Table 3 Application of Consolidated Framework for Implementation Science Research to the Partners Scale Up Project

  1. Innovation characteristics

 1. Oral prep for HIV prevention

 Innovation Source:

 Perception of key stakeholders about whether the innovation is externally or internally developed

▪ Ownership of the PrEP program at:

National, clinic, and provider level, e.g., provider perception of MOH/NASCOP work vs project.

 Adaptability:

 The degree to which an innovation can be adapted, tailored, refined, or reinvented to meet local needs.

▪ Adaptations—clinic level:

PrEP eligibility

PrEP baseline lab requirements

Visit schedules

 Complexity

 Perceived difficulty of the innovation, reflected by duration, scope, radicalness, disruptiveness, centrality, and intricacy and number of steps required to implement.

▪ Perceived difficulty of delivering PrEP:

Perceived ease/complexity of counseling and delivering PrEP: time, labs, steps; challenges counseling about counseling about viral suppression

  2. Outer setting

 2. External influence of prep implementation

 External policy and incentives

 A broad construct that includes external strategies to spread innovations including policy and regulations (governmental or other central entity), external mandates, recommendations and guidelines, pay-for performance, collaborative, and public or benchmark reporting.

▪ External enablers and policy:

MOH policy framework and guidance

MOH tools

MOH supervision

County government involvement

 Peer pressure

 Mimetic or competitive pressure to implement an innovation, typically because most or other key peer or competing organizations have already implemented or are in a bid for a competitive edge.

▪ Clinic-level peer pressure:

Motivation/pride from being the first to implement PrEP

  3. Inner setting

 3. Clinic-level factors

 Structural characteristics

 The social architecture, age, maturity, and size of an organization

▪ Infrastructure and staff:

Patient volume, space, staffing

 Relative priority

 Individuals’ shared perception of the importance of the implementation within the organization

▪ Clinic-level priority:

Tension between PrEP implementation (healthy person) vs ART services at the clinic (sick person)

 Leadership engagement

 Commitment, involvement, and accountability of leaders and managers with the implementation of the innovation.

▪ Leadership engagement:

Facility/HIV clinic manager involvement in PrEP implementation

 Access to knowledge and information

▪ Staff training:

Adequacy of training, models of PrEP training

 Available resources

  4. Characteristics of individuals

 4. Health care provider factors

 Knowledge and beliefs about the innovation

 Individuals’ attitudes toward and value placed on the innovation, as well as familiarity with facts, truths, and principles related to the innovation.

▪ Provider adoption and experience:

Knowledge and attitudes about PrEP

 Self-efficacy

 Individual belief in their own capabilities to execute courses of action to achieve implementation goals.

▪ Self-efficacy:

Staff confidence in counseling and delivering PrEP, staff confidence in counseling about PrEP and condoms, confidence in viral undetectable=no transmission (u=u)

  5. Process

 5. Prep implementation process

 Engaging

 Attracting and involving appropriate individuals in the implementation and use of the innovation through a combined strategy of social marketing, education, role modeling, training, and other similar activities.

▪ Demand creation strategies:

Successful and unsuccessful demand creation strategies

▪ Retention strategies

Successful and unsuccessful engagement/retention strategies

▪ Stakeholder engagement

 Champions

 Individuals who dedicate themselves to supporting, and “driving through” an [implementation], overcoming indifference or resistance that the innovation may provoke in an organization

▪ PrEP champions:

Types, roles, and how they have emerged, challenges, and how to harness champions

 External change agents

 Individuals who are affiliated with an outside entity who formally influence or facilitate innovation decisions in a desirable direction.

▪ External change agents:

Roles and impact of PrEP technical advisors, county/sub county AIDS and STI coordinators involvement, other implementing partners

 Execution

 Carrying out or accomplishing the implementation according to plan

▪ Fidelity, clinic innovations, and adaptations—PrEP provision:

Clinical encounter form completeness, same-day PrEP initiation, requirements for baseline creatinine and hepatitis B testing, assessment of acute HIV symptoms, PrEP visit frequency/schedule, quantity of PrEP dispensed, PrEP vs condom disconnect between providers and patients, demand creation, and retention strategies

▪ Demand creation strategies

▪ Opportunities for efficient PrEP delivery

 Innovation participants

 Individuals served by the organization that participate in the innovation, e.g., patients in a prevention program in a hospital.

▪ Patient experiences:

Confidence in health system, stigma of coming to an HIV clinic, facilitators and barriers to access to PrEP, benefits/challenges of integrating PrEP in IV clinics, confidence in stopping PrEP when HIV partner achieves viral suppression

 Reflecting and evaluating

 Quantitative and qualitative feedback about the progress and quality of implementation accompanied with regular personal and team debriefing about progress and experience

▪ M & E activities:

Best practices, role of technical assistance, rapid cycle analysis, adoption of PrEP delivery, quality improvement activities, M & E measures to assess progress