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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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Wagner AD, Beima-Sofie K, Awuor M, Owade W, Neary J, Dettinger JC, Pintye J, Abuna F, Lagat H, Weiner BJ, Kohler P, Kinuthia J, John-Stewart G, O’Malley G. Implementation determinants and strategies in integration of PrEP into maternal and child health and family planning services: experiences of frontline healthcare workers in Kenya. FRONTIERS IN REPRODUCTIVE HEALTH 2023; 5:1205925. [PMID: 37799494 PMCID: PMC10548203 DOI: 10.3389/frph.2023.1205925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 09/04/2023] [Indexed: 10/07/2023] Open
Abstract
Background Delivery of PrEP to adolescent girls and young women (AGYW) and to pregnant women through maternal and child health (MCH) and family planning (FP) clinics is scaling up in Kenya. Evaluation of implementation challenges and strategies is critical to optimize delivery. Methods We conducted focus group discussions (FGDs) with healthcare workers (HCWs) in MCH and FP clinics offering PrEP in a large implementation project in Kisumu, Kenya. Discussion guides were based on the Consolidated Framework for Implementation Research (CFIR). FGDs were audio recorded and transcribed. Directed content analysis was used to identify implementation challenges and strategies to overcome them. Results Fifty HCWs from 26 facilities participated in 8 FGDs. HCWs believed PrEP integration was appropriate because it met the needs of AGYW and pregnant women by providing a female-controlled prevention strategy and aligned with policy priorities of elimination of vertical HIV transmission. They were universally accepting of PrEP provision, especially through MCH clinics, noting the relative advantage of this approach because it: (1) enabled high coverage, (2) harmonized PrEP and MCH visits, and (3) minimized stigma compared to PrEP offered through HIV care clinics. However, HCWs noted implementation challenges affecting feasibility and adoption including: (1) increased workload and documentation burden amid workforce shortages, (2) insufficient health care worker knowledge (3) multiple implementing partners with competing priorities (4) drug and documentation form stockouts. HCWs employed various implementation strategies to overcome challenges, including task shifting from nurses to HIV testing providers, patient flow modifications (e.g., fast-tracking PrEP clients to reduce wait times), PrEP demand generation and myth clarification during health talks, provider education, dedicated PrEP delivery rooms, and coordination with adolescent-friendly services. Additional suggested strategies to improve PrEP integration included community education to increase broader PrEP awareness and enable shorter counseling sessions, and task-shifting data entry and client risk assessments. Conclusions HCWs were enthusiastic about the appropriateness and acceptability of integrating PrEP services into MCH and FP clinics but noted challenges to adoption and feasibility. Strategies to address challenges focused on improving provider time and space constraints, and increasing provider and client knowledge.
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Affiliation(s)
- Anjuli D. Wagner
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Kristin Beima-Sofie
- Department of Global Health, University of Washington, Seattle, WA, United States
| | | | | | - Jillian Neary
- Department of Epidemiology, University of Washington, Seattle, WA, United States
| | - Julia C. Dettinger
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Jillian Pintye
- Department of Biobehavioral Nursing and Health Informatics, School of Nursing, University of Washington, Seattle, WA, United States
| | - Felix Abuna
- Research & Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Harison Lagat
- Research & Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Bryan J. Weiner
- Department of Global Health, University of Washington, Seattle, WA, United States
- Department of Health Systems and Population Health, University of Washington, Seattle, WA, United States
| | - Pamela Kohler
- Department of Global Health, University of Washington, Seattle, WA, United States
- Department of Child, Family, and Population Health Nursing, University of Washington, Seattle, WA, United States
| | - John Kinuthia
- Research & Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - 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 and Medicine, University of Washington, Seattle, WA, United States
| | - Gabrielle O’Malley
- Department of Global Health, University of Washington, Seattle, WA, United States
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