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High demand for HIV pre-exposure prophylaxis (PrEP) services amongst key populations in Sierra Leone: early lessons from the country's first PrEP program

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BACKGROUND: HIV pre-exposure prophylaxis (PrEP), recommended since 2015 by WHO for high-risk groups, including key populations (KPs), has been unavailable in Sierra Leone (SL), a low-income country with limited data on KP population size and HIV prevalence. In 2021, the SL Ministry of Health and Sanitation (MoHS) and National AIDS Secretariat partnered with ICAP at Columbia University (ICAP) to launch the country's first PrEP program with support from the U.S. Health Resources and Services Administration (HRSA).
DESCRIPTION: Following stakeholder consultation, ICAP partnered with nine KP-led community-based organizations to design and implement PrEP services with a goal of initiating PrEP for 800 clients within six months. Eight KP-led drop-in centers (DICs) were supported to provide PrEP and linked to four public-sector health facilities (HFs) to manage clients testing positive for HIV. Guidelines, training materials, job aids, monitoring and evaluation (M&E) systems, and safety monitoring protocols were developed. PrEP medications were procured with HRSA support, DICs were refurbished, and 24 healthcare workers were trained. DIC staff provided information, eligibility screening, PrEP prescriptions, condoms, lubricants and other commodities, adherence support, and side effect monitoring. Peer educators generated demand for PrEP via their social and sexual networks. Blood samples were collected at DICs, and screening tests were performed at accredited laboratories. ICAP staff provided supportive supervision, mentorship, and M&E support.
LESSONS LEARNED: Between May and September 2021, 1450 KPs were assessed; 1308 (90.2%) initiated PrEP. 83.4% of the clients enrolled on PrEP were female, the median age was 23 years (range 14-71 years), 83% were sex workers, 10% injected drugs, and 7% were men who have sex with men. Of the 142 ineligible for PrEP, 111 were HIV-positive at screening, and all were linked to care. Suspected acute HIV infection (30) and abnormal creatinine (14) delayed PrEP initiation for others. No PrEP-related side effects were reported, and 5-month retention was 97.1% (1270/1308).
CONCLUSIONS: Demand creation and delivery of PrEP via KP-led DICs supported by public-sector HFs and an implementing partner facilitated rapid PrEP roll out to a high-risk population. Close monitoring as the program matures will be important as MoHS and its partners scale up PrEP in SL.