Background: Roll out of pre-exposure prophylaxis (PrEP) has begun in several African countries. In Kenya, PrEP delivery is largely in public health facilities, which successfully provide services to large numbers of clients in spite of facing multiple challenges including understaffing, long waiting times, poor infrastructure, and commodity stock outs. The Partners Scale-Up Project is an on-going prospective implementation science evaluation that aims to catalyze integration of PrEP in 24 public HIV care clinics in Kenya using existing facility infrastructure and personnel. As of December 2018, participating clinics have initiated 4000 clients on PrEP. We describe how public clinics are adapting PrEP implementation guidelines to facilitate successful delivery.
Methods: To understand the service integration process, we conducted qualitative interviews with health providers and documented clinic observations in technical assistance (TA) reports over eighteen months. Using a combination of deductive and inductive approaches, we analyzed 71 health provider interviews and TA reports from the 24 clinics to identify clinic level adaptations to national PrEP implementation guidelines.
Results: Clinics tried multiple adaptations to facilitate PrEP delivery. First, renal function testing is recommended (but not required) by Kenyan guidelines but due to unavailability of creatinine tests, clients were often initiated on PrEP without such testing if otherwise healthy. Second, to address long waiting times, almost all clinics reported fast-tracking PrEP users. Third, some clinicians reported dispensing PrEP medication from the clinical room, saving PrEP users time associated with waiting at the pharmacy, a practice that also mitigated the stigma associated with being seen at a pharmacy that predominantly serves HIV infected persons. Fourth, while Kenyan guidelines recommend monthly refill appointments, the majority of clinics issued PrEP users 2-3 months of pills at a time, depending on client request and adherence; this adaptation also eased provider workload. Finally, when stock outs of tenofovir/emtricitabine (TDF/FTC) occurred, clinics readily dispensed tenofovir/lamivudine (TDF/3TC) as PrEP.
Conclusions: Health providers in public HIV care clinics instituted practices and made innovative adaptations to recommendations in order to overcome PrEP delivery challenges and reduce barriers for clients and staff. Enabling clinic level adaptations to national implementation guidelines will facilitate the scale-up of PrEP delivery.