Implementation strategy package improves PrEP implementation for pregnant women in antenatal care clinics in western Kenya


BACKGROUND: Pre-exposure prophylaxis (PrEP) is safe and effective during pregnancy and postpartum and recommended by the WHO and Kenyan Ministry of Health. Integration of PrEP into antenatal care is promising, but gaps exist in resource-limited settings.
METHODS: Between June-December 2021, we conducted a difference-in-differences study (3 months pre and post intervention; 4 intervention & 4 comparison facilities) in Western Kenya. We tested 3 implementation strategies ' video-based PrEP information, HIV self-testing, and dispensing PrEP in antenatal care rooms ' together to improve PrEP delivery. We compared absolute changes in: proportion of antenatal attendees screened for PrEP (PrEP penetration), proportion receiving all PrEP steps (HIV testing, risk screening, PrEP counseling) (PrEP fidelity), client PrEP knowledge, client satisfaction, and waiting time and service time (a priori outcomes);post hoc we compared the proportion offered PrEP and receiving HIV testing. We measured provider perceptions of acceptability and appropriateness.
RESULTS: Overall, 1,919 women were assessed for PrEP outcomes (960 in intervention and 958 in comparison) and 768 for service timings.
PrEP penetration (+5 percentage points; p=0.010), PrEP fidelity (+7 percentage points; p=0.073), and PrEP offer (+4 percentage points; p=0.004) changes were higher in intervention versus comparison facilities.
Client PrEP knowledge (+1.8/6 total points; p<0.001) and client satisfaction (+0.7/30 total points; p=0.003) changes were higher in intervention versus comparison facilities. Provider perceptions of implementation strategies was favorable (median acceptability: 20/20; median appropriateness: 19.5/20).
We observed no differences in service time (+0.9 minutes; p=0.328) or HIV testing (-5 percentage points, p=0.46), and a small increase in waiting time (+1.4 minutes; p=0.009).
However, absolute levels in the PrEP cascade remained suboptimal; no step besides HIV testing exceeded 33% coverage.

CONCLUSIONS: This implementation strategy package may be useful to integrate PrEP provision into antenatal clinics. It enhanced PrEP delivery across implementation outcomes and client satisfaction without meaningfully increasing wait time or decreasing provider-client time.

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