<p>Does Antiretroviral Therapy Packaging Matter? Perceptions and Preferences of Antiretroviral Therapy Packaging for People Living with HIV in Northern Tanzania</p>

Abstract

Introduction: Despite improvements in treatment (eg, reduction in pill intake), antiretroviral therapy (ART) is dispensed in socially inefficient and uneconomical packaging. To make pills less conspicuous and decrease the risk of being stigmatized, people living with HIV (PLWH) often engage in self-repackagingthe practice of transferring ART from original packaging to alternative containers. This behavior has been associated with ART nonadherence and failure to achieve viral load suppression. While much of the literature on ART packaging has centered around medication adherence, patients stated preferences for ART packaging and packaging attributes that influence the observed ART nonadherence are understudied. Methods: We conducted a qualitative study to elucidate perceptions of ART packaging among PLWH at two large referral hospitals in Northern Tanzania. Interviews were conducted until thematic saturation was reached. Interviews were audio-recorded, transcribed and coded. Results: Of the 16 participants whose data were used in the final analysis, a majority were between 36 and 55 years of age (Mean 45.5 years SD: 11.1), had primary-level education (n=11, 68.8%), were self-employed (n=9, 56.3%), reported that they had self-repacked ART (n=14, 88%), and were taking ART for more than 6 years (n=11, 68.8%). Participants identified three attributes of ART packaging that increased anticipated HIV stigma and prompted self-repackaging, including visual identification, bulkiness, and the rattling noise produced by ART pill bottles. Conclusion: Given the drastic reduction in the number of pills required for HIV treatment, there is an opportunity to not only assess the cost-effectiveness of innovative ART packaging but also evaluate the acceptability of such packaging among PLWH in order to address stigma and improve ART adherence.

Patients’ preferences for antiretroviral therapy service provision: a systematic review

“…Our data comprised of seven studies from the African region [ 34 – 40 ], 10 in the Americas [ 23 , 41 – 49 ], five in Europe [ 50 – 54 ], and one in both the Americas and Europe (USA and Germany) [ 55 ]. Sixteen studies were quantitative [ 23 , 34 , 36 , 38 , 40 , 41 , 43 , 44 , 46 – 48 , 51 – 55 ] and three were qualitative [ 35 , 39 , 42 ]. Four articles reported both qualitative and quantitative findings [ 37 , 45 , 49 , 50 ].…”

“…Qualitative evidence about patient preferences for ART service provision was reported in seven studies [ 35 , 37 , 39 , 42 , 45 , 49 , 50 ]. Data from qualitative studies were also organized into the structure, process, and outcome dimensions of the quality of care [ 22 ].…”

“…you would go to a regimen which means twenty-seven tablets, but there would be not such a high risk for having liver problems, and your renal system would be great, would you do it?’’ [Subject:] ‘‘I would try it, yes.’’ [ 49 ] [Interviewer:] ‘‘So there’s a drug which would cause dizziness, but you could go down to one tablet in the morning, and there’s a drug which doesn’t cause dizziness, but you would have to take two tablets two times daily.’’ [Subject:] ‘‘Two tablets two times a day. I probably would go with the two tablets twice a day.’’ [ 49 ] Pill burden and pill size Structure The problem of swallowing big pills Willingness to accept higher pill burden in exchange for reduced side or long-term effect The patient prefers drugs in the form of a liquid, capsule, or injection to either avoid swallowing pills or to lower the intake frequency with an injection once a week or month Drug administration choice “The other thing is I would like for or want this medicine to be in a convenient 3, 6, or 12-months injections.” [ 42 ] “One 37-year-old female participant raised the possibility of monthly ART injections, stating this would allow them to receive their medication at the clinic and eliminate the risk of unwanted disclosures in their daily lives”[ 35 ] ‘‘Some pills have an after taste once you swallow it, and it can be a severe case to the point where you just do not want to take it.’’[ 49 ] Drug administration Structure Feeling burdened due to daily drug taking Unpleasant drug taste Privacy of drugs Perceived challenges with ART packaging and self-repackaging “It is easy for people to recognize the ARTs when they are in their boxes. Even a child can recognize them.” [ 35 ] “if the medicines are in the bottle, it’s a normal thing to produce some kind of noise, and this is not for ARTs only; it’s for all other types of medicines.” [ 35 ] “Some of us stigmatize ourselves, thinking that if people see us carrying the medicines in the box, they will know that we have HIV.” [ 35 ] “If people see [the pills], they will not respect the person who takes the medicines because they will know your status.” [ 35 ] “Maybe they are afraid to be stigmatized.…”

“…Even a child can recognize them.” [ 35 ] “if the medicines are in the bottle, it’s a normal thing to produce some kind of noise, and this is not for ARTs only; it’s for all other types of medicines.” [ 35 ] “Some of us stigmatize ourselves, thinking that if people see us carrying the medicines in the box, they will know that we have HIV.” [ 35 ] “If people see [the pills], they will not respect the person who takes the medicines because they will know your status.” [ 35 ] “Maybe they are afraid to be stigmatized. You know people live in different circumstances, so it depends on the community that the person lives in and how they perceive the problem.” [ 35 ] “There are some patients who don’t like to be seen by others; they hide even while at the clinic. They hide because they are afraid to be seen by the people they know, especially if it’s their first time.” [ 35 ] “Repackaging can affect the quality of the medicines and the health of the person who takes the medicines because if the medicines have been repacked and are not kept in a proper bottle, that can allow water or air to come into contact with the medicines.” [ 35 ] “The health workers advise us not to repack the medicines because, if we do so, we will make the medicines be less efficient.” [ 35 ] You know we are human beings, and we are all different.…”

“I Wish to Continue Receiving the Reminder Short Messaging Service”: A Mixed Methods Study on the Acceptability of Digital Adherence Tools Among Adults Living with HIV on Antiretroviral Treatment in Tanzania

“…This number was deemed adequate to reach data saturation. 27 , 28 Informed consent was obtained for all participants to take part in this acceptability study, and that this informed consent included consent to publish the participant’s anonymized responses.…”