Distribution of antiretroviral therapy through private pharmacies and postal courier services during COVID‐19 in Botswana: acceptability and reach of two out‐of‐facility individual differentiated service delivery models

Abstract

IntroductionThe advent of COVID‐19 has put pressure on health systems as they implement measures to reduce the risk of transmission to people living with HIV (PLHIV) and healthcare workers. For two out‐of‐facility individual differentiated service delivery (DSD) models, we assessed acceptability of antiretroviral therapy (ART) distribution through private pharmacies and reach of home delivery of ART through courier services during the COVID‐19 pandemic in Botswana.MethodsFrom 24 July to 24 August 2020, we conducted exit interviews with PLHIV receiving ART from 10 high‐volume public facilities in Gaborone, and mapped and conducted an online survey with private pharmacies to assess willingness and capacity to dispense ART to PLHIV enrolled in the Botswana national ART program. We piloted ART home delivery from September 2020 to January 2021 in Gaborone and Kweneng East districts for PLHIV accessing ART at two Tebelopele Wellness Clinics. We used cascade analysis to measure the enrolment and eventual reach (percentage of those reached amongst those who are eligible) of ART home delivery.ResultsSixty‐one PLHIV and 42 private pharmacies participated. Of the PLHIV interviewed, 37 (61%) indicated willingness to access ART from private pharmacies and pay BWP50 (∼US$4) per refill for a maximum of two refills per year. All private pharmacies surveyed were willing to provide ART, and 26 (62%) would charge a dispensing fee (range = BWP50–100; ∼US$4–8) per refill. All pharmacies operated 12 h/day, 6 days/week and on public holidays. In the home delivery pilot, 650 PLHIV were due for refills, 69.5% (n = 452) of whom were eligible for home delivery. Of these, 361 were successfully offered home delivery and 303 enrolled (enrolment = 83.9%: female = 87.2%, male = 77.8%, p = 0.013). A total of 276 deliveries were made, a reach of 61%.ConclusionsProviding ART through private pharmacies and home delivery was acceptable in Botswana during COVID‐19. Surveyed pharmacies were willing and able to dispense ART to PLHIV attending public sector facilities for free or for a nominal fee. Additionally, using courier services for ART home delivery is a novel and viable model in countries with a reliable courier service like Botswana and should be scaled up, particularly in urban areas.

The effectiveness, feasibility and acceptability of HIV service delivery at private pharmacies in sub‐Saharan Africa: a scoping review

“…The eight additional studies found that the delivery of ART services at private pharmacies was largely feasible and acceptable [ 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 ]. Three pilot studies in Uganda and Nigeria that assessed the feasibility of pharmacy‐delivered ART refills found that the majority (>90%) of ART clients chose this option and refilled on schedule [ 49 , 51 , 56 ].…”

“…An analysis of in‐depth interviews with stakeholders in South Africa reported that private pharmacies were an instrumental and underexplored component of differentiated HIV service delivery [ 50 ]. In acceptability studies in South Africa and Botswana, ART clients reported that they would be willing to pay for pharmacy‐delivered ART refills [ 57 ], most found these services to be quicker and more convenient than clinic‐delivered refills [ 53 ], and many indicated that this model fit their values, preferences and needs [ 55 ]. However, some clients were concerned with inadvertent disclosure of their HIV status when pharmacy providers refill ART [ 53 ] and potentially lower‐quality communication, education and emotional support received with the delivery of ART refills at pharmacies versus clinics [ 55 ].…”

“…However, we cannot rule out the possibility that these results are due, in part or in whole, to selection bias and/or to the lack of alternative service delivery models in some studies. For example, in many of the pharmacy‐delivered ART refill models, only stable ART clients were given the option to refill at pharmacies, and in some models, clients were not given the option to choose a clinic‐based refill model [ 54 ]. Therefore, additional research among clients who struggle to engage in clinic‐based HIV services is needed to understand whether pharmacy‐based models are a good alternative.…”

“…In the studies that measured acceptability outcomes, our review suggests that while pharmacy‐delivered HIV services are perceived to be largely acceptable, this may be conditional on pharmacy providers’ ability to maintain clients’ privacy [ 46 , 57 , 63 , 65 , 66 ] and provide high‐quality services [ 53 , 55 , 63 , 67 ]. As such, implementers should consider interventions that might increase the privacy of pharmacy‐delivered HIV services, such as integrating self‐screening tools for HIV risk [ 74 , 75 ], delivering antiretroviral drugs in discrete packaging [ 76 , 77 ] and counselling clients in a private setting [ 62 ].…”

“…Many of the studies that measured acceptability outcomes also suggested a link between the acceptability of pharmacy‐delivered HIV services and service affordability [ 41 , 43 , 57 , 61 ]. Determining the cost of these services to clients, pharmacies and third‐party payers, like ministries of health, will be critical.…”