Impact of two stakeholder selected implementation strategy bundles on PrEP delivery in maternal and child health clinics in Kenya

Abstract

IntroductionWomen remain at substantial risk for HIV acquisition during pregnancy and breastfeeding due to changes in biological and behavioral factors. Although PrEP has been recommended as safe and effective during pregnancy by the WHO and Kenyan government, barriers still exist in its delivery in sub-Saharan Africa. Integration of PrEP during antenatal care in maternal and child health (MCH) clinics remains sub-optimal. MethodsWe piloted 2 bundles of 3 implementation strategies selected by stakeholders to enhance delivery in Western Kenya.: 1) task shifting PrEP counselling from clinicians/nurses to HIV testing services providers (HTS), training different cadres, and dispensing PrEP in MCH; 2) use of PrEP educational materials, PrEP health talks in waiting bays, and dispensing PrEP in MCH. We assessed each bundle using a difference-in-differences design, comparing the 3-month periods before and after implementation, in 8 facilities (4 intervention and 4 comparison). Absolute changes were evaluated in primary outcomes: PrEP penetration, PrEP fidelity, PrEP offer, PrEP risk screening, client PrEP knowledge & satisfaction, and timeliness (waiting and service times); and 135 Health providers reported acceptability and appropriateness of the implementation strategies. ResultsOverall, 4,872 women seeking MCH services participated, (2,450 in the first bundle and 2,422 in the second). Both strategy bundles were associated with significant improvements in PrEP fidelity, PrEP penetration, and PrEP offer. With the first bundle, PrEP fidelity increased by 15.8% points (95%CI: 7.3%, 24.3%; p<0.001), PrEP penetration by 7.7% points (95%CI: 2.5%, 12.9%; p=0.004), and PrEP offer by 7.7% points (95%CI: 3.3%, 12.1%; p=0.001) in intervention vs comparison sites. With the second bundle, PrEP fidelity increased by 32.0% points (95%CI: 20.9%, 43.0%; p<0.001), PrEP penetration by 22.3% points (95%CI: 15.9%, 28.7%; p<0.001), and PrEP offer by 10.7% points (95%CI: 5.5%, 15.9%; p<0.001) in intervention vs comparison sites. With the first bundle, PrEP risk screening increased by 11.7% points (95%CI: 3.4%, 20.0%; p=0.006), while the second bundle was associated with a non-significant increase in PrEP risk screening (6.9% points (95%CI: -1.5%, 15.3%; p=0.106). Neither strategy bundle was associated with changes in HIV testing, client satisfaction, client service time, or waiting time (p>0.05). Both bundles were highly rated by healthcare providers on acceptability (median: 19/20 points; IQR: 16, 20) and appropriateness (median: 20/20 points; IQR: 18, 20). ConclusionStakeholder-selected implementation strategy bundles addressing provider type, service location, and educational materials significantly improved PrEP implementation outcomes without affecting client satisfaction, service and waiting times.