Botswana has quietly begun a pilot project that allows HIV patients to have their medications delivered at their door steps with testing conducted in their place of abode at the height of Covid-19 restrictions.
This is contained in a report titled “Decentralized Drug Distribution (DDD) in Botswana” which shows that the trial started from September 2020 to March 2021 with the support of an organisation identified as FHI 360 and US Agency for International Development (USAID) and the Ministry of Health and Wellness (MOHW).
The report says FHI 360 supported the decentralization of two services in Botswana through the EpiC project; home delivery of ART/ARV using courier services and decentralized viral load (VL) testing through private laboratories. The report says these models were rolled out in Tebelopele Wellness Centers (TWC), which are community clinics.
“The TWC were prioritized to demonstrate proof of concept prior to expansion to public facilities as recommended by the Ministry of Health and Wellness (MOHW) and USAID,” the report says.
According to the report, to ensure uninterrupted access to ART and viral load (VL) testing during the Covid-19 emergency in Botswana, the Meeting Targets and Maintaining Epidemic Control (EpiC) project, funded by the United States Agency for International Development and the U.S. President’s Emergency Plan for AIDS Relief, provided technical assistance (TA) to introduce decentralized drug distribution (DDD) of ART through the private sector.
The report says following USAID’s approval of the scope of work for DDD in Botswana, EpiC held several consultative meetings with the Ministry of Health and Wellness (MOHW) and other stakeholders to seek approval for the introduction of DDD models to the clients of public facilities, beyond the TWCs, and report on progress.
The report shows that a client survey was also conducted to understand the experiences of PLHIV in accessing ART services, and their willingness to use private pharmacies for ART/ARV refills if a fee were required. Of the 62 clients interviewed (26 males, 36 females), the majority (54%) lived within 30 minutes of the clinics where they received HIV services. The average waiting time at the facility for the majority (58%) was one to three hours. Overall, 44 percent expressed interest in using private pharmacies for refills with a dispensing fee, depending on the cost. Among them, 41 percent were willing to pay if the dispensing fee at a private pharmacy was less than 50 BWP (~US$5) per refill twice a year.
The report says 43 pharmacies from three health districts of Botswana were surveyed. Seventy-nine percent were in Gaborone, 12 percent in South East, and 9 percent in Kweneng East. All private pharmacies that responded were willing to provide ART on behalf of public facilities, although 62 percent indicated they would require a dispensing fee of about 60 BWP (range: 50–100 BWP; ~US$5–10) per refill.
Among the 42 pharmacies that responded, all were already dispensing ART to private clients. They reported having adequate space in the waiting areas and a designated private area for counseling. They also operated at least 12 hours per day on weekdays, compared to eight hours per day among public sector pharmacies.
The report shows that Botswana Postal Service (BPS) and FHI 360 signed a service-level agreement with the negotiated cost of the home-delivery (HD) services. It says Standard operating procedures (SOPs) were developed to quickly deploy this model to eligible clients, who were PLHIV who had been on treatment for more than six months, were virally suppressed, and did not need clinical review.
The report says clients were contacted by phone, offered the option of participating, and asked for their consent.
Regarding the success of the pilot project, the report says from September 2020 to March 2021 a total of 371 home deliveries of ARVs were completed, with 48.8 percent of these for KP (key populations) individuals, a total of 1,594 VL tests were conducted via private labs, with 31 percent for KP individuals.
It says viral load testing coverage increased from 83 percent to 96 percent among KP individuals and from 86 percent to 91 percent among the general population adding that 97 percent of KPs who had a viral load test through the private lab and 98 percent of the general population who had a viral load test through a private lab were virally suppressed.
The report further notes that implementation of these models remains at small scale while the Ministry of Health and Health and Wellness approval is pending for EpiC to implement decentralized drug distribution models with public facilities and to implement the private pharmacy model. The achievements presented are from implementation in the three TWC. The Ministry of Health and Health and Wellness approval will enable scale-up to additional public facilities, the report says.
The report the overall success rate for completed deliveries was 93 percent adding that the most common reason for failed deliveries was clients being unreachable by phone on the day of the delivery. A large proportion (30%) of clients who provided a reason opted out of the home delivery model because they preferred to pick up ARVs at the facility. Nineteen percent opted out because they had mobile jobs that made it difficult to have a stable delivery address, and 15 percent cited workplace constraints (e.g., domestic helpers did not want their ARVs delivered when their employers were home).
With regard to costing of decentralized drug delivery and viral load, the report says costing analysis using data from 10 high-volume districts was conducted to model the costs of expanding decentralized drug distribution (home delivery, automated lockers, and private pharmacy models) and decentralizing viral load testing to the private sector.
The results showed cost savings to both the clients and the government, as well as its partners. The analysis found approximately US$500,000 in annual savings to the government if, among the estimated 172,472 people living with HIV (PLHIV) ages 18 and over eligible to enroll in decentralized drug delivery, 41,298 clients (24%) accessed ART/ARV through one of the decentralized drug delivery (DDD) models. This would be a 2.4 percent cost savings to the government and other donors. The savings would increase to 7.5 percent if 40 percent of stable ART clients received treatment through DDD models.
The report says that stakeholder engagement in the planning and conceptualization phases is critical for the adoption of interventions, especially where government approval is needed adding that the private sector (pharmacies, BPS, and private lab networks) is willing to partner with the government and FHI 360 in rolling out DDD models, and they have the capacity to provide quality services and absorb high volumes of clients from the public sector.
The report says provision of capacity building and mentorship for providers is key to having their buy-in on new interventions, rapid deployment, and scale-up adding that there is no one-size-fits-all for service delivery. Despite the availability of home delivery, 30 percent of clients still preferred to come to the facility for their medication pick-up.
The report also says the home delivery model may be more suitable to urban areas where there is better physical planning of roads and infrastructure.