Table 1.

Themes and Illustrative Quotations of Providers' Attitudes and Experiences with Pre-Exposure Prophylaxis in Kenya and Uganda

Theme	Elaboration	Data excerpts
Heterogenous attitudes toward PrEP	Enthusiasm for PrEP	It is a good experience, seeing people who are at risk of contracting HIV getting protected from it. I personally think PrEP is a good idea… Clinical Officer, male, Eastern Uganda When a 24 year old man comes to you and tells you he is a fisherman with about 10 girlfriends, you see the need to give him PrEP. Nurse, female, Kenya PrEP helps them. After the encounter they don't have to keep wondering if they are infected, they don't have to be stressed over that. Peer educator, female, Southwest Uganda
	Ambivalence about providing PrEP	The clients complain when they have just started taking the pills. Say, out of 30 pills, they will complain when they have taken only 2 or 4. Some of them complain of side effects even when they have not even started taking the pills! Nurse tracker, male, Southwestern Uganda I was concerned that it was not going to be accepted, because remember, these are people who are not sick, and the drugs too have the side effects. Nurse, female, Kenya
Concerns about patient behavior and provider responsibility	Concerns about patients' ability to adhere to PrEP	My first question was whether PrEP will be sustainable. Will the clients manage to come for the drugs? Because we have all types of people here, especially the boda boda riders are ever busy… Nurse, female, Kenya
	Fears of being blamed for PrEP “failures”	My biggest fear was seroconversion. I was wondering if we would be able to ensure that these people stay HIV negative. Nurse, female, Kenya The clients on ART…said that we have brought PrEP which has made people more sexually active in this community. They were complaining that we have encouraged people to just have sex. They were also asking if we have now forgotten about condoms. Nurse, female, Kenya
	“Moral” dilemma: responsibility for increases in risk behavior and incident HIV infections	I felt [PrEP] would increase promiscuity, people would start sleeping anyhow because they are sure, they are taking PrEP and they are safe, so the level of promiscuity would so high… Clinical Officer, female, Eastern Uganda I thought to myself, now that PrEP has come, promiscuity will be on the rise… unwanted pregnancies, STDs will also rise. Peer educator, male, Southwestern Uganda I thought that people were going to start having serious unprotected sex; like tying a boom on the neck, a kind of self-suicide. Being on PrEP does not mean that one should stop using condoms and have unprotected sex, which community people seem to think. Nurse tracker, male, Southwestern Uganda
Communication challenges	Assessing and explaining HIV risk	The question they ask, ‘out of the many people that were there, why did they choose me to be at risk, am I the worst out of all those people? Clinical Officer, female, Southwestern Uganda I ask myself questions sometimes, because some people come for PrEP based on suspicion and no conclusive evidence that the partner is cheating or has other sexual partners. Clinical Officer, male, Eastern Uganda
	Difficulties conveying complex adherence and stopping and restarting guidelines	Most participants stop taking PrEP earlier than the time they inform us they have stopped—yet it is supposed to be that they first communicate to us on their desire to stop PrEP, and then we guide them on how to phase out slowly […] We do not know who is taking really well and who is not. Nurse tracker, male, Eastern Uganda I was asking myself, for how long an individual should take PrEP? There was also a mixed feeling of PEP vs. PrEP; which one gives a greater benefit? Nurse tracker, male, Eastern Uganda
Concerns regarding serving specific client populations	Women	Some of the women also say that their husbands have refused them to use the drugs; we have some who have returned the drugs because their husbands have refused. Nurse, female, Kenya
	Youth and adolescents	[Youth] know that this is a clinic for HIV positive clients. So they have a feeling that if someone sees them coming to the HIV clinic, they may think that they are also HIV positive. For that reason they want to come very few times here at the clinic in a year. Nurse, male, Uganda Adolescents… come willing to be initiated on PrEP […] but now for subsequent visits, it's either they haven't started using them or used them for two days and stopped. If you ask them the reason, they'll say like their parents refused and also heard from their friends that the drug is not a good thing. Clinical Officer, male, Kenya
Support for serodifferent couples	Safety, morale, and harmony for couples	Like the ones I saw last week [with HIV-positive partners], their morale was [high] since they started using PrEP. They have not been using condoms—this is a challenge on its own… and they are happy because they have been testing HIV negative. Clinical Officer, male, Kenya Like we know that a positive partner may suppress after taking ART. But since this is a lifelong treatment, at some point they are likely to be lazy to take up their medicine. So if the negative partner is on PrEP it helps to protect the negative partner from seroconverting. But also the positive partner will be motivated to take the medicine since the negative partner is also taking something. One participant came the other day and told me, ‘my husband now is very happy because I am also taking PrEP. He is taking his ART medicine and I am taking PrEP. He is now motivated.’ Nurse tracker, male, Eastern Uganda I realized that PrEP would help us a lot with discordant couples. PrEP is really working for such homes—using a condom is something terrible. Peer educator, male, Southwestern Uganda She went there with her husband. When she took her pill and realized that she was now safe, she felt her home was now strong. Peer educator, male, Southwestern Uganda
Continuation facilitators	Counseling	Those who were referred from the clinic… are easy to be retained compared to those counseled at the [community health campaigns]… time was taken with them, so when they were consented on PrEP, they fully understood what it was all about… Clinical Officer, male, Kenya
	Removing transportation and time barriers through community-based delivery	Now that we take [PrEP] to them, they feel relieved of the transport, and they feel like we care about them… we find out that they are tightly held up in their jobs until they have no time to come to the facility for the drugs. Nurse, female, Kenya You need to be closer to them. That doesn't mean that we are coercing them, but when they see you, they are reminded that there is something that I need to take up and they ask you, ‘uh my medicine is finished; have you brought? I needed to come and test but I am busy doing some work, and cannot come there.’ The [community-based delivery] needs to be strengthened so that we are able to sustain this PrEP program. Nurse tracker, male, Eastern Uganda

ART, antiretroviral therapy; PrEP, pre-exposure prophylaxis.