How did Kenya build Africa’s largest PrEP programme?

Around 25,000 people are taking pre-exposure prophylaxis (PrEP) in Kenya, making it Africa’s largest PrEP programme, ahead of South Africa (9000 people), Uganda (4000) and Zimbabwe (4000). The roll-out was recently described by officials from Kenya’s Ministry of Health in the journal Sexual Health and also at October's HIV Research for Prevention conference.

Overall 5.6% of Kenya’s approximately 50 million citizens are living with HIV, but HIV risk is not evenly distributed. A third of all new infections are in adolescent girls and young women, aged 15 to 24. Another third of new infections are in ‘key populations’ – sex workers, men who have sex with men and people who inject drugs.

With funding from the Global Fund, PEPFAR and other donors, the programme has been led by the country’s government and PrEP is being rolled out in the public sector. Government leadership and co-ordination has helped create synergies and a national approach.

In July 2016, revised antiretroviral therapy guidelines included a recommendation for oral PrEP to be offered to HIV-negative individuals at substantial ongoing risk of HIV infection. A working group then gathered evidence from demonstration projects (several of which were already underway in the country) and sought input from stakeholders, leading to the launch of an implementation framework in May 2017.

PrEP has been targeted to 19 of the country’s 47 counties. Counties with very high incidence were selected for a large-scale roll out of PrEP, in almost all health facilities. Counties with lower incidence but significant numbers of key populations have had a more targeted approach. 

While communications have presented PrEP as being appropriate for anybody, the implementation framework does target particular communities. The aim is for PrEP to be primarily accessed by female sex workers (39%), people in serodiscordant couples (34%), adolescents and young people (10%), people in the general population with multiple sexual partners or other risk situations (8%), men who have sex with men (8%) and people who inject drugs (1%).

Engagement so far has been most successful among serodiscordant couples and female sex workers, but recruitment of adolescents and young people has been very slow.

Communication and social marketing activities have helped deal with myths and misconceptions. The first phase of communications targeted the general population and influential figures such as religious leaders, politicians and the media. The second phase focused on the healthcare sector and key population networks, before a third phase that attempted to reach potential PrEP users. The slogan ‘Jipende JiPrEP’ (love yourself, PrEP yourself) was created and used in channels including community radio, YouTube and social media. Specific materials for female sex workers and gay and bisexual men have been created.

Integrating PrEP into existing processes and services has been key to its rapid scale-up. PrEP can be provided at a wide range of services, including HIV testing centres, drop-in centres for key populations and maternal health clinics. Over 900 different health facilities currently offer PrEP.

Similarly, PrEP modules have been added to existing training programmes on HIV testing and antiretroviral therapy for healthcare workers. Training is based on case studies, with role plays and practical exercises.

A supply chain for PrEP medications has been integrated into the existing system for antiretroviral treatment, which supplies over 3000 health clinics. Facilities that supply PrEP but not HIV treatment have been integrated into this system. For monitoring and evaluation, officials identified a series of key indicators (such as the number of people eligible for, starting and discontinuing PrEP) and developed a number of data collection tools to track them.

Dr Irene Mukui of the Ministry of Health said that challenges remain, including user discontinuation: only half of PrEP users are still in follow-up. Demand creation activities need to be sustained and re-invigorated so as to reach different sub-populations. The scale-up needs to be more thoroughly evaluated, with a focus on who is not accessing PrEP. Most of all, health officials need to better understand the perceptions, preferences and misconceptions of potential PrEP users and then develop strategies to address these.