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.