Early Lessons from Kenya’s Oral PrEP Rollout Planning

Over the past three years, Kenya has been home to multiple oral PrEP demonstration projects and has progressed in its planning process to introduce oral PrEP as part of the country’s HIV response. Dr. Michael Kiragu is Technical Advisor for HIV Prevention at LVCT Health and a Principal Investigator in the Introducing PrEP into Combination Prevention (IPCP) demonstration project in Kenya. In an interview earlier this year, Dr. Kiragu shared his insights on the planning for PrEP introduction in Kenya, lessons learned from that experience and the questions and challenges that lay ahead.

Contributed by Neeraja Bhavaraju and Daniela Uribe from FSG, a member of the OPTIONS Consortium.

What factors have supported or accelerated progress on PrEP?

In Kenya, when we look back over the last few years we see that we have had tremendous progress. Sometimes those of us who are in oral PrEP—who call ourselves advocates or researchers or service delivery people—sometimes feel that things are moving slowly, but when we look back over the last 3-4 years we see tremendous progress. We have had accelerated progress in Kenya and that is a result of many things but primarily we have had exceptional leadership by the ministry of health. We have a ministry of health that is really progressive but focuses on evidence when making decisions, and we are really grateful for that. We have had exceptional policies developed because of the evidence that is available around HIV prevention and oral PrEP. We have the Kenya Prevention Revolution Roadmap that was led by the Ministry of Health, through NACC and NASCOP. It was followed by the Kenya Strategic Framework and there is also the Kenya’s Fast-track Plan to end HIV and AIDS among Adolescents and Young People. All of these policies have given the impetus for PrEP delivery, so the Ministry of Health has given us exceptional direction.

The communities and the beneficiaries have also been key for moving PrEP forward in the agenda. We have had strong, powerful advocates who have focused on getting PrEP to the communities, getting the communities interested in oral PrEP, and getting researchers, providers and policy makers involved, talking and discussing as we move forward for oral PrEP.

But we are also beneficiaries of great research work. There has been research like the Partners demonstration project, the Partners PrEP trial, Partners Open Label Extension, and FEM-PrEP, which were all conducted in Kenya and that also has played really well in terms of introducing oral PrEP to Kenya.

What are the biggest challenges in the introduction of PrEP in Kenya?

For me I think the biggest challenge has been that there are many questions around a new product and how difficult it is to get everyone to be at the same level of understanding in terms of how we deliver it—that has been the biggest challenge. Also, getting communities to figure out what it is that we are doing without stigmatizing beneficiaries. Just getting everyone to have the same level of knowledge, the same level of understanding in terms of oral PrEP: what are the pros, what are the cons... that has been a big challenge.

What are the biggest questions that remain?

The delivery of oral PrEP still remains the main challenge. How do we do it for different populations within a health system that is constrained, that has challenges even before we introduce oral PrEP? The delivery mechanisms are still not clear for different populations. Oral PrEP can benefit many populations, many of whom are marginalized, who have no access to health services, so it’s a big challenge to figure out all the operational and implementation issues that are still lingering. But that is basically something that can be figured out as we go, as we continue implementing oral PrEP, we can learn what does and does not work, what settings and approaches work for what populations, so these are things we can learn as we continue to scale introduction of PrEP.

What are the biggest lessons you have learned?

Biggest lesson has been to focus on evidence. I think there has been a lot of evidence generated. The evidence is the truth; it gives us the confidence to act. There has been a lot of evidence generated from around the world about the effectiveness and the efficacy of oral PrEP and if you continuously put evidence as a primary consideration I think that it is really useful. That really helps in terms of really building a case for how we are going to implement oral PrEP.

Secondly, what is important is that everyone is engaged across the board. When we saw that as a guidance in the Prevention Revolution Roadmap, which says HIV prevention should be everyone’s business, when the consideration for oral PrEP started, you could see the Ministry of Health trying to rally everyone, from researchers to providers to communities, to get them to make the decision on whether this is something that we want to implement as a country. So in terms of moving the PrEP agenda forward, it is important that we make sure that no one is left behind in the decision making and make sure that everyone understands benefits and maybe the challenges of implementing oral PrEP.