Estimating the Cost and Efficiency of Differentiated Direct-to-Pharmacy PrEP Refill Model in Kenya

OBJECTIVES: Delivery of oral pre-exposure prophylaxis (PrEP) is rapidly scaling up, including in Kenya, as part of the national HIV prevention strategy. However, barriers such as high patient volume, long waiting time, and busy personnel schedule may impair PrEP delivery in real-world clinics. We examined the cost and efficiency of implementing a direct-to-pharmacy PrEP delivery pathway during follow-up visits in Kenyan public HIV clinics.

METHODS: We conducted a micro-costing study from 9/2022 to 1/2023 to estimate and compare the cost of a differentiated direct-to-pharmacy PrEP refill delivery model (intervention) versus usual care from the payer's perspective. The core components of the intervention included: (i) direct-to-pharmacy refill visits with optional clinician interaction (ii) three-month PrEP refills, and (iii) client HIV self-testing. We conducted time and motion observations to examine the types and duration of activities, and resources involved in PrEP delivery. Costing questionnaires and administrative staff interviews were used to capture personnel time spent on PrEP services and the associated start-up (building, equipment, furniture, training) and recurrent costs (salaries, utilities, HIV testing, PrEP) in 2023 US dollars (USD).

RESULTS: We observed 58 visits in the intervention arm and 22 visits in usual care. Patients spent an average of 37.6 and 69.5 minutes at the clinics implementing the intervention versus usual care, respectively. The wait time was 3.5 versus 18.2 minutes, respectively, for the intervention versus usual care. Variable personnel time cost was $2.84 versus $4.17 for differentiated PrEP versus usual care and the cost per clinic visit was $2.79 versus $3.39 respectively. Major drivers of cost savings were lower personnel time and fewer PrEP-related visits

CONCLUSIONS: Differentiated direct-to-pharmacy PrEP refill visits supported with HIV self-testing may lower cost, reduce wait time, and improve efficiency of PrEP delivery in this setting.