Expanding the delivery of HIV pre-exposure prophylaxis (PrEP) in Kenya

From the Ortblad Lab, Public Health Sciences Division

HIV pre-exposure prophylaxis (PrEP) is an effective and safe intervention for individuals with behaviors that are considered high risk for acquiring HIV infection. Despite the success of this preventative option, barriers to delivery among individuals who could benefit remain, especially in low and middle-income countries. The barriers to initiation and continued use of PrEP derive from issues of time availability and convenience as well as stigma associated with accessing HIV services. For example, client care is accompanied by long wait times at public clinics which are typically far from the client’s residence and simultaneously visited by many individuals seeking generalized care. Furthermore, “providers at public clinics are often overscheduled and prioritize delivery of curative over preventive health services,” commented Dr. Katrina Ortblad, an assistant professor in the Public Health Sciences Division at Fred Hutchinson Cancer Center. As an alternative to care offered at public health clinics, private pharmacies provide a location with trainable healthcare professionals capable of caring for clients with HIV-related needs. “Concerns remain, however, with the fidelity and quality of PrEP services delivered in this new setting,” added Dr. Katrina Ortblad. The Ortblad team and collaborators sought to provide support for this change in care by conducting a pilot study in Kenya to evaluate the performance of private pharmacies to counsel clients on PrEP, complete a medical safety assessment, conduct HIV testing, and dispense PrEP to clients in a confidential and respectful manner. The outcome of this pilot study confirmed that private pharmacies could in fact provide the necessary services which are needed to expand delivery of care and treatment for those with behaviors associated with risk of HIV acquisition. This work was recently published in the Journal of Acquired Immune Deficiency Syndromes.

Since a significant number of individuals living in low and middle-income countries seek health-related care at private pharmacies and often perceive care there to be discrete, private pharmacies may provide another PrEP delivery location that addresses key barriers to care. To evaluate care provided at these sites, a differentiated service delivery (DSD) model was created. The pharmacy providers were trained, and the pilot study was conducted at five private pharmacies in Kenya, Africa. One of the outcomes of this pilot was to evaluate the fidelity of pharmacy-delivered PrEP services which were assessed by client exit surveys and standardized client actor visits (i.e., mystery shoppers). High fidelity of care, or reproducibility of quality care, was observed across the different core components of the model: counseling, HIV testing, and PrEP dispensing, as detailed in the bar graph below. “Our findings demonstrate that with proper training Kenyan pharmacy providers are able to deliver PrEP services with high fidelity and quality,” shared Dr. Ortblad.

Survey findings on HIV/PrEP related care provided to clients visiting the five private pharmacies involved in the pilot study.
Survey findings on HIV/PrEP related care provided to clients visiting the five private pharmacies involved in the pilot study. Image provided by Dr. Ortblad

“The delivery of HIV PrEP at private pharmacies is an exciting new DSD that could help overcome barriers to PrEP access at public clinics (e.g., stigma, long travel times, overcrowding) and reach new populations who could benefit,” commented Dr. Ortblad. “In this study, we found that five Kenyan pharmacies delivered PrEP services with high fidelity and quality (as assessed by pharmacy PrEP clients and unannounced standardized client actors). These findings support task-shifting PrEP delivery to pharmacy providers and the scale-up of pharmacy-delivered PrEP services, with proper provider training, in Kenya and similar settings.” Despite having optimal outcomes from this pilot study, a few logistical aspects remain. While the public healthcare facilities are non-profit entities, “private pharmacies are for-profit businesses that historically have not delivered public services,” Dr. Ortblad shared. “Next, we want to understand the potential value-add of expanding PrEP services to private pharmacies over the current alternative (i.e., pharmacy referral to free services at public clinics). In an upcoming cluster-randomized controlled trial, we and collaborating researchers from the Kenya Medical Research Institute, Jomo Kenyatta University of Agriculture and Technology, and Jhpiego will test different models for sharing the cost of pharmacy-delivered PrEP services between clients, Ministry of Health (MOH), and implementors (which could include MOH).”

The spotlighted research was funded by the National Institute of Mental Health.

Fred Hutch/University of Washington/Seattle Children's Cancer Consortium member Katrina Ortblad contributed to this work.

Omollo V, Asewe M, Mogere P, Maina G, Kuo AP, Odoyo J, Oware K, Baeten JM, Kohler P, Owens T, Bukusi EA, Ngure K, Ortblad KF. 2023. The fidelity of a pharmacy-based oral HIV pre-exposure prophylaxis delivery model in Kenya. J Acquir Immune Defic Syndr. Online ahead of print.