Provider perspectives on service delivery modifications to maintain access to HIV pre‐exposure prophylaxis during the COVID‐19 pandemic: qualitative results from a PrEP implementation project in Kenya

Abstract

Introduction HIV pre‐exposure prophylaxis (PrEP) is an essential prevention strategy being scaled up for priority populations in Kenya, including for HIV serodiscordant couples. The COVID‐19 pandemic posed challenges to PrEP rollout. We conducted a qualitative study of PrEP providers to understand how clinics adjusted PrEP delivery during the COVID‐19 pandemic. Methods Since 2017, the Partners Scale‐Up Project has integrated PrEP into 25 HIV clinics in Central and Western Kenya. We conducted qualitative interviews with 40 purposively sampled clinic personnel. We interviewed personnel once during the first pandemic wave (May–Aug 2020) and again after some decline in COVID‐19 rates (Nov–Jan 2021). We analysed data using inductive memo‐writing and summarized data by themes along the PrEP delivery cascade, guided by the Framework for Reporting Adaptation and Modifications (FRAME). Results We interviewed 27 clinical officers, five nurses, four health records and information officers, and four counsellors from Central ( n = 20) and Western ( n = 20) Kenya. About half ( n = 19) were female, with a median age of 32 (IQR: 29–34) and 2.3 years of experience delivering PrEP (IQR: 2–3). All participants reported clinic changes in PrEP demand creation and service delivery during the pandemic. Modifications occurred during PrEP implementation and sustainment phases, were partly reactive to the pandemic and also facilitated by interim Ministry of Health guidance on PrEP delivery during COVID, and were made by PrEP delivery teams, clients and clinic managers. Commonly reported modifications included dispensing multiple‐month PrEP refills, intensifying phone‐based client engagement and collaborating with other HIV clinics to ensure that clients with prolonged stays in other regions could continue to access PrEP. Some clinics also adopted practices to streamline visits, such as within clinical‐room PrEP dispensing, pre‐packing PrEP and task‐shifting. Most providers liked these changes and hoped they would continue after the pandemic subsides. Conclusions COVID‐19 served as a catalyst for PrEP delivery innovations in Kenya. HIV clinics successfully and rapidly adapted their PrEP demand creation, refill and retention strategies to promote PrEP uptake and effective use. These modified implementation strategies highlight opportunities to streamline the delivery of PrEP, as well as other HIV and chronic care services, and strengthen engagement with populations post‐pandemic.

Stand‐alone model for delivery of oral HIV pre‐exposure prophylaxis in Kenya: a single‐arm, prospective pilot evaluation

“…Because utilization and implementation outcomes were only measured among pharmacy clients (and not providers) who initiated and continued pharmacy‐delivered PrEP services, we do not know why clients never initiated or discontinued pharmacy PrEP services. Finally, the COVID‐19 pandemic may have impacted our continuation outcomes, as Kenya experienced various lockdown periods, and some pharmacy clients may have relocated away from the pharmacy where they initiated PrEP [ 53 ].…”

Understanding adaptive responses in PrEP service delivery in Belgian HIV clinics: a multiple case study using an implementation science framework

“…shifting resources) but also transformative, resulting in service delivery innovations [30][31][32]. This transformative capacity of providers was also apparent in many recent reports on COVID-19-induced adaptations to PrEP service delivery [33][34][35][36]. Yet, considerably fewer studies have focused on PrEP providers' adaptive responses under "normal" conditions [19,20].…”

Delivering HIV and TB services amidst the COVID-19 pandemic in Indonesia: a qualitative study of challenges and mitigation strategies

“…Semi-structured interview guides were developed based on a similar study on mitigation strategies conducted in Kenya 26 and other studies of health system challenges during the COVID-19 pandemic associated with this study. 39,40 The interview guides for the healthcare workers and the clients consisted of questions about the impact of the COVID-19 pandemic on TB and HIV programs, mitigation strategies taken to reduce the impact and challenges in implementing these strategies, the daily routines of health workers, perceived quality of care and medical supplies and COVID-19 exposure.…”

“…22 Based on qualitative interviews with health workers and TB and HIV clients in Indonesia, the study presented here aims to document these lessons for Indonesia, contributing to the pool of studies conducted elsewhere exploring mitigation strategies to maintain TB and HIV services during the pandemic. [23][24][25][26][27][28]…”