Improving HIV pre-exposure prophylaxis (PrEP) uptake and initiation: process evaluation and recommendation development from a national PrEP program

Claudia S. Estcourt*, Jennifer MacDonald, John Saunders, Rak Nandwani, Ingrid Young, Jamie Frankis, Dan Clutterbuck, Nicola Steedman, Lisa McDaid, Jenny Dalrymple, Paul Flowers

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

1 Citation (Scopus)
32 Downloads (Pure)


BACKGROUND: HIV pre-exposure prophylaxis (PrEP) is key to HIV transmission elimination but implementation is challenging and under-researched. We undertook a process evaluation of the first 2years of a national PrEP program to explore barriers and facilitators to implementation and to develop recommendations to improve implementation, focusing on PrEP uptake and initiation. METHODS: Stage 1 involved semi-structured telephone interviews and focus groups (September 2018-July 2019) with geographically and demographically diverse patients seeking/using/declining/stopping PrEP (n =39), sexual healthcare professionals (n =54), community-based organisation service users (n =9) and staff (n =15) across Scotland. We used deductive thematic analysis, to derive and then map key barriers and facilitators to priority areas that experts agreed would enhance uptake and initiation. In Stage 2, we used analytic tools from implementation science to systematically generate evidence-based, theoretically-informed recommendations to enhance uptake and initiation of PrEP. RESULTS: Barriers and facilitators were multi-levelled and interdependent. Barriers included the rapid pace of implementation without additional resource, and a lack of familiarity with PrEP prescribing. Facilitators included opportunities for acquisition of practice-based knowledge and normalisation of initiation activities. We refined our 68 'long-list' recommendations to 41 using expert input and the APEASE (Acceptability, Practicability, Effectiveness, Affordability, Side-effects, and Equity) criteria. Examples include: provision of PrEP in diverse settings to reach all in need; co-produced, culturally sensitive training resources for healthcare professionals, with focused content on non-daily dosing; meaningful collaborative working across all stakeholders. CONCLUSIONS: These evidence-based, theory informed recommendations provide a robust framework for optimising PrEP uptake and initiation in diverse settings to ensure PrEP reaches all who may benefit.

Original languageEnglish
Pages (from-to)282-295
Number of pages14
JournalSexual Health
Issue number4
Early online date15 May 2023
Publication statusPublished - 1 Aug 2023


  • Behaviour Change Wheel
  • HIV prevention
  • PrEP
  • implementation study
  • pre-exposure prophylaxis
  • process evaluation
  • recommendation-development

ASJC Scopus subject areas

  • General Medicine


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