Providing antiretroviral therapy outside the hospital in a low-resource setting: a pilot study

Abstract Background For nearly three decades, hospitals have been the only source of antiretroviral therapy (ART) for many people living with HIV. Yet, developing countries with the largest burden of HIV commonly lack the hospitals and health-care workers to care for these patients. In 2013, WHO recommended the use of structures outside hospitals for management of HIV. We piloted a community pharmacy ART model in communities with high HIV prevalence in Nigeria. The purpose was to develop a treatment model that could be expanded into an overarching comprehensive response to HIV management, especially in resource-limited settings with weak health systems. Methods Registered community pharmacies linked to participating hospitals were recruited between February 2016 and May 2017. Patients with stable viral loads (≤20 copies/mL) who were willing to have their care devolved to a community pharmacy were referred by trained contact persons at the hospitals. Registered pharmacists at the community pharmacies counselled referred patients and refilled their prescriptions. Biodemographic and clinical data were collected from Feb 25, 2016, to May 31, 2017. The outcome measures were percentage of patients retained in care and adherence to therapy. Mean difference in the viral load at the baseline (≤20 copies/mL) and after 6 months was assessed using a paired sample t-test. Findings 26 community pharmacies and 14 hospitals were included in the pilot. 375 patients (median baseline viral load 19 copies/mL [IQR 19–32]; median CD4 count 460 cells/mL [277–648]) had their care devolved to the community pharmacies. After 12 months, almost all the patients (374 [99·7%] of 375) were retained in care and adherence to medication (measured by prescription refill) was 100%. After 6 months of follow-up, 19 patients received results of their second viral load test, showing no significant difference in the mean viral load between baseline and after 6 months (p Interpretation We show that patients can conveniently access ART in community pharmacies linked to hospitals, with no adverse effects on adherence or viral load. The model will be rolled-out to other regions in Nigeria, and could potentially be applied elsewhere. Funding PEPFAR.