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. 2021 Jul 9;11(7):e047017.
doi: 10.1136/bmjopen-2020-047017.

Initial implementation of PrEP in Zambia: health policy development and service delivery scale-up

Cassidy W Claassen  1   2   3 , Daliso Mumba  4   5 , Mwansa Njelesani  6 , Derrick Nyimbili  7 , Linah K Mwango  8 , Mundia Mwitumwa  2   3 , Ellen Mubanga  4 , Lloyd B Mulenga  2   3   5 , Tina Chisenga  5 , Brooke E Nichols  9   10 , Cheryl Hendrickson  10 , Lastone Chitembo  11 , Jackson Okuku  12 , Heidi O'Bra  13
Affiliations

Initial implementation of PrEP in Zambia: health policy development and service delivery scale-up

Cassidy W Claassen et al. BMJ Open. .

Abstract

Introduction: Daily pre-exposure prophylaxis (PrEP) for HIV prevention is highly effective, but not yet widely deployed in sub-Saharan Africa. We describe how Zambia developed PrEP health policy and then successfully implemented national PrEP service delivery.

Policy development: Zambia introduced PrEP as a key strategy for HIV prevention in 2016, and established a National PrEP Task Force to lead policy advocacy and development. The Task Force was composed of government representatives, regulatory agencies, international donors, implementation partners and civil society organisations. Following an implementation pilot, PrEP was rolled out nationally using risk-based criteria alongside a national HIV prevention campaign.

National scale-up: In the first year of implementation, ending September 2018, 3626 persons initiated PrEP. By September 2019, the number of people starting PrEP increased by over sixfold to 23 327 persons at 728 sites across all ten Zambian provinces. In the first 2 years, 26 953 clients initiated PrEP in Zambia, of whom 31% were from key and priority populations. Continuation remains low at 25% and 11% at 6 and 12 months, respectively.

Lessons learnt: Risk-based criteria for PrEP ensures access to those most in need of HIV prevention. Healthcare worker training in PrEP service delivery and health needs of key and priority populations is crucial. PrEP expansion into primary healthcare clinics and community education is required to reach full potential. Additional work is needed to understand and address low PrEP continuation. Finally, a task force of key stakeholders can rapidly develop and implement health policy, which may serve as a model for countries seeking to implement PrEP.

Keywords: HIV & AIDS; health policy; public health.

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Conflict of interest statement

Competing interests: None declared.

Figures

Figure 1
Figure 1
Timeline of PrEP policy and implementation in Zambia. PrEP, pre-exposure prophylaxis; SDC, serodiscordant couples; UMB, University of Maryland Baltimore; UTH, University Teaching Hospital.
Figure 2
Figure 2
Selected materials from Zambia ending AIDS campaign. PrEP, pre-exposure prophylaxis.
Figure 3
Figure 3
Total number of new PrEP initiates by population type since beginning of Zambian PrEP programme, in half-year increments. AGYW, adolescent girls and young women; FSW, female sex workers; KP, key population; MSM, men who have sex with men; PWID, people who inject drugs; TG, transgende.
Figure 4
Figure 4
PrEP information access correlates to ending AIDS campaign media broadcasts. Snapshots of national radio listeners and TV broadcasts over a 6-month period in 2019, with overlay of frequency of USSD PrEP code being accessed. USSD PrEP codes track closely with Zambia ending AIDS campaign media broadcasts. PrEP, pre-exposure prophylaxis.
Figure 5
Figure 5
Geographic distribution of HIV PrEP sites in Zambia in 2019. Panel (A) Zambian government health facilities providing PrEP in orange, overlaying HIV prevalence by Province. Panel (B) Zambian government health facilities providing PrEP in orange, overlaying population density by Province. PrEP, pre-exposure prophylaxis.
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