In 2017, the Government of Kenya adopted a new policy called “A Framework for Pre-exposure Prophylaxis of IV in Kenya.” This framework directed the roll out of pre-exposure prophylaxis (PrEP) in Kenya, addressing the key focus areas of: availability, acceptability, accessibility of PrEP, and the holistic integration into the national HIV combination prevention strategy. To align with the government, Ciheb in Kenya’s PACT Endeleza program, which recently ended, also started offering PrEP that same year.
PrEP is a medicine that people at high risk of infection take as a daily pill to prevent HIV.
To date, 30 PACT Endeleza-supported health facilities in Nairobi County have provided PrEP and partnered with the Nairobi Metropolitan Service (NMS). For key populations, the program partnered with the University of Manitoba through their program called Partners for Health and Development in Africa, which worked through a sex workers’ outreach program called SWOP. Collaborating with NOCET, a civil society organization that works with people who inject drugs (PWID), also allowed PACT Endeleza to offer PrEP to PWIDs.
PACT Endeleza used a peer-led approach, whereby peer educators or leaders helped in terms of awareness and demand creation.
With key populations, those who initiated PrEP were organized into WhatsApp groups where they shared experiences and encouraged each other to continue adhering and using PrEP. In the general population, PACT Endeleza established clubs where PrEP users were profiled by gender and age and organized into WhatsApp groups.
Another key demographic was discordant couples. “If they’re assessed to be at substantial risk upon testing negative, then we initiate them on PrEP, and we group them into discordant groups where we can continuously follow through and continue to provide PrEP,” said Patrick Eshikumo, HIV prevention specialist for PACT Endeleza.
PACT Endeleza continuously assessed these people for risk to determine if PrEP was still applicable. If the risk decreased, the clinician suggested the client consider discontinuing PrEP with instructions to continue other prevention interventions. Clients could always return to restart PrEP if their situation changed.
Mobile outreach was organized for key populations where clinicians and clinical providers went to the community and provided all clinical services, including PrEP. “The other setup is through the drop-in centers, which are a clinical setup where all clinical services are provided,” Eshikumo said.
Eligibility screeners were stationed at entry points of the 30 supported facilities and used a rapid assessment screening tool. Clients who screened as at-risk were subsequently linked to providers for testing. Those who tested negative were given more information on PrEP, and, if they opted for PrEP, were referred to clinicians to initiate treatment.
The program increased uptake over time and interest among key populations, particularly among female sex workers and men who have sex with men. “We started the programming for transgenders this year, and the uptake for PrEP is good,” Eshikumo said.
Cumulative New Clients on PrEP by Population Type
Although there were steady improvements, results were slow at first. “Uptake was a challenge because the other interventions that we were providing for key populations, such as condoms, seemed to have worked,” Eshikumo said.
Continuation was a larger issue among key populations compared to the general population and the serodiscordant population. A majority of those dropping out or discontinuing were due to missing appointments, with staff unable to reach them via phone.
PrEP continuation by demographics from October 2020 to March 2021
The partnership with NMS has been a major milestone for PACT Endeleza for current and future interventions. Nairobi County through NMS will be able to continue the successes that have been achieved at the public health facilities. From the launch to pre-implementation training of healthcare workers, PACT Endeleza involved the county staff. In most of the public health facilities program, PACT Endeleza staff also worked with the county health staff.
“We believe after the transition, we are certain that the services we are providing, with PrEP in particular, will continue and clients will continue to benefit,” Eshikumo said.