1
|
Mekonnen G, Liknaw T, Anley A, Afenigus AD. Knowledge, attitudes, and associated factors towards HIV pre-exposure prophylaxis among health care providers. Sci Rep 2024; 14:6168. [PMID: 38485990 PMCID: PMC10940609 DOI: 10.1038/s41598-024-56371-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 03/05/2024] [Indexed: 03/18/2024] Open
Abstract
The knowledge and attitudes of health care providers were limited as reviewed in many studies. Attitudes and knowledge about pre-exposure prophylaxis among healthcare providers have not been investigated in Ethiopia even though pre-exposure prophylaxis is a novel healthcare topic. The aim was to assess knowledge, attitudes, and associated factors towards pre-exposure prophylaxis among healthcare providers in Gojjam health facilities, North West Ethiopia, 2022. An institutional-based cross-sectional study was conducted from June 1-30 among 410 healthcare providers in public health facilities in the East Gojjam zone. A simple random sampling technique was used to recruit the required study participants. The statistical program EPI Data version 4.6 was used to enter the data, and statistical packages for Social science version 25 was used for analysis. Variables with a p-value less than 0.25 in the bivariable analysis were included in the multivariable logistic regression analysis. Statistical significance was determined with a p-value less than 0.05. The good knowledge and the favorable attitude of healthcare providers toward HIV pre-exposure prophylaxis were 55.7% (50.6-60.2%) and 60.2% (55.0-65.0%) respectively. male participant (AOR 1.67; 95% CI (1.01-2.55), service year ≥ 10 years (AOR 2.52; 95% CI (1.23-5.17), favorable attitudes (AOR 1.92; 95%CI (1.25-2.95), and providers good sexual behavior (AOR 1.85; 95%CI (1.21-2.82) were significantly associated with the good knowledge, and training (AOR 2.15; 95% CI (1.23-3.76), reading the guideline (AOR 1.66; 95% CI (1.02-2.70), and good knowledge (AOR 1.78; 95% CI (1.16-2.75) was significantly associated with the favorable attitudes. In general, the finding of this study shows that the knowledge and attitudes of healthcare providers were low. Since this is a new initiative their knowledge is lower than their attitudes. Male, service year 10 years, and good provider sexual behavior were factors significantly associated with good knowledge. Training, reading the guidelines, and good knowledge were factors significantly associated with a favorable attitudes. As a result, healthcare facilities intervention programs and strategies better target these factors to improve the knowledge and attitudes of healthcare providers. Preparing training programs to enhance knowledge and attitudes towards PrEP is recommended.
Collapse
Affiliation(s)
- Getachew Mekonnen
- Department of Nursing, Shebel Berenta Hospital, Shebel Berenta, Ethiopia.
| | - Tiliksew Liknaw
- Department of Nursing, College of Medicine and Health Sciences, Debre Markos University, Debre Markos, Ethiopia
| | - Alemayehu Anley
- Department of Nursing, College of Medicine and Health Sciences, Arba Minch University, Arba Minch, Ethiopia
| | - Abebe Dilie Afenigus
- Department of Nursing, College of Medicine and Health Sciences, Debre Markos University, Debre Markos, Ethiopia
| |
Collapse
|
2
|
Wairimu N, Malen RC, Reedy AM, Mogere P, Njeru I, Culquichicón C, McGowan M, Gao F, Baeten JM, Ngure K, Ortblad KF. Peer PrEP referral + HIV self-test delivery for PrEP initiation among young Kenyan women: study protocol for a hybrid cluster-randomized controlled trial. Trials 2023; 24:705. [PMID: 37925450 PMCID: PMC10625301 DOI: 10.1186/s13063-023-07734-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 10/16/2023] [Indexed: 11/06/2023] Open
Abstract
BACKGROUND Oral HIV pre-exposure prophylaxis (PrEP) for HIV prevention is highly effective, but uptake remains low in Africa, especially among young women who are a priority population for HIV prevention services. HIV self-testing (HIVST) has been proven to increase HIV testing in diverse populations but has been underutilized to support linkage to HIV prevention services. Most young women who initiate PrEP in Africa do so through informal peer referral. We wanted to test a model of formalized peer referral enhanced with HIVST delivery among young Kenyan women. METHODS The Peer PrEP Trial is a two-arm hybrid effectiveness-implementation cluster-randomized controlled trial being conducted in central Kenya. Eligible participants (i.e., peer providers, n = 80) are women (≥ 16-24 years) refilling or initiating PrEP at public healthcare clinics who can identify at least four peers who could benefit from PrEP and not enrolled in another HIV study. Peer providers will be 1:1 randomized to (1) formal peer PrEP referral + HIVST delivery, where they will be encouraged to refer four peers (i.e., peer clients, ≥ 16-24 years) using educational materials and HIVST kits (two per peer client), or (2) informal peer PrEP referral, where they are encouraged to refer four peer clients using informal word-of-mouth referral. In both arms, peer providers will deliver a standard PrEP referral card with information on nearby public clinics delivering PrEP services. Peer providers will complete surveys at baseline and 3 months; peer clients will complete surveys at 3 months. Our primary outcome is PrEP initiation among peer clients, as reported by peer providers at 3 months. Secondary outcomes include PrEP continuation (any refilling), HIV testing (past 3 months), sexual behaviors (past month), and PrEP adherence (past month) among peer clients, as reported by both peer providers and clients at 3 months. Implementation outcomes will include participants' perceived acceptability, appropriateness, and feasibility of the intervention as well assessments of the intervention's fidelity and cost. DISCUSSION Evidence from this trial will help us understand how HIVST could support health systems by facilitating linkage to PrEP services among young women who could benefit in Kenya and similar settings. TRIAL REGISTRATION ClinicalTrials.gov NCT04982250. Registered on July 29, 2021.
Collapse
Affiliation(s)
- Njeri Wairimu
- Partners in Health and Research Development, Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Rachel C Malen
- Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, USA
| | - Adriana M Reedy
- Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, USA
| | - Peter Mogere
- Partners in Health and Research Development, Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Irene Njeru
- Partners in Health and Research Development, Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Carlos Culquichicón
- Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, USA
- Department of Epidemiology, University of Washington, Seattle, USA
| | - Maureen McGowan
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
| | - Fei Gao
- Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, USA
- Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Center, Seattle, USA
| | - Jared M Baeten
- Department of Global Health, University of Washington, Seattle, USA
- Department of Medicine, University of Washington, Seattle, USA
| | - Kenneth Ngure
- School of Public Health, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | - Katrina F Ortblad
- Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, USA.
| |
Collapse
|
3
|
Camlin CS, Getahun M, Koss CA, Owino L, Akatukwasa C, Itiakorit H, Onyango A, Bakanoma R, Atwine F, Maeri I, Ayieko J, Atukunda M, Owaraganise A, Mwangwa F, Sang N, Kabami J, Kaplan RL, Chamie G, Petersen ML, Cohen CR, Bukusi EA, Kamya MR, Havlir DV, Charlebois ED. Providers' Attitudes and Experiences with Pre-Exposure Prophylaxis Implementation in a Population-Based Study in Kenya and Uganda. AIDS Patient Care STDS 2022; 36:396-404. [PMID: 36201226 PMCID: PMC9595612 DOI: 10.1089/apc.2022.0084] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Pre-exposure prophylaxis (PrEP) implementation is underway across sub-Saharan Africa. However, little is known about health care providers' experiences with PrEP provision in generalized epidemic settings, particularly outside of selected risk groups. In this study (NCT01864603), universal access to PrEP was offered to adolescents and adults at elevated risk during population-level HIV testing in rural Kenya and Uganda. Providers received training on PrEP prescribing and support from local senior clinicians. We conducted in-depth interviews with providers (n = 19) in four communities in Kenya and Uganda to explore the attitudes and experiences with implementation. Transcripts were coded and analyzed using interpretivist methods. Providers had heterogenous attitudes toward PrEP in its early implementation: some expressed enthusiasm, while others feared being blamed for "failures" (HIV seroconversions) if participants were nonadherent, or that offering PrEP would increase "immorality." Providers supported PrEP usage among HIV-serodifferent couples, whose mutual support for daily pill-taking facilitated harmony and protection from HIV. Providers reported challenges with counseling on "seasons of risk," and safely stopping and restarting PrEP. They felt uptake was hampered for women by difficulties negotiating with partners, and for youth by parental consent requirements. They believed PrEP continuation was hindered by transportation costs, stigma, pill burden, and side effects, and was facilitated by counseling, proactive management of side effects, and home/community-based provision. Providers are critical "implementation actors" in interventions to promote adoption of new technologies such as PrEP. Dedicated training and ongoing support for providers may facilitate successful scale-up.
Collapse
Affiliation(s)
- Carol S. Camlin
- Department of Obstetrics, Gynecology, & Reproductive Sciences, University of California, San Francisco (UCSF), San Francisco, California, USA
- Department of Medicine, Center for AIDS Prevention Studies, University of California, San Francisco (UCSF), San Francisco, California, USA
| | - Monica Getahun
- Department of Obstetrics, Gynecology, & Reproductive Sciences, University of California, San Francisco (UCSF), San Francisco, California, USA
| | - Catherine A. Koss
- Division of HIV, Infectious Diseases & Global Medicine, Department of Medicine, University of California, San Francisco (UCSF), San Francisco, California, USA
| | - Lawrence Owino
- Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | | | | | | | - Robert Bakanoma
- Infectious Diseases Research Collaboration (IDRC), Kampala, Uganda
| | - Fredrick Atwine
- Infectious Diseases Research Collaboration (IDRC), Kampala, Uganda
| | - Irene Maeri
- Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - James Ayieko
- Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | | | | | - Florence Mwangwa
- Infectious Diseases Research Collaboration (IDRC), Kampala, Uganda
| | - Norton Sang
- Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Jane Kabami
- Infectious Diseases Research Collaboration (IDRC), Kampala, Uganda
| | - Rachel L. Kaplan
- Department of Obstetrics, Gynecology, & Reproductive Sciences, University of California, San Francisco (UCSF), San Francisco, California, USA
| | - Gabriel Chamie
- Division of HIV, Infectious Diseases & Global Medicine, Department of Medicine, University of California, San Francisco (UCSF), San Francisco, California, USA
| | - Maya L. Petersen
- Divisions of Biostatistics & Epidemiology, School of Public Health, University of California, Berkeley, Berkeley, California, USA
| | - Craig R. Cohen
- Department of Obstetrics, Gynecology, & Reproductive Sciences, University of California, San Francisco (UCSF), San Francisco, California, USA
| | | | - Moses R. Kamya
- Infectious Diseases Research Collaboration (IDRC), Kampala, Uganda
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Diane V. Havlir
- Division of HIV, Infectious Diseases & Global Medicine, Department of Medicine, University of California, San Francisco (UCSF), San Francisco, California, USA
| | - Edwin D. Charlebois
- Department of Medicine, Center for AIDS Prevention Studies, University of California, San Francisco (UCSF), San Francisco, California, USA
| |
Collapse
|
4
|
Muwonge TR, Nsubuga R, Ware NC, Wyatt MA, Pisarski E, Kamusiime B, Kasiita V, Nalukwago GK, Brown C, Nakyanzi A, Bagaya M, Bambia F, Ssebuliba T, Katabira E, Kyambadde P, Baeten JM, Heffron R, Celum C, Mujugira A, Haberer JE. Health Care Worker Perspectives of HIV Pre-exposure Prophylaxis Service Delivery in Central Uganda. Front Public Health 2022; 10:658826. [PMID: 35444979 PMCID: PMC9013815 DOI: 10.3389/fpubh.2022.658826] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 02/14/2022] [Indexed: 01/29/2023] Open
Abstract
Background Scale-up of HIV pre-exposure prophylaxis (PrEP) services in Uganda is ongoing. However, health care workers (HCWs) may not be aware of PrEP nor what offering this service entails. We explored the impact of standardized HCW training on the knowledge and perspectives of PrEP service delivery in Uganda. Methods We recruited HCWs from facilities that offered HIV-related services in Central Uganda. Using the Uganda Ministry of Health curriculum, we trained HCWs on PrEP services. We collected data about PrEP knowledge, preparedness, and willingness to deliver PrEP to multiple key populations before the training, immediately after the training, and >6 months later (exit). We additionally conducted 15 qualitative interviews after the exit survey. Quantitative data were analyzed by Fisher exact test, while qualitative interview data were analyzed inductively. Results We recruited 80 HCWs from 35 facilities in urban (N = 24, 30%), peri-urban (N = 30, 37%), and rural (N = 26, 33%) areas. Most HCWs were nurse counselors (N = 52, 65%) or medical/clinical officers (N = 15, 18%). Surveys indicated that awareness of PrEP increased after the training and remained high. Knowledge of PrEP (i.e., as an effective, short-term antiretroviral medication to use before HIV exposure for people at high risk) generally increased with training, but significant gaps remained, and knowledge decreased with time. Most HCWs recommended PrEP for female sex workers and HIV serodifferent couples, as well as other key populations. We observed increases in the number of HCW who felt their facility was prepared to cater for HIV prevention and provide PrEP, but this view was not universal. HCWs believed in PrEP effectiveness and embraced it as an additional HIV prevention method. Concerns included patient adherence and behavioral risk compensation. HCWs noted challenges in PrEP delivery in terms of inadequate clinic preparedness, infrastructure, staff capacity, and poor attitudes toward key populations by untrained health workers. They felt further training was needed to ensure a smooth scale-up of services without stigmatization. Conclusions Standardized training improved knowledge, willingness, and preparedness to offer PrEP services among most HCWs in Central Uganda. Ongoing training will be needed to optimize PrEP delivery services and expand delivery to levels needed for population-level impact.
Collapse
Affiliation(s)
- Timothy R. Muwonge
- Infectious Diseases Institute, Makerere University, Kampala, Uganda,*Correspondence: Timothy R. Muwonge
| | - Rogers Nsubuga
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | | | | | - Brenda Kamusiime
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Vicent Kasiita
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | - Charles Brown
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Agnes Nakyanzi
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Monica Bagaya
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Felix Bambia
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | - Elly Katabira
- Department of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Peter Kyambadde
- Most At-Risk Populations Initiative, Kampala, Uganda,STD/AIDS Control Program, Ministry of Health, Kampala, Uganda
| | - Jared M. Baeten
- Departments of Global Health and Epidemiology, University of Washington, Seattle, WA, United States,Gilead Sciences, Foster City, CA, United States
| | - Renee Heffron
- Departments of Global Health and Epidemiology, University of Washington, Seattle, WA, United States
| | - Connie Celum
- Departments of Global Health and Epidemiology, University of Washington, Seattle, WA, United States
| | - Andrew Mujugira
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Jessica E. Haberer
- Harvard Medical School, Boston, MA, United States,Center for Global Health, Massachusetts General Hospital, Boston, MA, United States
| |
Collapse
|
5
|
Irungu EM, Mugwanya KK, Mugo NR, Bukusi EA, Donnell D, Odoyo J, Wamoni E, Peacock S, Morton JF, Ngure K, Mugambi M, Mukui I, O'Malley G, Baeten JM. Integration of pre-exposure prophylaxis services into public HIV care clinics in Kenya: a pragmatic stepped-wedge randomised trial. Lancet Glob Health 2021; 9:e1730-e1739. [PMID: 34798031 PMCID: PMC8609282 DOI: 10.1016/s2214-109x(21)00391-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 07/29/2021] [Accepted: 08/11/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Successful and sustainable models for HIV pre-exposure prophylaxis (PrEP) delivery in public health systems in Africa are needed. We aimed to evaluate the implementation of PrEP delivery integrated in public HIV care clinics in Kenya. METHODS As part of Kenya's national PrEP roll-out, we conducted a stepped-wedge cluster-randomised pragmatic trial to catalyse scale-up of PrEP delivery integrated in 25 public HIV care clinics. We selected high-volume clinics in these regions (ie, those with a high number of people living with HIV enrolled in HIV care and treatment). Clinics (each representing a cluster) were stratified by region and randomly assigned to the order in which clinic staff would receive PrEP training and ongoing technical support using numbered opaque balls picked from a bag. There was no masking. PrEP provision was done by clinic staff without additional financial support. Data were abstracted from records of individuals initiating PrEP. The primary outcome was the number of people initiating PrEP per clinic per month comparing intervention to control periods. Other outcomes included PrEP continuation, adherence, and incident HIV infections. This trial is registered with ClinicalTrials.gov, NCT03052010. FINDINGS After the baseline period, which started in January, 2017, every month two to six HIV care clinics crossed over from control to intervention, until August, 2017, when all clinics were implementing the intervention. Of 4898 individuals initiating PrEP (27 during the control period and 4871 during the intervention period), 2640 (54%) were women, the median age was 31 years (IQR 25-39), and 4092 (84%) reported having a partner living with HIV. The mean monthly number of PrEP initiations per clinic was 0·1 (SD 0·5) before the intervention and 7·5 (2·7) after intervention introduction (rate ratio 23·7, 95% CI 14·2-39·5, p<0·0001). PrEP continuation was 57% at 1 month, 44% at 3 months, and 34% at 6 months, and 12% of those who missed a refill returned later for PrEP re-initiation. Tenofovir diphosphate was detected in 68 (96%) of 71 blood samples collected from a randomly selected subset of participants. Six HIV infections were observed over 2531 person-years of observation (incidence 0·24 cases per 100 person-years), three of which occurred at the first visit after PrEP initiation. INTERPRETATION We observed high uptake, reasonable continuation with high adherence, frequent PrEP restarts, and low HIV incidence. Integration of PrEP services within public HIV care clinics in Africa is feasible. FUNDING National Institute of Mental Health and Bill & Melinda Gates Foundation.
Collapse
Affiliation(s)
- Elizabeth M Irungu
- Department of Global Health, University of Washington, Seattle, WA, USA; Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya.
| | | | - Nelly R Mugo
- Department of Global Health, University of Washington, Seattle, WA, USA; Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Elizabeth A Bukusi
- Department of Global Health, University of Washington, Seattle, WA, USA; Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Deborah Donnell
- Department of Global Health, University of Washington, Seattle, WA, USA; Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center Seattle, WA, USA
| | - Josephine Odoyo
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Elizabeth Wamoni
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Sue Peacock
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Jennifer F Morton
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Kenneth Ngure
- Department of Global Health, University of Washington, Seattle, WA, USA; School of Public Health, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | - Mary Mugambi
- National AIDS and STI Control Program, Nairobi, Kenya
| | - Irene Mukui
- National AIDS and STI Control Program, Nairobi, Kenya
| | | | - Jared M Baeten
- Department of Global Health, University of Washington, Seattle, WA, USA; Department of Epidemiology, University of Washington, Seattle, WA, USA; Department of Medicine, University of Washington, Seattle, WA, USA
| |
Collapse
|
6
|
Acceptability, Appropriateness, and Preliminary Effects of the PrEP Diffusion Training for Lay HIV Workers: Increased PrEP Knowledge, Decreased Stigma, and Diffusion of Innovation. AIDS Behav 2021; 25:3413-3424. [PMID: 33791880 DOI: 10.1007/s10461-021-03248-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2021] [Indexed: 11/27/2022]
Abstract
Training lay health workers is a critical intervention strategy to support HIV pre-exposure prophylaxis (PrEP) implementation. However, few evaluations of such trainings have been published. We conducted multi-time-point surveys to evaluate the effect of a training intervention on knowledge, PrEP stigma, and implementation behavior among lay HIV workers in China. Results indicated high acceptability and appropriateness of the training. PrEP knowledge score increased by 65% from pre- to post-training, and remained high one-month post-training. We observed a significant decrease in PrEP stigma and a positive influence on determinants of implementation behaviors. All lay HIV workers surveyed one-month after the training reported having disseminated PrEP information in social networks; 43% reported integrating PrEP education into routine work. The training is an effective strategy to build lay HIV workers' capacity in PrEP implementation. Longer-term post-training follow up would be ideal to further assess actual PrEP uptake and sustained effects on PrEP implementation.
Collapse
|
7
|
Irungu EM, Odoyo J, Wamoni E, Bukusi EA, Mugo NR, Ngure K, Morton JF, Mugwanya KK, Baeten JM, O'Malley G. Process evaluation of PrEP implementation in Kenya: adaptation of practices and contextual modifications in public HIV care clinics. J Int AIDS Soc 2021; 24:e25799. [PMID: 34496148 PMCID: PMC8425783 DOI: 10.1002/jia2.25799] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 08/03/2021] [Indexed: 11/16/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Elizabeth M Irungu
- Department of Global Health, University of Washington, Seattle, Washington, USA.,Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Josephine Odoyo
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Elizabeth Wamoni
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Elizabeth A Bukusi
- Department of Global Health, University of Washington, Seattle, Washington, USA.,Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington, USA.,Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Nelly R Mugo
- Department of Global Health, University of Washington, Seattle, Washington, USA.,Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Kenneth Ngure
- Department of Global Health, University of Washington, Seattle, Washington, USA.,School of Public Health, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | - Jennifer F Morton
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Kenneth K Mugwanya
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Jared M Baeten
- Department of Global Health, University of Washington, Seattle, Washington, USA.,Department of Epidemiology, University of Washington, Seattle, Washington, USA.,Department of Medicine, University of Washington, Seattle, Washington, USA.,Gilead Sciences, Foster City, CA, USA
| | - Gabrielle O'Malley
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | | |
Collapse
|
8
|
Were DK, Musau A, Atkins K, Shrestha P, Reed J, Curran K, Mohan D. Health system adaptations and considerations to facilitate optimal oral pre-exposure prophylaxis scale-up in sub-Saharan Africa. Lancet HIV 2021; 8:e511-e520. [PMID: 34265282 DOI: 10.1016/s2352-3018(21)00129-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 06/06/2021] [Accepted: 06/08/2021] [Indexed: 12/26/2022]
Abstract
Following WHO's 2015 recommendation, countries in sub-Saharan Africa have progressively scaled up oral pre-exposure prophylaxis (PrEP) as part of combination HIV prevention. PrEP has potential to significantly reduce new HIV infections in sub-Saharan Africa if it is widely available, accessible, and effectively used. Initial scale-up efforts have generated progress, drawing lessons from existing HIV interventions, such as antiretroviral therapy and biomedical prevention. However, beset by unprepared health systems, scale-up has been slow, resulting in suboptimal coverage among priority groups at higher risk of HIV acqusition. Using the WHO health system building blocks framework, this Review synthesises literature on essential considerations for PrEP scale-up in sub-Saharan Africa, highlighting the importance of health system adaptability and responsiveness.
Collapse
Affiliation(s)
| | | | - Kaitlyn Atkins
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Prakriti Shrestha
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | | | - Diwakar Mohan
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| |
Collapse
|
9
|
Ngure K, Ongolly F, Dolla A, Awour M, Mugwanya KK, Irungu E, Mugo N, Bukusi EA, Morton J, Odoyo J, Wamoni E, Barnabee G, Peebles K, O'Malley G, Baeten JM. "I just believe there is a risk" understanding of undetectable equals untransmissible (U = U) among health providers and HIV-negative partners in serodiscordant relationships in Kenya. J Int AIDS Soc 2020; 23:e25466. [PMID: 32144888 PMCID: PMC7060133 DOI: 10.1002/jia2.25466] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Accepted: 02/05/2020] [Indexed: 11/11/2022] Open
Abstract
Introduction Sustained HIV viral suppression resulting from antiretroviral therapy (ART) eliminates the risk of HIV transmission, a concept popularly framed as Undetectable = Untransmittable (U = U). We explored knowledge and acceptance of information around the elimination of HIV transmission risk with ART (U = U) in Kenya. Methods Our qualitative study was conducted within a project evaluating the use of pre‐exposure prophylaxis (PrEP) integrated into ART care for HIV serodiscordant couples in public clinics in Kenya (the Partners Scale Up Project). From February 2017 to April 2019, we conducted semi‐structured key informant interviews with 83 health providers and in‐depth interviews with 61 HIV‐negative people in serodiscordant relationships receiving PrEP services. Transcripts were coded using thematic analysis. Results Health providers reported being aware of reduced risk of HIV transmission as a result of consistent ART use and used words such as “very low,” “minimal” and “like zero” to describe HIV transmission risk after viral suppression. Providers reported finding viral load results helpful when counselling clients about the risk of HIV transmission. Many lacked confidence in U = U and counselled on consistent condom use even after viral suppression while some expressed concerns that communicating this message to people living with HIV (PLHIV) would lead them to engage in multiple sexual relationships. Other providers reported that they did not counsel about the reduced risk of HIV transmission after viral suppression for fear of being blamed if HIV transmission occurred. HIV‐negative partners reported being informed about U = U by providers but they did not believe nor trust the message. Even after their partners achieved viral suppression, some HIV‐negative partners were unwilling to stop PrEP, while others indicated that they would use condoms if they stopped PrEP to be sure that they were protected from HIV. Conclusions Despite awareness that effective ART use eliminates HIV transmission risk, there is both a lack of in‐depth knowledge and conviction about the strategy among health providers and HIV‐negative partners in serodiscordant relationships. New strategies that go beyond communicating the science of U = U to consider the local social and clinical environments could maximize the effectiveness of U = U.
Collapse
Affiliation(s)
- Kenneth Ngure
- Department of Community Health, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya.,Department of Global Health, University of Washington, Seattle, WA, USA
| | - Fernandos Ongolly
- Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Annabell Dolla
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Merceline Awour
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Elizabeth Irungu
- Department of Community Health, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | - Nelly Mugo
- Department of Global Health, University of Washington, Seattle, WA, USA.,Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Elizabeth A Bukusi
- Department of Global Health, University of Washington, Seattle, WA, USA.,Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Jennifer Morton
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Josephine Odoyo
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Elizabeth Wamoni
- Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Gena Barnabee
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Kathryn Peebles
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | | | - Jared M Baeten
- Department of Global Health, University of Washington, Seattle, WA, USA.,Department of Epidemiology, University of Washington, Seattle, WA, USA.,Department of Medicine, University of Washington, Seattle, WA, USA
| | | |
Collapse
|
10
|
Irungu EM, Baeten JM. PrEP rollout in Africa: status and opportunity. Nat Med 2020; 26:655-664. [PMID: 32405065 DOI: 10.1038/s41591-020-0872-x] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 04/06/2020] [Indexed: 12/14/2022]
Abstract
Following recommendations by the World Health Organization in 2015, and key clinical trials, countries in sub-Saharan Africa, the region with the highest burden of human immunodeficiency virus (HIV), developed policies that incorporate pre-exposure prophylaxis (PrEP) into national HIV-prevention strategies. By the end of 2019, more than one third of people receiving PrEP globally were in Africa. Crucial understandings gained from early rollout among at-risk populations, such as HIV-serodiscordant couples, adolescent girls and young women, female sex workers, and men who have sex with men, include the importance of strategies for maintaining persistent adherence to PrEP and novel approaches to making PrEP services accessible, simplified and efficient. This Perspective will discuss the current status of these programs and how to further widen their implementation.
Collapse
Affiliation(s)
- Elizabeth M Irungu
- College of Health Sciences, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya.,Department of Global Health, University of Washington, Seattle, WA, USA
| | - Jared M Baeten
- Department of Global Health, University of Washington, Seattle, WA, USA. .,Department of Epidemiology, University of Washington, Seattle, WA, USA. .,Department of Medicine, University of Washington, Seattle, WA, USA.
| |
Collapse
|
11
|
Irungu EM, Ngure K, Mugwanya KK, Awuor M, Dollah A, Ongolly F, Mugo N, Bukusi E, Wamoni E, Odoyo J, Morton JF, Barnabee G, Mukui I, Baeten JM, O'Malley G. "Now that PrEP is reducing the risk of transmission of HIV, why then do you still insist that we use condoms?" the condom quandary among PrEP users and health care providers in Kenya. AIDS Care 2020; 33:92-100. [PMID: 32207327 DOI: 10.1080/09540121.2020.1744507] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Communication around condom use in the context of PrEP services presents a potential conundrum for patients and providers. Within the Partners Scale-Up Project, which supports integration of PrEP delivery in HIV care clinics, we interviewed 41 providers and 61 PrEP users and identified themes relating to condom messaging and use. Most providers counselled PrEP initiators to always use both PrEP and condoms, except when trying to conceive. However, others reported contexts and rationales for not emphasizing condom use. Providers reported that PrEP users were sometimes confused, even frustrated, with their insistence on using condoms in addition to PrEP. PrEP users generally regarded PrEP as a more feasible and desirable HIV prevention method than condoms, enabling increased sexual pleasure and conception, and reducing the conflict and stigma associated with condom use. Innovative approaches to condom counselling in PrEP programs are needed.
Collapse
Affiliation(s)
- Elizabeth M Irungu
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya.,Department of Global Health, University of Washington
| | - Kenneth Ngure
- Department of Global Health, University of Washington.,School of Public Health, Jomo Kenyatta University of Agriculture and Technology
| | | | - Merceline Awuor
- Centre for Microbiology Research, Kenya Medical Research Institute
| | - Annabelle Dollah
- Centre for Microbiology Research, Kenya Medical Research Institute
| | - Fernandos Ongolly
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Nelly Mugo
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya.,Department of Global Health, University of Washington
| | - Elizabeth Bukusi
- Department of Global Health, University of Washington.,Centre for Microbiology Research, Kenya Medical Research Institute
| | - Elizabeth Wamoni
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Josephine Odoyo
- Centre for Microbiology Research, Kenya Medical Research Institute
| | | | - Gena Barnabee
- Department of Global Health, University of Washington
| | | | - Jared M Baeten
- Department of Global Health, University of Washington.,Department of Epidemiology, University of Washington.,Department of Medicine, University of Washington
| | | | | |
Collapse
|