HIV incidence rates remain higher than the level of epidemic control in many African countries. Despite the availability of cost-free, highly-effective HIV prevention interventions, such as pre-exposure prophylaxis (PrEP), individuals in need often face challenges accessing these interventions, particularly in public healthcare settings. Key barriers to PrEP access and continuation in public healthcare clinics include long travel distances to clinics, extended wait times, and fears of stigma associated with visiting HIV care centers. Additionally, clinics often suffer from understaffing and limited hours of operation, which can deter individuals from continuing their clinic-based PrEP regimen.
A recent study published in BMC Health Services Research by Dr. Katrina Ortblad and colleagues investigated the dynamics of PrEP delivery and client preferences. PrEP is a preventive treatment for individuals not living with HIV who are at risk of acquisition. It involves taking a daily pill that contains two antiretroviral medications, which can reduce the risk of HIV infection by up to 99% when taken consistently. The primary objective of this study was to evaluate whether allowing clients who initiated PrEP at public clinics to refill their prescriptions at nearby private pharmacies would decongest public clinics and improve PrEP continuation. By offering a potentially more convenient and less stigmatized alternative, the researchers aimed to determine if private pharmacies could play a significant role in enhancing PrEP continuation.
The study utilized a mixed methods approach with an explanatory sequential design, conducted from November 2020 to November 2021 in Kiambu County, Kenya. This research method first collects and analyses quantitative to identify trends, then collects and analyzes qualitative data to explain and provide context to those trends. Clients aged 18 and above who initiated PrEP at two public clinics were given the option to refill their prescriptions at the clinic where they initiated PrEP for free or at one of three nearby private pharmacies for a fee of 300 Kenyan Shillings (~$3 US Dollars). The pharmacy providers were trained in a model of PrEP service delivery that utilizes a prescribing checklist with remote clinician oversight. Clients were followed for seven months, with scheduled refill visits at one, four, and seven months. The primary outcomes measured were the selection of pharmacy-based PrEP refills and PrEP continuation rates. Additionally, the study conducted in-depth interviews with clients who refilled PrEP to understand their experiences and perceptions.
The study enrolled 106 participants, predominantly women with a median age of 31 years. Over the study period, only 39% of participants refilled PrEP, and a mere 3% did so at a participating pharmacy.
From the qualitative data, the researchers identified five primary reasons why most interviewees preferred clinic-based PrEP services: existing relationships, access to additional services, concerns about the quality of care at pharmacies, costs, and lack of awareness about the pharmacy option. Interviews revealed that clients valued the familiarity and perceived higher quality of clinic-based services. “You know, these [clinic-based providers] are people that I had already familiarized with. So, on coming to the hospital, they already know what I want,” one interviewee stated. Or another interviewee emphasized the importance of free service delivery at the public clinic. “In the chemist, I would have to pay for it [PrEP]. And [at] the hospital, it would be given for free. That, too, was a first priority [i.e., key consideration].” Moreover, despite initial interest, the actual selection of pharmacy refills was significantly low, highlighting a gap between anticipated and actual behavior.
The findings suggest that clients who overcome initial barriers to accessing PrEP at public clinics develop a preference for these settings, making the shift to pharmacy-based refills less appealing. This preference underscores the importance of continuity in healthcare provider relationships and the perceived quality of care. The study indicates that to potentially reach new populations that could benefit from PrEP, a stand-alone model for pharmacy-delivered PrEP services that enables PrEP initiations might be necessary, potentially coupled with robust awareness and trust-building initiatives. Dr. Ortblad emphasized "This research, in combination with other research from this team, suggests that the benefit of delivering PrEP at private pharmacies in Kenya might be to expand the reach of PrEP to new populations that could benefit versus decongesting public clinics. These findings motivate ongoing research this team is doing to develop and test different stand-alone models of pharmacy-delivered PrEP services in Kenya."
This study received support through the National Institute of Allergy and Infectious Disease. Additional funding was provided by the National Institute of Mental Health.
Fred Hutch/University of Washington/Seattle Children’s Cancer Consortium member Dr. Katrina Ortblad contributed to this study.
Ortblad, K. F., Kuo, A. P., Mogere, P., Roche, S. D., Kiptinness, C., Wairimu, N., Gakuo, S., Baeten, J. M., & Ngure, K. (2024). Low selection of HIV PrEP refills at private pharmacies among clients who initiated PrEP at public clinics: findings from a mixed-methods study in Kenya. BMC health services research, 24(1), 618.