivery. We aimed to describe adaptations made by public HIV clinics in Kenya to integrate PrEP delivery into existing services. Methods The Partners Scale‐Up Project aimed to catalyse integration of PrEP in 25 public HIV care clinics. Between May and December 2018, we conducted qualitative interviews with health providers and documented clinic observations in technical assistance (TA) reports to understand the process of PrEP service integration. We analysed 36 health provider interview transcripts and 25 TA reports to identify clinic‐level adaptations to activities outlined in Kenyan Ministry of Health PrEP guidelines and modifications made to existing service delivery practices to successfully incorporate PrEP services. Identified adaptations were reported using the expanded framework for reporting adaptations and modifications (FRAME). Results All clinics ( n = 25) performed HIV testing, HIV risk assessment, PrEP education and adherence counselling as stipulated in the guidelines. Most clinics initiated clients on PrEP without creatinine testing if otherwise healthy. While monthly refill appointments are recommended, a majority of clinics issued PrEP users two to three months of pills at a time. Clinics also implemented practices that had not been specified in the guidelines including incorporating PrEP‐related topics into routine health talks, calling clients with missed PrEP appointments, discussing PrEP service delivery in regular staff meetings, ‘fast‐tracking’ PrEP clients and dispensing PrEP in clinic rooms rather than at clinic‐based pharmacies. PrEP initiation numbers were highest among clinics that did not require creatinine testing, conducted peer on‐the‐job PrEP training and those that discussed PrEP delivery in their routine meetings. Above‐average continuation was observed among clinics that discussed PrEP in their routine meetings, dispensed PrEP in clinic rooms and offered PrEP at nonregular hours. Conclusions Health providers in public HIV care clinics instituted practices and made innovative adaptations to PrEP delivery to reduce barriers for clients and staff. Encouraging clinic level adaptations to national implementation guidelines will facilitate scale‐up of PrEP delivery.

Provider perspectives on service delivery modifications to maintain access to HIV pre‐exposure prophylaxis during the COVID‐19 pandemic: qualitative results from a PrEP implementation project in Kenya

“…This is consistent with findings from Zimbabwe on the benefits of multi-month PrEP dispensing to support PrEP continuation among female sex workers and was recommended recently by the World Health Organization as an approach to streamline PrEP delivery [20,30,31]. It also supports prior programmatic work from our PSUP team, which found that Kenyan clinics were moving towards efficiencies in PrEP refills with multi-month PrEP dispensing and fast-tracking stable PrEP clients through their visits even prior to the pandemic [25]. We heard about COVID-related changes to laboratory procedures during PrEP initiation and refill visits that could be maintained after the pandemic.…”

“…Prior to the COVID‐19 pandemic, several clinics had already begun modifying how they deliver PrEP, including the adoption of multi‐month PrEP dispensing, phone calls for participants who missed visits and “fast‐tracking” stable PrEP clients (i.e. sending them directly to a clinical room without having to queue) [ 25 ], and it is possible that these clinics would have continued with these modifications in the absence of the COVID‐19 pandemic. Yet, our study found that, for some clinics, the pandemic instigated and cemented these changes.…”

Adoption of HIV pre-exposure prophylaxis among women at high risk of HIV infection in Kenya

“…Barriers to PrEP uptake include low risk perception of HIV, concern of male partners, and stigma associated with HIV and PrEP [5,9,18]. In addition, the additional clinical resources and training associated with PrEP prescribing to an overburdened public health system may have diminished the initial impact of the PrEP roll-out [19]. We did observe increasing rates of PrEP use at 6-and 12-month follow-up, suggesting that national uptake of PrEP is increasing and ongoing.…”

“…the study, changes in risk perception of HIV, pill burden, lack of social support, and stigma have been described as barriers to persistence on PrEP among women in Kenya [8,17]. From a PrEP provider perspective, reduced barriers to PrEP prescribing, including reducing the frequency of clinic visits and longer refill dates, as well as sending clinic reminders may result in higher rates of persistence on PrEP [19]. Interventions to support adherence and persistence on PrEP may borrow approaches from ART adherence strategies, such as simplified PrEP delivery models (including pharmacy-deliveredwhen or other non-clinical sites), adherence clubs, and stigma reduction activities [11,19].…”

“…From a PrEP provider perspective, reduced barriers to PrEP prescribing, including reducing the frequency of clinic visits and longer refill dates, as well as sending clinic reminders may result in higher rates of persistence on PrEP [19]. Interventions to support adherence and persistence on PrEP may borrow approaches from ART adherence strategies, such as simplified PrEP delivery models (including pharmacy-deliveredwhen or other non-clinical sites), adherence clubs, and stigma reduction activities [11,19]. Our finding that PrEP use was associated with engaging in transactional sex, having a recent STI diagnosis, and having an HIV positive partner are consistent with the Kenya national guidelines for PrEP use [21].…”