Disparities In Hiv Pre Exposure Prophylaxis Implementation For Black And Latinx Adults Receiving Care In Public Health Clinics PDF Download

Daily, oral pre-exposure prophylaxis (PrEP) with emtricitabine/tenofovir disoproxil fumarate (FTC/TDF) is a highly potent HIV prevention intervention with potential to reduce HIV incidence among populations at risk of HIV in Africa if delivered with sufficient coverage. There are extensive data from high-income countries describing diverse settings in which PrEP services are offered. However, data describing PrEP scale-up models in low- and middle-income countries are limited. Public HIV care and treatment programs in Africa have been very successful at scaling up antiretroviral therapy (ART) over the last 15 years and are an attractive choice for integration of PrEP delivery. The main objective of the work described in this dissertation was to evaluate the effectiveness of PrEP implementation and integration in public HIV care clinics. The specific aims include to 1) conduct a step wedge cluster randomized trial of PrEP integration in public health HIV care clinics (the Partners Scale-Up Project) and evaluate impact; 2) conduct a process evaluation of PrEP integration in public HIV care clinics in Kenya, focusing on adaptation; 3) develop and evaluate the effectiveness of an on-site modular training approach to amplify the number of health care providers trained to deliver PrEP in public HIV care clinics in Kenya; and 4) summarize early PrEP rollout in African settings, challenges encountered and opportunities to expand implementation. We found evidence that integration of PrEP in public HIV clinics was feasible. By improving the capacity of health providers in those care clinics to offer PrEP services through training and technical support, PrEP uptake increased more than 20-fold and was sustained. With existing personnel and infrastructure, the high-volume HIV care clinics efficiently reached partners of HIV infected persons and other populations at HIV risk. PrEP users had reasonable continuation rates and objective evidence of high adherence. Using qualitative methods, we found that clinics made pragmatic, effective adaptations to non-core components of PrEP delivery services and to their routine practice to address challenges in PrEP delivery. We established that clinics that instituted some of the adaptations had above average monthly PrEP initiation and continuation rates. To amplify PrEP delivery in public health facilities, we developed and evaluated an innovative on-site modular training approach. We found that this approach was acceptable and it enabled many health providers to receive PrEP training conveniently and at a relatively low cost. Finally, our summary of early PrEP roll out in Africa revealed that there was high interest in PrEP among all populations at risk of acquiring HIV, but individuals did not continue use as expected. We suggested strategies to make PrEP delivery efficient, including delivery within community pharmacies, use of peers, services availed in low tier facilities and exploration of one-stop services to make PrEP delivery less burdensome. The collective results presented in this dissertation illustrate that integration of PrEP services in public HIV care clinics in Kenya is a successful and sustainable model for PrEP implementation. We posit that this model can be scaled up in African countries planning to set up PrEP programs.