Inner Setting (Pamoja CBO) and Intervention Characteristics: PrEP Integration into the DREAMS Initiative by Pamoja CBO
Pamoja staff members acknowledged that AGYW were disproportionately affected by new HIV infections and carried some of the highest risks for disease transmission. They saw the adoption and adaptation of the DREAMS program including PrEP as a key addition to their HIV prevention strategy.
During the initial DREAMS implementation in 2015, Pamoja CBO established safe spaces and engaged peer mentors, local health care providers and government officials. This multi-layered approach, including the involvement of the Ministry of Health was the foundation of the success of PrEP. Pamoja CBO staff and health care providers identified the safe spaces as an important facilitator for PrEP because of the perceived privacy and friendly environment for AGYW to express themselves without fear of discrimination, shame or stigmatization.
“I think that the safe spaces are a brilliant idea because the girls feel safe in the safe spaces. Like in the facility where they might meet some of their relatives from the village and they will shy off from taking their medication. I think that the safe spaces are a nice place for them.” (Pamoja CBO Staff)
As observed by health care providers and Pamoja CBO staff members, peer mentors were also essential to the success of PrEP implementation. They kept safe-spaces active, ensured continuous education, liaised with service providers to ensure beneficiaries received different services at the safe space. Mentors also ensured that AGYW honored their clinic appointments, traced defaulters and linked them back to services. We observed that without peer mentors, enrollment and retention of young women on PrEP would have been difficult.
“Mentors are the backbone of the DREAMS program. Without them, I think we would not be anywhere near where we are because they are the people who are on the ground and talk to the ladies, talk to the parents, talk to the healthcare community.. .Without them, there wouldn’t be people to help organize the safe spaces, where we meet.. .. They are the people who pass the messages to the girls, even those who are in school that cannot pick up their drugs. They are the people who tell them. . .reminds them of their TCAs.” (Healthcare Provider)
AGYW noted that continuous education given in the safe space as a part of the PrEP implementation strategy was beneficial. They remarked on how knowledge surrounding PrEP increased their confidence in remaining on the medication and continuously reinforced their reasoning for taking it. Participants were aware that PrEP was not a lifelong intervention, accepting that it was an effective temporary measure as they worked to reduce their overall HIV risk by engaging in the other DREAMS interventions.
“Yeah, one leaves because she has seen risks are no more or have reduced. This is because we were taught that PrEP isn’t something you take the whole of your life.” (FGD Participant)
Male sexual partner(s) and parental education was an essential step to the implementation strategy as it promoted persistence and retention to PrEP. Both the key informants and DREAMS beneficiaries highlighted the importance of educating partners and parents, emphasizing how this helped to facilitate disclosure and understanding.
“But, we faced this challenge and took initiative of educating the male sexual partners. Now, they also have information about PrEP. They have knowledge about PrEP, so it’s even easier to give information to their wives. If the wife say ‘I’m now using PrEP’ it because the husband already has the information.” (Pamoja CBO Staff)
Participants identified timely disclosure of PrEP use to family members as another facilitating factor for PrEP initiation and persistence. They agreed that disclosure to family members and partners was essential to ensure retention, clinic follow up appointments and adherence to medication.
“Disclosing is good.. .there is this time a parent bumped into me along the road and he asked me, ‘the drugs that you wrote for my daughter, PrEP, when is the next refill date because my child is already in school, I thought I would pick it for her and take to her. I was surprised because I didn’t know she had already disclosed…so apparently they are free with each other back at home and that made me happy.” (FGD Participant)
Outer Setting: The influences of the AGYW, community, health systems.
In addition to their awareness of HIV risk factors and knowledge about the purpose and benefits of PrEP, we found that AGYW decisions to enroll in PrEP were influenced by community, structural and individual related factors. For example, young women said personal experiences with peers and community members determined whether or not one would enroll and stay on PrEP. Participants also identified other cultural and socioeconomic factors (poverty and financial instability, polygamous marriages, multiple sexual partners) as major barriers.
“What do I say? For me the reason why I started using PrEP is that I am in a polygamous marriage and you cannot know how the other person is same to the man, so even if he decides to have as many women as he wants, I am safe.” (FGD Participant)
Inadequate financial support was identified as a driver for unsafe sexual practices and transactional sex by most AGYW. Specifically, financial insecurity was acknowledged by the AGYW as one of the reasons why they continue to seek out PrEP while using other DREAMS interventions to reduce their chances of becoming infected with HIV. Some AGYW commented on their peers using sex in exchange for commodities and services.
“But you know the main reason why women get into other relationships outside marriages lack of money. Also, if that’s a school going child, she will get into such relationships because she has needs that aren’t being met. She needs pads, pocket money and yet when she asks the mother, she is told that during her days she used to use blankets as a substitute for pads. So, when she finds one who can do all those things for her, she will definitely be influenced.” (FGD Participant)
Process: Prep Implementation And Program Evaluation
The Pamoja CBO staff recognized that community structures and linkages were critical and their approach to identifying and engaging key opinion leaders was essential to successful PrEP rollout.
“So, we go through chiefs, the administrators, the village elders, we call them for a meeting and tell them that we want to do um, a pilot. .. And then we talk to them and explain to them what it’s all about. Then, they link us to the community and then we also have a meeting with the larger community like a baraza and then we talk to them about the program and what it wants to deal with and we ask for their cooperation. Then after that, we get into the community.” (Pamoja CBO Staff)
The implementation of the biomedical services offered by Pamoja CBO (PrEP, HIV testing, contraceptives, post violence care) are done in collaboration with the Ministry of Health. Without the assistance of the Ministry of Health and continuous data tracking, the rollout would not have been as successful.
“We report every month to [a donor agency] and also to the Ministry of Health. Yeah, because they want to see the trend of PrEP and how it is going up or going down. But at the moment it is going up, which is a good thing. We still need more girls to embrace PrEP because in DREAMS, [PrEP is] our main objective is prevention.” (Pamoja CBO Staff)
Challenges To Prep Implementation
Despite the successful integration of PrEP into the DREAMS Initiative at Pamoja CBO, it has been faced with several challenges that span multiple constructs in the CFIR framework. Some of the biggest barriers that affect PrEP initiation and persistence were found in the constructs within intervention characteristics and the outer setting. These included perceived medication side effects, community stigma against PrEP, frequent relocation of AGYW, and limited human and financial resources to supports scale-up of PrEP distribution.
Known side effects of the medication remains a concern among the beneficiaries. Although most participants reported good persistence, some worried about the resulting side effects of the drug. Some complained about poor appetite, dizziness, nausea, vomiting, and stomachaches. These beliefs surrounding drug side effects contributed poor PrEP adherence and retention to PrEP.
“What I would say about challenges is the side effects- as one of the people who are on PrEP, the challenge that comes with it is the side effects-because after taking this drug, you may feel sickly in the morning hours and that would make a parent be concerned and want to know why that’s the case….” (FGD Participant)
Despite continued community engagement and education, stigma remains a barrier to successful PrEP implementation among AGYW. Most beneficiaries reported that the stigma against anti-retroviral therapy (ART) in the community is transferred onto PrEP in part due to similar pill appearance and packaging. Respondents also noted attitudes that PrEP use is associated with increased promiscuity, commercial sex workers, and people who are infected with HIV.
“Some of my peers say that I’m a prostitute though for me I know I’m not. I use PrEP so
that I prevent HIV infection while others say I pretend to be taking PrEP while I am on ARVs even so this didn’t worry me because I never used to ask anyone so no one knows my thoughts.” (FGD Participant)
Service providers observed that the frequency of AGYW relocation due to schooling or marriage was a barrier to PrEP persistence and engagement in the DREAMS program overall. AGYW who relocated were more vulnerable to losing consistent access to PrEP, leading to defaulting. Most beneficiaries vocalized the same thoughts and admitted that in some occasions, these relocations happened without Pamoja staff members or healthcare providers knowing.
“What I think that can make someone to stop using PrEP, is when a woman changes residence, especially in places where access to hospital and PrEP in particular may be a challenge, then I can stop it because returning here frequently will be difficult. It will force me to withdraw because in my new location there is no way out and here, I may not return faster to get PrEP”. (FGD Participant).
The insufficient number of healthcare providers qualified to offer PrEP continues to be a challenge in the current PrEP implementation strategy, making PrEP initiation and persistence more difficult. Barriers to providing PrEP to AGYW included low clinic staffing and lack of transport available to reach the safe spaces and community events.
“Staffing is an issue ‘cause at times you like want to you, but you are alone here [at clinic]. So, you are left with your hands tied. So, as much as you really want to go to that baraza or chief camp to maybe enlighten them on PrEP, you find yourself here at the facility. So maybe I can say staffing issue is a challenge” (Healthcare Provider)
Limited financial resources at health care facilities has also made the initial initiation and clinical monitoring of PrEP and its side effects difficult. This included either inability or delays in required laboratory tests, resulting in skipping the tests to avoid slow in PrEP initiation.
“There are times where funds are limited and to order pertinent lab tests such as liver
function tests and creatinine clearance. This is a detriment to the delivery of PrEP, because the inability to adequately screen for health problems or detect potential complications caused by PrEP may delay the initiation and continued administration of the drug to certain individuals.” (Healthcare Provider)