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Chhun N, Oketch D, Agot K, Mangale DI, Badia J, Kibugi J, Jiang W, Kirk M, Richardson BA, Kohler PK, John‐Stewart G, Beima‐Sofie K. Using FRAME to characterize provider-identified adaptations to a stepped care intervention for adolescents and youth living with HIV in Kenya: a mixed methods approach. J Int AIDS Soc 2024; 27 Suppl 1:e26261. [PMID: 38965971 PMCID: PMC11224585 DOI: 10.1002/jia2.26261] [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: 08/28/2023] [Accepted: 04/19/2024] [Indexed: 07/06/2024] Open
Abstract
INTRODUCTION The Data-informed Stepped Care (DiSC) study is a cluster-randomized trial implemented in 24 HIV care clinics in Kenya, aimed at improving retention in care for adolescents and youth living with HIV (AYLHIV). DiSC is a multi-component intervention that assigns AYLHIV to different intensity (steps) of services according to risk. We used the Framework for Reporting Adaptations and Modifications-Expanded (FRAME) to characterize provider-identified adaptations to the implementation of DiSC to optimize uptake and delivery, and determine the influence on implementation outcomes. METHODS Between May and December 2022, we conducted continuous quality improvement (CQI) meetings with providers to optimize DiSC implementation at 12 intervention sites. The meetings were guided by plan-do-study-act processes to identify challenges during early phase implementation and propose targeted adaptations. Meetings were audio-recorded and analysed using FRAME to categorize the level, context and content of planned adaptations and determine if adaptations were fidelity consistent. Providers completed surveys to quantify perceptions of DiSC acceptability, appropriateness and feasibility. Mixed effects linear regression models were used to evaluate these implementation outcomes over time. RESULTS Providers participated in eight CQI meetings per facility over a 6-month period. A total of 65 adaptations were included in the analysis. The majority focused on optimizing the integration of DiSC within the clinic (83%, n = 54), and consisted of improving documentation, addressing scheduling challenges and improving clinic workflow. Primary reasons for adaptation were to align delivery with AYLHIV needs and preferences and to increase reach among AYLHIV: with reminder calls to AYLHIV, collaborating with schools to ensure AYLHIV attended clinic appointments and addressing transportation challenges. All adaptations to optimize DiSC implementation were fidelity-consistent. Provider perceptions of implementation were consistently high throughout the process, and on average, slightly improved each month for intervention acceptability (β = 0.011, 95% CI: 0.002, 0.020, p = 0.016), appropriateness (β = 0.012, 95% CI: 0.007, 0.027, p<0.001) and feasibility (β = 0.013, 95% CI: 0.004, 0.022, p = 0.005). CONCLUSIONS Provider-identified adaptations targeted improved integration into routine clinic practices and aimed to reduce barriers to service access unique to AYLHIV. Characterizing types of adaptations and adaptation rationale may enrich our understanding of the implementation context and improve abilities to tailor implementation strategies when scaling to new settings.
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Affiliation(s)
- Nok Chhun
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
| | | | - Kawango Agot
- Impact Research and Development OrganizationKisumuKenya
| | - Dorothy I. Mangale
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
- Department of OncologyWashington UniversitySt. LouisMissouriUSA
| | - Jacinta Badia
- Impact Research and Development OrganizationKisumuKenya
| | - James Kibugi
- Impact Research and Development OrganizationKisumuKenya
| | - Wenwen Jiang
- Department of EpidemiologyUniversity of WashingtonSeattleWashingtonUSA
| | - Mary Kirk
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
| | - Barbra A. Richardson
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
- Department of BiostatisticsUniversity of WashingtonSeattleWashingtonUSA
| | - Pamela K. Kohler
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
- Department of Child, Family, and Population Health NursingUniversity of WashingtonSeattleWashingtonUSA
| | - Grace John‐Stewart
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
- Department of EpidemiologyUniversity of WashingtonSeattleWashingtonUSA
- Department of PediatricsUniversity of WashingtonSeattleWashingtonUSA
- Department of MedicineUniversity of WashingtonSeattleWashingtonUSA
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Vanhamel J, Reyniers T, Vuylsteke B, Callens S, Nöstlinger C, Huis in ’t Veld D, Kenyon C, Van Praet J, Libois A, Vincent A, Demeester R, Henrard S, Messiaen P, Allard SD, Rotsaert A, Kielmann K. Understanding adaptive responses in PrEP service delivery in Belgian HIV clinics: a multiple case study using an implementation science framework. J Int AIDS Soc 2024; 27 Suppl 1:e26260. [PMID: 38965986 PMCID: PMC11224588 DOI: 10.1002/jia2.26260] [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: 08/29/2023] [Accepted: 04/19/2024] [Indexed: 07/06/2024] Open
Abstract
INTRODUCTION In Belgium, oral HIV pre-exposure prophylaxis (PrEP) is primarily provided in specialized clinical settings. Optimal implementation of PrEP services can help to substantially reduce HIV transmission. However, insights into implementation processes, and their complex interactions with local context, are limited. This study examined factors that influence providers' adaptive responses in the implementation of PrEP services in Belgian HIV clinics. METHODS We conducted a qualitative multiple case study on PrEP care implementation in eight HIV clinics. Thirty-six semi-structured interviews were conducted between January 2021 and May 2022 with a purposive sample of PrEP care providers (e.g. physicians, nurses, psychologists), supplemented by 50 hours of observations of healthcare settings and clinical interactions. Field notes from observations and verbatim interview transcripts were thematically analysed guided by a refined iteration of extended Normalisation Process Theory. RESULTS Implementing PrEP care in a centralized service delivery system required considerable adaptive capacity of providers to balance the increasing workload with an adequate response to PrEP users' individual care needs. As a result, clinic structures were re-organized to allow for more efficient PrEP care processes, compatible with other clinic-level priorities. Providers adapted clinical and policy norms on PrEP care (e.g. related to PrEP prescribing practices and which providers can deliver PrEP services), to flexibly tailor care to individual clients' situations. Interprofessional relationships were reconfigured in line with organizational and clinical adaptations; these included task-shifting from physicians to nurses, leading them to become increasingly trained and specialized in PrEP care. As nurse involvement grew, they adopted a crucial role in responding to PrEP users' non-medical needs (e.g. providing psychosocial support). Moreover, clinicians' growing collaboration with sexologists and psychologists, and interactions with PrEP users' family physician, became crucial in addressing complex psychosocial needs of PrEP clients, while also alleviating the burden of care on busy HIV clinics. CONCLUSIONS Our study in Belgian HIV clinics reveals that the implementation of PrEP care presents a complex-multifaceted-undertaking that requires substantial adaptive work to ensure seamless integration within existing health services. To optimize integration in different settings, policies and guidelines governing PrEP care implementation should allow for sufficient flexibility and tailoring according to respective local health systems.
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Affiliation(s)
- Jef Vanhamel
- Department of Public HealthInstitute of Tropical MedicineAntwerpBelgium
| | - Thijs Reyniers
- Department of Public HealthInstitute of Tropical MedicineAntwerpBelgium
| | - Bea Vuylsteke
- Department of Public HealthInstitute of Tropical MedicineAntwerpBelgium
| | - Steven Callens
- Department of General Internal Medicine and Infectious DiseasesGhent University HospitalGhentBelgium
| | | | - Diana Huis in ’t Veld
- Department of General Internal Medicine and Infectious DiseasesGhent University HospitalGhentBelgium
| | - Chris Kenyon
- Department of Clinical SciencesInstitute of Tropical MedicineAntwerpBelgium
| | - Jens Van Praet
- Department of Nephrology and Infectious DiseasesAZ Sint‐Jan Brugge‐Oostende AVBruggeBelgium
| | - Agnes Libois
- Department of Infectious DiseasesSaint Pierre University HospitalUniversité Libre de BruxellesBrusselsBelgium
| | - Anne Vincent
- Department of Internal Medicine and Infectious DiseasesCliniques Universitaires Saint‐LucBrusselsBelgium
| | - Rémy Demeester
- HIV Reference CentreUniversity Hospital of CharleroiCharleroiBelgium
| | - Sophie Henrard
- HIV Reference Centre and Internal MedicineErasme HospitalUniversité Libre de BruxellesBrusselsBelgium
| | - Peter Messiaen
- Department of Infectious Diseases and ImmunityJessa HospitalHasseltBelgium
- Faculty of Medicine and Life SciencesLCRCHasselt UniversityHasseltBelgium
| | - Sabine D. Allard
- Department of Internal Medicine and Infectious DiseasesUniversitair Ziekenhuis BrusselVrije Universiteit BrusselBrusselsBelgium
| | - Anke Rotsaert
- Department of Public HealthInstitute of Tropical MedicineAntwerpBelgium
| | - Karina Kielmann
- Department of Public HealthInstitute of Tropical MedicineAntwerpBelgium
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Wyatt MA, Pisarski EE, Nalumansi A, Kasiita V, Kamusiime B, Nalukwago GK, Thomas D, Muwonge TR, Mujugira A, Heffron R, Ware NC. How PrEP delivery was integrated into public ART clinics in central Uganda: A qualitative analysis of implementation processes. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0002916. [PMID: 38452111 PMCID: PMC10919847 DOI: 10.1371/journal.pgph.0002916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 01/08/2024] [Indexed: 03/09/2024]
Abstract
Tailored delivery strategies are important for optimizing the benefit and overall reach of PrEP in sub-Saharan Africa. An integrated approach of delivering time-limited PrEP in combination with ART to serodifferent couples encourages PrEP use in the HIV-negative partner as a bridge to sustained ART use. Although PrEP has been delivered in ART clinics for many years, the processes involved in integrating PrEP into ART services are not well understood. The Partners PrEP Program was a stepped-wedge cluster randomized trial of integrated PrEP and ART delivery for HIV serodifferent couples in 12 public health facilities in central Uganda (Clinicaltrials.gov NCT03586128). Using qualitative data, we identified and characterized key implementation processes that explain how PrEP delivery was integrated into existing ART services in the Partners PrEP Program. In-depth interviews were conducted with a purposefully-selected sub-sample of 83 members of 42 participating serodifferent couples, and with 36 health care providers implementing integrated delivery. High quality training, technical supervision, and teamwork were identified as key processes supporting providers to implement PrEP delivery. Interest in the PrEP program was promoted through the numerous ways health care providers made integrated ART and PrEP meaningful for serodifferent couples, including tailored counseling messages, efforts to build confidence in integrated delivery, and strategies to create demand for PrEP. Couples in the qualitative sample responded positively to providers' efforts to promote the integrated strategy. HIV-negative partners initiated PrEP to preserve their relationships, which inspired their partners living with HIV to recommit to ART adherence. Lack of disclosure among couples and poor retention on PrEP were identified as barriers to implementation of the PrEP program. A greater emphasis on understanding the meaning of PrEP for users and its contribution to implementation promises to strengthen future research on PrEP scale up in sub-Saharan Africa.
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Affiliation(s)
- Monique A. Wyatt
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
- Harvard Global, Cambridge, Massachusetts, United States of America
| | - Emily E. Pisarski
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
| | | | - Vicent Kasiita
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Brenda Kamusiime
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | - Dorothy Thomas
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | | | - Andrew Mujugira
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Renee Heffron
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Norma C. Ware
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
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Sila J, Wagner AD, Abuna F, Dettinger JC, Odhiambo B, Ngumbau N, Oketch G, Sifuna E, Gómez L, Hicks S, John-Stewart G, Kinuthia J. An implementation strategy package (video education, HIV self-testing, and co-location) improves PrEP implementation for pregnant women in antenatal care clinics in western Kenya. FRONTIERS IN REPRODUCTIVE HEALTH 2023; 5:1205503. [PMID: 38045529 PMCID: PMC10690761 DOI: 10.3389/frph.2023.1205503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 10/20/2023] [Indexed: 12/05/2023] Open
Abstract
Background Pre-exposure prophylaxis (PrEP) is recommended by the World Health Organization and the Kenyan Ministry of Health for HIV prevention in pregnancy and postpartum for women at risk for HIV. Integration of PrEP into antenatal care is promising, but delivery gaps exist in the face of healthcare provider shortages in resource-limited settings. Methods Between May and November 2021, we conducted a difference-in-differences study (3 months pre-intervention data collection and 3 months post-intervention data collection) analyzing four intervention facilities, where the strategies were implemented, and four comparison facilities, where no strategies were implemented. We tested a combination of three implementation strategies-video-based PrEP information in the waiting bay, HIV self-testing, and dispensing of PrEP in the antenatal care rooms-to improve PrEP delivery. We compared absolute changes in the proportion of antenatal attendees screened for PrEP (PrEP penetration), the proportion receiving all PrEP-specific steps in a visit (HIV testing, risk screening, and PrEP counseling) (PrEP fidelity), and client PrEP knowledge, client satisfaction, and waiting time and service time (a priori outcomes); post hoc, we compared the proportion offered PrEP (PrEP offer) and completing HIV testing. We measured provider perceptions of the acceptability and appropriateness of the implementation strategies. Results We observed significant improvements in PrEP penetration, PrEP offer, satisfaction, and knowledge (p < 0.05) and improvements in fidelity that trended towards significance (p = 0.057). PrEP penetration increased 5 percentage points (p = 0.008), PrEP fidelity increased 8 percentage points (p = 0.057), and PrEP offer increased 4 percentage points (p = 0.003) in intervention vs. comparison facilities. Client PrEP knowledge increased by 1.7 out of 6 total points (p < 0.001) and client satisfaction increased by 0.7 out of 24 total points (p = 0.003) in intervention vs. comparison facilities. We observed no changes in service time (0.09-min decrease; p = 0.435) and a small increase in waiting time (0.33-min increase; p = 0.005). HIV testing among those eligible did not change (1.5 percentage point decrease, p = 0.800). Providers felt the implementation strategies were acceptable and appropriate (median acceptability: 20/20; median appropriateness: 19.5/20). However, absolute levels of each step of the PrEP cascade remained suboptimal. Conclusions An implementation strategy package with video information, HIV self-testing, and co-location of medication dispensing enhanced PrEP delivery across several implementation outcomes and client satisfaction, while not substantially increasing wait time or decreasing provider-client contact time. Clinical trial registration ClinicalTrials.gov , identifier, NCT04712994.
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Affiliation(s)
- Joseph Sila
- Research & Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Anjuli D. Wagner
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Felix Abuna
- Research & Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Julia C. Dettinger
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Ben Odhiambo
- Research & Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Nancy Ngumbau
- Research & Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - George Oketch
- Research & Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Enock Sifuna
- Research & Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Laurén Gómez
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Sarah Hicks
- Department of Epidemiology, University of Washington, Seattle, WA, United States
| | - Grace John-Stewart
- Department of Global Health, University of Washington, Seattle, WA, United States
- Department of Epidemiology, University of Washington, Seattle, WA, United States
- Departments of Pediatrics & Medicine, University of Washington, Seattle, WA, United States
| | - John Kinuthia
- Research & Programs, Kenyatta National Hospital, Nairobi, Kenya
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Neill R, Zia N, Ashraf L, Khan Z, Pryor W, Bachani AM. Integration measurement and its applications in low- and middle-income country health systems: a scoping review. BMC Public Health 2023; 23:1876. [PMID: 37770887 PMCID: PMC10537146 DOI: 10.1186/s12889-023-16724-2] [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: 01/05/2023] [Accepted: 09/08/2023] [Indexed: 09/30/2023] Open
Abstract
BACKGROUND Despite growing interest in and commitment to integration, or integrated care, the concept is ill-defined and the resulting evidence base fragmented, particularly in low- and middle-income countries (LMICs). Underlying this challenge is a lack of coherent approaches to measure the extent of integration and how this influences desired outcomes. The aim of this scoping review is to identify measurement approaches for integration in LMICs and map them for future use. METHODS Arksey and O'Malley's framework for scoping reviews was followed. We conducted a systematic search of peer-reviewed literature measuring integration in LMICs across three databases and screened identified papers by predetermined inclusion and exclusion criteria. A modified version of the Rainbow Model for Integrated Care guided charting and analysis of the data. RESULTS We included 99 studies. Studies were concentrated in the Africa region and most frequently focused on the integration of HIV care with other services. A range of definitions and methods were identified, with no single approach for the measurement of integration dominating the literature. Measurement of clinical integration was the most common, with indicators focused on measuring receipt of two or more services provided at a single point of time. Organizational and professional integration indicators were focused on inter- and intra-organizational communication, collaboration, coordination, and continuity of care, while functional integration measured common information systems or patient records. Gaps were identified in measuring systems and normative integration. Few tools were validated or publicly available for future use. CONCLUSION We identified a wide range of recent approaches used to measure integration in LMICs. Our findings underscore continued challenges with lack of conceptual cohesion and fragmentation which limits how integration is understood in practice.
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Affiliation(s)
- Rachel Neill
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins International Injury Research Unit, Health Systems Program, 615 N. Wolfe Street Suite E8527, Baltimore, MD, 21205, USA.
| | - Nukhba Zia
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins International Injury Research Unit, Health Systems Program, 615 N. Wolfe Street Suite E8527, Baltimore, MD, 21205, USA
| | - Lamisa Ashraf
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins International Injury Research Unit, Health Systems Program, 615 N. Wolfe Street Suite E8527, Baltimore, MD, 21205, USA
| | - Zainab Khan
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins International Injury Research Unit, Health Systems Program, 615 N. Wolfe Street Suite E8527, Baltimore, MD, 21205, USA
| | - Wesley Pryor
- Nossal Institute for Global Health, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, 3010, Australia
| | - Abdulgafoor M Bachani
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins International Injury Research Unit, Health Systems Program, 615 N. Wolfe Street Suite E8527, Baltimore, MD, 21205, USA
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Omollo V, Asewe M, Mogere P, Maina G, Kuo AP, Odoyo J, Oware K, Baeten JM, Kohler P, Owens T, Bukusi EA, Ngure K, Ortblad KF. The Fidelity of a Pharmacy-Based Oral HIV Pre-Exposure Prophylaxis Delivery Model in Kenya. J Acquir Immune Defic Syndr 2023; 93:379-386. [PMID: 37079900 PMCID: PMC10337311 DOI: 10.1097/qai.0000000000003208] [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: 10/31/2022] [Accepted: 02/22/2023] [Indexed: 04/22/2023]
Abstract
BACKGROUND HIV pre-exposure prophylaxis (PrEP) delivery at private pharmacies is a promising new differentiated service delivery model that may address barriers to PrEP delivery at public health care facilities. We measured the fidelity of this model (ie, delivery as intended) in a pilot study in Kenya. SETTING Five private, retail pharmacies in Kisumu and Thika Counties. METHODS Trained pharmacy providers delivered PrEP services, including identifying eligible clients, counseling on HIV risk, assessing PrEP safety, testing for HIV, and dispensing PrEP. Pharmacy clients completed surveys that assessed the fidelity of the services received after each visit. Standardized client actors (ie, mystery shoppers) were trained on 4 different case scripts, then made unannounced pharmacy visits, and then completed a 40-item checklist that assessed the fidelity and quality of service delivery components. RESULTS From November 2020 to December 2021, 287 clients initiated and 159 (55%) refilled PrEP. At initiation, most clients were counseled on PrEP adherence (99%, 284 of 287) and potential side effects (97%, 279 of 287) and all received provider-assisted HIV self-testing before PrEP dispensing (findings consistent across refill visits). Nine standardized client actors completed 15 pharmacy visits. At each visit, most actors were asked about their behaviors associated with HIV risk (80%, 12/15) and all were counseled on PrEP safety and side effects. All actors reported that pharmacy providers treated them with respect. CONCLUSIONS In this first pilot study of pharmacy-delivered PrEP services in Africa, the fidelity of service delivery was high, suggesting that trained providers at private pharmacies can deliver quality PrEP services.
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Affiliation(s)
- Victor Omollo
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Magdaline Asewe
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Peter Mogere
- Partners in Health and Research Development, Thika, Kenya
| | - Gakuo Maina
- Partners in Health and Research Development, Thika, Kenya
| | | | - Josephine Odoyo
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Kevin Oware
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Jared M. Baeten
- Global Health
- Epidemiology
- Medicine, University of Washington, Seattle, WA
- Currently, Gilead Sciences, Foster City, CA
| | - Pamela Kohler
- Global Health
- Department of Nursing, University of Washington, Seattle, WA
| | | | - Elizabeth A. Bukusi
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
- Epidemiology
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA
| | - Kenneth Ngure
- School of Public Health, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya; and
| | - Katrina F. Ortblad
- Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, WA
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Mbachu CO, Ekenna AC, Agbawodikeizu UP, Onwujekwe O. Role and use of evidence in health system response to COVID-19 in Nigeria: a mixed method study. Pan Afr Med J 2023; 44:191. [PMID: 37484579 PMCID: PMC10362686 DOI: 10.11604/pamj.2023.44.191.38990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 03/18/2023] [Indexed: 07/25/2023] Open
Abstract
Introduction evidence-based decision-making in health is an aspiration needed to effectively respond to current outbreaks and prepare for future occurrences. This paper examines the roles and use of evidence in health systems response to COVID-19 in Nigeria. Methods this was a mixed method study comprising nine key informant interviews and rapid review of 126 official online documents, journal articles and media reports published from December 2019 to December 2020 with a national and sub-national focus. Key informants were drawn from the government agencies that were involved in making or implementing decisions on the health sector response to COVID-19. Data collection was performed by three researchers. Thematic analysis and narrative synthesis of data was done. Results various forms of evidence were used to make decisions on Nigeria´s health system response to COVID-19, and these are broadly classified into three, namely, i) lessons learned from past experiences such as community engagement activities, early recognition of risks and deployment of non-pharmaceutical pandemic control measures, ii) proven interventions with contextual relevance like the emphasis on hand hygiene education for health workers, and iii) risk assessment and situation analysis reports like adopting a multi-sector response to COVID-19 control, expanding COVID-19 diagnostic laboratories to new sites across the country, and relax lockdown restrictions while maintaining key limitations to curb a spike in COVID-19 cases. Conclusion Nigeria´s health system response to COVID-19 upheld the use of evidence in making critical decisions on the prevention and control of the pandemic.
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Affiliation(s)
| | - Adanma Chidinma Ekenna
- Health Policy Research Group, University of Nigeria, Enugu Campus, Enugu, Nigeria
- Department of Community Medicine, University of Nigeria Teaching Hospital, Enugu, Nigeria
| | - Uju Patricia Agbawodikeizu
- Health Policy Research Group, University of Nigeria, Enugu Campus, Enugu, Nigeria
- Department of Social Work, Faculty of Social Sciences, University of Nigeria, Nsukka, Nigeria
| | - Obinna Onwujekwe
- Health Policy Research Group, University of Nigeria, Enugu Campus, Enugu, Nigeria
- Department of Health Administration and Management, University of Nigeria, Enugu Campus, Enugu, Nigeria
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Velloza J, Roche SD, Owidi EJ, Irungu EM, Dollah A, Kwach B, Thuo NB, Morton JF, Mugo N, Bukusi EA, O'Malley G, Ngure K, Baeten JM, Mugwanya KK. 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. J Int AIDS Soc 2023; 26:e26055. [PMID: 36739603 PMCID: PMC9899492 DOI: 10.1002/jia2.26055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 12/19/2022] [Indexed: 02/06/2023] Open
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.
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Affiliation(s)
- Jennifer Velloza
- Department of Epidemiology & BiostatisticsUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Stephanie D. Roche
- Public Health DivisionFred Hutchinson Cancer Research CenterSeattleWashingtonUSA
| | | | | | - Annabell Dollah
- Washington State University – Global Health KenyaNairobiKenya
| | - Benn Kwach
- Kenya Medical Research InstituteKisumuKenya
| | | | | | - Nelly Mugo
- Partners in Health and Research DevelopmentThikaKenya,Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
| | - Elizabeth A. Bukusi
- Kenya Medical Research InstituteKisumuKenya,Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
| | | | - Kenneth Ngure
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA,Department of Community HealthJomo Kenyatta University of Agriculture and TechnologyNairobiKenya
| | - Jared M. Baeten
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA,Gilead SciencesFoster CityCaliforniaUSA,Department of MedicineUniversity of WashingtonSeattleWashingtonUSA,Department of EpidemiologyUniversity of WashingtonSeattleWashingtonUSA
| | - Kenneth K. Mugwanya
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA,Department of EpidemiologyUniversity of WashingtonSeattleWashingtonUSA
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Bien-Gund CH, Ochwal P, Marcus N, Bair EF, Napierala S, Maman S, Agot K, Thirumurthy H. Adoption of HIV pre-exposure prophylaxis among women at high risk of HIV infection in Kenya. PLoS One 2022; 17:e0273409. [PMID: 36084050 PMCID: PMC9462728 DOI: 10.1371/journal.pone.0273409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Accepted: 07/26/2022] [Indexed: 11/18/2022] Open
Abstract
In 2017, Kenya became one of the first African countries to provide pre-exposure prophylaxis (PrEP) in its national HIV prevention plan. We sought to characterize factors associated with PrEP uptake and persistence among a cohort of women at risk of HIV infection during the early stages of PrEP scale-up in Kenya. HIV-negative women ≥18 years with ≥2 sexual partners in the past 4 weeks were recruited as part of an ongoing cluster randomized trial of an HIV self-testing intervention. PrEP use was assessed at baseline and at 6- and 12-month follow-up visits. Between June 2017 and August 2018, 2,086 were enrolled and had complete baseline data. 138 (6.6%) reported PrEP use during the first year of the study. Although PrEP use increased, persistence on PrEP was low, and less than half of individuals reported continuing PrEP at follow-up visits. In multivariate analyses, PrEP use was associated with recent STIs, having an HIV-positive primary partner, having regular transactional sex in the past 12 months, and being a female sex worker. In the early stages of PrEP scale-up in Kenya, uptake increased modestly among women with risk factors for HIV infection, but overall uptake and persistence was low.
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Affiliation(s)
- Cedric H. Bien-Gund
- Division of Infectious Diseases, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States of America
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, PA, United States of America
- * E-mail:
| | - Perez Ochwal
- Impact Research and Development Organisation, Kisumu, Kenya
| | - Noora Marcus
- Division of Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States of America
| | - Elizabeth F. Bair
- Division of Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States of America
| | - Sue Napierala
- Women’s Global Health Imperative, RTI International, Berkeley, CA, United States of America
| | - Suzanne Maman
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Kawango Agot
- Impact Research and Development Organisation, Kisumu, Kenya
| | - Harsha Thirumurthy
- Division of Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States of America
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