Making post-exposure prophylaxis effective for leprosy elimination: Insights from a multi-country study on low-endemic settings

Countries with low endemicity for leprosy face context-specific challenges in interrupting the transmission of Mycobacterium (M.) leprae to reach subsequent non-endemic status. This study explores the tensions and synergies that arise in resource-limited, low endemic settings when implementing and scaling-up single dose rifampicin (SDR) post-exposure prophylaxis (PEP) for leprosy control and elimination. We conducted 12 semi-structured in-depth interviews with key informants across six countries on the challenges and enablers in active case detection (ACD) and SDR-PEP implementation in low endemic countries. Key informants included medical practitioners, programme coordinators, researchers, policy makers, and experts, all with experience in PEP. Findings showed that lowering endemicity led to a fall in disease prioritization, lower levels of disease awareness within policy and healthcare practice, and the challenge of limited funding and resource accessibility. Advocating for leadership in leprosy control within national government and policy was central to long-term SDR-PEP implementation success, allowing for local alignment of policy and greater flexibility to adjust to changing disease patterns, resource availability and population health needs and priorities. Strengthening active coordination between stakeholders, both nationally and internationally, is vital for rifampicin procurement and supporting the integration of PEP into routine programmes. If the interruption of M. leprae transmission – and eventually leprosy disease elimination – is to be achieved, low endemic settings must also be considered in policy and practice. Our results provide key considerations for improving SDR-PEP implementation, specific to low endemic settings.Author summary: Despite global efforts, leprosy transmission remains static and high globally, with low-resourced, low endemic settings being disproportionately overlooked in policy and research as an opportunity to invest into effective leprosy control efforts. These settings face unique barriers to implementing post-exposure prophylaxis (PEP) with single dose rifampicin (SDR), a strategy proven to reduce transmission among contacts of leprosy patients. This study addresses this critical research gap by exploring the experiences, through in-depth interviews, of key stakeholders, including programme implementers, policymakers, and leprosy experts involved in active case detection (ACD) and SDR-PEP delivery across six low endemic countries. The study shows how diminishing leprosy endemicity leads to reduced funding, lower prioritization for leprosy control efforts by governments, and lack of awareness and expertise in the public and medical field, complicating the continuity of ACD and hindering the routine use of SDR-PEP for contacts of leprosy patients. Our findings reveal key insights into the structural, operational and financial tensions surrounding resource allocation and accessibility unique to low-endemic settings. In conclusion, a focus is needed on how to reposition leprosy control and SDR-PEP as a priority for funding and resources, particularly for high-risk and neglected populations, by ensuring governmental support and fostering national leadership in leprosy control. Our recommendations emphasise the importance of integration and cross-stakeholder coordination, both within and across countries, to secure resources, in particular rifampicin, to allow for routine implementation of SDR-PEP, thereby reducing transmission and contributing to the future elimination of this disease.