Interventions to enhance uptake of PrEP for high-risk populations in Nampula Province, Mozambique

BACKGROUND: Mozambique has a generalized HIV epidemic, with 13.2% overall prevalence among adults aged 15-49 and 15.4% among women. Pre'exposure prophylaxis (PrEP) is an evidence-based HIV combination prevention intervention. Recognizing its importance for epidemic control, the Mozambique Ministry of Health (MOH) initiated PrEP implementation in select provinces in 2018. However, limited demand creation for PrEP impacted uptake, with only 3,504 individuals enrolled in PrEP services by September 2018. By January 2019, the MOH expanded PrEP to Nampula province, targeting female sex workers (FSW), men who have sex with men (MSM), serodiscordant couples, and adolescent girls and young women (AGYW).
DESCRIPTION: In January 2019, ICAP began to support the Nampula Provincial Health Directorate (DPS) and health facilities (HF) in its implementation of PrEP through targeted training, tools, job aids, and communication materials. ICAP redesigned patient flow to ensure demand creation at entry points and client referrals to points of service offering PrEP. In May 2020, ICAP implemented a PrEP champions strategy, using experienced PrEP clients with strong adherence to support demand creation, patient navigation, phone reminders, and outreach. ICAP supported the DPS to expand PrEP services to additional HF'16 in 2019, 34 in 2020, and 59 in 2021'and integrated PrEP service delivery into community ART distribution strategies in 16 communities in July 2020. Lastly, ICAP strengthened capacity of community partners to reinforce PrEP literacy and demand creation among subpopulations through development and dissemination of radio spots in local languages.
LESSONS LEARNED: There was a 251% increase in clients enrolling in PrEP between the Quarter 1 (October-December 2019; n=643) and Quarter 4 (July-September 2020; n=2,256). Of the 5,729 clients enrolled in PrEP in Nampula between October 2019 and September 2020, 3,578 (61%) were serodiscordant couples, 1,045 (20%) AGYW, 632 (11%) breastfeeding and pregnant women at high risk, 283 (5%) FSW, and 191 (3%) MSM.
CONCLUSIONS: Targeted demand creation and literacy strategies coupled with use of PrEP champions and expansion of PrEP services are an effective strategy to increase uptake. However, continued efforts are necessary, particularly for vulnerable populations. ICAP will expand the use of PrEP champions to venues where AGYW and key populations congregate.