Over the two phases of data collection a total of 54 HCWs participated in IDIs, including nurses, nurse’s assistants, HTS counsellors, expert clients (long-term adherent ART clients), and mentor mothers (Table 2). No HCWs refused to participate. All HCWs had received PrEP training, either within the clinic via senior colleagues or at an MoH and CHAI led PrEP training initiative. We present our results within a modified CFIR framework consisting of six domains. All domains are supported by quotations available in Table 3. These are described as the domain (D) and the quotation number (Q, #).
1. Intervention characteristics
As HCWs were interviewed at both the beginning and the second stage of the PrEP implementation project, we saw how some perceptions relating to the project’s characteristics persisted, while others changed over the course of a year. Most HCWs at both interview points were happy with the prevention ‘tool’ PrEP, were motivated to provide PrEP, and felt that this was an additional method to add to their toolbox of HIV prevention strategies (D1, Q 1&2). Providing PrEP bolstered HCWs’ professional counselling skills (D1, Q3), but some aspects of the implementation guidelines prevented them from reaching the most vulnerable clients, such as young women <16 years old. By the second round of interviews, HCWs described a more pragmatic approach to providing PrEP, indicating that any HIV negative person should be offered PrEP.
While most HCWs were positive about the availability of PrEP, many at the first stage of interviews had concerns regarding a subsequent decline in condom use, a rise in pregnancies and STIs, and a fear of resistance forming in non-adherent clients. The implications of resistance on future prescribing possibilities for HIV positive patients, and resources at the clinic level, were a major concern. Although these concerns did not prevent HCWs from prescribing PrEP, HCWs were cognizant that more training, or information on perceived impact of PrEP on other health issues, would be useful for their understanding of the larger impact of PrEP on the health of their clients (D1, Q4 & 5).
In the second round of interviews, these concerns were absent from nearly all the HCW interviews. HCWs accepted PrEP with the perspective that, for example, STIs and teenage pregnancy were already exceptionally high, and that the introduction of PrEP would do little to increase this. HCWs remarked that condom use had always been suboptimal, and that PrEP would support those who were inconsistent condom users or those who never used condoms (D1, Q6).
2. Outer setting
Interviewees said PrEP provided a viable alternative for people who did not pursue existing HIV prevention methods and was particularly effective for women, to whom they often had little to offer in terms of protection that they themselves could manage. HCWs spoke about young women under the age of 16 that would benefit from PrEP but were not eligible due to age. HCWs described how many young women who presented at the clinic with an STI or as pregnant (mentioning girls as young as 13) were those at most need of PrEP, but were not eligible to take PrEP because of their age, and said this was another major barrier to their ability to help girls and adolescents. HCWs desired a different criterion for prescribing PrEP, such as using the body weight or risk of a client to define eligibility rather than age (D2, Q7).
3. Inner setting
HCWs explained that PrEP was not suitable for many of their clients as adherence to a daily oral regimen was difficult, and that pills were not popular among Swazis in general (D3, Q8).
HCWs felt that many clients would be discouraged from taking PrEP because, by virtue of queuing and having the risk assessment, they would be inadvertently conveying to other clients that their partner was HIV positive, or, that they were promiscuous. This extended to the PrEP pills themselves, which HCWs explained, were too similar to ARVs and would cause confusion among partners and family members of PrEP users who would be unlikely to believe PrEP was to prevent HIV rather than to manage it (D3, Q9).
HCWs highlighted structural constraints such as that PrEP was only available at certain locations, and that clinic opening times were not conducive to most working people. Specified blood collection days limited the ability for confirmatory HIV testing, baseline creatinine and Hepatitis B testing. HCWs recommended alternative collection points for PrEP including general hospitals and pharmacies, where blood could be drawn and samples stored. HCWs felt that initial counselling should be completed in the community or clinic, but that pharmacies offered a more practical and accessible point for refills (D3, Q10).
4. Individuals involved
Rather seeing themselves as core influencers, HCW workers spoke of two key groups who influenced the intervention considerably. These were the husbands or male partners of female PrEP clients, and community members who held influence within the clinics catchment area. HCWs described how women said they needed to discuss with and gain permission from their partners regarding their PrEP use, and therefore needed more time to consider. This often led to those eligible for PrEP not returning to the clinic (D4, Q11 & 12).
HCWs explained that obtaining support from community leaders would allow for community events and community sensitization to take place. Designing outreach that was popular with rural communities, such as events with food and targeted counselling, would allow for accurate information to be received, and for an increase in knowledge and awareness of PrEP (D4, Q13).
HCWs explained that community information directed at men would not only encourage men to test and initiate on PrEP, but was also another way of supporting women. By giving men information and counselling, it may encourage them to speak to someone about PrEP, and then allow PrEP within their homes, if not for them but for their partners (D4, Q14).
On the rare occasion that a HCW described deliberately influencing the process of PrEP implementation, it related mostly to intention to prescribe. HCWs said that there were occasions where they had not provided PrEP to an eligible patient, as a result of a client showing ‘significant mental illness’ which would prevent them from fully understanding how to use and adhere to PrEP. HCWs also explained that on days where clinic patient volume was beyond the capacity of the staff, HCWs would be deterred from providing PrEP (D4, Q15).
5. Implementation process
HCWs said that the initiation process was too long – for both the client and the HCWs – and that this prevented many clients from being initiated and other patients from receiving care quickly. The risk assessment form was described as taking 30-35 minutes which, along with the wait time to initially be seen, and then the wait between HIV testing and initiation – which varied between 30 minutes to three hours - was considered unsustainable. Clients were ‘lost’ at any point between the completing the risk assessment, receiving a negative HIV test and waiting to see a nurse-led antiretroviral therapy initiation (NARTIS) trained nurse to receive their PrEP (D5, Q16, 17 & 18).
HCWs spoke extensively about client knowledge levels and said the information they received in clinic was often insufficient for them to make a decision whether or not to initiate PrEP on the day PrEP was introduced and offered. This issue persisted throughout both rounds of data collection. As there was no extension of PrEP information to and within the community, those eligible for PrEP would not be reached because high risk clients do not always visit clinics (D5, Q19).
HCWs consistently explained that the provision of PrEP would be easier if more HCWs could provide PrEP, and complete all parts of the PrEP initiation process. If this was not possible, HCWs said they needed more, or at least one, NARTIS trained nurse that could focus exclusively on promoting and providing PrEP (D5, Q20).
HCWs said they needed a more systematic approach to monitoring and supporting PrEP clients. If there was a process in place which alerted the HCWs to the number of clients who should return for a PrEP refill on any given day, this would allow them to prepare and allocate staff. Clients could also be given an appointment time, which would prevent them from waiting in line with ‘sick’ people (D5, Q21).
6. The adapted intervention
HCWs described several amendments to the delivery of PrEP which they felt would increase uptake, improve retention and simplify the initiation process. HCWs said that they followed guidelines for PrEP delivery, but adapted certain elements to inform more people and better suit the clinic environment, and made special arrangements to support certain individual Clients. The majority of HCWs said that clinic-based PrEP education and promotion was insufficient and that community education would allow for clients to discuss and consult with their family, gain permission from their partners and from community leaders.
As many HCWs felt the information in clinics was not effective as it was considered ‘too much to take in’, HCWs said that they had begun community outreach via talks at community meetings, by providing community health workers with information leaflets to take to houses, and by wearing the PrEP t-shirts to and from work, so that people could read and ask questions at bus ranks and when travelling. These actions began approximately six months after the initial round of interviews. HCW said they would like to provide more community services, but that their work schedule did not allow for it (D6, Q22).
HCWs spoke extensively about trying to find ways to support women who felt they wanted and needed PrEP, but were prohibited by their husbands. At one clinic, a male HCW had developed a system of informing and gaining permission from partners whereby the potential PrEP client could invite the partner to the clinic, as well as sharing the PrEP information leaflet at home. However, as the information was delivered by the woman and not the male HCW, it had not been successful (D6, Q23).
Clinic-based modifications included conducting PrEP risk assessments alongside existing TB screening services – which is standard procedure upon entering the clinic - and targeting PrEP counselling for pregnant women and patients with STIs. HCWs described streamlining the PrEP initiation process by fast-tracking at risk clients for initiation and pill collection (D6, Q24).
HCW said they placed emphasis on PrEP being for ‘everyone’ to avoid unnecessary stigma. By the second round of interviews, this included giving the new self-risk assessment form to everyone, and morning talks which emphasised that in Eswatini, most people are at high risk of HIV infection (D6, Q25).