Selecting strategies for implementation and comparing strategy prioritization methods for improving PrEP delivery in maternal and child health clinics in Kenya

In high HIV prevalence settings, women are at elevated risk for HIV during pregnancy and postpartum, and pre-exposure prophylaxis (PrEP) is recommended during this period. Integration of PrEP into maternal and child health (MCH) clinics requires implementation optimization. Furthermore, there is a lack of consensus about how to prioritize potential implementation strategies. The PrEP in Pregnancy, Accelerating Reach and Efficiency study (PrEPARE; NCT04712994) engaged stakeholders to identify determinants of PrEP implementation and identify and prioritize PrEP delivery implementation strategies at 55 facilities in Kenya through quantitative surveys and a stakeholder workshop. Strategies were prioritized using: 1) surveys with experienced practitioners reflecting on implementation experience (N=182); 2 & 3) ranking surveys before and after small group discussion with diverse stakeholders (N=44 & 40); 4) “go-zone” quadrant plots of perceived effectiveness vs feasibility. A stepwise elimination process was used to identify seven strategies for empirical testing. Facilitator debriefing reports from the workshop were used to qualitatively assess the decision-making process. We also compared the four strategy prioritization methods using Kendall’s correlation analysis. Additionally, the participants grouped strategies in three bundles with up to 4 strategies each by phone and online survey. Among 146 health care workers, the strongest reported barriers to PrEP delivery were: insufficient providers and inadequate training, insufficient space, and volume of patients. Sixteen strategies were assessed, 14 of which were included in the final analysis. Using rankings from 182 healthcare workers and 44 PrEP policymakers and implementers, seven strategies were eliminated based on low post-workshop ranking scores (bottom 50th percentile) or falling outside the go-zone (perceived low feasibility and low effectiveness) for at least 50% of the workshop groups. The top three strategies included 1) delivering PrEP within MCH clinics instead of pharmacies, 2) fast tracking PrEP clients to reduce waiting time, and 3) delivering PrEP-related health talks in waiting bays. All top seven ranked strategies were grouped into bundles for subsequent testing. Facilitator debriefing reports generally aligned with go-zone rankings but noted how stakeholders’ decision-making changed when considering the impact of strategies on facility staff and non-PrEP clients. The strategy ranking correlation was strongest between the pre- and post-small group rankings (Tau = 0.648; p<0.001). There was moderate correlation between go-zone plots and post-small group rankings (Tau = 0.363; p=0.079) and between past-experience surveys and post-small group rankings (Tau = 0.385; p=0.062). Strategy rankings remained similar between pre- and post-small group discussions; exceptions were in cases of feasibility concerns raised during discussions by experienced stakeholders. In both strategy bundle formats, participants primarily chose bundles of strategies in the order in which they appeared in the list, reflecting option ordering bias. Individuals who completed the phone survey with oversight from study staff were more likely to select the correct number of strategies per bundle. The most impactful barriers to integrated PrEP delivery in MCH clinics focused on insufficient staffing and space. Implementation strategies prioritized through multiple methods of stakeholder input focused on co-location of services and increasing clinic efficiency. Both experienced and inexperienced stakeholder participants’ strategy rankings tended to prioritize strategies that had been previously tested. Small group discussions focused on feasibility and effectiveness revealed moderately different priorities than individual rankings. The strategy bundling approach tested a less time- and resource-intensive method but was not effective. Future research should compare the relative agreement and pragmatism of methodologies to prioritize implementation strategies.