A pragmatic approach to identifying implementation barriers and facilitators for a novel pre-exposure prophylaxis (PrEP) delivery model at public facilities in urban Uganda

Dorothy Thomas, Andrew Mujugira, Katrina Ortblad, Sylvia Namanda, Joseph Kibuuka, Mai Nakitende, Florence Nambi, Lylianne Nakabugo, Caitlin Scoville, Timothy Muwonge, Renee Heffron, Dorothy Thomas, Andrew Mujugira, Katrina Ortblad, Sylvia Namanda, Joseph Kibuuka, Mai Nakitende, Florence Nambi, Lylianne Nakabugo, Caitlin Scoville, Timothy Muwonge, Renee Heffron

Abstract

Background: Scalable HIV pre-exposure prophylaxis (PrEP) delivery models for resource-limited settings are critical for improving PrEP coverage and interrupting HIV transmission. This research uses technical assistance (TA) reports to evaluate implementation barriers and facilitators for a novel delivery model integrating PrEP and antiretroviral therapy (ART) delivery for HIV sero-different couples in public health facilities in Kampala, Uganda.

Methods: We used data from the Partners PrEP Program (PPP)-a stepped-wedge cluster randomized trial that is launching PrEP delivery through an integrated model of oral PrEP and antiretroviral therapy (ART) delivery for HIV sero-different couples at public health facilities in Kampala and Wakiso, Uganda (NCT03586128). Technical assistance teams, comprised of PPP program staff, conducted monthly TA visits to implementing facilities where they identified and addressed implementation challenges in collaboration with health facility staff. Findings were recorded in TA reports, a standardized form structured using the Consolidated Framework for Implementation Research (CFIR). We used a conceptual content analysis approach to evaluate TA reports completed from January to December 2019 and identify implementation barriers and facilitators.

Results: Among 39 reports from the 8 implementing facilities (~ 5 per facility), we identified 11 CFIR constructs. Key implementation facilitators included sensitizing and educating facility staff about PrEP (knowledge and beliefs about the innovation); establishing formal and informal feedback and accountability mechanisms (reflecting and evaluating); and empowering facility staff to address implementation challenges (self-efficacy). Key implementation barriers were related to ineffective recruitment and referral of sero-different couples to and from nearby facilities (cosmopolitanism) as well as stockouts of laboratory resources and testing supplies (available resources).

Conclusions: This analysis featured a robust implementation science framework to assess the relationship between early implementation determinants and outcomes of this innovative PrEP delivery model. Further, we have provided important descriptions of early implementation barriers and facilitators that will inform scale-up efforts for PrEP delivery within and beyond Uganda. Future work will refine the analysis of pragmatic program data, qualitatively investigate the identified key themes, and explore strategies for addressing implementation barriers.

Keywords: Barriers; CFIR; Facilitators; HIV; Implementation; LMIC; PrEP; Uganda.

Conflict of interest statement

The authors declare that they have no competing interests.

© 2022. The Author(s).

Figures

Fig. 1
Fig. 1
Number of clients enrolled and on PrEP from step 1 and 2 PPP facilities

References

    1. Baeten JM, Donnell D, Ndase P, Mugo NR, Campbell JD, Wangisi J, et al. Antiretroviral prophylaxis for HIV prevention in heterosexual men and women. New Engl J of Med. 2012;367(5):399–410. doi: 10.1056/NEJMoa1108524.
    1. Organization WH . Guideline on when to start antiretroviral therapy and on pre-exposure prophylaxis for HIV: World Health Organization. 2015.
    1. Davey DJ, Bekker L-G, Gorbach P, Coates T, Myer L. Delivering PrEP to pregnant and breastfeeding women in sub-Saharan africa: the implementation science frontier. AIDS (London, England) 2017;31(16):2193. doi: 10.1097/QAD.0000000000001604.
    1. O’Malley G, Barnabee G, Mugwanya K. Scaling-up PrEP delivery in sub-Saharan Africa: what can we learn from the scale-up of ART? Curr Hiv/aids Rep. 2019;16(2):141–150. doi: 10.1007/s11904-019-00437-6.
    1. Pintye J, Davey DLJ, Wagner AD, John-Stewart G, Baggaley R, Bekker L-G, et al. Defining gaps in pre-exposure prophylaxis delivery for pregnant and post-partum women in high-burden settings using an implementation science framework. Lancet HIV. 2020;7(8):e582–ee92. doi: 10.1016/S2352-3018(20)30102-8.
    1. PrEPWatch. Ongoing and planned PrEP open label, demonstration and implementation projects in Uganda: AVAC; 2020 [Available from: .
    1. Schaefer R, Schmidt H-M, Ravasi G, Mozalevskis A, Rewari BB, Lule F, et al. Global adoption of guidelines on and use of oral pre-exposure prophylaxis (PrEP): current situation and future projections. 2021.
    1. PEPFAR. Uganda Country Operational Plan (COP) 2018. p. 2018.
    1. Baeten JM, Heffron R, Kidoguchi L, Mugo NR, Katabira E, Bukusi EA, et al. Integrated delivery of antiretroviral treatment and pre-exposure prophylaxis to HIV-1–serodiscordant couples: a prospective implementation study in Kenya and Uganda. PLoS medicine. 2016;13(8):e1002099. doi: 10.1371/journal.pmed.1002099.
    1. Foundation EGPA. HIV 101: Understanding technical assistance: Elizabeth Glaser Pediatric AIDS Foundation; 2014 [Available from: .
    1. Morton JF, Celum C, Njoroge J, Nakyanzi A, Wakhungu I, Tindimwebwa E, et al. Counseling framework for HIV-serodiscordant couples on the integrated use of antiretroviral therapy and pre-exposure prophylaxis for HIV prevention. J Acquired Immune Deficiency Synd (1999) 2017;74(Suppl 1):S15. doi: 10.1097/QAI.0000000000001210.
    1. Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implementation Sci. 2009;4(1):1–15. doi: 10.1186/1748-5908-4-50.
    1. Nilsen P. Making sense of implementation theories, models and frameworks. Implementation Sci. 2015;10(1):53. doi: 10.1186/s13012-015-0242-0.
    1. Damschroder LJ, Reardon CM, Lowery JC. The Consolidated Framework for Implementation Research (CFIR) In: PaBSA N, editor. Handbook on Implementation Science: Edward Elgar Publishing. 2020. pp. 88–112.
    1. Dedoose V. Web application for managing, analyzing, and presenting qualitative and mixed method research data. Los Angeles: SocioCultural Research Consultants; 2012.
    1. Stankevitz K, Schwartz K, Hoke T, Li Y, Lanham M, Mahaka I, et al. Reaching at-risk women for PrEP delivery: what can we learn from clinical trials in sub-Saharan Africa? PloS one. 2019;14(6):e0218556. doi: 10.1371/journal.pone.0218556.
    1. Were D, Musau A, Mutegi J, Ongwen P, Manguro G, Kamau M, et al. Using a HIV prevention cascade for identifying missed opportunities in PrEP delivery in Kenya: results from a programmatic surveillance study. Journal of the International AIDS Society. 2020;23:e25537. doi: 10.1002/jia2.25537.
    1. Beima-Sofie K, Wagner A, Pintye J, Abuna F, Lagat H, Baeten J, et al. Implementation challenges and strategies in integration of prep into maternal and child health and family planning services: experiences of frontline healthcare workers in kenya. journal of the international aids society. Southern Gate, Chichester: Wiley; 2019.
    1. Joseph Davey DL, Daniels J, Beard C, Mashele N, Bekker L-G, Dovel K, et al. Healthcare provider knowledge and attitudes about pre-exposure prophylaxis (PrEP) in pregnancy in Cape Town, South Africa. Aids Care. 2020;32(10):1290–1294. doi: 10.1080/09540121.2020.1782328.
    1. Greener R, Milford C, Bajunirwe F, Mosery FN, Ng CK, Rifkin R, et al. Healthcare providers’ understanding of HIV serodiscordance in South Africa and Uganda: implications for HIV prevention in sub-Saharan Africa. African J Aids Res. 2018;17(2):137–144. doi: 10.2989/16085906.2018.1462217.
    1. Pillay D, Stankevitz K, Lanham M, Ridgeway K, Murire M, Briedenhann E, et al. Factors influencing uptake, continuation, and discontinuation of oral PrEP among clients at sex worker and MSM facilities in South Africa. PLoS One. 2020;15(4):e0228620. doi: 10.1371/journal.pone.0228620.
    1. Masyuko S, Mukui I, Njathi O, Kimani M, Oluoch P, Wamicwe J, et al. Pre-exposure prophylaxis rollout in a national public sector program: the Kenyan case study. Sexual Health. 2018;15(6):578–586. doi: 10.1071/SH18090.

Source: PubMed

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