Phone calls to enhance PrEP persistence among Kenyan women accessing postabortal care: a cluster randomized trial

Renee Heffron^1*Lydia Etyang²Bernard Nyerere²Inviolata Wanyama³Yasaman Zia⁴Torin Schaafsma⁵Katherine Thomas⁵Margaret Mwangi²Lavender June²Felix Mogaka²Catherine Kiptinness²Michael Kamiru⁶Taryn Barker⁶Hideaki Okochi⁴Monica Gandhi⁴Kenneth Ngure²Elizabeth Bukusi²Nelly Rwamba Mugo²

• ¹University of Alabama at Birmingham, Birmingham, United States
• ²Kenya Medical Research Institute, Nairobi, Kenya
• ³Marie Stopes Kenya, Nairobi, Kenya
• ⁴University of California San Francisco, San Francisco, United States
• ⁵University of Washington, Seattle, United States
• ⁶Children's Investment Fund Foundation, London, United Kingdom

Introduction: In Kenya, young women face dual epidemics of HIV and unintended pregnancy yet provision of HIV pre-exposure prophylaxis (PrEP) in reproductive health settings is uncommon. We aimed to estimate PrEP uptake and persistence when PrEP was integrated into services for people seeking post-abortion care and we aimed to determine whether enhancing the PrEP program with an adherence intervention – simple phone calls – impacted PrEP persistence and use. Methods: Postabortion care (PAC) clinics in Kenya launched PrEP delivery and were randomized to conduct enhanced support (1/week calls during month 1, bi-weekly in month 2, and 1/month thereafter) or standard of care (SOC) for PrEP adherence and retention. The primary outcome for the cluster randomized trial was PrEP refills at one month. PrEP refills and adherence (collected on a subset through point-of-care urine tenofovir testing) were compared among participants accessing PrEP at facilities assigned to offer enhanced versus SOC support via Poisson regression models. Results: From April 2021 to March 2023, 8362 women sought PAC from participating facilities. 55% of women received PrEP information, 73% of those had HIV testing, and 36% of those received counseling and initiated PrEP. After the trial launch, 4112 women sought PAC and 655 (15.9%) initiated PrEP. At month 1, 63/408 (15.4%) women in facilities randomized to the enhanced arm and 14/247 (5.7%) in the SOC arm received a PrEP refill (RR=2.7, 95% CI 0.90-8.2). Tenofovir was detected at month 1 in 19.0% of the enhanced arm and 9.4% of the SOC arm (RR = 2.03, 95% CI 0.89-4.65). Conclusions: We observed large gaps in the provision of PrEP information and PrEP counseling that contributed to low PrEP uptake in PAC clinics. Among women who initiated PrEP, persistence and adherence were low. Phone calls yielded a statistically significant higher retention at month 1, a finding that may warrant further investigation. Funding: Children's Investment Fund Foundation.