Dispensing antiretrovirals during Covid-19 lockdown: re-discovering community-based ART delivery models in Uganda

Abstract

Background The notion of health-system resilience has received little empirical attention in the current literature on the Covid-19 response. We set out to explore health-system resilience at the sub-national level in Uganda with regard to strategies for dispensing antiretrovirals during Covid-19 lockdown. Methods We conducted a qualitative case-study of eight districts purposively selected from Eastern and Western Uganda. Between June and September 2020, we conducted qualitative interviews with district health team leaders (n = 9), ART clinic managers (n = 36), representatives of PEPFAR implementing organizations (n = 6).In addition, six focus group discussions were held with recipients of HIV care (48 participants). Qualitative data were analyzed using thematic approach. Results Five broad strategies for distributing antiretrovirals during ‘lockdown’ emerged in our analysis: accelerating home-based delivery of antiretrovirals,; extending multi-month dispensing from three to six months for stable patients; leveraging the Community Drug Distribution Points (CDDPs) model for ART refill pick-ups at outreach sites in the community; increasing reliance on health information systems, including geospatial technologies, to support ART refill distribution in unmapped rural settings. District health teams reported leveraging Covid-19 outbreak response funding to deliver ART refills to homesteads in rural communities. Conclusion While Covid-19 ‘lockdown’ restrictions undoubtedly impeded access to facility-based HIV services, they revived interest by providers and demand by patients for community-based ART delivery models in case-study districts in Uganda.

Uptake of community‐ versus clinic‐based antiretroviral therapy dispensing in the Central Chronic Medication Dispensing and Distribution program in South Africa

“…DSD options have been important in minimizing exposures and ensuring continuity of HIV care during Covid‐19 [ 53 , 54 ]. Mitigation efforts have led to increased eligibility, duration of ART refills and consultations, and community‐based delivery options across sub‐Saharan Africa [ 55 , 56 ]. Further, providers in Uganda have reported increased patient uptake of community‐based ART compared to before Covid‐19 [ 56 ].…”

“…Mitigation efforts have led to increased eligibility, duration of ART refills and consultations, and community‐based delivery options across sub‐Saharan Africa [ 55 , 56 ]. Further, providers in Uganda have reported increased patient uptake of community‐based ART compared to before Covid‐19 [ 56 ]. Additional research should focus on Covid‐19 effects on patient outcomes in CCMDD.…”

Out-of-Facility Multimonth Dispensing of Antiretroviral Treatment: A Pooled Analysis Using Individual Patient Data From Cluster-Randomized Trials in Southern Africa

“…34,35 Leveraging and scaling-up the MMD DSD model in new areas and accelerating the enrolment of stable patients in outof-facility peer-supported MMD can adapt the health system to maintain large numbers of patients receiving ART in the context of lockdowns (including possible travel restrictions). 36,37 It is reassuring that unscheduled facility visits were not increased in the intervention arms in this study and the numbers of participants referred back for clinic-based care was low during follow-up, with the vast majority of participants only needing to attend the facility once annually. There were differences in retention between the districts within each country and between countries, suggesting that extrapolation of the results to other sub-Saharan African countries should be done with consideration for client and system challenges that should be identified in each country.…”

“…34,35 Leveraging and scaling-up the MMD DSD model in new areas and accelerating the enrolment of stable patients in out-of-facility peer-supported MMD can adapt the health system to maintain large numbers of patients receiving ART in the context of lockdowns (including possible travel restrictions). 36,37 It is reassuring that unscheduled facility visits were not increased in the intervention arms in this study and the numbers of participants referred back for clinic-based care was low during follow-up, with the vast majority of participants only needing to attend the facility once annually.…”

Pre-exposure prophylaxis (PrEP) uptake and service delivery adaptations during the first wave of the COVID-19 pandemic in 21 PEPFAR-funded countries

“…Although, declines in achievement were noted initially and expected given COVID-19 mitigation strategies and focusing limited healthcare resources to controlling the COVID-19 pandemic, the absolute number of persons initiating PrEP doubled during the COVID-19 period by adapting programs for virtual and community service delivery. Therefore, best practices from countries with successful adaptations such as decentralized service delivery, virtual approaches to aspects of service delivery including training and demand creation, and multi-month dispensing which have also been proven to be effective in other programs should be disseminated PEPFAR-wide to ensure all countries are able to continue PrEP service delivery as a new standard of care and during future waves of the COVID-19 pandemic [ 7 – 9 , 18 – 20 ]. Furthermore, we note that four countries (Lesotho, Rwanda, Namibia, Vietnam) were also able to significantly improve PrEP coverage; these countries may not have been severely impacted by the first wave of the COVID-19 pandemic and some had already made progress towards HIV epidemic control prior to the start of the pandemic [ 21 – 23 ].…”