Standardized monitoring of antibiotic use underpins the effective implementation of antimicrobial stewardship interventions in combatting antimicrobial resistance (AMR). To date, few studies have assessed antibiotic use in hospitals in Uganda to identify gaps that require intervention. This study applied the World Health Organization’s standardized point prevalence survey methodology to assess antibiotic use in 13 public and private not-for-profit hospitals across the country. Data for 1077 patients and 1387 prescriptions were collected between December 2020 and April 2021 and analyzed to understand the characteristics of antibiotic use and the prevalence of the types of antibiotics to assess compliance with Uganda Clinical Guidelines; and classify antibiotics according to the WHO Access, Watch, and Reserve classification. This study found that 74% of patients were on one or more antibiotics. Compliance with Uganda Clinical Guidelines was low (30%); Watch-classified antibiotics were used to a high degree (44% of prescriptions), mainly driven by the wide use of ceftriaxone, which was the most frequently used antibiotic (37% of prescriptions). The results of this study identify key areas for the improvement of antimicrobial stewardship in Uganda and are important benchmarks for future evaluations.
BackgroundFor individuals who face challenges accessing clinic-based HIV pre-exposure prophylaxis (PrEP), differentiated service delivery models are needed to expand access and reach. During a pilot study testing a novel pharmacy-delivered oral PrEP model in Kenya, we used routine programmatic data to identify early implementation barriers and actions that providers and study staff took in response to the barriers.MethodsWe trained pharmacy providers at five private pharmacies in Kisumu and Kiambu Counties to initiate and continue clients at risk of HIV acquisition on PrEP for a fee of 300 KES per visit (∼$3 USD) using a prescribing checklist with remote clinician oversight. Research assistants stationed at the pharmacies completed weekly observation reports of pharmacy-delivered PrEP services using a structured template. We analyzed reports from the first 6 month of implementation using content analysis and identified multi-level early implementation barriers and actions taken to address these. We then organized the identified barriers and actions according to the Consolidated Framework for Implementation Research (CFIR).ResultsFrom November 2020 to May 2021, research assistants completed 74 observation reports (∼18/pharmacy). During this period, pharmacy providers screened 496 potential PrEP clients, identified 425 as eligible for pharmacy-delivered PrEP services, and initiated 230 (54%) on PrEP; 125 of 197 (63%) clients eligible for PrEP continuation refilled PrEP. We identified the following early implementation barriers to pharmacy-delivered PrEP services (by CFIR domain): high costs to clients (intervention characteristics), client discomfort discussing sexual behaviors and HIV testing with providers (outer setting), provider frustrations that PrEP delivery was time-consuming and disruptive to their workflow (inner setting), and provider hesitancy to deliver PrEP due to concerns about encouraging sexual promiscuity (characteristics of individuals). To help address these, pharmacy providers implemented a self-screening option for behavioral HIV risk assessment for prospective PrEP clients, allowed flexible appointment scheduling, and conducted pharmacy PrEP trainings for newly hired staff.ConclusionOur study provides insight into early barriers to implementing pharmacy-delivered PrEP services in Kenya and potential actions to mitigate these barriers. It also demonstrates how routine programmatic data can be used to understand the early implementation process.
Background. Access to safe, effective, quality and affordable essential medicines has become a key agenda at national and international levels following the adoption of the Sustainable Development Goals (SDG). This agenda is especially important in African countries where numerous studies have found high levels of medicine unavailability and unaffordability. In 2003, the World Health Organization (WHO)/ Health Action International (HAI) published a manual for assessing medicine availability and affordability. To date, there has not been a systematic study appraising medicine affordability and availability studies in the Africa region that identifies the methodologies and measures used to measure and monitor progress. Methods. We conducted a systematic scoping review of studies assessing medicine availability or affordability conducted in the WHO Africa region in the years 2009-2021. Results. 244 articles met our eligibility criteria. A majority (87%) of the articles reported descriptive studies, while 11% reported interventional studies. More than two-thirds (68%) reported studies conducted in four countries in eastern Africa. The most commonly studied medicines were antiparasitic and anti-bacterial medicines. The most commonly used measures of medicine availability were whether a medicine was in stock on the date of a survey, whether stockouts occurred during a particular period, whether a medicine was on a stock list, amount of stock available, respondent self-reported availability and prescription refill data. Of the 59 articles that included affordability measures, 39 compared the price of the medicine to the daily wage of the lowest paid government worker. Other affordability measures were patient self-reported affordability, capacity to pay based on individual income and expenses, and comparing medicines prices with a population-level income standard (such as minimum wage, poverty line, or per capita income). Conclusion. Our results indicate substantial adoption of the medicine availability and affordability assessment methodology recommended by WHO/HAI, but also revealed a promising set of alternative methods and measures. Our review also indicated a need for greater focus on medicines for certain non-communicable diseases, including anti-neoplastics, greater geographic diversity in the countries where these studies are conducted, and more interventional studies to identify interventions for improving access to medicines in the region.
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