Uganda’s Community Private Pharmacy Program: Bringing HIV Treatment Closer to Home
For Boniface (49), a security guard in a Kampala suburb, visiting the clinic to refill his antiretroviral treatment (ART) always caused trouble for him with his boss because it often meant long hours away from his duty station. Due to the demand at the clinic, even arriving early would not help—he still spent half the day or more at the facility. “I would feel anxious whenever I had to go for my refills,” he says. “Once, my boss asked, ‘Which disease is that, and how come you never get healed?’ And it was hard to explain.”
He was dealing with lost wages from missed hours, and he was on the verge of being dismissed entirely. All that changed, however, thanks to the Community Private Pharmacy ART Refill Program (CPPARP), which provides him the flexibility to pick up his drug refills from a point closer to his workplace at his own convenience. “I can’t believe it,” he says. “I can call the nurse and schedule an appointment. I can jog here and back. I can come after work…My boss even thinks I’m now healed because I no longer ask to go to the clinic.”
CPPARP: A Differentiated Model of Care
CPPARP, which began in November 2016, is a voluntary differentiated HIV care model involving the use of private pharmacies within Kampala to serve as drug pick-up points for stable patients and designed to ease overcrowding and patient load at the primary health facility. An initiative of the CDC-funded Infectious Diseases Institute (IDI), which provides care and treatment services to over 200,000 urban and rural HIV patients through its Centre of Excellence clinic at Mulago National Referral Hospital,, the program was is implemented in partnership with the Kampala City Council Authority (KCCA), the entity responsible for overseeing most of the city’s public health facilities. CPPARP focuses on the highest volume facilities across Kampala, which each see an average of 250-350 HIV patients daily. This number has increased with the advent of the country’s “Test and Treat” policy which calls for immediate initiation on ART of all HIV-positive individuals upon diagnosis—regardless of disease stage or CD4 cell count.
“Many HIV patients feel healthy and need to be at work,” says IDI’s Kampala Regional Manager Martin Ssuuna, MD. “The health care workers are wondering why they have to keep attending to the stable clients while the very sick patients are not getting the attention they deserve because the health facilities have become too congested with patients.” “Our data also showed that we had lots of ‘lost to follow-up’ patients, and when we traced them through phone interviews, the commonest reason was long waiting hours. Acknowledging that most of our patients are pre-occupied urban dwellers struggling to make a living, we devised this strategy to improve on our service delivery. We wanted to free up some space and time for clinicians to attend to the complicated cases; ensure timely access to ART for those who have yet to start, and improve the convenience of patients in receiving their medications.”
Forging the Partnership
To establish this partnership, IDI consulted with the Uganda National Drug Authority (NDA) and the Pharmaceutical Society of Uganda (PSU) for guidance on reputable pharmacies. “We had to be careful. We were going to put Government of Uganda drugs in private pharmacies,” explains Shamim Nakade, IDI Pharmacy Team Lead. “We particularly looked out for pharmacies that are registered with an operating license, have space to accommodate extra clients, are accessible by public means or have sufficient parking space for ‘drive-in’ clients, have pharmacy packaging material, and maintain a supervising pharmacist.”
IDI then met with the pharmacy directors to discuss the simple, scalable intervention that was not going to involve any exchange of money, but rather some accrued benefits such as:
- Increased patient traffic and potentially increased sales on other drugs as well as related commodities
- Marketing for the pharmacy through use of their brand to repackage the HIV medications. Patients did not want special packaging material for their drugs.
- Additional seating and a water dispenser in the waiting area provided by the program
- A nurse dispenser (paid for by IDI) to conduct basic patient assessment, dispense drugs or triage the patient back to the facility in case of a need for specialized care—who can also support the pharmacy staff more broadly.
So far, six private pharmacies have been accredited to serve the four high-volume health facilities identified. Each patient is assigned a pharmacy of their choice where they are expected to schedule their appointments to receive their drug refills every two months. Nonetheless, they are expected to report back to the original KCCA health facility twice a year, though they are also free to report to the facility in the case of complaints as needed.
Matching the Right Patients with CPPARP
Under the CPPARP model, those eligible for participation in the program are stable clients who have received ART for at least one year, have no adverse drug reactions that require regular monitoring and no current opportunistic infections, are not pregnant or breastfeeding, demonstrate good understanding of lifelong adherence, and are virally suppressed. They should be adults (19 years and above) with no child in care, who are on standard first-line ART (that is, the drug regimen on which a patient is initially started), have honored their appointments for the last six months, and provide reliable telephone and physical location details.
“When a client gets unsuppressed, pregnant, consecutively misses two scheduled appointments, or develops a major opportunistic infection, we hand them back to the facility,” Nakade says. “We now have 8,478 patients under the program [as of December 31, 2018].” The program, which is marketed through health education sessions, patient brochures, and testimonies from satisfied clients, incentivizes treatment adherence and health-seeking behaviors for clients and corporate social responsibility for the pharmacies. .
A Model for Success
“Because of the high demand, we are now insisting on a second suppressed viral load (VL) test result for any client to be enrolled on the program. This, in turn, is encouraging HIV patients to demand for VL monitoring tests,” Ssuuna reveals. “But waiting time at the main health facilities has decreased to two hours, and, as we task-shift, we hope to lower it further. We are also observing improved treatment adherence and better care for the critical patients because of more time with the health workers, who are additionally less stressed.”
It is not only patients who want in on CPPARP. IDI is now increasingly being approached by pharmacies for accreditation, which is good for patients on the waiting list. And while this kind of success is extremely encouraging, there are still some challenges even to this model. “Managing patient demands and expectations is a challenge,” Nakade notes. “They want refills of longer than two months, want to send other people, and want us to extend the pharmacy working hours beyond 8:00 pm—even though the dispensing nurses already work longer than their counterparts in the public facilities. HIV patients enrolled in other programs are also requesting to be transferred to the IDI sites so they can access this service, which increases the overall patient load.”
But, ultimately, for clients like Milka (48), a single mother of five who sells vegetables at a market in a Kampala suburb, the experience is entirely positive. “I spend 5-10 minutes at the pharmacy,” she says, smiling. “The nurse is very attentive and you can ask many questions. At first, we thought CPPARP was a conspiracy to get rid of us, but I have seen how well it works.”