CSIRO PUBLISHING

Sexual Health
https://doi.org/10.1071/SH18090

Pre-exposure prophylaxis rollout in a national public

sector program: the Kenyan case study

Sarah Masyuko A,L, Irene Mukui A, Olivia Njathi B, Maureen Kimani A, Patricia Oluoch C,
Joyce Wamicwe A, Jane Mutegi D, Susan Njogo A, Micah Anyona D, Phillip Muchiri B,
Lucy Maikweki E, Helgar Musyoki A, Prince BahatiF, Jordan KyongoG, Tom Marwa D,
Elizabeth IrunguH, Michael KiraguG, Urbanus KiokoI, Justus Ogando B, Dan Were D,
Kigen Bartilol A, Martin Sirengo A, Nelly MugoH, Jared M. BaetenJ and Peter CherutichK
on behalf of the PrEP technical working group

A
The National AIDS and STI Control Program, Ministry of Health, Afya Annex, Kenyatta National Hospital
Grounds, Nairobi, Kenya.
B
Clinton Health Access Initiative, Timau Plaza, 3rd Floor, Argwings Kodhek Road, Nairobi, Kenya.
C
Centers for Disease Control, KEMRI Complex, Mbagathi Road off Mbagathi Way, Nairobi, Kenya.
D
Jhpiego, Ring Road, 14 Riverside, Nairobi, Kenya.
E
Population Services International, Lenana Road, Jumuia Place, Wing B, 2nd Floor, Nairobi, Kenya.
F
International AIDS Vaccine Initiative, ABC Place, Building 2, 3rd Floor, Waiyaki Way, Nairobi, Kenya.
G
LVCT Health, Argwings Kodhek Road, Nairobi, Kenya.
H
Kenya Medical Research Institute, Centre for Clinical Research Laboratories, Nairobi, Kenya.
I
University of Nairobi, School of Economics, Nairobi, Kenya.
J
University of Washington, 510 San Juan Road, Seattle, WA 98195, USA.
K
Ministry of Health – Department of Preventive and Promotive Services, Cathedral Road, Nairobi, Kenya.
L
Corresponding author. Email: [email protected]

Abstract. Background: While advances have been made in HIV prevention and treatment, new HIV infections
continue to occur. The introduction of pre-exposure prophylaxis (PrEP) as an additional HIV prevention option for those
at high risk of HIV may change the landscape of the HIV epidemic, especially in sub-Saharan Africa, which bears the
greatest HIV burden. Methods: This paper details Kenya’s experience of PrEP rollout as a national public sector program.
The process of a national rollout of PrEP guidance, partnerships, challenges, lessons learnt and progress related to national
scale up of PrEP in Kenya, as of 2018, is described. National rollout of PrEP was strongly lead by the government, and
work was executed through a multidisciplinary, multi-organisation dedicated team. This required reviewing available
evidence, providing guidance to health providers, integration into existing logistic and health information systems, robust
communication and community engagement. Mapping of the response showed that subnational levels had existing
infrastructure but required targeted resources to catalyse PrEP provision. Rollout scenarios were developed and adopted,
with prioritisation of 19 counties focusing on high incidence area and high potential PrEP users to maximise impact and
minimise costs. Results: PrEP is now offered in over 900 facilities countrywide. There are currently over 14 000 PrEP
users 1 year after launching PrEP.Conclusions: Kenya becomes the first African country to rollout PrEP as a national
program, in the public sector. This case study will provide guidance for low- and middle-income countries planning the
rollout of PrEP in response to both generalised and concentrated epidemics.

Additional keywords: Africa, HIV, prevention.

Received 12 June 2018, accepted 29 September 2018, published online 9 November 2018

Introduction global epidemic by 2030.1 In Kenya, the Kenya AIDS

The Joint United Nations Programme on HIV/AIDS Strategic Framework (KASF) similarly aims at reducing
(UNAIDS) has called for a 75% reduction in new HIV HIV infections by 75% by 2020, and the Kenya HIV
infections by 2020 and a fast-track strategy to end the Prevention Revolution Roadmap defines a multipronged

Journal compilation Ó CSIRO 2018 www.publish.csiro.au/journals/sh

B Sexual Health S. Masyuko et al.

approach aimed at reducing new infections to zero by 2030, Establishment of coordination structures
including geographically and population-targeted combination National technical working group
prevention strategies, with focus on efficiencies, leveraging
Following inclusion of PrEP in the national ARV guidelines,
opportunities and advocacy.2,3 In 2015, there were 1.6 million
the Ministry of Health set up a PrEP Technical Working
Kenyans living with HIV, of whom 78 000 were newly infected.4
Group (TWG) in October 2016, chaired by NASCOP. The
The largest number of new infections occurred among young
TWG comprises representatives from development and
people aged 15–24 years and high-risk populations including
implementing partners, county governments, civil society and
sex workers, men having sex with men and injecting drug users;
persons living with HIV.11 The mandate of the TWG was to
new HIV infections are not evenly distributed within the country
provide strategic direction and oversight for the implementation
and have significant geographic differences, overall and within
of PrEP in Kenya in line with the health sector policies and the
subpopulations.
KASF. To deliver on this mandate, six thematic subcommittees
Pre-exposure prophylaxis (PrEP), in combination with
were formed: (1) Operations and Service Delivery; (2)
other HIV prevention and treatment interventions, is proven
Monitoring and Evaluation; (3) Commodity Security; (4)
to reduce new HIV infections by over 90%,5–8 with data
Communications and Advocacy; (5) Research and Impact
from Kenya contributing substantially to PrEP’s regulatory
Evaluation; and (6) Resource Mobilisation and Financing.
approval and normative guidance. Over the past two
This team developed a national scale-up plan with prioritised
decades, Kenya has successfully implemented highly
targets and operational mechanisms to guide implementation
effective HIV prevention interventions at scale, including
by all PrEP stakeholders. It was informed by lessons learnt from
immediate antiretroviral therapy to all who are HIV
the Partners PrEP Study clinical trial and demonstration
infected, voluntary medical male circumcision, prevention
projects including LVCT Health-led Introducing PrEP into
of mother-to-child transmission services and large-scale HIV
Combination Prevention (IPCP) and Partners Demonstration
testing programs. Mathematical modelling of Kenyan data
Project, confirming feasibility of delivering PrEP in non-
has provided evidence that combinations of highly effective
research settings.12–23 This culminated in the development
interventions, including PrEP, targeted to specific populations
and official launch of the Kenya PrEP Implementation
and geographical settings, could maximise effectiveness of
Framework and the national PrEP program in May 2017.11
the national prevention response.3,9 It is with this history in
The timeline is summarised in Figure 1.
mind that Kenya decided to make PrEP a part of its national
program, adding to the arsenal of combination HIV prevention
interventions. Here, we describe the process of the national Operations and service delivery subcommittee
PrEP rollout: guidance, partnerships, challenges, lessons Mandate. This subcommittee was mandated to operationalise
learnt and progress related to national scale up of PrEP in the PrEP guidelines. The priorities included defining service
Kenya, as of 2018. delivery approaches and models, outlining client management
criteria (identification, initiation of PrEP, follow up and
Methods monitoring) and developing a capacity-building plan for
Development of the policy framework service providers.
The Kenya HIV Prevention Revolution Roadmap, developed Action taken. To support harmonised implementation of
in 2013, set the direction for introduction of PrEP in Kenya PrEP at health facilities, the subcommittee developed a user-
by proposing high-impact, evidence-based HIV prevention, friendly toolkit for use by service providers (available at https://
including PrEP, targeted at county level, with a focus on www.nascop.or.ke/?page_id = 2744). This toolkit outlined the
prevention for different at-risk populations. By refocusing eligibility criteria for PrEP; the step-by-step procedures for risk
and prioritising key prevention interventions, including PrEP, assessment; PrEP initiation; follow up and monitoring; and
mathematical modelling conducted in support of the Roadmap quality improvement, as well as minimum requirements for
suggested Kenya could avert more the 1 million new infections a service point to provide PrEP. To reduce stigma, PrEP was
by 2030.3 recommended for all HIV-negative individuals at ongoing
In December 2015, the Kenya Pharmacy and Poisons substantial risk of HIV and was not limited to specific
Board (PPB), the national drug regulatory authority, approved populations. PrEP was offered as part of a combination and
tenofovir-disoproxil-fumarate combined with emtricitabine was then integrated into HIV testing, screening and treatment of
(TDF/FTC) for use in HIV prevention as oral PrEP. In 2016, sexually transmissible infections (STIs), prevention of mother-
the Kenya Ministry of Health, through the National AIDS and to-child transmission (PMTCT) and voluntary medical male
STI Control Program (NASCOP), led a participatory process circumcision services.
reviewing scientific evidence generated from clinical trials Kenya adapted both a community- and facility-based
and demonstration projects to inform development of national service delivery model for PrEP delivery. PrEP is initiated
guidelines on use of antiretroviral (ARV) drugs for HIV by a qualified and skilled healthcare provider and could be
treatment and prevention.10 That document, in addition to offered at HIV testing centres, antiretroviral treatment (ART)
recommending antiretroviral therapy at any CD4 count and clinics, outpatient or inpatient departments, drop-in centres
other updates to HIV testing and treatment, recommended (DICEs) for key populations, maternal and child health
offering PrEP as a TDF-containing daily pill to HIV-negative clinics, family planning clinics and youth-friendly centres,
individuals at substantial ongoing risk of HIV infection10 among others.10 At the community level, support groups,
(available at https://www.nascop.or.ke/?page_id = 2744). peer educators, community health volunteers, prevention
PrEP scale up in Kenya Sexual Health C

July 2016 November 2016 November 2016 - May 2017

April 2017
Launch of revised PrEP implementers PrEP TWG and National PrEP
ART guidelines meeting subcommittee working scale-up launch
group meetings

October 2016 November 2016 2016

Formation of PrEP Demo Projects Approval of
TWG by NASCOP Learning Workshop TDF generics

Fig. 1. Timeline for pre-exposure prophylaxis (PrEP) implementation in Kenya. ART, antiretroviral treatment; PrEP,
pre-exposure prophylaxis; TWG, technical working group; NASCOP, National AIDS & STI Control Programme; TDF,
tenofovir disoproxil fumarate.

centres, pharmacies and stand-alone DICEs play a vital role in The subcommittee was also tasked with development of the
demand creation and linkage with health facilities and other necessary components required to develop a PrEP cascade.
venues where PrEP is provided. Acton taken. PrEP M&E presented unique challenges, the
A national case-based training curriculum was developed, key of which was the ever-changing denominator, as PrEP use
relying heavily on existing materials used in demonstration and depends on period of risk, with individuals stopping and
delivery projects for PrEP (IPCP; Determined, Resilient, restarting PrEP dependent on risk. Use of electronic medical
Empowered, AIDS-free, Mentored and Safe (DREAMS); and record system or a mobile platform were proposed as one action
the Partners Scale-Up Project). To ensure a large pool of health to attempt to longitudinally track this denominator.
providers providing PrEP are trained, a cascade approach was A set of data collection tools were developed (see
adopted, where national and county level Trainer of Trainers Supplementary Material). These included: the Risk Assessment
(TOT) were trained, who, in turn, trained health workers and Screening Tool (RAST), a simple checklist that serves as a
peer educators. The training is interactive and case-based, with a screening tool at HIV testing and other primary service delivery
brief introductory presentation followed by facility-based case points to identify individuals potentially eligible for PrEP; a
discussions, case studies, role-plays and practical exercises. It clinical encounter form to document the clinical data for PrEP
consists of four units: (1) clinical case management of PrEP; initiation and follow up; longitudinal PrEP register that allows
(2) drug resistance testing for PrEP seroconverters (to support follow up of clients for a period of up to 4.5 years; a daily
national survey on PrEP); (3) commodity management; and activity register that helps with monthly aggregation of data;
(4) monitoring and evaluation of PrEP services. In addition, a and a monthly health facility reporting tool, which is uploaded
PrEP module was also incorporated in the existing training into the Ministry of Health District Health Information System
curricula related to HIV testing services, PMTCT, key (DHIS 2) platform.11 An M&E framework that outlines the
populations and ART delivery, to provide comprehensive targets and indicators for reporting was also developed.11
reach to HIV-related health workers in all settings and The key indicators selected for routine tracking include the:
delivery of a combination package. (1) number assessed for HIV risk; (2) number eligible for PrEP;
(3) number initiating PrEP; (4) number continuing PrEP; (5)
Monitoring and evaluation subcommittee number restarting PrEP; (6) number currently on PrEP; (7)
number who tested positive while on PrEP; (8) number
Mandate. The priority of this subcommittee was to
diagnosed with an STI; and (9) number who discontinued PrEP.
develop the monitoring and evaluation (M&E) plan for PrEP
rollout, which outlines the indicators (process, outcome and
effect), reporting requirements, data collection tools and
reporting mechanisms. Additionally, details of how PrEP Commodity security subcommittee
data could be analysed and utilised to provide feedback for Mandate. This subcommittee was tasked with defining the
policy, planning, quality improvement target setting and impact PrEP commodities supply chain that is aligned to the existing
evaluation at facility, county and national level was provided. national ARV commodities quantification, procurement and
D Sexual Health S. Masyuko et al.

distribution system; quantifying the national commodity need Action taken. The committee carried out a Strengths,
for PrEP; and negotiating for affordable generic formulations. Weaknesses, Opportunities and Threats (SWOT) analysis,
Action taken. PrEP delivery was integrated into the mapped stakeholders and the target audiences and assessed
existing and well-functioning system. their influence and perceptions of PrEP. This helped prioritise
Product negotiation. To encourage local registration of communication targets and the type of messages required.
generic products beyond the branded product Truvada, A communications plan was developed recommending
several consultations with manufacturers of TDF/FTC were rollout in three main phases. Phase 1 targeted the general
held where information regarding the PrEP demand forecast population, religious leaders, community leaders, political
was shared. As a result, Kenya is able to procure more leaders, policymakers, media and professional bodies.
affordable formulations. Phase 2 targeted healthcare workers, implementing partners,
Forecasting and quantification. As PrEP delivery was researchers and key population networks. Phase 3 would
new, determining quantities to be procured proved eventually target current and potential users. Kenya had
challenging. Despite this, NASCOP in collaboration with made a strategic decision in not making PrEP specific to any
stakeholders estimated the PrEP needs based on assumptions population to promote uptake to all and reduce stigma that may
on eligible populations and a 6-month use per client. These be associated with PrEP rollout to specific populations. The
were included in the annual national quantification exercise for immediate nationwide communication campaign was thus
HIV and AIDS commodities, and documented in the National targeted at allowing the general population to be aware of
Quantification Report for HIV management commodities PrEP, self-assess for risk and seek the service. Advocacy and
(2016–17 to 2019–20). Kenya Medical Supplies Authority engagement meetings were held with all county health
(KEMSA) was tasked with role of procurement, warehousing departments, HIV serodiscordant couples, youth, key
and distribution of all national procurements and to receive and populations, religious leaders and the private sector to
distribute all donations from multiple partners through the provide information on PrEP as well as receive feedback on
national system. developed key messages.
Procurement and distribution. NASCOP, through A PrEP communications brand going by the name ‘Jipende
KEMSA, distributes ARVs to over 3000 health facilities JiPrEP’ meaning ‘love yourself, PrEP yourself’ was developed
nationally using a hub-and-spoke system. Four hundred and to improve visibility, awareness and recall. This communications
sixty sites receive ARV medicines directly from KEMSA and, campaign was rolled out, targeting the general population
in turn, distribute to more than 2500 satellite health facilities. through community radio and digital platforms including
Facilities providing PrEP, if not already existing ART sites, YouTube, Facebook, Twitter and bloggers. These were a
were linked to existing ARV ordering sites. Existing ARV great avenue to provide messages and educate the public,
Logistics Management Information System recording and especially young people. Several tweets can be found at
reporting tools were revised to include ARVs for PrEP. https://twitter.com/nimejiprep?lang = en. Awareness tools targeting
Pharmaceutical staff and health providers were trained on various audiences were developed and disseminated, including
updated tools, resulting in monthly PrEP reports to the posters, frequently asked questions, radio and TV spots,
national level to track consumption and national and facility referral directory and visibility materials such as banners and
level stocks of ARVs for PrEP. t-shirts (Fig. 2).
Pre-exposure prophylaxis became available at the Media engagement was key. Over 30 journalists were
beginning of October 2016 through donations from DREAMS trained, resulting in extensive national and international
(a President’s Emergency Plan for AIDS Relief (PEPFAR) coverage of PrEP both before and after the launch of
supported project) and Jilinde (a Bill and Melinda Gates PrEP. Multiple print articles and news reports were carried
Foundation-funded project). Subsequent stocks were procured in local dailies, mentions and reports, with PrEP being covered
by the Ministry of Health through KEMSA. Other related by over 30 radio stations and three TV stations, timed to
commodities such as condoms, lubricants and HIV testing coincide with the national launch of PrEP in May 2017.
kits are accessed within existing mechanisms. Monthly Overall, more than 11 922 211 people were reached through
monitoring is conducted to keep track of consumption and radio and media advertising; 351 123 people were reached
stocks available to avoid running out of stock and advise through social media; nine education and communication
timing of procurement. packets of materials were developed; and more than 9256
female sex workers (FSW) and 10 000 men who have sex
with men (MSM) were estimated to have been reached with
Communication and advocacy subcommittee information within the first 4 months following the program
Mandate. This subcommittee was mandated to develop launch.
a communications and advocacy plan aimed at increasing
stakeholder awareness and knowledge of PrEP, and
promote it as part of combination prevention with a goal of Research and implementation science subcommittee
increasing acceptability and PrEP uptake. The committee Mandate. This subcommittee was tasked with providing
consisted of communication experts and individuals from evidence to inform PrEP scale up nationally. This subcommittee
implementing and development partners and the Ministry consisted of members from the Ministry of Health, donor
of Health (NASCOP and National AIDS Control Council community, researchers, implementing partners and academia
(NACC)). who worked in collaboration with the other PrEP TWG
PrEP scale up in Kenya Sexual Health E

Fig. 2. Sample messaging posters for pre-exposure prophylaxis (PrEP).

committees and target populations to: (1) conduct a situation indicators into national surveys; ecological studies; and
analysis of PrEP research, implementation and associated randomised controlled studies. The committee also proposed
challenges in Kenya; and (2) develop a research framework electronic routine PrEP data collection where possible and the
to continually inform PrEP implementation in Kenya. establishment of sentinel sites for the initial phase of data
Pre-exposure prophylaxis rollout in Kenya was implemented collection. To collect national level data on PrEP uptake,
in the context of global randomised clinical trials that provided PrEP assessment was included in the Kenya Population-
evidence on the efficacy of PrEP for HIV serodiscordant based HIV Impact Assessment (KENPHIA 2018). In
couples, MSM, persons who inject drugs (PWID) and addition, a national HIV drug resistance survey to test for
heterosexual individuals.5–8,24,25 The Partners Scale Up, resistance among seroconverters is ongoing. Costing and
LVCT Health-led IPCP and the Jilinde scale-up project were other impact modelling are also ongoing.
designed to continue generating evidence on PrEP uptake by
serodiscordant couples, MSM, FSW and young women to
inform the national program. Resource mobilisation and financing subcommittee
Action taken. At baseline, NASCOP spearheaded a Mandate. This subcommittee was tasked to estimate the
countrywide mapping of partners implementing PrEP cost of delivering PrEP and the resources needed to provide a
projects and studies and collected data from research ethics comprehensive package of PrEP services in addition to
committees countrywide, NACC, student theses and conference identifying innovative strategies of mobilising additional
presentations. Based on these data, the committee iteratively resources for scale up.
outlined and prioritised PrEP implementation science research Action taken. Using data from costing studies including
questions that were also aligned to the KASF and the Kenya the IPCP, the estimated resources needed over 5 years was
HIV and AIDS Research Agenda.2,26 High priority was given to ~300 million USD, with commodities contributing 85% of this
questions crucial for initial PrEP scale up and for which funding budget. The estimated cost of delivering PrEP per person
was available. These included questions on health providers per year is USD 300–600, depending on the geographical
PrEP knowledge, attitudes and practice; who to target; most location and population targeted for a target of 100 000.27
effective demand-creation approaches; acceptability by end This target was calculated using the national HIV incidence,
users and providers; appropriate packaging of PrEP the estimated population sizes for serodiscordant couples, key
according to end users; HIV risk characterisation among populations and estimated risk in the general population
users; appropriate dispensing models; description of uptake including adolescents. We then adjusted for a slow rise in
by different populations; description of coverage required to PrEP uptake per year. Future targeting will incorporate data
avert new infections per risk group; description of adherence on proportion of partners in serodiscordant relationships who
by those enrolled; patterns of use among those who take up are virally suppressed. Further data are being sought on the
PrEP; documentation of drug resistance among seroconverters; number of undiagnosed HIV-positive persons with negative
population effect of oral PrEP; and costing and feasibility partners and risk profiles in the general population to support
of integration of PrEP with existing service delivery models. target setting.
Medium- and low-priority questions were also identified. These Important funding gaps were identified, which formed the
were integrated into the PrEP research agenda that also basis of resource mobilisation through PEPFAR, Global Fund
defined the rationale, data sources, proposed methodologies, and other donors and plans. Kenya included PrEP as a priority
timelines and funding sources.11 Proposed approaches in the national and county budgets and plans. NASCOP made
included: mathematical modelling; costing studies; marketing applications to the Global Fund and negotiated inclusion of
surveys; routine data collection for pharmacovigilance and PrEP in the PEPFAR Country Operations Plan 2017, both of
cohort studies; operations research; embedding priority PrEP which were successful. In addition, continued advocacy
F Sexual Health S. Masyuko et al.

requests were made to increase government allocation at both and routine commodity quantification for ARVs and HIV
county and national level. test kits. Limited HIV funding at county level, availability of
laboratory testing of creatinine clearance and surveillance of
HIV drug resistance among seroconverters were common
Planning for implementation
challenges for all counties. The assessments provided a
Field situational analysis baseline to measure system performance and improvement
NASCOP, in collaboration with partners, conducted a following rollout of PrEP.
situational analysis to identify gaps and opportunities for To target PrEP delivery, the Optimizing Prevention
PrEP implementation across a five-factor value chain, which Technology Introduction on Schedule (OPTIONS)
included: planning and budgeting; supply chain management; consortium under the leadership of NASCOP conducted a
delivery platforms; individual uptake; and effective use and PrEP rollout scenario analysis with the goal of informing
monitoring. Mapping of PrEP implementing projects, partners, population and geographical targeting of PrEP (Fig. 3). Key
objectives, targets, funding sources, target populations, factors considered in these rollout scenarios included
geographical coverage, indicators and tools was conducted. determining which counties and populations in Kenya would
The mapping highlighted underserved regions and populations benefit most from PrEP; how these populations differed
for consideration in PrEP rollout. Given the subnational by county; what delivery approach (e.g. generalised for full
delivery of health services in 47 counties, a SWOT analysis population or targeted to key populations) was most appropriate
and readiness assessment conducted at national and subnational for each county; and what were the cost and impact implications
levels, identified the gaps, opportunities and areas needing of different scenarios for national PrEP rollout.
immediate action and investment for successful PrEP uptake. In brief, this analysis revealed a trade-off between impact
It revealed that while all counties have AIDS strategic plans in and cost (greater access would stem more new infections but
place, less than 40% had included PrEP as a HIV prevention would also cost more). A focus on key populations (i.e. MSM,
strategy. However, given the existence of a mature HIV care FSW and PWID) but also on serodiscordant couples and
and treatment program in Kenya, there was ready infrastructure adolescent girls and young women, and high incidence
at both facility and community level for the introduction of counties, would be the most cost-effective approach of scale
PrEP. This includes communication and community engagement up.11,28–30 These scenarios helped in producing PrEP targets
structures, presence of national reporting tools for commodities that considered the HIV incidence rate, serodiscordance

Fig. 3. Rollout scenarios considered for population and geographic targeting of oral pre-exposure prophylaxis (PrEP)
scale up in Kenya. SDC, serodiscordant couples; AGYW, adolescent girls and young women; DICEs, drop-in centres;
NGO, non-governmental organisation; HTC, HIV testing and counselling; ARV, antiretroviral; CCC, comprehensive care
clinic; PLHIV, people living with HIV.
PrEP scale up in Kenya Sexual Health G

rates and population size estimates of key populations, increasing awareness on PrEP. The World Health Organization,
serodiscordant couples and young people. PEPFAR and UNAIDS provided normative guidance to this
process, in addition to technical and financial support.
Challenges
Despite the successful scale up, the following operational Operational lessons learnt
challenges remained. First, measurement of adherence and Several important lessons have been learnt to date. First,
retention are a challenge. Structural issues such as long waiting strategic training of service providers focusing on Knowledge
time, frequent visits, stigma and gender-based violence affect Attitudes and Perceptions (KAP) on PrEP, efficient integration
HIV prevention services. Innovative, individualised and client- within existing processes and quality assurance were important
centred approaches may be required to address these challenges. to successful initial scale up of PrEP in Kenya. Second, demand
Second, the multiplicity of data reporting tools by implementers creation and social marketing strategies involving different
created delays in national harmonisation of data, costing target communities in the design, implementation and
assumptions and integration of PrEP key indicators into the championing of PrEP is key to myth and misconception
national health information system. Third, the lag in well- management. A PrEP brochure with frequently asked
developed M&E and surveillance mechanisms for HIV drug questions on PrEP was developed, key media personnel were
resistance and related complications was a missed opportunity trained and consistent social media management was
for integrated M&E and surveillance alongside the scale up. implemented. Third, partner testing and community-led-
Finally, the lack of domestic financing posed a key challenge based PrEP programs can be efficient in reaching those at
in sustainability of the PrEP program and hence resource high risk of HIV. Fourth, integration of PrEP into the routine
mobilisation across all 47 counties with different levels of ART commodity management system and PrEP indicators
incidence and epidemic required significant negotiations (biomedical, behavioural and structural determinants) into
and a differentiated approach. national information systems (such as KENPHIA) are key to
building a long-term and strategic public health approach
Role of partnerships to ARV-based prevention tools into the comprehensive HIV
Partnership was key in the success of PrEP rollout. The program. Fifth, a coordinated and nationally led PrEP program
government, through NASCOP, collaborated with partners, provides more synergy and national ownership. Focus should be
county governments, PrEP-funded projects, communities of on engaging the Ministry of Health right from the pilot projects
people living with HIV and potential PrEP users to ensure and in harmonising assumptions (e.g. costing and cost-
coordination and inclusion in planning. The government effectiveness), surveillance and M&E. Finally, M&E should
provided overall coordination, while partners provided be an integral part of planning with national program data on
technical and financial support as well as experience from retention to develop a PrEP cascade.
pre-existing projects. The active involvement and leadership
by county-level health management expedited integration of Progress, outcomes and effects
PrEP into routine service provision. The collaboration between Since the launch in May 2017, PrEP is offered in more than 900
implementers allowed harmonised implementation of facilities nationally, with an estimated 14 000 users on PrEP
guidelines, training and service provision. Key stakeholders (52% serodiscordant relations, 21% key populations, 9%
supported the launch of PrEP and the development of training adolescents and 17% general population) as of March 2018.
materials and operational materials to ensure delivery of PrEP It is offered in diverse settings, including HIV treatment sites,
was successful. Partnering with PrEP users and communities testing or prevention centres, STI clinics, drop-in centres for key
created strong advocacy and ownership that was key to populations and safe spaces for adolescents. To strengthen

Table 1. Summary of selected pre-exposure prophylaxis programs and delivery approaches in Kenya
PrEP, pre-exposure prophylaxis; ART, antiretroviral treatment

Population targeted Delivery model

Partners Scale Up Project HIV serodiscordant couples PrEP as a bridge to ART in HIV care centres.
Delivers PrEP in HIV clinics
Jilinde – Bridge to Scale Female sex workers (FSW), men who have sex with Scale up and research implementation
men (MSM) and adolescent girls and young project. Delivers PrEP in drop-in centres
women (AGYW)
Introducing PrEP into Combination Young women at high HIV risk, female sex workers Demonstration project
Prevention (IPCP) (FSWs) and men who have sex with men (MSM)
Determined, resilient, empowered, AIDS- Adolescent girls and young women aged 10–24 years Integrated model offering four broad
free mentored and safe (DREAMS) components targeted at empowering girls
and young women, strengthening families,
mobilising communities for change and
reduction of risk among sex partners.
Uniquely delivers PrEP in safe spaces
located in communities
H Sexual Health S. Masyuko et al.

human resource for PrEP delivery, over 60 Master trainers, 240 Antiretroviral preexposure prophylaxis for heterosexual HIV
county trainers and 3000 service providers have been trained transmission in Botswana. N Engl J Med 2012; 367(5): 423–34.
countrywide. Implementation research has been incorporated doi:10.1056/NEJMoa1110711
into routine programming to collect critical information that can 7 Baeten JM, Donnell D, Ndase P, Mugo NR, Campbell JD, Wangisi J,
inform programming. Table 1 summarises selected projects that Tappero JW, Bukusi EA, Cohen CR, Katabira E, Ronald A,
Tumwesigye E, Were E, Fife KH, Kiarie J, Farquhar C, John-
are delivering PrEP in public health facilities as per national
Stewart G, Kakia A, Odoyo J, Mucunguzi A, et al. Antiretroviral
guidelines, provide feedback to the national program and have prophylaxis for HIV prevention in heterosexual men and women.
been catalytic to PrEP delivery in Kenya. Further data on N Engl J Med 2012; 367(5): 399–410. doi:10.1056/NEJMoa1
outcomes and impact will be provided through the Kenya 108524
Population and Impact Assessment 2018–19. 8 Choopanya K, Martin M, Suntharasamai P, Sangkum U, Mock PA,
Leethochawalit M, Chiamwongpaet S, Kitisin P, Natrujirote P,
Conclusions Kittimunkong S, Chuachoowong R, Gvetadze RJ, McNicholl JM,
Paxton LA, Curlin ME, Hendrix CW, Vanichseni S. Antiretroviral
Rollout of PrEP in Kenya was catalysed by strong government prophylaxis for HIV infection in injecting drug users in Bangkok,
leadership; partnerships between government, partners, Thailand (the Bangkok Tenofovir Study): a randomised, double-
communities and potential PrEP users; granular knowledge blind, placebo-controlled phase 3 trial. Lancet 2013; 381(9883):
of the HIV epidemic and response; a robust social marketing 2083–90. doi:10.1016/S0140-6736(13)61127-7
and communication campaign; integration of PrEP into existing 9 Anderson SJ, Cherutich P, Kilonzo N, Cremin I, Fecht D, Kimanga D,
logistics and health information systems; incorporation of Harper M, Masha RL, Ngongo PB, Maina W, Dybul M, Hallett TB.
implementation research into the routine program; and Maximising the effect of combination HIV prevention through
resource mobilisation to sustain PrEP programming. While prioritisation of the people and places in greatest need: a
modelling study. Lancet 2014; 384(9939): 249–56. doi:10.1016/
PrEP was successfully launched in Kenya, substantial work
S0140-6736(14)61053-9
remains to sustain the gains made. From the challenges 10 Ministry of Health. Guidelines on use of antiretroviral drugs for
encountered and lessons learnt, the country is now focusing treating and preventing HIV infection in Kenya 2016. Nairobi,
on collecting evidence to improve program targeting, as well Kenya: National AIDS & STI Control Programme (NASCOP),
as innovative approaches to increase PrEP uptake, improve Ministry of Health; 2016.
adherence to PrEP and assess for the impact of introducing PrEP 11 National AIDS & STI Control Programme (NASCOP) - Ministry of
on the HIV epidemic. Health. Framework for the implementation of pre-exposure
prophylaxis of HIV in Kenya. Nairobi, Kenya: NASCOP; 2017.
Conflicts of interest 12 Ying R, Sharma M, Heffron R, Celum CL, Baeten JM, Katabira E,
Bulya N, Barnabas RV. Cost-effectiveness of pre-exposure
The authors declare that they have no conflicts of interest. prophylaxis targeted to high-risk serodiscordant couples as a
bridge to sustained ART use in Kampala, Uganda. J Int AIDS Soc
Acknowledgements 2015; 18(4, Suppl 3): 20013.
13 Ngure K, Heffron R, Curran K, Vusha S, Ngutu M, Mugo N, Celum
The authors thank all the PrEP technical working group members for their
C, Baeten JM. I knew I would be safer. Experiences of Kenyan HIV
contributions. The authors also acknowledge the technical and financial
serodiscordant couples soon after pre-exposure prophylaxis (PrEP)
support from the World Health Organization, PEPFAR, the Bill and
initiation. AIDS Patient Care STDS 2016; 30(2): 78–83. doi:10.1089/
Melinda Gates Foundation and The Global Fund who supported this
apc.2015.0259
national rollout.
14 Baeten JM, Heffron R, Kidoguchi L, Mugo NR, Katabira E, Bukusi
EA, Asiimwe S, Haberer JE, Morton J, Ngure K, Bulya N, Odoyo J,
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