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

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 postabortion care (PAC) and to determine whether enhancing the PrEP program with an adherence intervention-simple phone calls-impacted PrEP persistence and use.

PAC clinics in Kenya launched PrEP delivery and were randomized to conduct enhanced support (weekly calls during Month 1, biweekly in Month 2, and monthly 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 (TFV) testing] were compared among participants accessing PrEP at facilities assigned to offer enhanced vs. SOC support via Poisson regression models.

From April 2021 to March 2023, 8,362 women sought PAC from participating facilities. Fifty-five percent of women received PrEP information, 73% of those had HIV testing, and 36% of those received counseling and initiated PrEP. After the trial launch, 4,112 women sought PAC, and 655 (15.9%) initiated PrEP. At Month 1, 63/408 (15.4%) women in facilities who were randomized to the enhanced arm and 14/247 (5.7%) in the SOC arm received a PrEP refill [relative risk (RR) = 2.7, 95% CI: 0.90-8.2]. TFV 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).

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 significantly higher retention at Month 1, a finding that may warrant further investigation.