February 7, 2018

Getting community pharmacists on the differentiated care train in Nigeria: Strengthening integrated delivery of HIV services

Written by the Strengthening Integrated Delivery of HIV/AIDS Services (SIDHAS) Project at FHI 360

Nigeria bears the second highest burden of HIV globally. By the end of 2016, about 30% of the 3.2M persons living with HIV (PLHIV) were receiving antiretroviral therapy (ART) in Nigeria. Most of these clients receive services in public facilities which have very high client loads and limited human resources, resulting in long waiting times, client disaffection and reduced retention on treatment. With the adoption of the Test and Start policy where ART is offered to every HIV positive person irrespective of the CD4, it is expected many more clients will begin ART, further increasing the pressure on the limited facilities and resources and possibly affect retention on ART.

A client refilling her ARV at MEBIK Pharmacy in Surulere LGA, Lagos, Nigeria.

‘Differentiated Models of Care’ (DMOC) is one strategy to mitigate these challenges. DMOC is a responsive, client-centered approach that simplifies and adapts HIV services across the cascade to better serve individual needs and reduce unnecessary burdens on the health system. This allows implementation of alternative models that will decongest health facilities, such as community drug delivery models.

One of the community models adapted by the USAID-funded and FHI 360-led project ‘Strengthening Integrated Delivery of HIV/AIDS Services’ (SIDHAS) is the Community Pharmacy ARV Refill Program (CPARP). Many patients seek care from community pharmacists at private health facilities. The mobilization of community pharmacists to provide differentiated drug delivery services for PLHIV has been positive; this success can be attributed to platforms previously established by Howard University under the USAID-funded FHI 360 led Global HIV/AIDS Initiative Nigeria (GHAIN) project.

The Community Pharmacy ART Refill Program

Under the SIDHAS project, the Community Pharmacy ART Refill Program (CPARP) also became a platform to further expand and sustain the community pharmacist’s role in the provision of HIV chronic care support within the community. The CPARP model of differentiated drug delivery provides routine drug refill services for stable ART clients at a registered private sector community pharmacy, while ensuring that clients are not alienated from standard public sector clinical and laboratory services.

To be eligible for CPARP, clients must meet the following criteria: stable on ART for at least 12 months, VL < 1000, no opportunistic infections, and have a good adherence to therapy. Stable clients receive bi-monthly ARV refills at community pharmacies and return to the health facility semi-annually for clinical and/or laboratory assessments. The pharmacies are more convenient for patients, and pharmacy assignment takes patients’ preferences into account. Each community-based drug refill visit involves provision of one-on-one ART dispensing services by a pharmacist. Refill visits also include medication adherence monitoring and counseling, chronic care screening and health assessment, and adverse drug reactions monitoring, as part of community-based pharmaceutical care services. To promote sustainability for the program, a service fee to be paid by the client was introduced, while the ARV and OI drugs remained free.

Stakeholder engagement was a critical element of this intervention. Key pharmacy stakeholders, such as the pharmacy regulatory body (Pharmacists Council of Nigeria) and professional associations [Pharmaceutical Society of Nigeria (PSN) and Association of Community Pharmacists of Nigeria (ACPN)] were engaged. A memorandum of understanding was signed between PSN and Howard University in support of the collaboration, as well as with each participating community pharmacist. In addition, other critical stakeholders in the State Ministries of Health, State Agency for Control of AIDS, the Hospital Management Boards, ART providers, and ART clients were engaged to get their support for the initiative prior to implementation.

A baseline assessment found that 92% of community pharmacists were willing to provide the services; over 30% of clients were willing to access services at community pharmacists; up to 20% of clients were willing to pay the service charge for drug refills, and health workers were, for the most part, comfortable with devolving clients to community pharmacies for their drug refills.

CPARP Implementation

Following orientations and trainings for participating providers, eligible clients willing to access refills at community pharmacies were devolved to community pharmacies of their choice after signing an informed consent form. After one year of CPARP implementation, a total of 181 community pharmacies in 4 States – Lagos, Rivers, Akwa Ibom and Cross Rivers – are providing ART refill services to a total of 5,846 ART Clients. In some of the devolving health facilities, more than 20% of willing stable clients receive their refills at community pharmacies.

There has been positive feedback on CPARP from hospital staff who report reduced workload; from community pharmacists who report expanded clientele, business and scope; and from clients reporting improved satisfaction. One client stated, “I like the new initiative because it is convenient, I get to discuss with the pharmacist, and I don’t have to spend my whole day anymore at the hospital. I have been attending a General Hospital since 2013 and I never spent less than four hours, unlike this new initiative. I spent twenty to thirty minutes with the pharmacist.” This change dramatically improves quality of life for stable clients receiving ART.

Under CPARP, community pharmacists are not only contributing to the national HIV response by augmenting the limited Human Resources for Health in the public sector, decongesting the health facilities, and expanding the public space for more clients to be placed on life saving ART – they are also providing the opportunity to focus on the client and to vary the frequency, intensity and location of HIV services according to client needs, in line with the principles of differentiated care.

Indeed, getting community pharmacists on the differentiated care train is another step in the right direction towards achieving epidemic control of HIV in Nigeria!