Health system opportunities and challenges for PrEP implementation in Kenya: A qualitative framework analysis

Prevalence of HIV infection and uptake of HIV/AIDs services among fishermen on the shores of Lake Victoria in Kagera region, Northwestern Tanzania

INTRODUCTION

The Tanzania HIV Impact Survey (THIS) 2022-2023 showed that HIV prevalence among the general population stabilises but varies geographically across the country. Despite this, disproportionate burdens of HIV continue among specific subpopulations, such as fishermen. Fishermen are particularly vulnerable to HIV infection and have a low uptake of HIV prevention and treatment services. This study aimed to understand the prevalence of HIV infection, uptake of HIV/AIDs services, and associated risk factors of HIV Infection among fishermen residing along the shores of Lake Victoria in the Kagera region, Tanzania, in 2024.

METHODS

A cross-sectional study among fishermen was employed from February to April 2024, using convenient sampling of 10 beach management units (BMUs) to obtain a robust sample of fishermen aged ≥15 years in Kagera. Participants were randomly selected across BMUs. Information was collected using an interviewer-administered questionnaire, and HIV testing was offered on-site according to national testing guidelines. Multivariable logistic regression was used to determine factors associated with HIV infection, adjusted for potential confounders.

RESULTS

A total of 774 fishermen with a median age of 31 years (interquartile range: 25-38 years) were recruited. The study found an HIV prevalence of 11.3% (95% CI: 9.2-13.8). HIV prevalence varied across selected districts: 12.7% in Muleba District, 10.1% in Bukoba Rural District, and 8.6% in Bukoba Urban District. The HIV prevalence was highest among fishermen aged 20-24 years (14.7% (95% CI: 9.7-21.5). The majority, 60.9% (95% CI: 57.4-64.2), had tested for HIV in the past 12 months. Of those living with HIV, 77.6% (95% CI: 67.3-85.9) self-reported using anti-retroviral therapy. In adjusted analysis, using alcohol before sex (aOR = 2.32, 95 CI: 1.42-3.80), not testing for HIV in the last 12 months (aOR = 4.69, 95% CI: 2.79-7.88), and not using condoms (aOR = 1.94, 95% CI: 1.13-3.27) were significantly associated with HIV infection among fishermen.

CONCLUSION

HIV prevalence among fishermen was nearly twice as high as in the general population in Kagera. HIV programming should be strengthened to reduce new HIV infections. Hotspot mapping to expand HIV prevention and treatment services is pivotal for controlling the HIV epidemic.

Structural influences on delivery and use of oral HIV PrEP among adolescent girls and young women seeking post abortion care in Kenya

Background

Adolescent girls and young women (AGYW) in East and southern Africa experience a disproportionate burden of HIV incidence. Integrating HIV pre-exposure prophylaxis (PrEP) within existing programs is a key component of addressing this disparity.

Methods

We evaluated an oral PrEP program integrated into post-abortion care (PAC) in Kenya from March 2021 to November 2022. Technical advisors trained staff at PAC clinics on PrEP delivery, abstracted program data from each clinic, and collected data on structural characteristics. Utilizing a modified Poisson regression, we estimated the effect of structural factors on the probability of PrEP offer and uptake.

Findings

We abstracted data on 6877 AGYW, aged 15-30 years, across 14 PAC clinics. PrEP offers were made to 57.4% of PAC clients and 14.1% initiated PrEP. Offers were associated with an increased probability at clinics that had consistent supply of PrEP (relative risk (RR):1.81, 95% CI: 1.1-2.95), inconsistent HIV testing commodities (RR: 1.89, 95% CI: 1.29-2.78), had all providers trained (RR: 1.65, 95% CI: 1.01, 2.68), and were public (RR: 1.89, 95% CI: 1.29-2.78). These same factors were associated with PrEP uptake: consistent supply of PrEP (RR: 2.71, 95% CI: 1.44-5.09), inconsistent HIV testing commodities (RR: 2.55, 95% CI: 1.39-4.67), all providers trained (RR: 2.61, 95% CI: 1.38-4.92), and were public (RR: 2.55, 95% CI: 1.39-4.67).

Interpretation

Greater success with integration of HIV prevention into reproductive health services will likely require investments in systems, such as human resources and PrEP and HIV testing commodities, to create stable availability and ensure consistent access.

Funding

PrEDIRA 2 was supported by funding from Children's Investment Fund Foundation (R-2001-04433). Ms. Zia was funded by the NIH Ruth L. Kirchstein pre-doctoral award (5F31HD105494-02) and Dr. Heffron was funded by National Institute of Mental Health (K24MH123371).

Implementation considerations for a point-of-care Neisseria gonorrhoeae rapid diagnostic test at primary healthcare level in South Africa: a qualitative study

BACKGROUND

South Africa maintains an integrated health system where syndromic management of sexually transmitted infections (STI) is the standard of care. An estimated 2 million cases of Neisseria gonorrhoeae (N. gonorrhoeae) occur in South Africa every year. Point-of-care diagnostic tests (POCT) may address existing STI control limitations such as overtreatment and missed cases. Subsequently, a rapid lateral flow assay with fluorescence-based detection (NG-LFA) with a prototype reader was developed for N. gonorrhoeae detection showing excellent performance and high usability; however, a better understanding is needed for device implementation and integration into clinics.

METHODS

A qualitative, time-series assessment using 66 in-depth interviews was conducted among 25 trained healthcare workers involved in the implementation of the NG-LFA. Findings were informed by the Normalization Process Theory (NPT) as per relevant contextual (strategic intentions, adaptive execution, and negotiation capacity) and procedural constructs (coherence, cognitive participation, collective action, reflexive monitoring) to examine device implementation within primary healthcare levels. Interviews were audio-recorded, transcribed, and then analyzed using a thematic approach guided by NPT to interpret results.

RESULTS

Overall, healthcare workers agreed that STI POCT could guide better STI clinical decision-making, with consideration for clinic integration such as space constraints, patient flow, and workload. Perceived NG-LFA benefits included enhanced patient receptivity and STI knowledge. Further, healthcare workers reflected on the suitability of the NG-LFA given current limitations with integrated primary care. Recommendations included sufficient STI education, and appropriate departments for first points of entry for STI screening.

CONCLUSIONS

The collective action and participation by healthcare workers in the implementation of the NG-LFA revealed adaptive execution within the current facility environment including team compositions, facility-staff receptivity, and STI management experiences. User experiences support future clinic service integration, highlighting the importance of further assessing patient-provider communication for STI care, organizational readiness, and identification of relevant departments for STI screening.

Awareness and Willingness to use Condoms and Preexposure Prophylaxis among Gay, Bisexual, and Other Cisgendered Men who Have sex with men in Slum Communities in Ghana. BSGH-004

Introduction: Research has begun to examine human immunodeficiency virus (HIV) prevention strategies within the Ghanaian context. Still, little is known about specific populations such as gay, bisexual, and other cisgender men who have sex with men (GBMSM) living in slum communities. We studied HIV prevention strategies such as condoms and preexposure prophylaxis (PrEP) in slum communities and the awareness and willingness to use these choices among GBMSM. This qualitative study examines HIV prevention strategies, specifically examining PrEP and condom use behaviors among GBMSM in Ghana. Methods: We conducted in-depth face-to-face interviews among 12 GBMSM from slums in Accra and Kumasi cities in Ghana. Data were analyzed through a summative content analysis with multiple reviewers to develop codes. Data were collected from participants in January 2022. Results: We found the fear and perceived risk of infection were motivators for consistent condom use, especially during anal sex. GBMSM living with HIV receiving antiretroviral therapy were more inclined to use condoms. We found motivations for using PrEP were influenced by the type of sexual activity and a history of negative HIV status. Also, the barriers to PrEP for GBMSM included limited access to healthcare facilities and the distance to these facilities. Conclusions: To improve condom and PrEP access and uptake, we recommend addressing structural barriers by increasing the number of health facilities and implementing targeted interventions to address the lack of information on HIV awareness and prevention. Involving peer educators may also effectively promote HIV prevention strategies, especially in communities with limited access to healthcare such as slums. Overcoming these access constraints could significantly enhance awareness and prevention of HIV, leading to improved health outcomes for GBMSM living in slum communities.