Using private pharmacies for decentralized distribution of antiretroviral therapy: early lessons from seven sub-Saharan African countries

BACKGROUND: Innovative approaches that increase access to antiretroviral therapy (ART) while reducing strain on the health system are needed as countries work toward HIV epidemic control. Decongesting health facilities while ensuring safe and continuous ART access has proven vital in mitigating the spread of COVID-19. The USAID- and PEPFAR-supported Meeting Targets and Maintaining Epidemic Control (EpiC) project explored the feasibility and acceptability of using private pharmacies as refill points for clients on ART.
METHODS: Between June 2020 and January 2021, cross-sectional pharmacy and client surveys were conducted in seven countries (Botswana, Cameroon, Cote d'Ivoire, Democratic Republic of the Congo, Eswatini, Liberia, and Mozambique). Pharmacy surveys (self-administered online or via an interviewer) assessed physical environment, staff qualifications, willingness to dispense antiretroviral (ARV) drugs with proper documentation, and expected compensation. Client interviews (conducted online or in person) examined barriers to access ART, willingness to pay a fee, and interest in refilling at pharmacies.
RESULTS: Of the 1,574 participating pharmacies (24'947 per country), 54%'99% expressed willingness to dispense ARVs and 80%'100% operated longer hours than public facilities, making them potentially more convenient to clients. Most pharmacies had the physical and human resource capacity to provide ARVs, including storage space and staff time required for counseling and documentation. A proportion (6%'60%) of pharmacies were willing to provide ARVs without fees. Among those that would require a fee, expected compensation ranged from USD $0.59 to $4.00 per pickup; higher in Botswana ($4.50'9.00).
A convenience sample of 1,194 ART clients participated across five countries (15'735 per country). In most countries, clients (61%'78%) expressed interest in the pharmacy model. Among those willing to pay for refills (44%'90%), USD $0.60'$1.00 was considered reasonable. Perceived benefits included convenience, friendly staff, guaranteed stock, and privacy. Client concerns included privacy, lack of full service (refilling at a pharmacy then seeking care at a public facility), and cost.
CONCLUSIONS: Private pharmacies have the capacity and are ready and willing to dispense ARVs. Many clients are interested in accessing ART at pharmacies, offering a sustainable opportunity for improving access and reducing the burden on the health system.