Jhpiego, Nairobi, Kenya.
International Center for Reproductive Health, Mombasa, Kenya.
J Int AIDS Soc. 2020 Jun;23 Suppl 3(Suppl 3):e25537. doi: 10.1002/jia2.25537.
HIV prevention cascades have been systematically evaluated in high-income countries, but steps in the pre-exposure prophylaxis (PrEP) service delivery cascade have not been systematically quantified in sub-Saharan Africa. We analysed missed opportunities in the PrEP cascade in a large-scale project serving female sex workers (FSW), men who have sex with men (MSM) and adolescent girls and young women (AGYW) in Kenya.
Programmatic surveillance was conducted using routine programme data from 89 project-supported sites from February 2017 to December 2019, and complemented by qualitative data. Healthcare providers used nationally approved tools to document service statistics. The analyses examined proportions of people moving onto the next step in the PrEP continuum, and identified missed opportunities. Missed opportunities were defined as implementation gaps exemplified by the proportion of individuals who could have potentially accessed each step of the PrEP cascade and did not. We also assessed trends in the cascade indicators at monthly intervals. Qualitative data were collected through 28 focus group discussions with 241 FSW, MSM, AGYW and healthcare providers, and analysed thematically to identify reasons underpinning the missed opportunities.
During the study period, 299,798 individuals tested HIV negative (211,927 FSW, 47,533 MSM and 40,338 AGYW). Missed opportunities in screening for PrEP eligibility was 58% for FSW, 45% for MSM and 78% for AGYW. Of those screened, 28% FSW, 25% MSM and 65% AGYW were ineligible. Missed opportunities for PrEP initiation were lower among AGYW (8%) compared to FSW (72%) and MSM (75%). Continuation rates were low across all populations at Month-1 (ranging from 29% to 32%) and Month-3 (6% to 8%). Improvements in average annual Month-1 (from 26% to 41%) and Month-3 (from 4% to 15%) continuation rates were observed between 2017 and 2019. While initiation rates were better among younger FSW, MSM and AGYW (<30 years), the reverse was true for continuation.
The application of a PrEP cascade framework facilitated this large-scale oral PrEP programme to conduct granular programmatic analysis, detecting "leaks" in the cascade. These informed programme adjustments to mitigate identified gaps resulting in improvement of selected programmatic outcomes. PrEP programmes are encouraged to introduce the cascade analysis framework into new and existing programming to optimize HIV prevention outcomes.
HIV 预防阶梯已在高收入国家得到系统评估，但在撒哈拉以南非洲，暴露前预防（PrEP）服务提供阶梯的各个步骤尚未得到系统量化。我们分析了肯尼亚一个为女性性工作者（FSW）、男男性行为者（MSM）和青少年女孩和年轻女性（AGYW）提供服务的大型项目中 PrEP 阶梯中的错失机会。
使用 2017 年 2 月至 2019 年 12 月期间 89 个项目支持站点的常规项目监测数据，以及定性数据进行方案监测。医疗保健提供者使用国家批准的工具记录服务统计数据。分析检查了处于 PrEP 连续体下一个步骤的人数比例，并确定了错失机会。错失机会被定义为实施差距的例子，即可能有多少人有机会接触到 PrEP 阶梯的每一步，而实际上没有接触到。我们还按月间隔评估阶梯指标的趋势。通过与 241 名 FSW、MSM、AGYW 和医疗保健提供者进行的 28 次焦点小组讨论收集定性数据，并通过主题分析确定错失机会的根本原因。
在研究期间，有 299798 人 HIV 检测呈阴性（211927 名 FSW、47533 名 MSM 和 40338 名 AGYW）。FSW 筛查 PrEP 资格的错失机会为 58%，MSM 为 45%，AGYW 为 78%。在接受筛查的人群中，28%的 FSW、25%的 MSM 和 65%的 AGYW 不符合条件。与 FSW（72%）和 MSM（75%）相比，AGYW（8%）开始接受 PrEP 的机会较低。所有人群在第 1 个月（26%至 32%）和第 3 个月（6%至 8%）的继续率都较低。2017 年至 2019 年期间，第 1 个月（从 26%增加到 41%）和第 3 个月（从 4%增加到 15%）的平均年度继续率有所提高。虽然年轻的 FSW、MSM 和 AGYW（<30 岁）的起始率较高，但继续率却相反。
PrEP 阶梯框架的应用使这个大规模的口服 PrEP 项目能够进行细致的方案分析，发现阶梯中的“泄漏”。这些信息为方案调整提供了信息，以减轻发现的差距，从而改善选定的方案成果。鼓励 PrEP 方案将阶梯分析框架引入新的和现有的方案中，以优化 HIV 预防成果。
