Barriers and facilitators to the introduction of doxycycline post-exposure prophylaxis into Kenyan HIV PrEP Programs for the prevention of bacterial sexually transmitted infections

Abstract

Doxycycline post exposure prophylaxis (dPEP) is a novel STI prevention strategy that can reduce the high prevalence of curable STIs among PrEP users. It has been shown to be efficacious among men who have sex with men and transgender women, but not cisgender women. Before its potential introduction to HIV PrEP programs, and to bridge the know-do gap, it is important to evaluate the potential barriers and facilitators to its implementation in order to implement appropriate evidence-informed implementation strategies that will achieve desired impact.Methods: A qualitative study exploring the potential barriers and facilitators to integrating a biomedical STI prevention innovation into Kenyan HIV PrEP programs. A total of 40 interviews were conducted with Kenyan HIV/STI policymakers, healthcare providers and PrEP users. The consolidated Framework for Implementation Research (CFIR) framework was utilized to evaluate the determinants of acceptability, feasibility and sustainability of integrating dPEP into HIV PrEP programs. Results: All groups of participants expressed concern about the high burden of STIs among people using PrEP. Participants found doxycycline post-exposure prophylaxis to be an acceptable strategy: there already exists a need for STI prevention services and the innovation covers both symptomatic and asymptomatic PrEP users. The key CFIR domains and constructs associated with acceptability were Innovation Characteristics (Relative Advantage, Evidence Strength and Quality), Inner Setting (Tension for change), Outer Setting (Needs and Resources of Recipients), and Individual Characteristics (Knowledge and Beliefs). Integrating dPEP into PrEP programs was deemed feasible, but there are concerns over long-term continuity of services and availability of resources for surveillance of prevalence, incidence, and antimicrobial resistance patterns. The key CFIR determinants associated with feasibility were Innovation Characteristics (Cost) and Inner Setting (Compatibility) while those associated with sustainability were Innovation Characteristics (Innovation Source, Cost) and Outer setting (External Policy & Incentives) and Process (Engaging). Conclusion: Kenyan HIV/STI policymakers, healthcare providers and HIV PrEP users are concerned about the high burden of STIs and perceive doxycycline post-exposure prophylaxis for STI prevention to be acceptable, feasible and sustainable. Pill burden, high workload and antibiotic resistance are concerns. Successful implementation is contingent on intentional navigation of the innovation through the stages of research, policy advocacy and implementation; generating diverse evidence that includes local, national, and international stakeholders along the cascade; and demand creation that is coupled with consistent commodity supplies.