Expanding the reach of HIV pre-exposure prophylaxis (PrEP) among Kenyan adolescent girls and young women: The acceptability of HIV PrEP integration into post-abortal care services

Abstract

Adolescent girls and young women (AGYW) seeking post-abortal care (PAC) often remain at risk of subsequent unintended pregnancies and HIV acquisition due to ongoing infrequent condom use. Integrating HIV prevention services such as PrEP into PAC services has the potential to enhance reach, uptake, and efficiency, particularly in high-burden HIV and unintended pregnancy settings such as Kenya. However, there is limited data regarding the acceptability, feasibility, and sustainability of PAC clinics as an entry point for PrEP services.

A cross-sectional qualitative study, part of a cluster-randomized trial in 14 Kenyan public and private facilities, explored the integration of PrEP delivery for 15–30-year-old AGYW within PAC clinics. Through in-depth interviews, focus group discussions, and key informant interviews, the study explored perspectives from AGYW, providers, and implementing partners.

Guided by the theoretical framework of acceptability (TFA), findings revealed receptiveness to the integration, seen as a timely and effective intervention to expand the reach of PrEP services, reduce PrEP stigma, and enhance ease of access. Provider competence in delivering integrated PrEP services, their attitudes toward providing PrEP and PAC, and AGYWs’ confidence in using PrEP were identified as essential influencers of PrEP delivery and access in PAC clinics. Staffing, availability of safe spaces, commodity management, and reporting systems were highlighted as critical factors influencing the efficient integration of PrEP into PAC services.

The study highlights the acceptability of integrating PrEP services into PAC and its potential for scaling up while emphasizing the importance of further strategies to enhance operational efficiency.

Introduction

Adolescent girls and young women (AGYW) in many sub-Saharan Africa, including Kenya, bear a disproportionate burden of unintended pregnancies and HIV infections despite efforts to scale up HIV and pregnancy prevention methods (Celum et al., 2019; Heffron et al., 2021; Kabiru et al., 2016; Mandiwa et al., 2021; Mugwanya et al., 2019). In Kenya, AGYW aged 15–24 years account for over half (51%) of the new HIV infections, predominantly through heterosexual transmissions (Heffron et al., 2021). Additionally, they experience unintended pregnancies, often resulting in high rates of unsafe abortions due to restrictive abortion laws and social stigma (Kabiru et al., 2016; Mbehero et al., 2022; Mugwanya et al., 2019; Ushie et al., 2018). Insufficient negotiation skills for safe sex, low-risk perception, peer pressure, and limited access to prevention services further exacerbate their vulnerability (Casmir et al., 2021; Harrington et al., 2021; Mugwanya et al., 2019). AGYW accessing post-abortal care (PAC) are particularly at risk of continued unprotected sex, further increasing their vulnerability. These challenges hinder AGYW from realizing their full potential and goals (Heffron et al., 2021; Kabiru et al., 2016; Makenzius et al., 2018; Mugwanya et al., 2019). To curb new HIV infections, targeted interventions prioritizing HIV prevention strategies for AGYW are essential (Harrington et al., 2021; Heffron et al., 2021; Kabiru et al., 2016; Rasch et al., 2006). Integrating HIV prevention services, including pre-exposure prophylaxis (PrEP), into existing reproductive health services can enhance access and efficiency of service delivery, ultimately supporting AGYW in realizing their full potential and goals (Casmir et al., 2021; Harrington et al., 2021; Heffron et al., 2021; Kabiru et al., 2016; Mugwanya et al., 2019; Rasch et al., 2006).

PrEP, a user-controlled HIV prevention method, significantly reduces the risk of HIV with consistent daily use (Celum et al., 2019; Mugwanya et al., 2019; Ortblad, Mogere, Roche, et al., 2020). In Kenya, the national HIV prevention roadmap aims to achieve nearly zero new HIV infections by 2030, with PrEP identified as a key component (Mugwanya et al., 2019). Various differentiated service delivery models such as pharmacies, peer-to-peer initiatives, outpatient clinics, family planning clinics, and maternal and child health clinics aim to expand PrEP access for all HIV-at-risk populations (Celum et al., 2019; Mayer et al., 2018; Mugwanya et al., 2019, 2021; Ortblad, Mogere, Bukusi, et al., 2020; Ortblad, Mogere, Roche, et al., 2020; Ralph et al., 2021). However, access and use among AGYW receiving PAC, who are at high risk for HIV infection, remain limited (Heffron et al., 2021). Integrating HIV counseling into PAC offers an opportunity to empower AGYW with prevention strategies and normalize PrEP delivery as part of routine services, potentially reducing the HIV burden (Celum et al., 2019; Heffron et al., 2021; Irungu et al., 2021; Kabiru et al., 2016; Mandiwa et al., 2021; Mayer et al., 2018; Mugwanya et al., 2019; Ortblad, Mogere, Bukusi, et al., 2020; Ortblad, Mogere, Roche, et al., 2020; Ralph et al., 2021; Rasch et al., 2006).

In a formative study, we assessed the feasibility of integrating PrEP into PAC for AGYW. Findings underscored the potential of PAC services as an entry point for PrEP reflected in the high risk for HIV as well as PrEP initiation and referrals (Heffron et al., 2021; Ralph et al., 2021). However, limited data exist on the acceptability, feasibility, and sustainability of this integration. Recognizing the significance of behavioral studies in understanding user perceptions and organizational factors (Glasgow et al., 2012), this study, guided by the theoretical framework of acceptability (TFA) (Sekhon et al., 2017), aimed to assess the acceptability of integrating PrEP into Kenyan PAC. Insights from this study may inform policy decisions and scale-up efforts to reduce new HIV infections among AGYW.

Methods

Study design and participants

In a cluster-randomized trial conducted between June 2022 and March 2023 in Kenya, we piloted PrEP delivery among AGYW aged 15–30 years seeking PAC in 14 public and private facilities across Kiambu, Nairobi, Murang’a, and Kisumu Counties. Facilities were selected based on the number of AGYW served and location diversity (urban, peri-urban, and rural areas). Reproductive health providers received training on PrEP delivery for AGYW seeking PAC, and facilities were randomized to standard of care or enhanced adherence support activities (follow-up via phone calls and text messages).

A total of 400 eligible AGYW aged 15–30 years were enrolled at the study clinics with approximately equal proportions from the Thika/Nairobi and Kisumu regions. All AGYW provided written informed consent for study procedures including qualitative interviews, with those aged 15–17 doing so as emancipated minors. The study had a six-month follow-up period, with visits scheduled at enrollment, in months 1, 3, and 6. Follow-up visits occurred at PAC, family planning (FP), maternal child health (MCH), or HIV care clinics—where the AGYW were enrolled or accessed PrEP care. Research procedures included adherence monitoring using the point of care urine tenofovir tests, structured questionnaires, and qualitative interviews—with AGYW, sexual and reproductive health (SRH) providers, and implanting partner representatives.

Qualitative interviews procedures

Trained social scientists approached participants to determine their interest in qualitative interviews focusing on the acceptability of integrating PrEP into PAC. Interested participants were invited by the researchers either in person or by phone. A sub-set of AGYW who consented to participate in qualitative interviews at enrolment were purposively sampled—with approximately equal representation across age groups, geographical regions (urban, peri-urban, rural), and study arms (enhanced adherence and standard of care arm). Interviews began at the month 3 visit to allow time for experiencing added elements for enhanced adherence. Health providers and representatives from reproductive health implementing partners were also purposively sampled—across regions and facilities— and invited to participate. These participants underwent an informed consent process prior to any data collection.

Interviews were conducted between June 2022 and March 2023 using a semi-structured interview guide. They were conducted in the participants’ preferred language and location, audio-recorded, and transcribed verbatim. AGYW’s interviews explored experiences with PrEP counseling and delivery, including service quality, ease of access, motivation to initiate PrEP, provider attitude, and privacy. SRH providers and implementing partner representatives discussed service quality and efficiency, provider willingness to offer PrEP alongside PAC, perceptions about integration, intervention success, and scale-up.

To monitor progress, the study team held regular calls during the interview process to identify emerging themes and areas for further probing. Sample size was defined by reaching saturation and ensuring a representative sample (Urquhart, 2013). Transcripts were peer-reviewed for quality control, and data were securely stored physically and electronically.

Data analysis

Trained social scientists used both inductive and deductive approaches (Urquhart, 2013) to analyze qualitative data from in-depth interviews (IDIs), key informant interviews (KIIs), and focus group discussions (FGDs), guided by the theoretical framework of acceptability(TFA) (Sekhon et al., 2017). A codebook was developed to guide the coding process, incorporating both deductive approaches (based on the interview guide questions) and inductive (identifying relevant themes from the transcripts). Transcripts were uploaded to Dedoose (dedoose.com), an online data analysis software, for coding by independent researchers, with regular check-in calls to ensure code application agreement.

Fifteen IDIs, six KIIs, four provider FGDs and four AGYW FGDs were randomly selected for resolution of disagreements. Inter-coder agreement was achieved through regular calls after which coding continued with weekly check-ins. Themes explored motivation for PrEP uptake, experiences in service delivery, and acceptability factors such as service quality, satisfaction, access ease, provider attitude, privacy, and efficiency. Additionally, adherence to PrEP and facilitators and challenges of rolling out and sustainability in Kenyan health facilities were explored. Major findings were summarized using TFA’s adopted definitions (Table 1), to identify facilitators, challenges, and lessons learned for PrEP integration into PAC. Excerpts were used to further explain the findings.

Table 1:

Adopted definitions of TFA constructs in the context of the integrated HIV PrEP program study.

TFA construct	Definition
Affective attitude	Providers, implementing partners, and AGYW’s positive and negative feelings towards the integrated PrEP program.
Perceived effectiveness	The extent to which the integrated PrEP program is likely to achieve its purpose, i.e., expanding reach for PrEP among AGYW at risk or perceived protection of PrEP against HIV infection.
Self-efficacy	Perceived confidence among providers and AGYW to participate in the integrated PrEP program, i.e., PrEP services delivery and use.
Ethicality	The extent to which the integrated PrEP program fits within AGYW’s, providers’, and implementing partners’ norms and value system.
Burden	The perceived amount of effort (for example, ease or difficulty; side effects) required for the AGYW, providers, and implementing partners to participate in the integrated PrEP program.

Results

A total of sixty IDIs and six FGDs were conducted with AGYW, alongside six SRH provider FGDs, and eighteen KIIs with providers and implementing partner representatives.

The median age for participants was 21 years, for AGYW in FGDs, 23 years for AGYW in IDIs, 42 years for the KII participants, and 38 years for RH provider FGDs (Table 2). Most AGYW participants—35% in the FGDs and 65% in the IDIs—reported a monthly household income of less than Ksh. 10,000 (USD 83). In the KII sample, men and women participated in nearly equal numbers, while 83% of RH FGD participants were females.

Table 2:

Participants Demographics

Variable	AGYW FGDs (n=19)	AGYW IDIs (n=26)	KIIs (n=9)	Provider FGDs (n=18)
Age (in years), mean, SD	21 (5.9)	23 (3.4)	42 (5.05)	38 (7.7)
Gender
Female	-	-	4 (44)	15 (83)
Male	-	-	5 (56)	3 (17)
Relationship status (n, %)
Divorced	1 (5)	2 (8)	-	-
Married	7 (37)	7 (27)	-	-
In a relationship	4 (21)	11 (42)	-	-
Single	7 (37)	6 (23)	-	-
Living with (n, %)
Alone	7 (37)	4 (15)	-	-
Family	6 (32)	11 (42)	-	-
Not Known	0 (0)	0 (0)	-	-
Partner	6 (32)	11 (42)	-	-
Years in school, mean, SD	12(2)	13(3)	-	-
Have children (n, %)
Not Known	0 (0)	0 (0)	-	-
Yes	10 (53)	11 (42)	-	-
Employment (n, %)
Not Known	0 (0)	0 (0)	-	-
Yes	13 (68)	17 (65)	-	-
Income Group (n, %)
Less than10000 Ksh	10 (53)	17 (65)	-	-
Between 10000 and 15000 Ksh	3 (16)	1 (4)	-	-
More than 15000 Ksh	6 (32)	8 (31)	-	-

Overall, PrEP integration into PAC was acceptable by all participant groups, serving as a novel and timely intervention to optimize PrEP services alongside other HIV prevention services for AGYW. Using the TFA, findings on major themes across five TFA constructs are presented, highlighting experiences with PrEP integration into PAC services, as well as facilitators and barriers to sustaining PrEP delivery. Insights into areas for improvement to support sustained PrEP delivery, initiation, adherence, and continuation are also provided.

Affective attitude: Positive and negative feelings towards PrEP integration into PAC

Theme 1: Integrating PrEP services into PAC motivated AGYW to initiate and continue PrEP.

Most participants expressed that offering PrEP alongside other services accessed by AGYW, such as PAC and FP, minimized stigma, improved privacy, and facilitated PrEP initiation and continuation. This approach enhanced their confidence and comfort levels regarding PrEP initiations and refills. Most AGYW preferred integrated PrEP services provided by the same provider, as it enhanced privacy, reduced time spent in facilities, and minimized travel for separate services, ultimately increasing PrEP uptake.

“Going for both (FP and PrEP) saves time as opposed to going for them on different dates. They may think you are going for FP when you’ve gone for PrEP so they won’t know your exact reason for going to FP clinic.” (AGYW IDI 08, Kisumu [KSM])

Participants noted that providing counseling on unplanned pregnancy alongside PrEP services encouraged AGYW to recognize their HIV infection risk and encouraged their willingness to use PrEP.

“You are doing a good job, apart from preventing HIV, you are also preventing unwanted pregnancy. You give girls a chance to be girls and to build themselves.” (AGYW IDI 07, KSM).

Additionally, some participants highlighted that most private facilities already integrated service delivery models, offering services from a single consultation room, which effectively facilitated PrEP and PAC integration.

Theme 2: AGYW expressed satisfaction with the providers’ enthusiasm that they perceived and mobile the phone-based adherence support they received.

Most AGYW expressed satisfaction with the quality of services provided attributing to providers’ enthusiasm about PrEP. High-quality HIV and PrEP counseling services enabled AGYW to recognize their HIV infection risk and PrEP benefits, leading them to eagerly start and continue PrEP from PAC points.

“I like how they talk to people. They talk politely. They also give good pieces of advice without scolding, unlike other nurses, that is what I like. They are trained.” (AGYW 1DI 10, KSM)

AGYW highlighted that providers’ counseling and enthusiasm created excitement about PrEP, particularly those unfamiliar with it. This enthusiasm encouraged them to recommend PrEP access from PAC points to their peers.

“The moment you gave me a call yesterday, I shared with my friend and she asked me to tag her along and not leave her behind.” (AGYW IDI 20, KSM)

Participants from the intervention arm reported receiving mobile-based adherence support, where providers contacted them to inquire about their PrEP experience. During these phone calls, AGYW discussed challenges, side effects, and other health concerns, and were encouraged to attend clinic appointments and adhere to PrEP.

“When you are followed-up, you have morale for swallowing, but when given drugs with no follow-up on you, you stop. But when a person cares to call and ask how I am doing, “have you finished? how many drugs remaining? have you gone for your drugs? you are motivated” (AGYW IDI 02, Thika [TKA])

Theme 3: The stigma associated with reproductive health services, familiar providers/ people, and age differences influence PrEP acceptance, adherence, and continuation.

Although PAC, FP, and MCH clinics were the preferred points for PrEP services among AGYW, some expressed concerns about the stigma associated with visiting these clinics due to societal expectations about sex, FP use, and unintended pregnancies among young people.

“Let’s say that place is for abortion. So anytime she goes there (laughs) someone might think she has gone to abort. The doctor should tell her “if you are comfortable you can come or go to such a place to choose where she is comfortable.” (AGYW IDI 01, KSM)

To avoid stigma associated with seeking PAC services from familiar providers or people, most AGYW reported traveling long distances to facilities far from their residences. This could pause particularly in PrEP follow-up, as some AGYW may struggle to reach the facilities due to transportation costs.

“When I was at home, I didn’t want to go to any center so there is no way I would have got the drug because I was far.” (AGYW IDI 22, TKA)

To improve PrEP access, participants suggested having multiple facilities and care delivery offering integrated PrEP services. However, HIV care clinics were deemed highly stigmatized, making it a challenge to offer PrEP follow-ups from these clinics.

Going back to the ward is better but as she asked, “whom am I going to find?” Do you have someone there who is easy to relate with and who you will feel comfortable with and not fear? It will help me because I will seek help immediately from a specific person as opposed to going to queue at the CCC. I think that would encourage people to go for PrEP drugs because they know they are getting it from a specific person. (AGYW FGD 04, TKA)

Some AGYW expressed discomfort accessing PrEP services from delivery points with older providers and clients, leading to a delayed acceptance of services or follow-up appointments, thereby increasing their risk of HIV infection. To address this, offering PrEP services in all care delivery points with young providers was recommended.

Perceived effectiveness: Perceptions of the likelihood that PrEP integration into PAC would achieve its purpose.

Theme 1: Integrating PrEP into PAC was perceived as an effective and timely intervention that expanded access to PrEP services for AGYW who could benefit the most, thus promoting initiation, adherence, and continuation of PrEP overall.

Most participants expressed excitement about integrating PrEP services into PAC, seeing it as a step towards making HIV prevention services more accessible to AGYW who could benefit the most. They noted the providers’ enthusiasm and warm approach which helped establish rapport and made them feel comfortable with PrEP counseling and initiation. This client-centered approach, coupled with providers’ willingness to offer friendly services, encouraged AGYW to initiate PrEP, especially those who perceived themselves at risk due to engaging in condomless sex with partners of unknown HIV status or those reluctant to test for HIV.

“I thought PrEP can assist me because I am still single and being single means, I may interact with more than two people so it’s good for my situation.” (AGYW IDI 26, TKA)

Moreover, integrating PrEP in PAC was seen as an opportunity to empower AGYW with knowledge about HIV prevention methods, enabling them to make informed decisions and share information with their peers.

“I am encouraged that I have shared PrEP information that will help them at some point in future. I know that one day they’ll tell me that, “by the way I want to start what you told me (PrEP)” (Provider FGD 01, TKA)

However, some participants felt that focusing on providing PrEP to AGYW who accessed PAC service left out eligible and willing AGYW seeking healthcare elsewhere.

“That arrangement is not bad, I learnt about PrEP and started using it. They should expand it since not all girls and women go there (PAC clinics), for example the maternity ward since women want it but lack the confidence going to hospital to ask for PrEP”. (AGYW IDI 02, KSM)

To address this, participants suggested integrating PrEP services into all care delivery points accessed by the AGYW, allowing for one-stop services and informed decision-making.

“What if PrEP is available in all departments and wards even surgical department? If made available in all departments, it will be easy for people with fears.” (AGYW IDI 04, TKA)

Self-efficacy: Perceived confidence to deliver and use PrEP services.

Theme 1: Provider training on PrEP integration into PAC and availability of PrEP supplies at PAC points enhanced PrEP services delivery and PrEP uptake opportunities among AGYW.

Most providers found the training on PrEP counseling, delivery, and adherence along with HIV testing and counseling, to significantly enhance their competence and confidence in providing quality services. Ongoing technical support and continuous medical education further enhanced their confidence as PrEP providers, especially given their initial lack of experience in PrEP provision. AGYW expressed satisfaction with PAC points for PrEP services, citing the impressive quality of services received including comprehensive reproductive health and PrEP counseling, privacy and accessibility, and provider positive attitude.

“I appreciate the training; the knowledge helps us to deliver more information and services to our clients as compared to before we knew about PrEP and how we could help them protect themselves, so it is good.” (Provider FGD 03, TKA)

Participants noted that facility-specific strategies and consistent distribution operations ensured a steady supply of PrEP commodities, including medication, HIV test kits, and registers, at the PAC points. This approach facilitated prompt offering of PrEP services provision, eliminating the need to refer AGYW to other service points and increasing PrEP uptake opportunities.

Theme 2: Existing differentiated reporting systems and facility operation, especially in public facilities, influenced the efficient integration of PrEP into PAC.

Most providers perceived documentation and reporting processes as demanding, adding to their workload within the existing system. PAC providers in public facilities received PrEP supplies from other departments, such as HIV care clinics, family planning, or MCH, leading to additional reporting responsibilities. This included maintaining records of PrEP supplies, preparing monthly reports, and updating PrEP registers during initiation and follow-ups, which also included documenting supplies acquired at the PAC clinic. Consequently, some providers expressed hesitancy to offer integrated PrEP services in the early stages of integration into PAC.

“We have a lot of workload. At a facility you will find a provider manning three or two clinics which challenges providing quality service.” (AGYW IDI 04, TKA)

To address these challenges, almost all providers suggested adopting a consolidated electronic medical reports (EMR) system to enhance reporting systems and reduce workload and reporting gaps resulting from differentiated reporting, especially in public facilities.

“We have a gap in the EMR. We need to invest in systems and ensure patients are being seen using an EMR. Probably that might make documentation and reporting easier.” (KII 01, TKA)

Some facilities prescribed and dispensed PrEP at different care points, leading to reluctancy towards referrals for PrEP follow-up to unfamiliar providers, which could lead to the loss of PrEP clients due to stigma. Missed PrEP client opportunities were also reported attributed to clinic operational factors, such as late-day or weekend client discharge and weekend clinic closures. Additionally, some providers were hesitant to offer integrated PrEP services without incentives, particularly in facilities previously collaborating with NGOs offering provider incentives.

Theme 3: Discomfort and trauma associated with PAC experiences may impede PrEP initiation and continuation from PAC clinics.

A few AGYW expressed discomfort being offered HIV testing, PrEP counseling, and medication, finding it overwhelming as they were still recovering from the traumatic, painful, and stressful experience of pregnancy loss. The trauma and pain associated with pregnancy loss, made it traumatizing for AGYW to return for PrEP refills at PAC points. To avoid experiencing these traumatic memories, some AGYW were unwilling to access PrEP services from PAC clinics.

“I didn’t feel like being asked questions and I was just angry being talked to especially when I knew that they wanted to test me (HIV testing) since I was still in pain.” (AGYW IDI 02, TKA)

Ethicality: The extent to which integrating PrEP into PAC fits within participants’ values

Theme 1: PrEP-associated misconceptions and stigma, and availability of safe spaces influenced interest in PrEP delivery, initiation, and continuation.

Some providers felt that offering PrEP services to AGYW may encourage risky and carefree sexual behaviors, influencing their willingness to provide PrEP services. This perception resulted from personal, religious, and community norms and values.

“Staff attitude affects delivery because some staff feel like it is not right to give PrEP to young girls. Some feel like giving PrEP is like telling her to continue.” (KII, 02)

Additionally, a few AGYW expressed concern that providers’ negative attitude towards offering PrEP and imposing their values on them could affect the PrEP counseling and delivery process, impacting their readiness to initiate PrEP. Participants recommended addressing these issues by providing community PrEP awareness, attitude transformation, and involving stakeholders in integration efficiency.

Stigma was a significant concern among AGYW, particularly regarding privacy at PAC points. Some AGYW felt uncomfortable being approached by providers for PrEP services in public facilities, fearing stigmatization due to assumptions about their sexual behaviors.

“It was difficult, everybody in the ward looks at you like, this one has been tested and has been found to have, so they need to make it more secretive.” (AGYW IDI 13, TKA)

Additionally, the lack of private spaces at the hospitals led to inadvertent disclosure of PrEP use further discouraging PrEP use, continuation, and adherence.

“When I was given PrEP, I hid them, I went and put them inside the bag, and they stayed there and I never removed them until the day I was discharged. I started swallowing it when I was at home. Just like that because I did not want to be seen by people.” (AGYW IDI 02, TKA)

To address these challenges, participants suggested improving facility structures by designing private consultation rooms at different PrEP delivery points to mitigate stigma among AGYW. Further, to promote PrEP awareness and uptake, participants recommended continuous PrEP counseling within facilities and community, utilizing youth-friendly IEC materials, and youth champion/peer mentor groups.

Burden: Ease or difficulty participating in PrEP integration into PAC

Theme 1: Inadequate staffing, high staff rotations, and turnovers influenced efficient PrEP delivery and uptake.

Due to staff shortages in facilities, only a few PAC providers received training on PrEP integration, especially in public facilities struggling to meet the overwhelming needs of a large number of patients with competing needs. As a result, PAC clinics experienced challenges offering PrEP services whenever trained providers were off duty, losing opportunities to initiate PrEP for willing AGYW. Additionally, staffing shortages led to providers being overburdened with predetermined work targets and serving clients in other departments, impacting their willingness and ability to provide integrated services promptly, resulting in long wait times.

“The other challenge is the burden, they have the back services to provide, then an addition of PrEP counseling, so the workload sometimes is too much, and some will be so negative and will not even be willing to offer those counseling.” (Provider FGD 02, TKA)

High staff rotations and turnovers among trained PAC providers further exacerbated the knowledge gap in PrEP delivery, necessitating incoming providers to undergo training, leading to inefficiencies in PrEP delivery.

“Providers with an idea why we should give clients PrEP are taken to other departments. I think the best thing is to train more providers.” (Provider, FGD 02, TKA)

To address these challenges, continuous provider training, employing additional providers, task-shifting, and attitude transformation were suggested. Incorporating technical support components and regularly sharing provider feedback across facilities to enhance learning were also recommended.

Theme 2: Difficulties taking PrEP daily, side effects, monthly follow-ups, low self-HIV risk perception, and fear of HIV tests influence PrEP service acceptance.

Some AGYW hesitated to access PrEP services when their primary reason for visiting the PAC clinic was to receive PAC. Consequently, many providers approached PAC clients for PrEP counseling, but only initiated a few clients on PrEP, which was discouraging for providers. Private clinic providers felt that providing PrEP detracted the time that should be spent reaching targets for other services with predetermined goals.

“I was getting discouraged because I used to tell them and they continuously kept refusing to enroll, it makes you feel like “Maybe I’m not doing enough, maybe it’s something they can’t take.” But a day when two girls accepted PrEP, I was like okay.” (Provider FGD 01, TKA)

Most AGYW expressed concerns about the stigmatizing nature of the pill size, daily use, and packaging, which made adherence difficult. These suggested developing alternative PrEP formulations, such as long-term injectables or implants to increase use and adherence. Additionally, suggestions were made regarding PrEP pill size and packaging, as well as PrEP couple counseling.

“I haven’t seen PrEP being injected. If it was injectable such that once you are injected, you stay with it, then again you can come back for the injection, because sometimes, this one for swallowing is tricky.” (AGYW IDI 13, KSM)

Discussion

This study showed that the integrated PrEP program was acceptable (Heffron et al., 2021), serving as an effective and timely intervention for reducing high HIV incidence among Kenyan AGYW. This acceptance was attributed to critical components of the intervention, including integrated PrEP services encompassing comprehensive SRH, HIV, and PrEP counseling, along with PrEP awareness creation and stigma reduction efforts (Celum et al., 2019; Mugwanya et al., 2019; Ortblad, Mogere, Bukusi, et al., 2020; Ortblad, Mogere, Roche, et al., 2020). Factors influencing the efficient integration of PrEP into PAC services included: (1) providers’ confidence in offering integrated PrEP services; (2) staffing levels; (3) facility structure and operation including the availability of safe/private spaces, commodity management, and reporting systems; (4) AGYWs’ confidence in using PrEP; and (5) the attitudes of providers, implementing partners and AGYW attitudes toward PrEP and PAC services.

This study contributes to the evidence showing that provider training enhances competence and confidence in service delivery and PrEP utilization (Irungu et al., 2022; Ramakrishnan et al., 2021). The integrated PrEP program training, which included continuous technical support and medical education focusing on HIV and PrEP counseling, delivery, and awareness was a key facilitator of PrEP delivery and acceptance(Irungu et al., 2022). Providers delivered PrEP services tailored to the needs of the AGYW, with a friendly and non-judgmental approach, ensuring confidentiality and providing high-quality comprehensive reproductive health and PrEP counseling (Ramakrishnan et al., 2021; Rao et al., 2022). This approach was crucial for AGYW to recognize their HIV risk, understand the need for PrEP services, and make informed decisions about PrEP use, adherence, and continuation, as well as for referring their peers. However, challenges such as inadequate staffing, busy schedules and workload in public facilities resulted in only a few providers trained to offer PrEP services, hindering efficient PrEP delivery. These findings highlight the importance of adequate staffing to improve service utilization and the necessity of training all carder providers to ensure sustained PrEP delivery at PAC and optimize PrEP opportunities (Irungu et al., 2022; Ramakrishnan et al., 2021; Rao et al., 2022). Additionally, it highlights the essential role of attitude change training in promoting PrEP uptake and providing high-quality PrEP services among AGYW.

This study is consistent with previous research which showed that while PAC points were preferred for PrEP initiation, AGYW may be discouraged from accessing services, such as PrEP, due to the stigma associated with care delivery points (Heffron et al., 2021; Lanham et al., 2021; Mugwanya et al., 2021; Nakambale et al., 2023). Additionally, reluctance to get PrEP refills from PAC was observed resulting from the desire to avoid the trauma and stigma associated with PAC experiences (Heffron et al., 2021). The significant age gap between AGYW and providers at these was also a concern. AGYW expressed a preference for private, youth-friendly spaces for PrEP services, (Mugwanya et al., 2021), and suggested delivering PrEP from locations such as community pharmacies and private clinics to improve accessibility (Kuo et al., 2022; Ortblad, Mogere, Bukusi, et al., 2020; Ortblad, Mogere, Roche, et al., 2020; Roche et al., 2021). Further, to enhance PrEP accessibility and reach, integrating PrEP services into routine care across the various delivery sites within facilities was deemed crucial (Mugwanya et al., 2019, 2021). Facility-specific structures and operations, including the availability of private areas, commodity management, and reporting systems, were found to impact PrEP delivery and acceptability readiness. Facilities with integrated services had an easier time integrating PrEP into PAC services compared to those without integrated services, especially public facilities, which had to devise means of obtaining PrEP supplies and managing reporting systems.

Similar to previous studies, PrEP stigma and pill burden significantly influenced PrEP use among AGYW. Societal and individual norms, perceptions, and stigma surrounding PrEP contributed to varying levels of interest in PrEP delivery and use among this population (Bekker et al., 2022; Haberer et al., 2022; Heffron et al., 2021; Nakambale et al., 2023). PrEP use was highly stigmatized due to its association with multiple sexual partnerships (Haberer et al., 2022; Lanham et al., 2021), and confusion with HIV medication packaging exacerbated stigma and reduced acceptance. Participants recommended community outreach and health talks to disseminate PrEP information widely. Challenges such as daily use, pill size, and side effects hindered PrEP use (Bekker et al., 2022; Haberer et al., 2022; Heffron et al., 2021), highlighting the importance of developing alternative formulations to accommodate individual preferences (Minnis et al., 2020). Providing product choices, including long-term injectables or implants alongside monthly pills, could enhance uptake, use, and continuation of PrEP (Bekker et al., 2022; Minnis et al., 2020).

To the best of our knowledge, this is the first qualitative study to explore the acceptability of PrEP integration into PAC points among AGYW receiving pregnancy loss care in Kenya. By addressing gaps in data, this study contributes valuable insights into maximizing PrEP benefits in reducing new HIV infections. While the study benefits from a large sample size across diverse geographical regions, its focus on AGYW accessing PAC from partners and receptiveness to PrEP limits its generalizability to the broader population.

Conclusion

Integrating PrEP services into routine PAC services was acceptable as a novel approach to expand the reach of PrEP among AGYW, meriting consideration for scaled-up by public health and medical policy bodies in Kenya. To optimize program outcomes, several structural enhancements are recommended. These include increasing staffing levels and providing comprehensive training on PrEP, integrating medical reporting systems, implementing direct-to-pharmacy PrEP initiation and follow-up, creating safe and private space for AGYW to receive services, and integrating PrEP as part of routine care across all service delivery points. Moreover, expanding PrEP availability to community settings and private clinics would enhance accessibility to AGYW unable to access public facilities. Embracing multifaceted approaches to HIV services delivery, including PrEP integration into PAC, can effectively address the unique needs of Kenyan AGYW who could benefit the most. However, achieving this requires concerted efforts to strengthen the existing healthcare delivery structures and operations.

Data availability

Data supporting this study’s findings from the principal investigators (NM, KN, RH) on request.