A Meta-Analysis of Operational Barriers to Scaling Up Oral Pre-Exposure Prophylaxis for Female Sex Workers in Mombasa, Kenya

Oral pre-exposure prophylaxis (PrEP) is a key biomedical intervention for HIV prevention among female sex workers (FSWs). In high-prevalence settings such as Mombasa, Kenya, scaling up PrEP for this population is a public health priority. Scale-up is, however, dependent on addressing operational barriers within the health system. This meta-analysis aimed to synthesise and quantify the principal operational barriers hindering the scale-up of oral PrEP programmes for FSWs in Mombasa, Kenya, to inform future implementation strategies. A systematic search of electronic databases was conducted for relevant qualitative, quantitative, and mixed-methods studies. Identified studies were screened and assessed for quality using standardised tools. Data on operational barriers were extracted, thematically categorised and, where possible, pooled for quantitative analysis. The review adhered to established meta-analytic and meta-synthesis protocols. The analysis identified five overarching categories of barriers: health system constraints, client-level challenges, socio-structural factors, product-specific issues, and policy gaps. Systemic resource limitations were a predominant theme. Pooled analysis indicated that over 60% of included studies cited commodity stock-outs and inadequate staffing as major impediments to consistent service delivery. Operational barriers to PrEP scale-up for FSWs in Mombasa are multifaceted and embedded within both the health system and broader social context. Without targeted interventions to address these systemic constraints, the potential of PrEP to reduce HIV incidence in this population will remain unrealised. Programme planners should prioritise securing reliable supply chains and investing in dedicated, trained human resources. Interventions must be integrated with efforts to reduce stigma and discrimination and should be coupled with community-led demand creation strategies. HIV prevention, pre-exposure prophylaxis, female sex workers, operational barriers, scale-up, Kenya, health systems This synthesis provides consolidated evidence on the operational barriers to PrEP delivery for a key population in a high-prevalence urban African setting, offering actionable insights for programme implementers and policymakers.