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May 2022

A Quality Improvement Initiative to Integrate Oral PrEP and Family Planning Services in Nairobi County: Results and Lessons Learned

A client receiving PrEP services from a clinician at a health facility

In Kenya, Adolescent Girls and Young Women (AGYW) face increased HIV incidence and a high risk of unintended pregnancy. Statistics show that AGYW in Kenya (aged between 15–24 years) account for 30% of all new HIV infections, and 54% of sexually active AGYW (aged between 15–and 19 years) have an unmet need for contraception. (Adding it up: investing in contraception and maternal and newborn health for adolescents in Kenya, 2018. New York: Guttmacher Institute; February 2019. Kenya HIV Estimates Report 2018, National AIDS Control Council and National AIDS and STI Control Programme; 2018)

HIV prevention and Family Planning (FP) are critical in protecting the Sexual and Reproductive Health Rights (SRHR) of AGYW. Integration of these services can significantly improve access, uptake, and continuation.

LVCT Health, in collaboration with FHI 360 and the Nairobi Metropolitan Services (NMS) Directorate of Health Services, implemented the Collaboration for HIV Prevention Options to Control the Epidemic (CHOICE) project.

The 18-month USAID-funded project in partnership with PEPFAR sought to address technical gaps and support the national scale-up of antiretroviral-based HIV prevention products (collectively referred to as pre-exposure prophylaxis or PrEP) through catalytic evidence generation, translation, and research utilization.
During the implementation period, the project applied a collaborative Plan-Do-Study-Act (PDSA) Quality Improvement approach in three select government facilities within Nairobi County with high volumes of AGYW accessing contraceptives and PrEP. The facilities were Mukuru Health Centre (Embakasi East Sub-County), Lungalunga Health Centre (Makadara Sub-County), and Kangemi Health Centre (Westlands Sub-County).

Figure 1 shows the 4 stages of quality improvement approach towards the implementation of the project

Challenges Hindering Integration of Services
Integration of the services came with some challenges:

  1. COVID-19 delayed the project startup, limiting in-person planning meetings and workshops between project staff and collaborators
  2. A nationwide Health Care Workers’ strike delayed service provider training, coupled with reluctance by some providers to integrate PrEP-FP due to the high workload
  3. Providers had monetary compensation expectations, with some demanding additional monthly pay
  4. Some clients declined PrEP referrals because they wanted to discuss them with their partners and for fear of Intimate Partner Violence (IPV). In contrast, others accepted the referral but left the facility before seeing the next provider due to long queues or “getting lost”

Key Indicators that Demonstrated Integration
The project screened 4,014 (62%) of 6,624 FP clients for PrEP at the participating facilities throughout the implementation period. Of those screened, 179 were determined to be eligible for PrEP, and 77 (43%) of those eligible initiated on PrEP. The majority of those initiated on PrEP (41 out of 77) were aged 15–24 years. There was a wide variation in performance on key indicators observed across the three facilities. However, overall performance gradually improved as facilities reviewed their data and made adjustments. The project was not designed to assess PrEP continuation among those who did accept PrEP or their satisfaction with the integrated services received. (The project did not follow up on the clients who stopped taking PrEP, it also did not seek the satisfaction of the services the clients received.

Key Recommendations and Lessons learned
The routine engagement of FP/RH co-implementers and HIV stakeholders at the National, County, and Sub-County levels is critical to the progress and scale-up of PrEP-FP integration. They need to have roles in key activities, including QI workshops, training, and joint supervision of FP and HIV Testing Services (HTS). It is also critical that PrEP providers receive training on PrEP-FP integration to foster coordination in rolling out integration procedures.
Given staff attrition /transfers, there is a need to institutionalize provider training on PrEP-FP integration through pre-service training; and supplemented via On-The-Job (OJT) CME sessions. Additionally, there should be concerted efforts to have more than one provider at each Service Delivery Point (SDP) to provide integrated services to ensure integration continues when one provider leaves or transfers. Furthermore, it is crucial for FP, HTS, and PrEP providers to understand, very clearly and specifically, how and to what extent integration of the other service is expected and for those expectations to be reinforced by National, County, Sub- County, and Facility leadership through the following ways:

  • Use of Job aids and Standard Operating Procedures (SOPs) that are instrumental in setting these expectations and supporting the implementation).
  • Routine coaching, data reviews, and supervision will consequently reduce provider biases and ascertain that healthcare providers are appropriately administering the Routine Assessment Screening Tool (RAST). This will allow them to identify clients who may benefit from PrEP and ultimately provide the required counseling and referral services.

Authors
Nelius Ruiru, Program Officer and Naumy Mumo, Data Officer
Photo by: Rebecca Musanga, Communications and Knowledge Management Assistant

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