Acceptability of HIV Pre-exposure Prophylaxis Integration into Post-abortal Care Services to Expand the Reach of PrEP among Kenyan Adolescent Girls and Young Women

Abstract

Introduction: Globally, adolescent girls and young women (AGYW) continue to bear a disproportionate burden of HIV and unintended pregnancies. In low-resource settings, including Kenya, AGYW seeking post-abortal care (PAC) often continue to engage in sex with infrequent condom use, resulting in subsequent unintended pregnancies and risk for HIV infection. This situation demonstrates the potential for integrating HIV prevention services such as PrEP into PAC services to increase reach, uptake, and efficiency. However, data informing the acceptability, feasibility, and sustainability of PAC clinics as an entry point for PrEP services, including actual service delivery, are limited. Therefore, we assessed AGYWs, providers, and the implementing partner to inform the feasibility, scale-up, and sustainability of integrating PrEP into PAC. Methods: Between June 2022 and March 2023, we conducted a cross-sectional qualitative study as part of a cluster-randomized trial piloting PrEP delivery among 15–30-year-old AGYW within PAC clinics in 14 Kenyan public and private facilities in Kiambu, Nairobi, Murang'a, and Kisumu Counties. We collected data using in-depth interviews (n=60) among purposively sampled AGYW who initiated PrEP while receiving PAC in the partner facilities, focus group discussions (n=6) among AGYW and (n=6) among PAC providers, and key informant interviews (n=18) with PAC providers and implementing partners' representatives. Interviews were audio-recorded and transcribed verbatim. The data were analyzed thematically using inductive and deductive approaches. The theoretical framework of acceptability (TFA) guided this process. Results: We found that PrEP integration into PAC was highly acceptable as an effective and timely intervention to improve reach for PrEP services since it reduced PrEP stigma and enhanced ease of access among AGYW, who could benefit the most. Additionally, providers' competence in offering integrated PrEP services, attitudes toward providing PrEP and PAC for AGYW, and AGYWs' confidence in using PrEP all influence PrEP delivery and access in PAC clinics. Moreover, staffing, availability of safe spaces, commodity management, and reporting systems are crucial in influencing the efficient integration of PrEP into PAC services. Conclusion: Integrating PrEP services into PAC was highly acceptable as an effective and timely intervention to improve PrEP services reach among Kenyan AGYW. Therefore, scaling-up integration of PrEP in PAC scale-up would improve reach for PrEP among at-risk AGYW. However, enhancing PrEP integration into PAC efficiency requires further strategies to strengthen facility operations and structure.