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.

ObjectivesHIV 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 Scotlands national PrEP programme to develop recommendations for future provision. DesignMulti-perspectival qualitative approach incorporating implementation science tools. SettingSexual health services and sexual health/HIV community-based organisations (CBOs) in Scotland. ParticipantsSemi-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). AnalysisUsing 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. ResultsBarriers 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. ConclusionImproving 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. Article SummaryO_ST_ABSStrengths and limitations of this studyC_ST_ABSO_LIWe used novel methods and a rigorous study design to create auditable evidence-based and theoretically informed recommendations, moving beyond simple thematic analysis or sole use of expert opinion C_LIO_LIThe recommendations are built upon multi-perspectival qualitative data from diverse stakeholders and varied expert opinions. C_LIO_LIWhere meta-analyses or meta-syntheses of implementation studies are not available, we offer a structured, practical, evidence-based approach to generating recommendations. C_LIO_LILimitations include the sole reliance on qualitative insights and our focus on a single national context (Scotland) in the early years of programme delivery. C_LI