Barriers to and strategies for early implementation of pharmacy-delivered PrEP services in Kenya: An analysis from routine data

Abstract

Background: In settings where populations at high risk of HIV acquisition face challenges using clinic-based pre-exposure prophylaxis (PrEP) for HIV prevention, differentiated PrEP delivery models are needed to expand access and reach. During a pilot study testing a novel pharmacy-delivered PrEP model in Kenya, we identified early implementation barriers and actions that providers and study staff took in response. Methods: We trained pharmacy providers at four private pharmacies in Kisumu and Thika, Kenya to initiate and continue clients at risk of HIV acquisition on PrEP using a prescribing checklist with oversight from remote clinicians. Research assistants stationed at the pharmacies completed weekly observation reports. Using content analysis, we analyzed reports from the first six months of implementation and notes from a subsequent member-checking meeting with pharmacy providers and research staff near the study endline to identify multi-level barriers to implementation and actions taken in response. We organized identified barriers and actions by domains of the Consolidated Framework for Implementation Research (CFIR). Results: From November 2020 to May 2021, pharmacy providers screened 472 potential PrEP clients and initiated 211 (45%) on PrEP. Research assistants stationed at the pharmacies completed 74 weekly observation reports (~18 reports/pharmacy). We identified barriers to pharmacy-delivered PrEP across CFIR domains: high costs to clients (intervention characteristics), client discomfort discussing sexual behaviors and HIV testing with providers (outer setting), and provider frustrations that PrEP delivery was time-consuming and disruptive to their workflow (inner setting), high provider turnover (inner setting), and provider hesitancy to deliver PrEP due to concerns about encouraging promiscuity (characteristics of individuals). To help address these, pharmacy providers implemented an HIV risk self-screening option for prospective PrEP clients, allowed flexible appointment scheduling, and conducted pharmacy PrEP training for newly hired providers. Conclusions: Our study provides insight into early barriers to implementing pharmacy-delivered PrEP in Kenya and potential actions to mitigate these barriers. Future research is needed to understand client perspectives on this delivery model, to evaluate the feasibility and effectiveness of this model, and assess late-stage implementation outcomes.