Distribution of antiretroviral therapy through private pharmacies and postal courier services during COVID-19 in Botswana: acceptability and reach of two out-of-facility individual differentiated service delivery models

Engaging the private sector to increase access to HIV services and increase sustainability of the HIV response

BACKGROUND

Public health facilities often manage high volumes of HIV clients and face challenges with long wait times, poor client satisfaction, and low retention in care. The private sector is a major provider of health services in many countries but is a relatively untapped resource for reducing congestion in high-volume public HIV facilities and increasing access to HIV services, particularly for clients who already use the private sector as their first point of care. Private banks, corporations, and clients themselves can also be a resource for generating additional financing for HIV and reducing reliance on donor funding. Through the President's Emergency Plan for AIDS Relief's Sustainable Financing Initiative (SFI), USAID engaged the private sector to expand access to HIV care and mobilize private financing for HIV in low- and middle-income countries.

METHODS

SFI worked in 11 countries and two regional programs on private sector activities, including technical assistance to financial institutions and private providers on lending to the health sector, facilitating the growth of social enterprise models, enabling private providers to offer additional HIV services, and generating and communicating evidence to host governments to strengthen the policy and regulatory environment for private HIV service delivery. SFI's impact was estimated through a financial return on investment.

RESULTS

Over 48,000 clients accessed HIV services in the private sector across three countries, and $6.3 million was mobilized in private loans to the health sector in Tanzania. Additional successes in policy, evidence generation, innovative financing, and service delivery were demonstrated globally.

LESSONS LEARNED AND RECOMMENDATIONS

SFI demonstrated the feasibility of delivering high-quality HIV services through the private sector and the high demand for those services; the need for evaluation techniques that incorporate patient experience in addition to program costs, benefits, and clinical outcomes; and the need for long-term strategic donor and government coordination around private sector engagement.

CONCLUSIONS

Engaging the private sector in HIV can reduce the burden on public health facilities, provide greater opportunities for access to care, and increase domestic financing for HIV without putting clients into financial hardship.

Extreme geographic misalignment of healthcare resources and HIV treatment deserts in Malawi

The Joint United Nations Programme on HIV and AIDS has proposed that human rights should be at the center of efforts to end the HIV pandemic and achieving equity in access to antiretroviral therapy (ART) and HIV healthcare is essential. Here we present a geospatial and geostatistical modeling framework for conducting, at the national level, an equity evaluation of access to ART. We apply our framework to Malawi, where HIV prevalence is ~9%. Access depends upon the number of available healthcare facilities (HCFs), the travel times needed to reach these HCFs, the mode of transportation used (walking, biking, driving) and the supply-to-demand ratio for ART at the HCFs. We find extreme inequities in access to ART. Access maps show striking geographic patterns, revealing clusters of communities with very low or high levels of access. We discover that an extreme geographic misalignment of healthcare resources with respect to need has generated a new type of medical desert: an HIV treatment desert. Around 23% of people living with HIV reside in deserts where they have to walk up to 3 h to reach HCFs; in 2020, these HCFs only received 3% of the national supply of ART. We recommend strategies for shrinking deserts; if not implemented, deserts will grow in size and number.

Courier delivery of antiretroviral therapy: a cohort study of a South African private-sector HIV programme

INTRODUCTION

Courier delivery has become a popular antiretroviral therapy (ART) distribution method in some HIV care settings, yet data on ART courier delivery and how it relates to ART outcomes are scarce. We studied the differences in viral suppression rates between individuals from a South African private sector HIV programme receiving ART by courier delivery and those receiving ART through traditional retail dispensing.

METHODS

Individuals aged 15 years or older who were actively enrolled in the Aid for AIDS programme between January 2011 and July 2022 were eligible for the analysis. The outcome of interest was viral suppression defined as a viral load (VL) <400 copies per ml. We calculated adjusted odds ratios (OR) for the association between the ART distribution method and viral suppression, comparing those receiving refills through courier pharmacies versus retail dispensing at the time of the VL testing. We used generalized estimating equations to account for repeated VL testing of the same individual. The models were adjusted for age, sex, calendar year, ART regimen, history of mental illness and medical insurance scheme. We computed adjusted ORs for the calendar periods 2011-2013, 2014-2016, 2017-2019, 2020-2022 and overall.

RESULTS

We extracted 442,619 VL measurements from 68,720 eligible individuals, 39,406 (57.3%) were women. The median number of VL measurements per individual was 6 (IQR 3-10). VL suppression was detected in 398,901 (90.1%) tests, and 185,701 (42.0%) of the tests were taken while the individual was receiving ART by courier delivery. Overall, courier delivery was associated with 5% higher odds of viral suppression than retail dispensing (adjusted OR 1.05, 95% CI 1.02-1.08). The strength and direction of this association varied by calendar period, with an adjusted OR of 1.37 (95% CI 1.27-1.48) in 2011-2013 and 1.02 (95% CI 0.97-1.07) in 2020-2022.

CONCLUSIONS

Courier delivery of ART is a viable alternative to retail dispensing in the South African private sector, as it was associated with higher viral suppression until 2016 and similar suppression rates in recent years. Further research is needed to investigate the potential benefits and drawbacks of courier delivery of ART in both private and public healthcare settings.

Dispensation of outpatient hospital medicines by hospital only versus hospital-community pharmacies collaboration: a cross-sectional study and survey of patient's satisfaction

Goal

To describe the experience of a dispensing model of outpatient hospital medicines (OHM) via collaboration of hospital and community pharmacies, and to explore patient satisfaction with the strategy as compared with the hospital pharmacy only service.

Background

Patient satisfaction is an important component of the quality of health care.

Study

A new model of dispensing OHM was conducted in the Outpatients Unit of the Service of Hospital Pharmacy of Hospital del Mar, in Barcelona, Spain. Participants were patients on stable chronic treatment with clinical or social fragility, immunocompromised patients, and those whose residence was located at a distance from the hospital that justified drug delivery through the community pharmacy. A cross sectional study was done using an ad hoc 14-item questionnaire collecting demographic data, duration of treatment, usual mode of collecting medication, and the degree of satisfaction regarding waiting time for the collection of medication, attention received by professionals, information received on treatment, and confidentiality.

Results

The study population included a total of 4,057 patients (66.8% men) with a mean age of 53 (15.5) years, of whom 1,286 responded, with a response rate of 31.7%. Variables significantly associated with response to the survey were age over 44 years, particularly the age segment of 55-64 years (odds ratio [OR] 2.51) and receiving OHM via the community pharmacy (OR 12.76). Patients in the community pharmacy group (n = 927) as compared with those in the hospital pharmacy group (n = 359) showed significantly higher percentages of 'satisfied' and 'very satisfied' (p < 0.001) in the waiting time for the collection of OHM (88.1% vs. 66%), attention received by professionals (92.5% vs. 86.1%), and information received on treatment (79.4% vs. 77.4%). In relation to confidentiality, results obtained were similar in both pharmacy settings.

Conclusion

Dispensing OHM through the community pharmacy was a strategy associated with greater patient satisfaction as compared with OHM collection at the hospital pharmacy service, with greater accessibility, mainly due to close distance to the patient's home. The participation of community pharmacists could further optimize the care received by patients undergoing OHM treatment.

HIV Testing Disruptions and Service Adaptations During the COVID-19 Pandemic: A Systematic Literature Review

Access to treatment and care in safe clinical settings improves people's lives with HIV. The COVID-19 pandemic disrupted vital HIV programs and services, increasing the risk of adverse health outcomes for people with HIV and HIV transmission rates in the community. This systematic literature review provides a meta-analysis of HIV testing disruptions and a synthesis of HIV/AIDS services adapted during COVID-19. We searched scholarly databases from 01 January 2020 to 30 June 2022 using key terms on HIV testing rates and services during the COVID-19 pandemic. The process of how the included articles were identified, selected, appraised, and synthesised was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We included 17 articles that reported changes in HIV testing during the COVID-19 pandemic and 22 that reported adaptations in HIV/AIDS services. We found that HIV testing decreased by 37% during the search period because of the COVID-19 pandemic. Service providers adopted novel strategies to support remote service delivery by expanding community antiretroviral therapy dispensing, setting up primary care outreach points, and instituting multi-month dispensing services to sustain client care. Therefore, service providers and policymakers should explore alternative strategies to increase HIV testing rates impacted by COVID-19 and leverage funding to continue providing the identified adapted services.

The HIV/AIDS responses pre and during the COVID-19 pandemic in sub-Saharan Africa: A basis for sustainable health system strengthening post-COVID-19

In May 2023, the World Health Organization announced that COVID-19 was no longer a global emergency. The impact of COVID-19 on the provision of HIV/AIDS services was not that severe due to the reprogramming of key resources. For health systems in sub-Saharan Africa to become resilient to future pandemics, lessons should be learned from the successful HIV/AIDS response in the region, and how the HIV/AIDS services were successfully adapted to the COVID-19 pandemic. In this article, we reviewed the 6 World Health Organization health system building blocks on how the best practices from the provision of HIV/AIDS services and the services' response to the COVID-19 pandemic can be used as a basis for restoring and strengthening health systems to offer universal access to quality essential health services. The success of the leadership and governance for universal access to anti-retroviral therapy can be a blueprint for the realization of universal health coverage. Significant efficiencies that resulted in the reduction in anti-retroviral therapy costs can be leveraged to ensure cheaper essential drugs while differentiated service delivery models can be used to improve health service accessibility. New technologies that have proven to be successful in HIV/AIDS care can also be used in the care of other diseases, including disease outbreaks. The strong health information systems developed for HIV programs can be used as a foundation for developing health information systems for the whole health sector while the healthcare professionals trained for the provision of HIV/AIDS services can be trained to provide services for a variety of other conditions.

Planning for decentralized, simplified prEP: Learnings from potential end users in Ga-Rankuwa, gauteng, South Africa

Background

In South Africa, youth experience challenges with oral Pre-Exposure Prophylaxis (PrEP) access and uptake. Taking services out of healthcare settings has the potential to increase reach and overcome these challenges. This paper presents young and older people's preferences for decentralized, simplified PrEP service delivery and new long-acting HIV prevention methods, in Ga-Rankuwa, South Africa.

Methods

Between May and August 2021, both PrEP user and non-user adolescent girls and young women (AGYW), pregnant AGYW, female sex workers, adolescent boys and young men (ABYM), and men who have sex with men (MSM) were recruited to participate in focus group discussions (FDGs) in Ga-Rankuwa, Gauteng. Twenty-two FGDs were conducted. Participants were asked about PrEP uptake, potential acceptability of long-acting HIV prevention products, provision of integrated, simplified, and decentralized services, and digital tools to facilitate access to PrEP and other SRH services. A qualitative approach using inductive thematic analysis was carried out to explore emerging themes on decentralized, simplified delivery and the acceptability of long-acting methods.

Results

Of the 109 participants included in the study approximately 45% (n = 50) were female, the median age was 23 years ± 5.3. A third (n = 37) were current or previous PrEP users, of which, 59.5% (n = 22) collected PrEP refills from the clinic. Decentralized, simplified service delivery was appealing; health facilities, pharmacies and institutions of learning were preferred as service points for PrEP and SRH services, and recreational spaces preferred for dissemination of health information and engagement. ABYM were more open to having recreational spaces as service points. Long-acting Cabotegravir was preferred over the Dapivirine Vaginal Ring due to concerns around perceived side-effects, efficacy, and comfort.

Conclusion

Providing long-acting PrEP methods through decentralized, simplified service delivery was appealing to this population. They provided practical locations for decentralized service provision to potentially increase their engagement with and uptake of HIV prevention and SRH services.

SARS-CoV-2/COVID-19: Clinical Course Among Subjects HIV-1-Infected in Sao Paulo

INTRODUCTION

People living with Human Immunodeficiency Virus (HIV) are under risk for co-infection with SARS-CoV-2. This population may be more prone to complications from COVID-19 due to persistent inflammation caused by HIV and higher incidence of metabolic syndromes, cardiovascular diseases, and malignancies, as well as being considered elderly at 50 years of age. The objective of this study was to report SARS-CoV-2 infection frequency, clinical evolution, and mortality in HIV-positive patients on antiretroviral therapy.

METHODS

The period of inquiry ranged from January to September 2020. Due to the social distance and the suspension of in-person medical care during the time of the investigation, we sent electronic questions about demographic, epidemiological, and clinical data to 403 HIV-infected patients.

RESULTS

Among 260 patients who answered the questionnaire, thirty-nine patients (15%) had suggestive symptoms and were tested for SARS-CoV-2 infection. Of this, 11 had positive results (32.4%) and no patient died of COVID-19 complications. Nine were male (3.4%), and the mean age of the patients with positive results was 43.2 years (± 9.6). 107 patients (41.1%) were over 50 years of age and their mean T-CD4+ cell count was 768. Eleven patients (4.2%) had a detectable HIV RNA viral load and 127 (48.8%) had comorbidities. These variables were not associated with an increased risk for infection.

CONCLUSION

The frequency of SARS-COV2 infection among HIV-infected is similar to the general population, and the clinical course is associated with the presence of comorbidities and not due to the HIV infection. However, new studies should be done to assess if this vulnerable population could answer the vaccine anti-SARS-Cov2.

The effectiveness, feasibility and acceptability of HIV service delivery at private pharmacies in sub-Saharan Africa: a scoping review

INTRODUCTION

Private pharmacies are an understudied setting for differentiated delivery of HIV services that may address barriers to clinic-delivered services, such as stigma and long wait times. To understand the potential for pharmacy-delivered HIV services in sub-Saharan Africa, we conducted a scoping review of the published and grey literature.

METHODS

Using a modified Cochrane approach, we searched electronic databases through March 2022 and HIV conference abstracts in the past 5 years for studies that: (1) focused on the delivery of HIV testing, antiretroviral therapy (ART) and/or pre-exposure prophylaxis (PrEP) at private pharmacies in sub-Saharan Africa; (2) reported on effectiveness outcomes (e.g. HIV incidence) or implementation outcomes, specifically feasibility and/or acceptability; and (3) were published in English. Two authors identified studies and extracted data on study setting, population, design, outcomes and findings by HIV service type.

RESULTS AND DISCUSSION

Our search identified 1646 studies. After screening and review, we included 28 studies: seven on HIV testing, nine on ART delivery and 12 on PrEP delivery. Most studies (n = 16) were conducted in East Africa, primarily in Kenya. Only two studies evaluated effectiveness outcomes; the majority (n = 26) reported on feasibility and/or acceptability outcomes. The limited effectiveness data (n = 2 randomized trials) suggest that pharmacy-delivered HIV services can increase demand and result in comparable clinical outcomes (e.g. viral load suppression) to standard-of-care clinic-based models. Studies assessing implementation outcomes found actual and hypothetical models of pharmacy-delivered HIV services to be largely feasible (e.g. high initiation and continuation) and acceptable (e.g. preferable to facility-based models and high willingness to pay/provide) among stakeholders, providers and clients. Potential barriers to implementation included a lack of pharmacy provider training on HIV service delivery, costs to clients and providers, and perceived low quality of care.

CONCLUSIONS

The current evidence suggests that pharmacy-delivered HIV services may be feasible to implement and acceptable to clients and providers in parts of sub-Saharan Africa. However, limited evidence outside East Africa exists, as does limited evidence on the effectiveness of and costs associated with pharmacy-delivered HIV services. More research of this nature is needed to inform the scale-up of this new differentiated service delivery model throughout the region.

Provider Perspectives on HIV Pre-Exposure Prophylaxis Service Disruptions and Adaptations During the COVID-19 Pandemic in Baltimore, Maryland: A Qualitative Study

The COVID-19 pandemic continues driving unprecedented disruptions to health care provision, including HIV pre-exposure prophylaxis (PrEP) services. We explored service provider experiences promoting and prescribing PrEP to marginalized populations during the COVID-19 pandemic in Baltimore, Maryland. In February to April 2021, we facilitated four virtual focus group discussions with 20 PrEP providers, representing various professional cadres and practice settings. Employing an iterative, team-based thematic analysis, we identified salient enablers and constraints to PrEP promotion, initiation, and maintenance in the COVID-19 era, along with innovative adaptations to PrEP service delivery. Discussants described attenuated demands for PrEP early in the pandemic, exemplified by high PrEP discontinuation rates. This was attributed to changes in clients' sexual behaviors and shifting priorities, including caregiving responsibilities, during the pandemic. Substantial systems-level disruptions impacting PrEP provision were identified, including outreach service suspension, personnel shortages, and facility restrictions on face-to-face visits. Providers emphasized that these disruptions, though occurring early in the pandemic, had protracted impacts on PrEP accessibility. The transition to telemedicine rendered health care services, including PrEP, more accessible/convenient to some clients and expeditious to providers. However, structural barriers to telehealth engagement (telephone/internet access), coupled with limitations of the virtual care environment (difficulty establishing rapport), impeded efforts to equitably promote and prescribe PrEP. Expanding the PrEP outreach workforce and availing alternatives to telemedicine (e.g., community-based PrEP provision, specimen self-collection) could facilitate PrEP care continuity, especially as COVID-19 transitions from an acute to a protracted health crisis.