July 20, 2015

Simple but elusive – why are we still talking about HIV drug delivery?

Written by Médecins Sans Frontières

This post originally appeared on PLOS Speaking of Medicine Community Blog here.

Ahead of the International AIDS Society (IAS) Conference held in 2015 in Vancouver, Canada (July 19-22), Helen Bygrave of MSF discusses her frustrations with the lack of implementation of simple, programmatic strategies for improving HIV care.

My main memory of the last IAS conference I attended, held in Vienna in 2010, was a resounding standing ovation for a presentation (including this video) by one of my colleagues working in Mozambique. In a situation where antiretroviral therapy (ART) had not been extensively decentralised, and where drug supply limitations meant people had to attend a clinic every month to pick up their drugs, a simple idea had transformed the way that patients received their HIV care. In short, people living near each other had got together and agreed to take it in turns to pick up each other’s drugs. This resulted in less time spent at the clinic and lower transport costs for patients and an immediate reduction in workload for clinic staff.

Simple, no? So why are people living with HIV/AIDS still queuing up all day every month (or couple of months if they are lucky) outside a clinician’s door to pick up their ART? Many of them feel well, their CD4 counts are fine, and some now even know that their viral load is undetectable. There must be a more efficient way to deliver medications to these patients.

How we deliver ART as a chronic medication has become a hot topic of debate. Examples range from facility-based fast-track through to adherence clubs, community ART groups (CAGS), and, finally, some examples of community-based pharmacies are appearing. These strategies have been variously named alternative-refill strategies, community models of care, and differentiated models of ART delivery. Whatever the title, the strategy must be patient-centred, ie responsive to patients’ needs, and context-adapted – since what might work in a busy clinic in Johannesburg may not work in rural Zimbabwe. My dream is to be able to offer patients a range of options to choose from when collecting their repeat drug refills. Some of the community strategies may even provide opportunities beyond easing drug supply, such as strengthening community engagement with the aim of mobilising local communities, reducing stigma, and enhancing their link with health-care systems.

In light of the ambitious 90-90-90 targets of UNAIDS (by 2020, 90% of all people living with HIV will know their HIV status, 90% of whom will receive sustained antiretroviral therapy, 90% of whom will have viral suppression), how we take the issue of ART supply forward is clearly of great importance, but I wonder whether we are overcomplicating the discussion. Starting up models such as adherence clubs and CAGs requires coordination, but once in place these approaches should alleviate workload and provide opportunities for community engagement. Providing a 3-month supply of drugs could go a long way towards improving access and adherence. It happens in some countries, so why are these systems not shared? There is still insistence on patients seeing a clinician for every visit, often just for a few minutes to write a prescription. How can we persuade our systems to delink the need for sick patients to see a clinician from the need for drug collection by healthy individuals? Flexible hours, like opening the pharmacy a bit earlier and later once a week, or possibly one Saturday morning every month could eliminate the need for some patients to choose between their job and their health. Booking all paediatric patients on the same day each month would allow children and their carers to automatically have some peer support.

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