"PrEP Gives the Woman the Control": Healthcare Worker Perspectives on Using pre-Exposure Prophylaxis (PrEP) During Pregnancy and Postpartum in Kenya.

Background: Pregnant and postpartum women in high HIV prevalent regions are at increased HIV risk. Oral pre-exposure prophylaxis (PrEP) can decrease HIV incidence reducing infant HIV infections. Understanding healthcare worker (HCW) beliefs about PrEP prior to national roll-out is critical to supporting PrEP scale-up. Methods: We conducted 45 semi-structured interviews among a range of HCW cadres with and without PrEP provision experience purposively recruited from four clinics in Kenya to compare their views on prescribing PrEP during pregnancy and postpartum. Interviews were analysed using a conventional content analysis approach to identify key influences on PrEP acceptability and feasibility. Results: All HCWs perceived PrEP as an acceptable and feasible HIV prevention strategy for pregnant and postpartum women. They believed PrEP meets women's needs as an on-demand, female-controlled prevention strategy that empowers women to take control of their HIV risk. HCWs highlighted their role in PrEP delivery success while acknowledging how their knowledge gaps, concerns and perceived PrEP implementation challenges may hinder optimal PrEP delivery. Conclusion: HCWs supported PrEP provision to pregnant and postpartum women. However, counseling tools to address risk perceptions in this population and strategies to reduce HCW knowledge gaps, concerns and perceived implementation barriers are required.

"Now that PrEP is reducing the risk of transmission of HIV, why then do you still insist that we use condoms?" the condom quandary among PrEP users and health care providers in Kenya.

Communication around condom use in the context of PrEP services presents a potential conundrum for patients and providers. Within the Partners Scale-Up Project, which supports integration of PrEP delivery in HIV care clinics, we interviewed 41 providers and 61 PrEP users and identified themes relating to condom messaging and use. Most providers counselled PrEP initiators to always use both PrEP and condoms, except when trying to conceive. However, others reported contexts and rationales for not emphasizing condom use. Providers reported that PrEP users were sometimes confused, even frustrated, with their insistence on using condoms in addition to PrEP. PrEP users generally regarded PrEP as a more feasible and desirable HIV prevention method than condoms, enabling increased sexual pleasure and conception, and reducing the conflict and stigma associated with condom use. Innovative approaches to condom counselling in PrEP programs are needed.

Integrating PrEP into HIV care clinics could improve partner testing services and reinforce mutual support among couples: provider views from a PrEP implementation project in Kenya.

INTRODUCTION: Partner notification services (PNS) increase the HIV status knowledge and linkage to care and treatment. However, it is unclear if PNS can facilitate linkage of HIV-negative partners to prevention services such as pre-exposure prophylaxis (PrEP). Using qualitative methods, we explored provider perspective regarding the interaction of PrEP availability, PNS and antiretroviral treatment (ART) outcomes within a project integrating PrEP services into HIV care clinics in eight counties in western and central Kenya. METHODS: From May 2017 to August 2018, data on integrated PrEP service delivery including its interaction with PNS were collected through 71 key informant in-depth interviews with healthcare providers and 24 standardized technical assistance reports summarizing implementation at the participating clinics. Thus, the perspective was from that of providers; analyses focused on emergent themes relating PNS to PrEP and ART services. RESULTS: Providers found that PrEP integration provided an additional concrete prevention option for HIV-negative partners and created a motivation to offer PNS to persons living with HIV. PrEP availability also seemed to operate as an incentive for those living with HIV to participate in PNS, which in turn enhanced identification of potential PrEP clients and created an environment for discussing HIV transmission risk. Providers commented that initiating HIV-negative partners on PrEP enhanced mutual monitoring of health outcomes, including improved adherence to ART by partners living with HIV. Clinics noted prioritizing people living with HIV with detectable viral loads for PNS in order to identify HIV-negative partners who would benefit most from PrEP. Providers felt motivated by the apparent synergistic interaction of PNS, PrEP and ART. CONCLUSIONS: Providers felt that the integration of PrEP into HIV care clinics stimulated the provision of PNS, and PNS was used to improve the identification of potential PrEP clients. The integrated combination of PNS, PrEP and ART is synergistic and should be promoted in HIV clinics.