Background: There is limited information on the process of offering oral PrEP to the general at-risk population in resource-limited public sector settings globally. Programming has been limited to private sector demonstration projects targeting key populations. This study aims to provide operational guidance to the Zimbabwe Ministry of Health on national public sector integration of oral PrEP as part of combination HIV prevention.
Description: PrEP was piloted in an urban family planning clinic and a rural youth center, integrating it into existing HIV prevention and reproductive health services and activities. 150 HIV negative clients screened as being at high risk of HIV infection were offered PrEP between January and April 2018, primarily through provider initiative. Demand generation included group client education and in-facility posters and pamphlets; community leader sensitization was also conducted at the rural center. Semi-structured interviews on PrEP experiences were conducted with five healthcare workers (HCWs) and 37 clients who agreed to be followed up (7 decliners and 30 accepters).

Graph showing percentage uptake of PrEP and risk status of clients
[Graph showing percentage uptake of PrEP and risk status of clients]

Lessons learned: PrEP risk assessment can be integrated into existing routine family planning and HIV testing and counselling services. Differences in facility enrollment data and interviews with study participants indicate that HCW knowledge and attitudes, and client awareness, affect whether PrEP is offered and/or accepted. PrEP uptake is driven by partner''s risky behaviour or positive HIV status; this did not vary by population group. Female uptake, retention and adherence is largely determined by family or partner support. Male PrEP clients were primarily in polygamous marriages where one wife is HIV positive. Male decliners prefer condoms. Females in sero-discordant marriages report decreased condom use after PrEP initiation. This is driven by their male HIV positive partners.
Conclusions/Next steps: PrEP demand generation strategies should address HCW knowledge and client awareness. National clinical training tools for HCWs should emphasize client education and counselling on PrEP as part of combination of HIV prevention options. The national HIV Communication Strategy should focus on increasing general awareness of how PrEP works in order to increase uptake and reduce stigma associated with use. Adjustments to national PrEP target-setting will be informed by study findings on PrEP uptake among those testing HIV negative.