Using developmental evaluation to implement an oral pre-exposure prophylaxis (PrEP) project in Kenya

Oral Pre-Exposure Prophylaxis (PrEP) is highly effective in lowering HIV transmission risk. The Bill and Melinda Gates-funded Jilinde Project was designed to identify the best ways to introduce and support PrEP services in Kenya for female sex workers, men who have sex with men, and adolescent girls and young women. We chose Developmental Evaluation (DE) as a core project approach because our goal was not just to recruit 20,000 new PrEP users, but to learn how to deliver PrEP effectively to optimally benefit users in a complex, dynamic, resource-limited setting. This paper describes how we incorporated DE into the Jilinde Project, and shares experiences and lessons learned about the value of DE in PrEP service implementation in a real-world situation. With the Ministry of Health, Jilinde developed consensus about the structure and roll-out of PrEP services. The DE evaluator, embedded in Jilinde, designed and implemented the five-step DE methodology—collect, review, reflect, record and act—according to a core set of project guiding principles. The paper describes how we operationalized the five elements, citing findings reported and actions taken reflecting on the data. It summarizes challenges to DE implementation, such as uneven uptake and competing demands, and how we addressed those challenges. Used consistently, DE helped adapt and refine PrEP services, improve service access, reach target audiences and improve continuation rates. The look, feel and yield of our DE efforts evolved over time, increasingly integrated into existing systems and providing deeper and richer understandings, and we learned how to better implement DE in the future. This case study provides practical guidance for using a DE approach in program design. The DE process can be used successfully working with partners on a common complex public health challenge within a dynamic environment in a way that feeds back into and improves programs.