Improving HIV pre-exposure prophylaxis (PrEP) uptake and initiation: process evaluation and recommendation development from a national PrEP program†
Claudia S. Estcourt
A B * , Jennifer MacDonald A , John Saunders C D , Rak Nandwani B E , Ingrid Young F , Jamie Frankis A , Dan Clutterbuck G , Nicola Steedman H , Lisa McDaid I , Jenny Dalrymple A and Paul Flowers J
+ Author Affiliations
- Author Affiliations
A School of Health & Life Sciences, Glasgow Caledonian University, Cowcaddens Road, Glasgow G4 0BA, UK.
B Sandyford Sexual Health Services, NHS Greater Glasgow & Clyde, 6 Sandyford Place, Glasgow G3 7NB, UK.
C Institute for Global Health, University College London, Mortimer Market Centre, London WC1E 6JB, UK.
D HPA Health Protection Services, Public Health England, 61 Colindale Avenue, London NW9 5EQ, UK.
E College of Medical, Veterinary & Life Sciences, University of Glasgow, University Avenue, Glasgow G12 8QQ, UK.
F Centre for Biomedicine, Self & Society, Usher Institute, University of Edinburgh, Teviot Place, Edinburgh, EH8 9AG, UK.
G Chalmers Sexual Health Centre, NHS Lothian, 2A Chalmers Street, Edinburgh EH3 9ES, UK.
H Chief Medical Officer Directorate, Scottish Government, St Andrew’s House, Regent Road, Edinburgh, EH1 3DG, UK.
I Institute for Social Science Research, The University of Queensland, Brisbane, St Lucia, Qld 4072, Australia.
J School of Psychological Sciences & Health, University of Strathclyde, 16 Richmond Street, Glasgow G1 1XQ, UK.
Sexual Health 20(4) 282-295 https://doi.org/10.1071/SH22170
Submitted: 14 October 2022 Accepted: 19 April 2023 Published: 15 May 2023
© 2023 The Author(s) (or their employer(s)). Published by CSIRO Publishing. This is an open access article distributed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License (CC BY-NC-ND)
Abstract
Background: HIV pre-exposure prophylaxis (PrEP) is key to HIV transmission elimination but implementation is challenging and under-researched. We undertook a process evaluation of the first 2 years of a national PrEP program to explore barriers and facilitators to implementation and to develop recommendations to improve implementation, focusing on PrEP uptake and initiation.
Methods: Stage 1 involved semi-structured telephone interviews and focus groups (September 2018–July 2019) with geographically and demographically diverse patients seeking/using/declining/stopping PrEP (n = 39), sexual healthcare professionals (n = 54), community-based organisation service users (n = 9) and staff (n = 15) across Scotland. We used deductive thematic analysis, to derive and then map key barriers and facilitators to priority areas that experts agreed would enhance uptake and initiation. In Stage 2, we used analytic tools from implementation science to systematically generate evidence-based, theoretically-informed recommendations to enhance uptake and initiation of PrEP.
Results: Barriers and facilitators were multi-levelled and interdependent. Barriers included the rapid pace of implementation without additional resource, and a lack of familiarity with PrEP prescribing. Facilitators included opportunities for acquisition of practice-based knowledge and normalisation of initiation activities. We refined our 68 ‘long-list’ recommendations to 41 using expert input and the APEASE (Acceptability, Practicability, Effectiveness, Affordability, Side-effects, and Equity) criteria. Examples include: provision of PrEP in diverse settings to reach all in need; co-produced, culturally sensitive training resources for healthcare professionals, with focused content on non-daily dosing; meaningful collaborative working across all stakeholders.
Conclusions: These evidence-based, theory informed recommendations provide a robust framework for optimising PrEP uptake and initiation in diverse settings to ensure PrEP reaches all who may benefit.
Keywords: Behaviour Change Wheel, HIV prevention, HIV/AIDS, implementation study, pre-exposure prophylaxis, PrEP, process evaluation, recommendation-development.
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