Improving HIV Pre Exposure Prophylaxis (PrEP) uptake and initiation: process evaluation and recommendation development from a national PrEP programme

Abstract

AbstractBackgroundHIV pre-exposure prophylaxis (PrEP) is key to HIV transmission elimination but implementation is challenging and under-researched. We undertook a process evaluation of the first two years of a national PrEP programme to explore barriers and facilitators to implementation and to develop recommendations to improve implementation, focussing on PrEP uptake and initiation.MethodsStage 1 involved semi-structured telephone interviews and focus groups (09/2018-07/2019) with geographically and demographically diverse patients seeking/using/declining/stopping PrEP (n=39), sexual healthcare professionals (n= 54), community-based organisation service users (n=9) and staff (n=15) across Scotland. We used deductive thematic analysis, to derive and then map key barriers and facilitators to priority areas that experts agreed would enhance initiation and uptake. In Stage 2 we used analytic tools from implementation science to systematically generate evidence-based, theoretically-informed recommendations to enhance uptake and initiation of PrEP.ResultsBarriers and facilitators were multi-levelled and interdependent. Barriers included the rapid pace of implementation without additional resource, and a lack of familiarity with PrEP prescribing. Facilitators included opportunities for acquisition of practice-based knowledge and normalisation of initiation activities. We refined our 68 “long-list” recommendations to 41 using expert input and the APEASE criteria. Examples include: provision of PrEP in diverse settings to reach all in need; co-produced, culturally sensitive training resources for healthcare professionals, with focused content on non-daily dosing; meaningful collaborative working across all stakeholders.ConclusionsThese evidence-based, theory informed recommendations provide a robust framework for optimising PrEP uptake and initiation in diverse settings to ensure PrEP reaches all who may benefit.Summary for table of contentsZero new HIV infections could become a reality if HIV pre-exposure prophylaxis (PrEP) programmes are successfully implemented but the World Health Organisation recognizes that large scale roll out is challenging.We used implementation science research tools in novel ways to evaluate one of the world’s first national PrEP programmes, to develop evidence-based recommendations for use across a range of settings to improve PrEP uptake and initiation.Adopting these recommendations could enable governments and societies to better address HIV prevention goals.