Background:
HIV pre-exposure prophylaxis (PrEP) delivery is rapidly scaling up globally, but variable discontinuation rates in early real-world data has made it difficult to define programmatic success. Whether discontinuation reflects non-use at times of risk or appropriate non-use during periods of low or no risk (i.e., prevention-effective use) is unknown for most PrEP programs.
Methods:
Between 2020 and 2022, we administered a standardized phone survey to clients who initiated and later discontinued PrEP at 4 public clinics in Central Kenya that participated in the Partners Scale-Up Project, a stepped-wedge cluster-randomized pragmatic trial of PrEP delivery integrated in public HIV clinics as part of Kenya’s national PrEP roll-out. The survey assessed duration of PrEP use, perceived HIV risk at initiation and present, satisfaction with current HIV prevention choice, primary reason for PrEP stop, experience at last clinic visit, and impact of clinic factors (i.e., wait time, visit frequency, staff attitude).
Results:
Of 300 interviewed, 63% were female, 33% ≤30 years, 80% in serodifferent partnership at initiation. About 85% had high self-perceived risk of acquiring HIV at PrEP initiation and 57% used PrEP for ≥3 months. Two-thirds reported it was their own decision to start PrEP and a third a shared client-provider decision. Overall, 73% reported their HIV risk status changed (feeling no longer at risk, U=U with virally suppressed partner, or separation from partner) and that was the primary reason for PrEP stop. Pill burden (9%) and side effects (11%) were relatively uncommon primary reasons for PrEP stop. Notably, >98% were satified with experience at the last clinic visit; < 1% attributed stopping to clinic factors. Overall, no method at all (24%), not feeling at risk (39%), practicing U=U (19%), no sexual partner (26%), condom (14%) were common HIV prevention choices practiced at time of the interview. Importantly, the majority (94%) were satisfied with their current HIV prevention method choice.
Conclusions:
Nearly three-quarters of PrEP discontinuations in large national public PrEP program in Kenya were appropriate PrEP non-use aligned with low HIV risk states or other prevention strategies, and almost all clients were satified with their current HIV prevention choice. Our findings illustrate that using client-level PrEP continuation rates without contextual dynamic individual risk and use of other HIV prevention options is not an appropriate measure of real-world PrEP program success.