Barriers to and strategies for early implementation of pharmacy-delivered HIV PrEP services in Kenya: An analysis of routine data

Abstract

BackgroundFor individuals who face challenges accessing clinic-based HIV pre-exposure prophylaxis (PrEP), differentiated service delivery models are needed to expand access and reach. During a pilot study testing a novel pharmacy-delivered oral PrEP model in Kenya, we used routine programmatic data to identify early implementation barriers and actions that providers and study staff took in response to the barriers.MethodsWe trained pharmacy providers at five private pharmacies in Kisumu and Kiambu Counties to initiate and continue clients at risk of HIV acquisition on PrEP for a fee of 300 KES per visit (∼$3 USD) using a prescribing checklist with remote clinician oversight. Research assistants stationed at the pharmacies completed weekly observation reports of pharmacy-delivered PrEP services using a structured template. We analyzed reports from the first 6 month of implementation using content analysis and identified multi-level early implementation barriers and actions taken to address these. We then organized the identified barriers and actions according to the Consolidated Framework for Implementation Research (CFIR).ResultsFrom November 2020 to May 2021, research assistants completed 74 observation reports (∼18/pharmacy). During this period, pharmacy providers screened 496 potential PrEP clients, identified 425 as eligible for pharmacy-delivered PrEP services, and initiated 230 (54%) on PrEP; 125 of 197 (63%) clients eligible for PrEP continuation refilled PrEP. We identified the following early implementation barriers to pharmacy-delivered PrEP services (by CFIR domain): high costs to clients (intervention characteristics), client discomfort discussing sexual behaviors and HIV testing with providers (outer setting), provider frustrations that PrEP delivery was time-consuming and disruptive to their workflow (inner setting), and provider hesitancy to deliver PrEP due to concerns about encouraging sexual promiscuity (characteristics of individuals). To help address these, pharmacy providers implemented a self-screening option for behavioral HIV risk assessment for prospective PrEP clients, allowed flexible appointment scheduling, and conducted pharmacy PrEP trainings for newly hired staff.ConclusionOur study provides insight into early barriers to implementing pharmacy-delivered PrEP services in Kenya and potential actions to mitigate these barriers. It also demonstrates how routine programmatic data can be used to understand the early implementation process.

Facilitators and barriers to community pharmacy PrEP delivery: A scoping review

“…Economic and social opportunity barriers for pharmacists included the country’s economic instability (60) and the inability to advertise branded medications in pharmacies (66). For the more specific aspects of PrEP delivery in community pharmacies, such as PrEP counselling and prescribing, pharmacists in the USA and Kenya reported the high turnover of staff (65) and the lack of skilled staff (e.g., only having one pharmacist on duty per shift) as barriers (28, 67, 70). Similarly, lack of staff time (28, 30, 47, 49, 53, 56, 70) was also found to be a barrier, particularly when needing longer consultation times (28) to initiate clients on PrEP (65) and carry out the required monitoring (e.g., kidney function) (33).…”

“…For the more specific aspects of PrEP delivery in community pharmacies, such as PrEP counselling and prescribing, pharmacists in the USA and Kenya reported the high turnover of staff (65) and the lack of skilled staff (e.g., only having one pharmacist on duty per shift) as barriers (28, 67, 70). Similarly, lack of staff time (28, 30, 47, 49, 53, 56, 70) was also found to be a barrier, particularly when needing longer consultation times (28) to initiate clients on PrEP (65) and carry out the required monitoring (e.g., kidney function) (33). There was also concern that an increased workload would negatively impact time allocated to delivery of other services (31).…”

“…Having a consultation room, private spaces or a separate room (28, 61, 66, 70) to have sensitive conversations in, in addition to facilities to enable STI and HIV testing (28), were reported to be facilitative of PrEP delivery. If there was a lack of facilities within the pharmacy, pharmacists reported that allowing clients to test themselves for HIV (65) or having a collaborative service with other health care providers could help facilitate PrEP delivery, adherence and continuation (28, 30, 42, 61, 62). Having a clear referral process for pharmacists to provide clients with the necessary treatment options for conditions identified during PrEP delivery was also found to facilitate PrEP delivery (35).…”

“…Clients also reported feeling less comfortable seeking a pharmacist for PrEP information and delivery (39, 58), preferring to speak to their physician (58), organisations that cater to the lesbian, gay, bisexual, transgender, queer/questioning and other (LGBTQ+) community or organisations that help cover the costs of PrEP (39). Some clients were also hesitant to be screened in pharmacies for fear of testing HIV-positive (65). Clients were also concerned about the misconceptions of PrEP being a medication for people living with HIV and that they could experience stigma from pharmacists (55, 59).…”

Systematic review of alternative HIV pre-exposure prophylaxis (PrEP) care delivery models to improve PrEP services

“…Also, a few barriers to pharmacist- prescribed PrEP (e.g. frustrations that PrEP delivery was time-consuming and disruptive to their workflow) have been reported, and further studies on pharmacist prescribers are needed [61].…”