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

Expanding the reach of HIV pre-exposure prophylaxis (PrEP) among Kenyan adolescent girls and young women: the acceptability of HIV PrEP integration into post-abortal care services

Adolescent girls and young women (AGYW) seeking post-abortal care (PAC) remain at risk of unintended pregnancies and HIV due to infrequent condom use. Integrating HIV prevention services, such as PrEP, into PAC services offers an opportunity to enhance reach, uptake, and efficiency, particularly in high-burden settings like Kenya. However, data on acceptability, feasibility, and sustainability of PAC clinics as entry points for PrEP is limited. A cross-sectional qualitative study, part of a cluster-randomized trial in 14 Kenyan public and private facilities, explored the integration of PrEP delivery for AGYW aged 15-30 within PAC clinics. Using in-depth interviews, focus group discussions, and key informant interviews, the study gathered perspectives from AGYW, providers, and implementing partners. Guided by the theoretical framework of acceptability, findings revealed receptiveness for the integration as a timely and effective intervention to expand PrEP reach, enhance access , and reduce stigma. Provider competence, their attitudes towards the integration, and AGYWs' confidence in using PrEP were identified as critical influencers. Essentail operational considerations were staffing, availability of safe spaces, commodity management, and efficient reporting systems. The study highlights the acceptability and scalability of integrating PrEP services into PAC while emphasizing the need for strategies to enhance operational efficiency.

Feasibility and Impact of Community Pharmacy and Novel Pick-up Points for Antiretroviral Therapy Pre-exposure Prophylaxis Initiation and Continuation in Low and Middle-income Countries

PURPOSE OF REVIEW

This review assesses recent developments in community access to pre-exposure prophylaxis (PrEP) for HIV prevention in low-and middle-income countries (LMICs). It examines literature on differentiated service delivery (DSD) and alternative delivery modes for PrEP, focusing on the role of community pharmacies and novel pick-up points. Key considerations include barriers to access, potential benefits, and strategies for implementation.

RECENT FINDINGS

Challenges to optimal HIV healthcare delivery persist globally, with LMICs facing greater barriers due to resource constraints and structural obstacles. Community pharmacies and novel pick-up points offer promising avenues to expand access to HIV medication, especially in hard-to-reach populations. However, operational complexities and regulatory frameworks present significant challenges. Recent initiatives, such as collaborative practice agreements and programmes by global health agencies, highlight efforts to integrate community pharmacies into HIV prevention and care delivery. Mobile health clinics and home delivery services have also shown promise in improving treatment coverage. Community pharmacies and novel pick-up points play a crucial role in enhancing access to HIV PrEP in LMICs. Despite challenges related to infrastructure, funding, and regulatory oversight, innovative strategies like DSD and mobile outreach offer opportunities to reach marginalized populations. Real-life examples from LMICs demonstrate the feasibility and effectiveness of leveraging community pharmacies for HIV treatment. However, addressing policy gaps, strengthening pharmacist training, and promoting patient-centred approaches are essential for scaling up access to PrEP. Collaboration between governments, health agencies, and local communities is key to realizing the full potential of community pharmacies in HIV prevention and care.

Uptake and acceptability of oral HIV self-testing in the context of assisted partner services in Western Kenya: A mixed-methods analysis

Integrating HIV self-testing (HIVST) into assisted partner services (APS) has potential to increase identification of people with HIV in the community, but little is known about acceptability of HIVST among partners traced via APS. We assessed characteristics of APS partners testing with HIVST, and factors influencing HIVST uptake and acceptability in a cluster-randomized control trial on APS+HIVST. Using convergent parallel mixed-methods design, we evaluated socio-demographic and behavioral characteristics of APS partners who were offered HIVST or provider-delivered testing, and purposively selected a sub-set of partners for in-depth interviews (IDIs). Descriptive and log-binomial regression analyses were performed controlling for health facility clusters, while IDIs were thematically analyzed applying the theoretical framework of acceptability. Among 3312 partners who were offered HIVST or provider-administered testing through APS, 2724 (82.2%) used HIVST. There was no association between partner demographics and HIVST uptake. HIVST use was less likely than provider-delivered testing among those identified as a casual (adjusted relative risk (aRR) = 0.93; 95% Confidence Interval (CI) 0.88-0.98) or transactional (aRR = 0.90; 95% CI 0.87-0.94) partner compared to those in a defined relationship. HIVST use was slightly lower among those offered the option of an additional kit when compared to those only offered one kit (aRR = 0.93; 95% CI 0.88-0.98). In the IDIs (N = 24), partners reported that HIVST was a viable option for individuals who do not find provider-delivered testing suitable or convenient. For the APS partners, 'intervention coherence', 'self-efficacy', and 'ethicality' presented as most significant theoretical framework of acceptability constructs. APS providers played a critical role in creating HIVST awareness and driving acceptability. Increasing HIVST awareness and providing tailored solutions will empower APS clients optimize their HIV testing decisions. Providers should consider context of the partner's sexual encounter and extend counselling support when recommending HIVST within APS.

Needs-Assessment for an Artificial Intelligence-Based Chatbot for Pharmacists in HIV Care: Results from a Knowledge-Attitudes-Practices Survey

BACKGROUND

Pharmacists need up-to-date knowledge and decision-making support in HIV care. We aim to develop MARVIN-Pharma, an adapted artificial intelligence-based chatbot initially for people with HIV, to assist pharmacists in considering evidence-based needs.

METHODS

From December 2022 to December 2023, an online needs-assessment survey evaluated Québec pharmacists' knowledge, attitudes, involvement, and barriers relative to HIV care, alongside perceptions relevant to the usability of MARVIN-Pharma. Recruitment involved convenience and snowball sampling, targeting National HIV and Hepatitis Mentoring Program affiliates.

RESULTS

Forty-one pharmacists (28 community, 13 hospital-based) across 15 Québec municipalities participated. Participants perceived their HIV knowledge as moderate (M = 3.74/6). They held largely favorable attitudes towards providing HIV care (M = 4.02/6). They reported a "little" involvement in the delivery of HIV care services (M = 2.08/5), most often ART adherence counseling, refilling, and monitoring. The most common barriers reported to HIV care delivery were a lack of time, staff resources, clinical tools, and HIV information/training, with pharmacists at least somewhat agreeing that they experienced each (M ≥ 4.00/6). On average, MARVIN-Pharma's acceptability and compatibility were in the 'undecided' range (M = 4.34, M = 4.13/7, respectively), while pharmacists agreed to their self-efficacy to use online health services (M = 5.6/7).

CONCLUSION

MARVIN-Pharma might help address pharmacists' knowledge gaps and barriers to HIV treatment and care, but pharmacist engagement in the chatbot's development seems vital for its future uptake and usability.

Getting HIV Pre-exposure Prophylaxis (PrEP) into Private Pharmacies: Global Delivery Models and Research Directions

PURPOSE OF REVIEW

To provide an overview of the current state of HIV pre-exposure prophylaxis (PrEP) delivery via private sector pharmacies globally, to discuss the context-specific factors that have influenced the design and implementation of different pharmacy-based PrEP delivery models in three example settings, and to identify future research directions.

RECENT FINDINGS

Multiple high- and low-income countries are implementing or pilot testing PrEP delivery via private pharmacies using a variety of delivery models, tailored to the context. Current evidence indicates that pharmacy-based PrEP services are in demand and generally acceptable to clients and pharmacy providers. Additionally, the evidence suggests that with proper training and oversight, pharmacy providers are capable of safely initiating and managing clients on PrEP. The delivery of PrEP services at private pharmacies also achieves similar levels of PrEP initiation and continuation as traditional health clinics, but additionally reach individuals underserved by such clinics (e.g., young men; minorities), making pharmacies well-positioned to increase overall PrEP coverage. Implementation of pharmacy-based PrEP services will look different in each context and depend not only on the state of the private pharmacy sector, but also on the extent to which key needs related to governance, financing, and regulation are addressed. Private pharmacies are a promising delivery channel for PrEP in diverse settings. Countries with robust private pharmacy sectors and populations at HIV risk should focus on aligning key areas related to governance, financing, and regulation that have proven critical to pharmacy-based PrEP delivery while pursuing an ambitious research agenda to generate information for decision-making. Additionally, the nascency of pharmacy-based PrEP delivery in both high- and low-and-middle-income settings presents a prime opportunity for shared learning and innovation.

"Emotional stress is more detrimental than the virus itself": A qualitative study to understand HIV testing and pre-exposure prophylaxis (PrEP) use among internal migrant men in South Africa

INTRODUCTION

South Africa has one of the highest rates of internal migration on the continent, largely comprised of men seeking labour in urban centres. South African men who move within the country (internal migrants) are at higher risk than non-migrant men of acquiring HIV yet are less likely to test or use pre-exposure prophylaxis (PrEP). However, little is known about the mechanisms that link internal migration and challenges engaging in HIV services.

METHODS

We recruited 30 internal migrant men (born outside Gauteng Province) during August 2022 for in-depth qualitative interviews at two sites in Johannesburg (Gauteng) where migrants may gather, a factories workplace and a homeless shelter. Interviewers used open-ended questions, based in the Theory of Triadic Influence, to explore experiences and challenges with HIV testing and/or PrEP. A mixed deductive inductive content analytic approach was used to review data and explain why participants may or may not use these services.

RESULTS

Migrant men come to Johannesburg to find work, but unreliable income, daily stress and time constraints limit their availability to seek health services. While awareness of HIV testing is high, the fear of a positive diagnosis often overshadows the benefits. In addition, many men lack knowledge about the opportunity for PrEP should they test negative, though they express interest in the medication after learning about it. Additionally, these men struggle with adjusting to urban life, lack of social support and fear of potential stigma. Finally, the necessity to prioritize work combined with long wait times at clinics further restricts their access to HIV services. Despite these challenges, Johannesburg also presents opportunities for HIV services for migrant men, such as greater anonymity and availability of HIV information and services in the city as compared to their rural homes of origin.

CONCLUSIONS

Bringing HIV services to migrant men at community sites may ease the burden of accessing these services. Including PrEP counselling and services alongside HIV testing may further encourage men to test, particularly if integrated into counselling for livelihood and coping strategies, as well as support for navigating health services in Johannesburg.

HIV Self-Testing for Efficient PrEP Delivery Is Highly Acceptable and Feasible in Public Health HIV Clinics in Kenya: A Mixed Methods Study

HIV self-testing (HIVST) has the potential to reduce barriers associated with clinic-based preexposure prophylaxis (PrEP) delivery. We conducted a substudy nested in a prospective, pilot implementation study evaluating patient-centered differentiated care services. Clients chose either a blood-based or oral fluid HIVST kit at the first refill visit. Data were abstracted from program files and surveys were administered to clients. We purposively sampled a subset of PrEP clients and their providers to participate in in-depth interviews. We surveyed (n = 285). A majority (269/285, 94%) reported HIV risk. Blood-based HIVST was perceived as easy to use (76/140, 54%), and (41/140, 29%) perceived it to be more accurate. Oral fluid-based HIVST was perceived to be easy to use (95/107, 89%), but almost all (106/107, 99%) perceived it as less accurate. HIVST improved privacy, reduced workload, and saved time. HIVST demonstrates the potential to streamline facility-based PrEP care in busy African public health facilities.

The South African community pharmacy sector-an untapped reservoir for delivering HIV services

Differentiated service delivery is recommended to improve the uptake of HIV testing and treatment for people living with HIV. One service delivery option yet to be fully capitalised on is community pharmacies. There are approximately 3,580 registered community pharmacies in South Africa. A total of 1,110 (31%) of these pharmacies are corporate chain pharmacies located in cities and towns, the remainder are individually owned, many of which are in less populated poorer settings. Community pharmacies traditionally play a pivotal role in providing health education to the populations they serve and are the first point of contact for people seeking health services, offering more convenient opening hours and shorter waiting times than public sector clinics or private doctors. As a result, patients regularly seek a variety of sexual and reproductive health services at community pharmacies such as self-testing devices for HIV, treatment for sexually transmitted diseases, and an array of reproductive health services, spanning emergency contraception to fertility advice, often signifying HIV risk. This has presented an opportunity for community pharmacies to provide access to HIV prevention and treatment to ensure the targets for HIV services set by international agencies and local government are achieved. Despite obstacles experienced with the expansion of the community pharmacist's role, exploring the potential of pharmacies to mediate the existing challenges with HIV service delivery has emerged as an important resource. Assessing the South African communities' specific HIV treatment needs and willingness to access HIV services from community pharmacies will benefit from additional research.

Effect of 6-Month HIV Preexposure Prophylaxis Dispensing With Interim Self-testing on Preexposure Prophylaxis Continuation at 12 Months: A Randomized Noninferiority Trial

Importance

Daily oral HIV preexposure prophylaxis (PrEP) delivery requires quarterly clinic visits for HIV testing and drug refilling that are costly to health systems and clients.

Objective

To evaluate whether 6-month PrEP dispensing supported with interim HIV self-testing (HIVST) results in noninferior PrEP continuation outcomes at 12 months compared with standard quarterly clinic visits.

Design, Setting, and Participants

This randomized noninferiority trial was conducted from May 2018 to May 2021 with 12 months of follow-up among PrEP clients aged 18 years or older who were returning for their first refill at a research clinic in Kiambu County, Kenya.

Intervention

Participants were randomized 2:1 to (1) 6-month PrEP dispensing with semiannual clinic visits and interim HIVST at 3 months or (2) standard-of-care (SOC) PrEP delivery with 3-month dispensing, quarterly clinic visits, and clinic-based HIV testing.

Main Outcomes and Measures

Prespecified 12-month outcomes included recent HIV testing (any in past 6 months), PrEP refilling, and PrEP adherence (detectable tenofovir-diphosphate concentrations in dried blood spots). Binomial regression models were used to estimate risk differences (RDs), and a 1-sided 95% CI lower bound (LB) of -10% or greater was interpreted as noninferior.

Results

A total of 495 participants were enrolled, with 329 enrolled in the intervention group and 166 enrolled in the SOC group; 330 (66.7%) were women, 295 (59.6%) were in serodifferent relationships, and the median (IQR) age was 33 (27-40) years. At 12 months, 241 individuals in the intervention group (73.3%) and 120 in the SOC group (72.3%) returned to clinic. In the intervention group, recent HIV testing was noninferior (230 individuals [69.9%]) compared with the SOC group (116 [69.9%]; RD, -0.33%, 95% CI LB, -7.44%). PrEP refilling in the intervention group (196 [59.6%]) was inconclusive compared with the SOC group (104 [62.7%]; RD, -3.25%; 95% CI LB, -10.84%), and PrEP adherence was noninferior in the intervention group (151 [45.9%]) compared with the SOC group (70 [42.2%]; RD, 4.96%; 95% CI LB, -2.46%). No HIV seroconversions were observed over the follow-up period.

Conclusions and Relevance

In this analysis of secondary trial end points at 1 year, semiannual PrEP dispensing with interim HIVST resulted in noninferior recent HIV testing and PrEP adherence compared with SOC quarterly PrEP dispensing. This novel model has the potential to optimize PrEP delivery.

Trial Registration

ClinicalTrials.gov Identifier: NCT03593629.