Providing PrEP.

Service delivery platforms varied across respondents’ programs, and included delivery of PrEP through DICEs, outreaches, sexual and reproductive health clinics, and comprehensive care clinics (CCC) for HIV treatment (Table 3).

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 3. PrEP service delivery platforms discussed by respondents.

https://doi.org/10.1371/journal.pone.0259738.t003

While they discussed benefits and challenges to each approach, most respondents felt that offering dedicated PrEP services through outreaches, community safe spaces, and DICEs was preferable to delivery through CCC, where PrEP clients would be served alongside people living with HIV. Respondents expressed that delivering PrEP through CCC, while streamlined from a staffing and commodities perspective, was not client-friendly, except when serving serodiscordant couples. A 44-year-old male county manager explained, “Sometimes they may be stigmatized… they don’t feel free with the infected people who are coming for the antiretrovirals.” Client wait times were also a concern for many respondents, particularly when it came to integrating PrEP with other HIV or sexual and reproductive health services; the same county manager said that clients “would be pretty happy to spend less time in the facilities.”

Where PrEP was delivered alongside other services, program and county managers differed in their views on how to allocate PrEP roles amongst staff in facilities. A 55-year-old male director of a Migori-based CSO stated about peer educators, “I don’t want them just to be labelled as the PrEP demand creators.” In contrast, many PrEP service providers felt that it was important to have dedicated PrEP staff, to ensure programs are adequately supported and staff are not overextended:. A 32-year-old female nurse from Machakos explained, “so that we don’t miss patients on PrEP, we identified a PrEP focal person … so if the HIV testing counsellor gets a patient who needs PrEP, she knows where to take the patient and who to contact.” In programs where PrEP was offered alongside other services, respondents emphasized the importance of close coordination and communication between PrEP programs and other HIV services in the same facility.

Many respondents expressed that it was challenging to streamline service delivery in the face of broader health system challenges, such as staff turnover and shortages. Staff shortages had implications for PrEP service providers, but ultimately respondents said they influenced their ability to provide services to clients. For example, a 22-year-old female HIV testing services provider from Migori explained that in their facility, “we have insufficient nurses there. The one who provides family planning is still the one providing PrEP. Sometimes the youths who come for PrEP go without PrEP, since there is no person to provide it for them.” PrEP service providers frequently discussed feeling burned out and overextended, due to limited staff in PrEP programs and in facilities more broadly:

“Another thing which actually contributes to those issues for instance in our case is work load. We have one clinician who is supposed to do the outpatient, is supposed to clear the queue, at the same time is the person who is supposed to operate in the CCC. At times he gets tired and tells them you come tomorrow for PrEP [participants laughing].”– 29-year-old male social worker, Machakos

Training staff.

To improve service delivery, beyond broader health system changes, several respondents discussed the importance of targeted staff capacity-building. Respondents across groups expressed that, while program staff were very aware of PrEP, there were training gaps for non-clinical program staff, such as receptionists or cleaners. One program manager described how, after holding a single training, “I realized PrEP needed some constant training.” The manager further described the importance of repeated peer educator training given their central role in the program:

“The [peer educator] is the client’s first contact. If you give wrong information to clients there [in the community], if someone comes here [to the facility], I don’t know whether providers will be ready.”– 34-year-old Program Manager, Nairobi-based CSO

Others discussed the importance of training PrEP service providers and peer educators to help potential clients make informed decisions about PrEP without feeling like they were forced to take it because of a certain identity or behavior:

“We need to create a very supportive environment to ensure that something like PrEP is really available and can be provided in a very friendly way, not in a way where you are pushing it down someone’s throat. … You should take PrEP because according to you, you feel that is what I need [not because you are deemed to be “high-risk” by a provider].” -- 39-year-old male program manager, Kisumu-based CSO

Indeed, across groups, respondents said that high-quality PrEP training would not only ensure accurate information is given to clients, but would also ensure friendly services were provided to clients.

Demand generation.

Respondents shared successful strategies for demand creation, and expressed the importance of using creative approaches for reaching clients with PrEP. Respondents reported that programs relied heavily on peer educators for demand creation, and peer educators themselves felt confident and well-trained to generate demand and communicate with PrEP clients.

Some respondents expressed a need for sites and PrEP service providers to improve coordination with peer educators. In addition, respondents suggested providers could improve their communication with PrEP clients. Providers themselves expressed a desire to feel more confident in the information they were sharing with clients. For example, one 29-year-old male clinical officer from Machakos emphasized that “adhering to a clinic appointment doesn’t really mean you adhere to the drugs,” and that “the first information you give to that client really matters for whether he or she will continue taking PrEP.” Another provider from Migori county described the need to be well-versed in PrEP, saying, “We should not sit and wait for the clients to come and ask us, but we should be ready for any client that comes.” A 33-year-old male program manager from a private facility in Kisumu noted that clear provider communication could help clients “make a full decision” to use PrEP.

In generating demand, respondents felt there was a need for more tailored messaging around PrEP. One 44-year-old male county manager emphasized the need for tailored messaging for key populations, saying that “there is a lot of awareness, but still people think they are not at a substantial ongoing risk to benefit from PrEP.” At the same time, some respondents were hesitant that key population-focused messaging could cause negative impacts:

“Let’s not generalize, it’s not good for everybody … don’t say ‘it was proposed for sex workers,’ let them give you their view. They might tell you ‘we don’t want that.’ Let’s not assume … let’s bring the people on the table. Let’s not think because they have not gone to school they don’t understand or they don’t know why it is good.” -- 50-year-old program manager of a predominantly FSW-serving CSO

Community engagement.

Indeed, respondents felt that overly-targeted communications could result in perceptions that PrEP is only appropriate for certain groups, and emphasized the importance of community engagement. Several respondents said that community sensitization and stakeholder engagement played a critical role in establishing sites as safe spaces in the community and promoting client engagement with the healthcare system. One 24-year-old male program manager from a Migori-based CSO whose program primarily served AGYW, described the important role of community leadership in bringing parents on board, saying that “[community leaders] come in and tell us ‘you are conducting these kinds of meetings but we have not been informed. If only you could inform us, we could be sensitizing the [AGYW’s] parents’.” Others discussed opportunities for PrEP programs to collaborate with traditional circumcisers, social workers, members of key population communities, and religious leaders to develop communication strategies.

Program and county managers also saw community health workers or volunteers and community health assistants as critical for the success of PrEP programs, and emphasized the need for coordination and collaboration with these groups:

“Those are the people who are good at health promotion. Service providers … may find it a bit difficult. You see from the community health volunteers, the community health assistants, and the public health officers, you will find it easier.”– 24-year-old male Program Manager, Migori-based CSO

Advocacy.

Finally, all respondents acknowledged the important role of stigma in PrEP implementation, and saw a role for themselves and the wider community in PrEP advocacy. Program and county managers discussed the influence of stigma in the community and in the health care system:

“What we need to do is to intensify sensitization at community level and also with the health care workers. You know, there are health care workers who don’t embrace [PrEP]. They always ask why are we doing that, and [saying] ‘we know it is wrong, why are you exposing yourself so that you take PrEP?’”– 44-year-old male county manager

Many peer educators emphasized the importance of widespread community sensitization around PrEP, saying that they themselves faced stigma for the work they do. They discussed the community’s perception of their work, saying “they say I promote immorality” and they face “discouragement” from others in the community. However, respondents also noted the role of stigma within the healthcare system. Many respondents discussed stigmatizing beliefs among PrEP service providers and other clinic staff, such as the belief that by providing PrEP “you are promoting promiscuity” or that “these guys [PrEP clients] are immoral and it is not supposed to be like this.” In response to this challenge, many program and county managers emphasized the need for community awareness creation and improved provider training and sensitization.

Data collection tools.

PrEP service providers had mixed experiences with data collection tools, particularly the risk assessment screening tool. Some were familiar with the tool and had no concerns, saying things like “it makes my work easier” and describing it as “friendly” to use. Others were aware of the tool, but had concerns about its usability from both a provider and client perspective.

A few PrEP service providers expressed that the questions on the risk assessment screening tool might be uncomfortable for clients to answer; for example, a 41-year-old female nursing officer from Mombasa said that “in exit interviews, clients say the risk assessment screening form is so detailed and personal, so they were complaining.” Another, a 27-year-old male HIV testing services provider from Migori, discussed the need to “equip our staff with all risk assessment screening questions and help us in constructing questions with the client” to improve both provider and client comfort with the questions in the tool.

Monitoring & evaluation needs. Despite general enthusiasm for program monitoring, a few respondents discussed challenges in this area. Some respondents said that data review meetings could be discouraging if not paired with solutions and support. For example, a 33-year-old female PrEP service provider from a DICE said, “the review meetings are good but sometimes… you will feel they have spoiled your whole day.” The same provider went on to say that “they expect those review meetings to be supportive supervision,” expressing frustration that those organizing the meetings did not appreciate the day-to-day realities of PrEP service delivery and their impact on the data. Other PrEP service providers felt that the amount of documentation involved in their day-to-day tasks was burdensome. In one FGD, providers discussed that HIV-related activities had a reputation of being difficult due to the paperwork burden:

“Most of the health workers don’t want anything dealing with HIV. They think it is a burden. It increases their work load because there is also a lot of documentation, counseling and follow-up of clients, viral load, CD4, tuberculosis screening. It involves a lot of documentation so that is why they are afraid of the [HIV programs].”– 26-year-old male nursing officer, Mombasa

Respondents across groups also discussed facing pressure to meet PrEP program targets. Providers and peer educators in particular were concerned that targets might hinder their ability to provide quality services. Some peer educators discussed feeling discouraged when they failed to meet targets. A 45-year-old female peer educator from Mombasa said, “This target thing has destroyed everything.” Another, a 22-year-old male peer educator from Migori expressed, “We try our best to mobilize, but people take a long time to accept the initiative. The clinic does not appreciate our efforts.”

Program and county managers similarly described how pressure to meet targets influenced services. According to one 34-year-old program manager from a Nairobi-based CSO, while programs are striving to meet targets, they may miss gaps in services, such as recruitment of ineligible PrEP clients or eligible clients remaining uninitiated due to overstretched PrEP service providers. The manager suggested that more regular data review meetings with the entire PrEP team could be a solution: “Those quarterly reviews… that concept would have helped a lot to curb those small things that were happening.” For managers, program monitoring presented an opportunity to revisit progress and reiterate program goals, which they felt should not be limited to program leadership.

Program and facility financing.

Respondents across groups described key financial considerations faced by PrEP programs and health facilities. Program and county managers highlighted the unique financial hurdles related to new programs. For example, one respondent discussed how there were inefficiencies early in the program, because they were not accustomed to a sub-contract mechanism:

“It was something very new to us. We were not well oriented and you are told do ‘milestones.’ What is milestones?… We are not used to such kind of stuff. I think for me it’s basically there was no orientation… Then there was those back and forth, coz you would present something, you are told you haven’t done this, repeat, put this, come back again… It wasn’t efficient.”– 34-year-old male director, Nairobi-based CSO

Other financial constraints faced at the facility level included lack of vehicles, inadequate transport reimbursement or per diem during trainings, and lack of airtime for client follow-up. For example, many PrEP service providers described using their own mobile phone airtime to contact PrEP clients, but felt that paying for this was the responsibility of the facility.

Most respondents said that payment of PrEP program staff, particularly PrEP service providers and peer educators, was a critical issue influencing service delivery. Where increasing payment to staff was not feasible, some respondents suggested offering additional incentives, such as branded merchandise, may help staff feel more connected to the program and alleviate tensions related to finances. Peer educators themselves said they were passionate about their work and often willing to do it for minimal pay. However, they also expressed that increasing their payment would boost their morale and motivate them to do more for the program. In particular, peer educators felt that they would benefit from transportation vouchers or mobile phone airtime in addition to their monthly stipend, given the time spent accompanying clients to clinics or calling them to follow up:

“Peer educators are paid 3,500 Ksh per month. You are not given transport reimbursements. You are told you have ten peers [clients] and they should come every three months. You should at least be given a transport voucher worth 2,000 Ksh per month. Then you will have that morale.”– 39-year-old female PE, Mombasa

Respondents saw payment of program staff not only as an issue of morale, but linked it to client experiences as well. For example, one PrEP service provider from Mombasa explained how failure to sufficiently pay peer educators could change PrEP program impact:

“That’s why I have been saying that the peer educators are very important, because once they relay the information that ‘I won’t take him [client] back because I haven’t been paid,’ that’s it. I was also working with [organization] and that is the same story that happened there… Once a peer educator is not paid, they fail to mobilize and won’t come for screening. They would rather go to other facilities.”– 38-year-old male clinical officer, Mombasa

User financing.

Some respondents also discussed the role of financing at the client level. Although PrEP was provided for free, respondents were aware of opportunity costs related to PrEP, such as time spent accessing services or dealing with side effects. In particular, respondents noted specific opportunity costs for FSW clients:

“Some [FSW] are saying if they use the drug maybe in the evening and she was preparing to leave they sleep and forget… she sleeps and when she wakes up it’s already morning and she was to go to work so they complain saying the drug gives sleep [and makes her lose business].”– 26-year-old-female PE, Mombasa

Client bus fare to and from clinics was an important consideration raised by respondents across groups. Respondents explained that, to initiate PrEP or refill a prescription, clients sometimes had to visit the facility multiple times, which increased costs. A 24-year-old female peer educator from Migori said that “this discourages them, because maybe she has gone back home and she doesn’t want to come back because fare is a problem.” Another respondent, a 33-year-old female PrEP service provider from a Nairobi-based DICE, said that fare becomes an issue when following up with PrEP clients: “Sometimes you have to follow them up. They will tell you, ‘Today I don’t have fare. I will come tomorrow.’”

While most respondents agreed that user financing created challenges for uptake and continued use of PrEP, a few respondents discussed how fee-for-service models could sustain PrEP programs in the long term. For some respondents, such a model could have broader implications for how clients approach their own healthcare:

“If you want tea or mandazi, you pay, isn’t it? You fill your stomach. Why won’t you pay for Panadol (paracetamol) to deal with your headache? Something small? It should not always be free, free, free… We pay for things that we value. These free things we don’t [value]. Let’s shift our mind, small [fee], not so much, but something that will make me feel I have contributed to my health.”– 50-year-old female Program Manager, Nairobi-based CSO