How can we enhance HIV Pre Exposure Prophylaxis (PrEP) awareness and access?: Recommendation development from process evaluation of a national PrEP programme using implementation science tools

Objectives HIV Pre-Exposure Prophylaxis (PrEP) is a highly effective biomedical intervention for HIV prevention and is key to HIV transmission elimination. However, implementation is challenging. We identified barriers and facilitators to PrEP awareness and access during the roll out of Scotland’s national PrEP programme to develop recommendations for future provision. Design Multi-perspectival qualitative approach incorporating implementation science tools. Setting Sexual health services and sexual health/HIV community-based organisations (CBOs) in Scotland. Participants Semi-structured telephone interviews and focus groups with geographically and demographically diverse patients seeking/using/declining/stopping PrEP (n=39), sexual healthcare professionals (n= 54), CBO users (n=9) and staff (n=15). Analysis Using deductive thematic analysis we mapped barriers and facilitators to PrEP awareness and access. We then applied the Theoretical Domains Framework, Behaviour Change Wheel, and Behaviour Change Technique Taxonomy to analyse barriers and facilitators to generate targeted solutions. Finally, we applied APEASE criteria, expert opinion, and the socio-ecological model to synthesise and present multi-levelled and interdependent recommendations to enhance implementation. Results Barriers and facilitators were multifaceted, relating to the macrosocial (e.g., government, service ecology), the mesosocial (e.g., values and practices of organisations and dynamics and norms of communities) and the microsocial (peer influence). We derived 28 overarching recommendations including: incentivising organisations to share expertise, addressing future generations of PrEP users, expanding the reach of PrEP services, cascading effective service innovations, changing organisational cultures, instigating and managing novel outreach, establishing monitoring systems, supporting diverse PrEP users, providing training addressing awareness and access to professionals, and development of “PrEP champions” within a range of organisations. Conclusion Improving awareness and access to PrEP sustainably will require intervention across the whole system, changing policy and practice, organisations and their cultures, communities and their social practices, and individuals themselves. These evidence-based recommendations will prove useful in extending the reach of PrEP to all who could benefit. Strengths and limitations of this study ### Competing Interest Statement The investigators named have no financial interests that impact on their responsibilities towards the scientific value or potential publishing activities associated with the study. However, the team has other interests within the field including various roles relating to HIV and sexual health within Government (Steedman, Estcourt, Nandwani, Clutterbuck), policy generation (Steedman, Nandwani, Estcourt, Saunders, Young, Flowers, HIV Scotland), practice (Steedman, Estcourt, Nandwani, Clutterbuck, Saunders) and advocacy (Young, HIV Scotland). PF reports research grants from National Institute of Health Research UK, Chief Scientist Office of Scotland. RN reports research grants from National Institute of Health Research UK, Chief Scientist Office of Scotland and non-executive director membership of the Board of Public Health Scotland from April 2020. JF reports research grants from Chief Scientist Office of Scotland. CSE reports research grants from National Institute of Health Research UK, Chief Scientist Office of Scotland, Engineering and Physical Sciences Research Council, UK Clinical Research Collaboration, Health Protection Scotland, European Centres for Disease Control. JM, JS, IY, DC, NS, LM & JD report no competing interests. ### Funding Statement This study was funded by Chief Scientist Office grant number [HIPS/17/47]. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The Glasgow Caledonian University Research Ethics Committee (REC) (HLS/NCH/17/037, HLS/NCH/17/038, HLS/NCH/17/044) and the South East of Scotland NHS REC (18/SS/0075, R&D GN18HS368) gave this study ethical approval. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable. Yes No data from this qualitative data set is publicly available. Supplementary file B provides an auditable account of anonymised data analysis.