Implementation strategies for integrating pre-exposure prophylaxis for HIV prevention and family planning services for adolescent girls and young women in Kenya: a qualitative study

Stephanie D Roche, Gena Barnabee, Victor Omollo, Felix Mogaka, Josephine Odoyo, Elizabeth A Bukusi, Jennifer F Morton, Rachel Johnson, Connie Celum, Jared M Baeten, Gabrielle O'Malley, Stephanie D Roche, Gena Barnabee, Victor Omollo, Felix Mogaka, Josephine Odoyo, Elizabeth A Bukusi, Jennifer F Morton, Rachel Johnson, Connie Celum, Jared M Baeten, Gabrielle O'Malley

Abstract

Introduction: Across sub-Saharan Africa, ministries of health have proposed integrating pre-exposure prophylaxis (PrEP) for HIV prevention into family planning (FP) services to reach adolescent girls and young women (AGYW); however, evidence on effective implementation strategies is still limited. We conducted a qualitative study of integrated PrEP-FP service implementation at two FP clinics in Kisumu, Kenya.

Methods: From June 2017 to May 2020, the Prevention Options for Women Evaluation Research (POWER) study enrolled 1000 sexually active, HIV-negative AGYW age 16 to 25. Actions taken to implement PrEP were captured prospectively in 214 monitoring and evaluation documents and 15 interviews with PrEP implementers. We analysed data using conventional and directed content analysis, with the latter informed by the Consolidated Framework for Implementation Research (CFIR) and the Expert Recommendations for Implementing Change (ERIC) compilation.

Results: POWER deployed a variety of implementation strategies to train and educate stakeholders (e.g., having new providers shadow PrEP providers); develop stakeholder interrelationships (e.g., organizing support teams with protected time to reflect on implementation progress and make refinements); provide technical assistance; and change physical infrastructure and workflow. Although these strategies reportedly influenced contextual factors across four of the five CFIR domains, they primarily interacted with contextual factors relevant to inner setting, especially implementation climate and readiness for implementation. Overall, implementing PrEP proved easier and less labor-intensive at a private, youth-friendly clinic than a public FP clinic, largely because the baseline structural characteristics (e.g., space, workflow) and organizational mission of the former were more conducive to offering AGYW-centered care. Nevertheless, adoption of PrEP delivery among non-study staff at both sites was low, likely due to the widespread perception that PrEP was not within their scope of work.

Conclusions: Some FP clinics may be "lower-hanging fruit" than others for PrEP implementation. Approaching PrEP implementation as a behavioral intervention for FP providers may help ensure that providers have the requisite capability, opportunity, and motivation to adopt the clinical innovation. In particular, PrEP implementers should assess the need for implementation strategies that support providers' clinical decision-making, establish worker expectations and accountability, and address workload constraints.

Trial registration: Clinical Trial Number: NCT03490058 .

Keywords: Delivery of health care, integrated; Family planning services; HIV infections; Implementation science; Kenya; Pre-exposure prophylaxis.

Conflict of interest statement

JMB is an employee of Gilead Sciences. For the remaining authors, none were declared.

© 2022. The Author(s).

References

    1. UNAIDS. UNAIDS Data 2020. Geneva: UNAIDS Joint United Nations Programme on HIV/AIDS; 2020.
    1. World Health Organization. WHO expands recommendation on oral pre-exposure prophlaxis of HIV infection (PrEP). World Heal Organ. 2015:2. .
    1. Fonner VA, Dalglish SL, Kennedy CE, et al. Effectiveness and safety of oral HIV preexposure prophylaxis for all populations. Aids. 2016;30(12):1973–1983. doi: 10.1097/QAD.0000000000001145.
    1. United States President’s Emergency Plan for AIDS Relief . DREAMS Partnership Fact Sheet 2019. 2019. p. 1.
    1. Pintye J, Kinuthia J, Abuna F, et al. Frequency and predictors of Tenofovir-diphosphate detection among young Kenyan women in a real-world pre-exposure prophylaxis implementation program. Clin Infect Dis. 2020;71(9):e509–e512. doi: 10.1093/cid/ciaa181.
    1. Were D, Musau A, Mutegi J, et al. Using a HIV prevention cascade for identifying missed opportunities in PrEP delivery in Kenya: results from a programmatic surveillance study. J Int AIDS Soc. 2020;23(S3):67–77. doi: 10.1002/jia2.25537.
    1. Velloza J, Donnell D, Anderson P, et al. PrEP adherence is associated with periods of HIV risk among adolescent girls and young women in South Africa and Zimbabwe [abstract] JIAS. 2021;24(S1):PE25.06.
    1. Pintye J, Beima-Sofie KM, Makabong’O PA, et al. HIV-uninfected Kenyan adolescent and young women share perspectives on using pre-exposure prophylaxis during pregnancy. AIDS Patient Care STDs. 2018;32(12):538–544. doi: 10.1089/apc.2018.0058.
    1. Pintye J, O’Malley G, Kinuthia J, et al. Influences on early discontinuation and persistence of daily oral PrEP use among Kenyan adolescent girls and young women. J Acquir Immune Defic Syndr. 2020;86(4):83–89. doi: 10.1097/qai.0000000000002587.
    1. Ongolly FK, Dolla A, Ngure K, et al. “I just decided to stop”: understanding PrEP discontinuation among individuals initiating PrEP in HIV care centers in Kenya. J Acquir Immune Defic Syndr. 2021;87. 10.1097/QAI.0000000000002625.
    1. Maughan-Brown B, Venkataramani AS. Accuracy and determinants of perceived HIV risk among young women in South Africa. 2018:1–9. 10.1186/s12889-017-4593-0.
    1. Corneli AL, Mckenna K, Headley J, et al. A descriptive analysis of perceptions of HIV risk and worry about acquiring HIV among FEM-PrEP participants who seroconverted in Bondo, Kenya, and Pretoria, South Africa. J Int AIDS Soc. 2014;17(Suppl 2):1–8.
    1. Sila J, Larsen AM, Kinuthia J, et al. High awareness, yet low uptake, of pre-exposure prophylaxis among adolescent girls and young women within family planning clinics in Kenya. AIDS Patient Care STDs. 2020;34(8):336–343. doi: 10.1089/apc.2020.0037.
    1. Lanham M, Stankevitz K, Ridgeway K, Mireku M. Healthcare providers’ attitudes and experiences delivering oral PrEP to adolescent girls and young women: implementation research to inform PrEP rollout in Kenya, South Africa, and Zimbabwe [abstract] IAS. 2019;22(S5):e25327.
    1. WHO . WHO PrEP implementation tool for pre-exposure prophylaxis (PrEP) of HIV infection. 2018.
    1. Daniels J, Bresenham D, de Vos L, et al. I’m taking PrEP for myself and not for people: PrEP disclosures influence adherence journeys for adolescent girls and young women in South Africa [abstract] JIAS. 2021;24(S1):OA07.04.
    1. Katz A, Rousseau E, Khoza N, et al. Using social maps to explore young women’s experiences with social support of their oral PrEP use in Kenya and South Africa [abstract] JIAS. 2021;24(S1):PE01.59.
    1. Rousseau E, Katz A, O’Rourke S, et al. Adolescent girls and young women’s PrEP-user journey during an implementation science study in South Africa and Kenya. PLoS One. 2021;16(10):1–18. doi: 10.1371/journal.pone.0258542.
    1. Haberer J. Monitoring pre-exposure prophylaxis for young adult women (MPYA) 2016.
    1. University of Washington. The UW Implementation Science Resource Hub. . Accessed 15 Mar 2021.
    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. Implement Sci. 2009;4(1):50. doi: 10.1186/1748-5908-4-50.
    1. Lewis CC, Klasnja P, Powell BJ, et al. From classification to causality: advancing understanding of mechanisms of change in implementation science. Front Public Heal. 2018;6. 10.3389/fpubh.2018.00136.
    1. Means AR, Kemp CG, Gwayi-Chore M-C, et al. Evaluating and optimizing the consolidated framework for implementation research (CFIR) for use in low- and middle-income countries: a systematic review. Implement Sci. 2020;15(1):1–19. doi: 10.1186/s13012-020-0977-0.
    1. Powell BJ, McMillen JC, Proctor EK, et al. A compilation of strategies for implementing clinical innovations in health and mental health. Med Care Res Rev. 2012;69(2):123–157. doi: 10.1177/1077558711430690.
    1. Powell BJ, Waltz TJ, Chinman MJ, et al. A refined compilation of implementation strategies: results from the expert recommendations for implementing change (ERIC) project. Implement Sci. 2015;10(1):1–14. doi: 10.1186/s13012-015-0209-1.
    1. Kirchner JAE, Smith JL, Powell BJ, Waltz TJ, Proctor EK. Getting a clinical innovation into practice: an introduction to implementation strategies. Psychiatry Res. 2020;283:112467. doi: 10.1016/j.psychres.2019.06.042.
    1. Perry CK, Damschroder LJ, Hemler JR, Woodson TT, Ono SS, Cohen DJ. Specifying and comparing implementation strategies across seven large implementation interventions: a practical application of theory. Implement Sci. 2019;14(1):1–13. doi: 10.1186/s13012-019-0876-4.
    1. Kenya Ministry of Health. Framework for the implementation of pre-exposure prophylaxis of HIV Kenya. Nairobi: National AIDS and STI Control Program; 2017.
    1. Kenya Ministry of Health. Kenya HIV Estimates Reports 2018. Nairobi; 2018.
    1. Hsieh H-F, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res. 2005;15(9):1277–1288. doi: 10.1177/1049732305276687.
    1. Saldaña J. The coding manual for qualitative researchers. 2. London: Sage Publications, Ltd.; 2013.
    1. University of California San Francisco. National Clinician Consultation Center. . Accessed June 19, 2020.
    1. Rousseau E, Katz A, O’Rourke S, et al. Adolescent girls and young women’s (AGYW) PrEP-user journey during an implementation science study in South Africa and Kenya [abstract] JIAS. 2021;24(S1):PE01.31.
    1. Giovenco D, Gill K, Fynn L, et al. Experiences of oral pre-exposure prophylaxis (PrEP) use disclosure among south African adolescent girls and young women and its perceived impact on adherence. PLoS One. 2021;16(3):1–13. doi: 10.1371/journal.pone.0248307.
    1. Maseko B, Hill LM, Phanga T, et al. Perceptions of and interest in HIV pre-exposure prophylaxis use among adolescent girls and young women in Lilongwe, Malawi. PLoS One. 2020;15(1):1–14. doi: 10.1371/journal.pone.0226062.
    1. Dunbar M, Ncube B, Otieno M, et al. Integration of oral PrEP and family planning in Kenya and Zimbabwe: assessment of HIV prevention and sexual and reproductive health services to strengthen access for adolescent girls and young women [abstract]. JIAS. 2021;24(S1) .
    1. World Health Organization. Making health services adolescent friendly: developing National Quality Standards for adolescent-friendly health services. Geneva: World Health Organization; 2012. ISBN 978 92 4 150359 4.
    1. Krakower D, Ware N, Mitty JA, Maloney K, Mayer KH. HIV providers’ perceived barriers and facilitators to implementing pre-exposure prophylaxis in care settings: a qualitative study. AIDS Behav. 2014;18(9):1712–1721. doi: 10.1007/s10461-014-0839-3.
    1. Calabrese SK, Krakower DS, Mayer KH. Integrating HIV preexposure prophylaxis (PrEP) into routine preventive health care to avoid exacerbating disparities. Am J Public Health. 2017;107(12):1883–1889. doi: 10.2105/AJPH.2017.304061.
    1. Stankevitz K, Nhamo D, Murungu J, et al. Test and Prevent: Evaluation of a Pilot Program Linking Clients With Negative HIV Test Results to Pre-exposure Prophylaxis in Zimbabwe. Glob Health Sci Pract. 2021;9(1):40–54. doi: 10.9745/GHSP-D-20-00444.
    1. Bärnighausen K, Matse S, Hughey AB, Hettema A, Bärnighausen TW, McMahon SA. “We know this will be hard at the beginning, but better in the long term”: understanding PrEP uptake in the general population in Eswatini. AIDS Care. 2020;32(2):267–273. doi: 10.1080/09540121.2019.1653437.
    1. Beima-Sofie K, Wagner A, Pintye 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 [abstract]. IAS. 2019;22(5) .
    1. Michie S, Atkins L, West R. The behaviour change wheel a guide to designing interventions. London: Silverback Publishing; 2014.
    1. Wanga V, Omollo V, Bukusi E, et al. Uptake and impact of facility-based HIV self-testing on PrEP delivery: a pilot study among young women in Kisumu, Kenya. J Int AIDS Soc. 2020;23(8):e25561. doi: 10.1002/jia2.25561.
    1. Peebles K, Mugwanya KK, Irungu E, et al. Low costs and opportunities for efficiency: a cost analysis of the first year of programmatic PrEP delivery in Kenya’s public sector. BMC Health Serv Res. 2021;21(1):1–8. doi: 10.1186/s12913-021-06832-3.
    1. Kedar F. Peer-led approaches for reaching female sex workers in Ethiopia [oral presentation]. . Accessed 10 Oct 2021.
    1. Irungu I, Ngure K, Mugwanya K, et al. Surmounting PrEP delivery challenges through adaptation of implementation guidelines: lessons learned from HIV care clinics in Kenya [abstract] JIAS. 2019;22(55):e253277.
    1. Ziwani A. PATH. DREAMS goes digital: using virtual platforms to maintain PrEP access among adolescent girls and young women in Kenya. 2020.
    1. Wanga V, Omollo V, Bukusi EA, et al. Uptake and impact of facility-based HIV self-testing on PrEP delivery: a pilot study among young women in Kisumu, Kenya. J Int AIDS Soc. 2020;23(8):14–18. doi: 10.1002/jia2.25561.
    1. Seidman D, Travill D, Dehlendorf C, et al. MyPrEP decision support tool increases PrEP persistence in adolescent girls and young women attending an urban primary health care clinic in South Africa [abstract]. JIAS. 2021;24(S1) .
    1. Proctor EK, Powell BJ, McMillen JC. Implementation strategies: recommendations for specifying and reporting. Implement Sci. 2013;8(1):139. doi: 10.1186/1748-5908-8-139.

Source: PubMed

Sponsorer och medarbetare

Medicinska tillstånd

Läkemedelsinterventioner

3
Prenumerera