BACKGROUND: Delivery of oral pre-exposure prophylaxis (PrEP) is being scaled up in Africa. However, health system barriers including lengthy visits endanger client continuation. We evaluated the efficiency and impact of direct-to-pharmacy PrEP refill visits with HIV self-testing (HIVST).

METHODS: Between September 2020 and January 2022, we conducted a quasi-experimental study of differentiated direct-to-pharmacy PrEP refill visits among adult men and women receiving PrEP at four public health HIV clinics in Central Kenya. Two clinics implemented the intervention which included direct-to-pharmacy for PrEP refill, HIVST while waiting and 3-monthly refill visits with pharmacist-led rapid risk assessment. Two clinics comparable in size and client volume served as controls with the usual standard of care (SOC), which typically includes monthly refills with multiple client room stops. We conducted 80 time and motion studies to determine client time in the clinics. PrEP continuation was evaluated by visit attendance and pharmacy refill records. We used logistic regression to assess the intervention effect on PrEP continuation and the Wilcoxon rank sum test to assess the impact on clinic time.

RESULTS: Overall, 746 clients were enrolled: 338 in SOC and 380 in intervention clinics; 57% were female, the median age was 33, and 58% were in serodifferent partnerships. Prior to implementation, intervention, and controls clinics were comparable on client characteristics (female: 51% vs 47%; median age: 33 vs 33 yrs) and PrEP continuation (35% vs 37% at 1 month, and 37% vs 39% at 3 months; P>0.05 for all). The intervention reduced total time spent at the clinic by 35%, the median time spent in SOC was 51 minutes while in intervention clinics was 33 minutes; p<0.001, However, time spent on HIV testing (20min vs 20 min; p=0.50) and pharmacy (8min vs 8 min; p=0.8) was unchanged. Similarly, PrEP continuation was significantly higher in the intervention clinics compared to control clinics: 45% vs 33% at 1 month and 34% vs 25% at 3 months; P<0.05 for all.
CONCLUSIONS: A client-centered PrEP delivery approach with direct-to-pharmacy PrEP refill visits plus client HIV self-testing reduced clinic visit time and significantly improved PrEP continuation in public health HIV clinics in Kenya.