Integration of pre-exposure prophylaxis services into public HIV care clinics in Kenya: a pragmatic stepped-wedge randomised trial

Irungu, Elizabeth; Mugwanya, Kenneth; Mugo, Nelly; Bukusi, Elizabeth A.; Donnell, Deborah; Odoyo, Josephine; Wamoni, Elizabeth; Peacock, Sue; Morton, Jennifer; Ngure, Kenneth; Mugambi, Mary; Mukui, Irene; O’Malley, Gabrielle; Baeten, Jared M.

doi:10.1016/s2214-109x(21)00391-0

Cited by 28 publications

(32 citation statements)

References 23 publications

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“…Clinics that instituted contextual modifications such as PrEP discussions in routine facility meetings, on-the-job PrEP training by peers, multi-month scripting and providing PrEP services outside of regular clinic hours had higher than average monthly PrEP initiations and continuation rates. The Partners Scale-Up Project, which to our knowledge was the first evaluation of a national PrEP rollout in Africa, had a mean monthly PrEP uptake that was similar to that observed in similar settings, though we observed higher mean month 6 continuation rates [30][31][32].…”

Section: Discussionsupporting

confidence: 69%

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

et al. 2021

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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.

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Section: Discussionsupporting

confidence: 69%

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

et al. 2021

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“…This program also found high frequency of PrEP initiation (mean PrEP initiations per month=7.5 during intervention periods) and high rates of PrEP discontinuation by HIV-negative partners at 6 months (34% of all PrEP initiators). 10 High discontinuation by 6 months that was observed in the Kenya program, as well as our Uganda program, was expected since PrEP discontinuation among HIV serodifferent couples is warranted when the partner living with HIV achieves sustained use of ART and there are no other potential sources of transmission.…”

Section: Discussionmentioning

confidence: 86%

“…5 Since ART clinics are adept at HIV testing and many have programs to identify and support HIV-serodifferent couples, an early strategy in countries with generalized HIV epidemics has been to make PrEP available through ART clinics to members of key populations and HIV serodifferent couples. 10 This approach leverages the expertise of providers skilled in ART management and counseling with clear benefits to PrEP uptake and cost effectiveness. 11 However, programs and research to date have not assessed the ways in which PrEP provision integrated into ART clinics may have unanticipated benefits or consequences for ART programs.…”

Section: Introductionmentioning

confidence: 99%

PrEP uptake and HIV viral suppression when PrEP is integrated into Ugandan ART clinics for HIV-negative members of HIV-serodifferent couples: A stepped wedge cluster randomized trial

et al. 2022

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“…In the TAPS study, conducted among FSWs in South Africa, self-reported adherence rates ranged from 70 to 85% [ 14 ], while a recent study conducted among FSWs in Kampala, Uganda showed adherence rates of 71% [ 38 ]. Other studies have shown PrEP discontinuation within six months of initiation [ 12 , 27 , 39 – 41 ]) due to reasons such as concerns about acute side effects, perceived low HIV risk and problems associated with daily dosing (pill burden). In this study, we examined adherence in FSWs who had been on PrEP for at least 5 months and were receiving PrEP routine care.…”

Section: Discussionmentioning

confidence: 99%

Self-reported and pill count measures of adherence to oral HIV PrEP among female sex workers living in South-Western Uganda

et al. 2022

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Background Female sex workers (FSWs) in Uganda are at high risk of HIV infection. Scaling up oral pre-exposure prophylaxis (PrEP) will reduce HIV incidence if high levels of adherence are maintained. This study evaluates PrEP adherence using clinic-based pill counts and self-reported measures, and factors associated with protective levels of adherence. Methods Participants were sex workers who had been taking PrEP for at least 5 months and were attending routine follow-up visits for PrEP care in fishing communities and along the Trans-African Highway. Participants who had a pill count showing at least 85% use since their last clinic visit and those who reported taking their PrEP every day in the last 5 months were categorised as having ‘protective adherence’. Spearman’s correlation and weighted kappa assessed the relationship between pill count and self-reported measures. Bivariate and multivariate logistic regression was used to determine factors associated with protective adherence as measured by pill count. Results We recruited 524 FSWs, with a median age of 29 years (IQR 23–35). Participants were recruited from fishing communities and Trans-African Highway towns (n = 297, 56.7%, and n = 227, 43.0%). Nearly three quarters (n = 372, 71.0%) of women were estimated to have protective adherence based on pill count (i.e., a pill count of >85%) and 50.4% by self-report in last 3 months. There was a strong positive association between self-reported measures and pill count measures (rest = 0.6453, 95% CI = 0.5924–0.6927) and a moderate agreement between self-reported measures and pill count measures, κ = 0.544 (95%CI = 0.4869–0.6011, p < 0.001). Factors associated with protective adherence included being aged 35 years or older (aOR = 2.40, 95% CI = 1.17–4.86), living in a fishing community (aOR = 1.45, 95% CI = 0.62–3.38), and having an STI in last 3 months (aOR = 1.64, 95% CI = 1.07–2.49). Conclusion Our findings indicate that PrEP-experienced FSWs attending clinical follow-up visits reported high protective levels of oral pre-exposure prophylaxis, as measured by both pill count and self-reported measures, and a moderate agreement between pill count and self-reported measures.

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Integration of pre-exposure prophylaxis services into public HIV care clinics in Kenya: a pragmatic stepped-wedge randomised trial

Cited by 28 publications

References 23 publications

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

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

PrEP uptake and HIV viral suppression when PrEP is integrated into Ugandan ART clinics for HIV-negative members of HIV-serodifferent couples: A stepped wedge cluster randomized trial

Self-reported and pill count measures of adherence to oral HIV PrEP among female sex workers living in South-Western Uganda

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