We used the Practical, Robust Implementation and Sustainability Model to evaluate implementation of South Africa’s Central Chronic Medicine Dispensing and Distribution (CCMDD) program, a differentiated service delivery program which allows clinically stable HIV-positive patients to receive antiretroviral therapy refills at clinic- or community-based pick-up points. Across ten clinics, we conducted 109 semi-structured interviews with stakeholders (pick-up point staff, CCMDD service providers and administrators) and 16 focus groups with 138 patients. Participants had highly favorable attitudes and said CCMDD decreased stigma concerns. Patient-level barriers included inadequate education about CCMDD and inability to get refills on designated dates. Organizational-level barriers included challenges with communication and transportation, errors in medication packaging and tracking, rigid CCMDD rules, and inadequate infrastructure. Recommendations included: (1) provide patient education and improve communication around refills (at the patient level); (2) provide dedicated space and staff, and ongoing training (at the organizational/clinic level); and (3) allow for prescription renewal at pick-up points and less frequent refills, and provide feedback to clinics (at the CCMDD program level).
We evaluated COVID-19 stigma and medical mistrust among people living with HIV in South Africa. We conducted telephone interviews with participants in a prospective study of a decentralized antiretroviral therapy program. Scales assessing medical mistrust, conspiracy beliefs, anticipated and internalized stigma, and stereotypes specific to COVID-19 were adapted primarily from the HIV literature, with higher scores indicating more stigma or mistrust. Among 303 participants, the median stigma summary score was 4 [interquartile range (IQR) 0–8; possible range 0–24] and 6 (IQR 2–9) for mistrust (possible range 0–28). A substantial proportion of participants agreed or strongly agreed with at least one item assessing stigma (54%) or mistrust (43%). Higher COVID-19 stigma was associated with female gender and antecedent HIV stigma, and lower stigma with reporting television as a source of information on COVID-19. Further efforts should focus on effects of stigma and mistrust on protective health behaviors and vaccine hesitancy.
Introduction: South Africa's government-led Central Chronic Medication Dispensing and Distribution (CCMDD) program offers people living with HIV the option to collect antiretroviral therapy at their choice of community-or clinic-based pickup points intended to increase convenience and decongest clinics. To understand CCMDD pick-up point use among people living with HIV, we evaluated factors associated with uptake of a community-versus clinic-based pick-up point at CCMDD enrolment. Methods: We collected baseline data from October 2018 to March 2020 on adults (≥18 years) who met CCMDD clinical eligibility criteria (non-pregnant, on antiretroviral therapy for ≥1 year and virologically suppressed) as part of an observational cohort in seven public clinics in KwaZulu-Natal. We identified factors associated with community-based pick-up point uptake and fit a multivariable logistic regression model, including age, gender, employment status, self-perceived barriers to care, selfefficacy, HIV-related discrimination, and perceived benefits and challenges of CCMDD. Results and Discussion: Among 1521 participants, 67% were females, with median age 36 years . Uptake of a community-based pick-up point was associated with younger age (aOR 1.18 per 10-year decrease, 95% CI 1.05-1.33), being employed ≥40 hours per week (aOR 1.42, 95% CI 1.10-1.83) versus being unemployed, no self-perceived barriers to care (aOR 1.42, 95% CI 1.09-1.86) and scoring between 36 and 39 (aOR 1.44, 95% CI 1.03-2.01) or 40 (aOR 1.91, 95% CI 1.39-2.63) versus 10-35 on the self-efficacy scale, where higher scores indicate greater self-efficacy. Additional factors included more convenient pick-up point location (aOR 2.32, 95% CI 1.77-3.04) or hours (aOR 5.09, 95% CI 3.71-6.98) as perceived benefits of CCMDD, and lack of in-clinic follow-up after a missed collection date as a perceived challenge of CCMDD (aOR 4.37,. Conclusions: Uptake of community-based pick-up was associated with younger age, full-time employment, and systemic and structural factors of living with HIV (no self-perceived barriers to care and high self-efficacy), as well as perceptions of CCMDD (convenient pick-up point location and hours, lack of in-clinic follow-up). Strategies to facilitate community-based pick-up point uptake should be tailored to patients' age, employment, self-perceived barriers to care and self-efficacy to maximize the impact of CCMDD in decongesting clinics.
To the Editor: Since the start of the COVID-19 pandemic, there have been significant concerns about disruptions to the continuum of HIV care worldwide. [1][2][3][4][5][6] Expansion of differentiated service delivery has been proposed as one strategy to maintain safe access to HIV care, [7] with increased use of differentiated services reported during the early stages of the COVID-19 pandemic. [8] Decentralised HIV care delivery programmes providing out-of-facility care, in particular, decrease frequency of visits to healthcare facilities, [7] minimising exposures to COVID-19 and allowing continuity of HIV care during lockdowns and other restrictions. However, providing decentralised, out-offacility HIV care during the pandemic requires access to COVID-19 information, capacity to screen patients for COVID-19 symptoms and adequate supply of personal protective equipment at all points of care. Supporting staff and ensuring access to these resources may be more difficult in community-based sites.We sought to evaluate perceptions of personal and facility preparedness among healthcare workers at primary health clinics and community-based pick-up points participating in a decentralised antiretroviral therapy (ART) delivery programme in KwaZulu-Natal, South Africa. The Central Chronic Medicines Dispensing and Distribution programme allows stable, virologically suppressed patients to collect ART at community-based pick-up points, such as private pharmacies and churches. [9] We administered a telephone questionnaire to a convenience sample of staff in primary health clinics during April and May 2020 and staff in clinics and community-based pick-up points in August 2020 to assess access to COVID-19 information, available resources and perceived personal and facility preparedness.We completed interviews with 112 clinic staff (n=49 in April -May 2020; n=63 in August 2020) and 24 pick-up-point staff. Most clinic staff were healthcare providers (e.g. nurses, medical officers) or ancillary providers (e.g. counsellors), while pick-up-point staff were mainly pharmacists and dispensing clerks. Respondents primarily perceived an increased need for prevention procedures and supplies (59%) as a challenge to their work during April -May, and COVID-19 infection risk (48%) in August. By August 2020, nearly all clinic staff reported access to resources (94%) and space (100%) to screen patients for COVID-19, while significantly fewer pick-up-point staff reported access to these tools (54%; p<0.001). In August 2020, pick-up-point staff, compared with clinic staff, reported significantly lower rates of access to information to perform work duties during the COVID-19 pandemic (67% v. 94%; p=0.003), perceived facility preparedness to work with COVID-19 patients (54% v. 81%; p=0.016) and access to the necessary protective equipment (50% v. 89%; p<0.001). Our results suggest that staff working in out-of-facility, communitybased sites participating in decentralised HIV care programmes do not feel as prepared to work with patients during the COVID...
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