Surmounting PrEP delivery challenges through adaptation of implementation guidelines: lessons learned from HIV care clinics in Kenya Elizabeth M. Irungu, Kenneth Ngure, Kenneth Mugwanya, Nelly Mugo, Elizabeth A. Bukusi, Josephine Odoyo, Elizabeth Wamoni, Jennifer F. Morton, Gabrielle O'Malley, Jared Baeten, for the Partners Scale-Up Team

Background PrEP services in Kenya are provided mainly in public HIV care clinics These clinics provide HIV treatment and prevention services to many clients despite having multiple challenges such as understaffing, long waiting times for patients and inadequate infrastructure The objective of this analysis is to describe modifications made in HIV clinics in public health facilities and adaptations made to implementation guidelines to facilitate successful PrEP delivery

Methods The Partners Scale-Up Project aims to catalyze integration of PrEP in public HIV care clinics by training providers and providing technical support in 24 clinics in Kenya To understand PrEP service integration processes, we conducted qualitative interviews with health care providers and documented clinic observations in technical assistance reports Using a combination of deductive and inductive approaches we analyzed 71 health provider interviews and TA reports from the 24 clinics to identify adaptations made at the clinic level Technical assistants also documented clinic observations every time they made a visit to support and mentor the providers.

Baseline Creatinine Tests Rarely Done Results Baseline Creatinine Tests Rarely Done “The challenge ... in regards to some of these tests like the baseline ones like creatinine and the rest. Some clients are not in a position to afford the prices” KII Clinician Creatinine tests were rarely done at baseline. Guidelines recommend that creatinine testing is performed at baseline and annually thereafter – however the guidelines also state that PrEP initiation should not be delayed in the absence of the test results. Creatinine was not done because it is expensive to do this test either in the facility or in private labs should the facility lack reagents.

Refill visits are often Results Refill visits are often > 1 month “..if patients come back without any problem or side effects, we give two or even three months according to the convenience of the patient”. KII, Clinician PrEP users should be seen by a provider one month after initiation and every three months thereafter. However, they are to receive PrEP refills every month. We found that health providers often issued more than a month’s supply of PrEP at a time – sometimes two, sometimes three. This they said was for the convenience of the PrEP users who found monthly visits too frequent and costly.

Results PrEP discontinuation is not always done when partner attains viral suppression “No, they just say they want to continue...... yeah, they just need it, some don’t even give reasons, they just say I just want to continue with this drug, I don't want to get infected” KII, Counsellor PrEP users sometimes declined to discontinue PrEP when their partners attained viral suppression. Sometimes they did not give a reason for wanting to continue using the pills, they just knew the pills would keep them HIV free. Providers allowed them to continue using PrEP.

PrEP is sometimes dispensed in clinic rooms Results PrEP is sometimes dispensed in clinic rooms “the CCC Nurse in-charge would keep a few bottles of PrEP so that clients did not have to visit the pharmacy as there were concerns about the pharmacy hours and stigma of having to go to the main pharmacy.” TA report In a few clinics we found that clinicians dispensed PrEP in the clinical rooms rather than having clients go to the pharmacy. This was aimed at addressing long waiting times and stigma associated with queuing at the pharmacy.

PrEP clients are often fast tracked Results PrEP clients are often fast tracked “ We have lost two [clients] and I think it is the issue of stigma, may be they have seen someone they know so when they ......sit there they may think that these guys will think that I am taking ARVs” Nurse manager In all clinics we found that clients were fast tracked – or given priority over other clients and did not queue for services at some points. There were variations in how the fast tracking was done – only at initiation visit, or for all visits or everywhere else except at pharmacy, Providers wanted PrEP clients to spend a short time in the clinic so as to avoid stigma associated with being in a HIV care clinic and also reduce the likelihood that they will go away without receiving service because they do not want to queue.

Conclusions Health care providers made adaptations to implementation guidelines and innovative modifications to their routine practices The adaptations were made to overcome PrEP delivery challenges and reduce barriers for clients and staff. Enabling clinic level adaptations to national implementation guidelines will facilitate scale up of PrEP delivery

Acknowledgements National AIDS and STI Control Program (NASCOP) Participating county health management teams Participating clinics in the Partners Scale-Up Project Funders: National Institutes of Health Bill and Melinda Gates Foundation