Surveillance data from public and private primary care facilities uncover implementation successes and gaps during pre-exposure prophylaxis scale-up: Results from the Jilinde project in Kenya

Background: Government and private sector facilities constitute the majority of health facilities in Kenya. Primary care units in these facilities have supported a vibrant HIV program and yield enormous potential to accelerate PrEP scale-up reaching diverse populations. PrEP is nascent in Kenya and lessons garnered through various implementation platforms are germane. This study employs a cascade approach to elucidate successes and gaps in PrEP delivery through primary care units in Kenya. Methods: The Jilinde project supports PrEP scale-up in ten Kenyan counties through 50 public and 12 private facilities. Routinely integrated PrEP is offered by trained providers who collect and aggregate service data using nationally approved tools, which is routinely analyzed to inform programmatic changes. We analyzed these data using a prevention cascade approach to unearth implementation gaps comparing trends in proportions of clients receiving services across the PrEP continuum: behavioral risk screening; clinical eligibility assessment; receipt of first PrEP prescription; and, receipt of refill prescriptions. Results: Between May 2017 and October 2019, 334,068 individuals tested HIV-negative, of which (93,429) 28% received behavioral risk screening. Among these, 16,673 (18%) were clinically assessed and deemed eligible. From the pool of eligible individuals, 11,087 (66%) initiated, consisting of 55% HIV-negative individuals in serodiscordant relationships, 25% high-risk general population individuals, 14% female sex workers, and 2% men who have sex with men. After a month, 3610 (34%) clients returned for a PrEP refill. Rates of attrition did not vary by population group or public vs. private facilities. The proportion of clients receiving month-one refills in private facilities progressively increased from 25% in 2017 to 36% in 2018, to 44% in 2019 unlike in public facilities. Overall, receiving a month-three refill, upon receiving a month-one refill, increased from 26% in 2017 to 52% in 2018 and 69% in 2019. Conclusions: Overall, 72%, 34%, and 62% of HIV-negative clients in primary care settings did not receive risk screening, first prescription, or one-month refill respectively, culminating in 322,981 individuals who might have benefited from PrEP that didn't receive it. Missed opportunities underscore the need for continuous surveillance to identify and respond to implementation challenges and opportunities to enhance PrEP's impact.