Integrating PrEP into HIV services in Kenya proves a success

When staff from 25 public HIV clinics in Kenya were trained to provide PrEP it increased uptake 20-fold in two years – but are the right people being reached? 

What is the research about? 

Between 2017 and 2019, researchers worked with 25 busy public HIV clinics across the country to see how feasible it is for staff to provide PrEP alongside other HIV services.  

Nurses, clinical officers and HIV counsellors were trained on PrEP demand creation, risk assessment, prescribing, counselling and retention activities. They received technical support from the study but no extra staffing or resources. 

Why is this research important? 

Declines in HIV infections have been slower than expected over the last decade. So there is a need to focus more on HIV prevention, including PrEP.  

To increase access to PrEP for people who are most at risk of getting HIV, successful and sustainable ways to provide PrEP are needed.  

In many African countries, public HIV care clinics have been successful in scaling up antiretroviral treatment (ART). This means they are an attractive choice for PrEP delivery. But testing whether these clinics can successfully provide PrEP is crucial for understanding whether this option will work in reality. 

What did they find out? 

1. PrEP uptake increased more than 20-fold 

Just under 5,000 people started using PrEP during the study. Each clinic started an average of 7.5 people on PrEP each month, which was a 20-fold increase. 

Of those starting PrEP, 54% were women, the average age was 31, and 84% had a partner with HIV. 

People starting PrEP reported other HIV risk behaviours, including inconsistent or no condom use (58%), not knowing the HIV status of their partners (16%), and having sex with multiple partners (12%).  

2. Retention in care was mixed 

People who had a high risk of getting HIV due to multiple risk behaviours were more likely than others to still be taking PrEP after three months. But, overall, only 34% of people who had started PrEP were still using it after 6 months and 23% after 12 months.  

Among those who said why they stopped taking PrEP, over half said it was because they were less at risk of getting HIV (for example, because their partner was now virally suppressed). But 84% of people who stopped taking PrEP did not give a reason. It is possible many found it difficult to take PrEP every day but this is unknown. 

3. People on PrEP took it consistently  

Over the course of the study, 70% of participants self-reported good adherence to PrEP. This was backed up by random blood tests, which found PrEP drugs in 96% of samples. This is encouraging, as good adherence is needed for PrEP to work. 

4. Some people stopped then restarted PrEP  

About one in ten people who did not come for their arranged refill did return for a refill after that. This suggests that people continued to think about their HIV risk and resumed PrEP when they needed to.  

5. HIV infections were low 

During the study, six people became HIV positive. This represents a 90% reduction when compared with a predicted incidence rate for people whose partner has HIV but there is no access to PrEP or ART. 

What does this mean for HIV services? 

That public HIV clinics in Kenya can successfully provide PrEP – but to certain groups and with certain limitations. 

This evidence will be used to inform policy in other countries in East and Southern Africa that are considering national PrEP programmes. This means that access to PrEP may become more widespread in the region in the next few years.  

Most people using PrEP in this study were in a relationship with someone with HIV. Although this is an important group, it is young women who are the primary target group for PrEP in the region. Often, young women do not know whether their partner has HIV. 

The average age of people taking PrEP was 31. But evidence suggests HIV infections are highest among young women aged 15–24 and men aged 20–29.  

This means that providing PrEP in public HIV clinics did not reach people who face the greatest risk of getting HIV, who often do not see themselves as being at risk and so are not motivated to use HIV prevention services. 

People from communities that are marginalised and criminalised, such as gay people and sex workers, are also much more likely than others to get HIV. But these groups were not a focus of the study. 

If you are working with young women or men in their 20s, making them aware of their HIV risk and the existence of PrEP when it becomes more widely available will be important. Doing community outreach in places such as youth clubs, schools or universities could help increase demand. 

Given the stigma many at-risk groups experience, community-led sensitisation of healthcare providers in public HIV clinics will also be needed. Without it, young people and those from marginalised communities may not feel comfortable to ask for PrEP.  

If your country is involved in PrEP rollout plans, now is the time for advocacy to ensure the needs of people most at-risk of HIV are considered. This could include a push to provide PrEP in places such as family planning clinics and wider sexual health services, so that more at-risk people are reached.