LAUSR

Background : HIV pre-exposure prophylaxis (PrEP) is key to HIV transmission elimination but implementation is challenging and under-researched. We undertook a process evaluation of the first two years of a national PrEP programme to explore barriers and facilitators to implementation and to develop recommendations to improve implementation, focussing on PrEP uptake and initiation. Methods : Stage 1 involved semi-structured telephone interviews and focus groups (09/2018-07/2019) with geographically and demographically diverse patients seeking/using/declining/stopping PrEP (n=39), sexual healthcare professionals (n= 54), community-based organisation service users (n=9) and staff (n=15) across Scotland. We used deductive thematic analysis, to derive and then map key barriers and facilitators to priority areas that experts agreed would enhance initiation and uptake. In Stage 2 we used analytic tools from implementation science to systematically generate evidence-based, theoretically-informed recommendations to enhance uptake and initiation of PrEP. Results : Barriers and facilitators were multi-levelled and interdependent. Barriers included the rapid pace of implementation without additional resource, and a lack of familiarity with PrEP prescribing. Facilitators included opportunities for acquisition of practice-based knowledge and normalisation of initiation activities. We refined our 68 “long-list” recommendations to 41 using expert input and the APEASE criteria. Examples include: provision of PrEP in diverse settings to reach all in need; co-produced, culturally sensitive training resources for healthcare professionals, with focused content on non-daily dosing; meaningful collaborative working across all stakeholders. Conclusions: These evidence-based, theory informed recommendations provide a robust framework for optimising PrEP uptake and initiation in diverse settings to ensure PrEP reaches all who may benefit. Complex multi-levelled factors shaped PrEP implementation. Nine specific areas of the PrEP care cascade involved in initiation and uptake of PrEP were both amenable to change and prioritised for improvement. The corresponding barriers and facilitators were multi-levelled and interdependent. Many were psychosocial, relating directly to the way staff or patients thought and felt; others related to the organisation of services, wider issues of access to support and training, and factors relating to the environmental infra-structure of services. Using tools from implementation science, we systematically generated highly specific, theoretically informed and evidence-based ways of optimising PrEP implementation in the future. Examples include: provision of PrEP in diverse settings to reach all in need; co-produced, culturally sensitive training resources for healthcare professionals, with focused content on non-daily dosing; meaningful collaborative working across all stakeholders.