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

Elizabeth M Irungu, Josephine Odoyo, Elizabeth Wamoni, Elizabeth A Bukusi, Nelly R Mugo, Kenneth Ngure, Jennifer F Morton, Kenneth K Mugwanya, Jared M Baeten, Gabrielle O'Malley, Partners Scale-Up Project Team, Elizabeth M Irungu, Josephine Odoyo, Elizabeth Wamoni, Elizabeth A Bukusi, Nelly R Mugo, Kenneth Ngure, Jennifer F Morton, Kenneth K Mugwanya, Jared M Baeten, Gabrielle O'Malley, Partners Scale-Up Project Team

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.

Trial registration: ClinicalTrials.gov NCT03052010.

Keywords: PrEP continuation; PrEP implementation; PrEP initiation; PrEP integration; adaptation; public HIV care clinics.

Conflict of interest statement

The authors declare that they have no competing interests.

© 2021 The Authors. Journal of the International AIDS Society published by John Wiley & Sons Ltd on behalf of the International AIDS Society.

Figures

Figure 1
Figure 1
Adherence to activities laid out in the Kenyan Ministry of Health PrEP service delivery guidelines. CEF, clinical encounter form; M1, month 1; PrEP, pre‐exposure prophylaxis.
Figure 2
Figure 2
Modifications made to existing HIV care programme practices to facilitate PrEP delivery in public HIV care clinics in Kenya. PrEP, pre‐exposure prophylaxis; †TDF/3TC, tenofovir disoproxil fumarate/lamivudine.
Figure 3
Figure 3
Meanpre‐exposure prophylaxis (PrEP) initiations among clients at public HIV care clinics that adopted specified modifications compared to clients at clinics that did not. Mean number of individuals initiating PrEP at facilities that did (purple) or did not (green) implement specified modifications. †Creatinine: purple bar ‐ no creatinine testing done; green bar ‐ creatinine testing done sometimes.
Figure 4
Figure 4
Mean month 6 pre‐exposure prophylaxis (PrEP) continuation among clients at public HIV care clinics that adopted specified modifications compared to clients at clinics that did not. Proportion of all individuals initiating PrEP who were continuing to use PrEP at six months in facilities that did (purple) or did not (green) implement specified modifications. †Creatinine: purple bar ‐ no creatinine testing done; green bar ‐ creatinine testing done sometimes.

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