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Eluke Francis Blessing, FHI 360 Nigeria
Valery Nzima Nzima
Valery from USAID Cameroon
Akpakwu Augustine, HUGIN, Nigeria
Nana Fosua V. A. Clement
Nana Fosua Clement, FHI 360 LINKAGES Liberia
Geoff Soybel - USAID HQ - USA
Omeh Idoko Onuche, Howard University (HUGIN), Nigeria
Good day, Olubusola Ojo APIN. Public Health Initiatives. Nigeria
Emmanuel Ndubuisi Center For Clinical Care and Clinical Research Nigeria
Irina Yacobson, FHI 360, NC
Ichima Oche, CCCRN Nigeria
Good day all. Balogun Stephen Taiye from IHVN, Abuja Nigeria
Andrew Maranga EpiC, Mozambique
Dr Mwanza Wa Mwanza
Mwanza Wa Mwanza, Centre for Infectious Disease Research in Zambia (CIDRZ). Zambia
Laura Muzart, FHI 360 ESwatini. Afternoon everyone!
Good day everyone, Philomina Desben from Nigeria
Dr. Estella Birabwa USAID Uganda
Festus Agu, HU, Nigeria
Esther Umana, Howard University ,Nigeria
Giuliana C. Walker (Chemonics)
Hi everyone, Giuliana Canessa Walker from Chemonics
Mohammed Usman Ndabida
Good afternoon everyone, Mohammed Usman Ndabida. General Hospital Tungan Magajiya, Rijau, Niger state
Elfriede Agyemang, CDC Atlanta
Ivan Luswata - Joint Medical Store (JMS) -Uganda
Hello. Hally Mahler, project director EpiC at FHI 360.
Chris Akolo, EpiC, FHI 360, Washington
Tiffany Lillie, Senior Technical Advisor , EpiC/LINKAGES
Rose Wilcher, LINKAGES and EpiC
Hi everyone, Bhagawan from LINKAGES Nepal
Hello! I am Justin Mandala, Senior Technical Advisor. HIV Department, FHI 360, Washington DC
Hi Everyone, Dismas Gashobotse, LINKAGES Burundi
Good afternoon everyone. Dorothy OQUA Howard University, Nigeria
Please type any questions in the chat. we want this to be an active discussion. Also feel free to share any experience you have on this topic
What percentage of your patients are on the Automated model?
@Busola, we don't want to preempt the next session in 2 weeks which is on automated models and will be led by Right to Care who are implementing this model . We have included a link to the DDD guide where there is more written about the models.
Is there any research on client experiences with the 3 models?
Ok that's fine, thanks
What are the criteria for defining client stability in the region?
@ Tracy there are some studies but as you can imagine, not randomized trials but a lot of implementation lessons. Some of the presenters have and will share some references.
The decentralized distribution model is a good initiative.Am a community Pharmacist who served last year with the CIHP in Gombe State, where we use the Cluster distribution model where drugs are distributed in small groups based on location which was mostly for the rural areas.
@Omeh-Client stability is based on the national guidelines of the specific country.
Mohammed Usman Ndabida
Community pharmacies have a role to play in providing community ART services and reducing burden on patients and health care providers. But most community pharmacy in Nigeria don't have enough trained staff.
Hi everyone. Nicholas Kisyeri DDD coordinator with FHI360 in Eswatini
In the Uganda model, is there payment for the services provided (to the pharmacist and the Nurse-dispenser). If yes, who pays?
Do you have one pharmacy receiving clients from different health facilities or is each pharmacy linked to only one facility?
How much do you pay nurse dispenser every month?
What were the sustainability considerations for the IDI program? Were there any conversations about transitioning responsibility to private sector staff vs seconded IDI staff?
@ Martin,99% suppression is excellent. Are there people who have dropped out?
@Martin, do the clients come for refill visits unprompted or they are given refill reminders always before they come for their refills?
Given that you post the nurse-dispenser to the pharmacy, does it mean that this is the only personnel who has contact with the patient? is the nurse available throughout the pharmacy operating hours?
it will be good to link data from the community pharmacy to the health facilities real time.How do you want to achieve this.
@Martins, how have the clients been accessing viral load testing?
what cost would the insurance company be expected to cover?
What are the key lessons you have learnt when implementing the pharmacy refill model in Uganda?
@Martin: are you also implementing MMD? Are patients sill required to come to health facilities for their medical check-up? I guess yes, how often?
in Uganda, what was the acceptability for private pharmacies to offer ARVs without any incentive ? or you pay something for nurses.
accreditation of Pharmacy to offer ARVs. this mean that the national program was not involved in the process and at that stage pharmacies have to be accredited ?
How do you make sure the ARVs are not sold or leaked?
@Onuche Omeh - The private pharmacies are supporting this model as CSR in anticipation for increased sales of non-ARV drugs from increased client traffic. Whereas the private pharmacy meets costs for the supervising pharmacist, the nurse-dispenser's salary if covered by PEPFAR through IDI.
For Uganda and Nigeria. How did you empower the Community pharmacies to carry out this functions in term of knowledge and motivation.
@Tinei - There is an existing MOU signed between the community pharmacy, their professional body, Howard University and finally, the pharmacy regulator that licenses the pharmacist. There will heavy backlash on the pharmacy if there is unprofessional management of the drugs. We have no had any experience of stealing of the drugs
How were patients assigned to pharmacies.....How did they make the choice of which pharmacy to go
@ Tinei, you raise a good questions about selling drugs. The fact that there may be people willing to buy ARVs means that the private sector has a role. That there may be people willing to pay for services.
Peter, do you have similar data on how on time refills were affected at the public facilities (for non-devolved clients)?
@Andrew Muranga - Each of the 4 facilities is tagged to a specific pharmacy in order to ensure ease of managing the logistics. Clients from a given facility are assigned a pharmacy that is tagged to their parent facility.
@Olubukola - Each facility has a list of community pharmacies linked to it. Clients are at liberty to chose the community pharmacy of their choice from the approved list for the facility.
What is the fee patients have to pay in CPARP?
@Peter: What has been the biggest incentive for private pharmacies to participate in the model
@Olubokola, the program has a directory of pharmacies in each participating hospital and the clients choose the pharmacy of their choice.
@ Carthy - N1000 naira (approximately $3) per refill visit which could be every three months or six months
@Cathy Michel - Each nurse dispenser earns USD500 (gross) per month. This cost is met by PEPFAR through IDI.
How are you addressing issues around stigma since clients are now accessing ARVs at community pharmacies?
CPARP: On average, how much time does the pharmacy personnel spend per patient considering the provision of service/care and documentation? Are you using manual or electronic methods of data management and reporting?
CPARP has a good model for sustainability. There will always be a group of clients with the capacity to pay for convenience and comfort.
@Chris, important question about stigma. Some of the client surveys we are doing as part of scale up show that people feel that there is less stigma in the pharmacies than in the public facilities. But hope the presenters can share
@Onuche is the N1000 per refill born by the Patient or the implementing partner
CPARP- Can clients be enrolled through Community Pharmacies? Especially those who have refused to enroll in Facility
@Peter and Martin, do you have a training package for private pharmacies?
@ Tinei. the community pharmacy only receives stock of drugs based on prescriptions provided for each client assigned to it. The community pharmacy does not stock bulk drugs and for any client to receive refills they must go back to the hospital for a new prescription. There is a robust drug inventory control led by the hospital pharmacist.
Good day all....sorry to be coming in late.
this CPD model is applicable in rural area ? or is only in urban area ?
Noted, thank you.
@Hannah, yes. As a program we track refill rates at a granular level for all supported sites. Though not shared in the presentation, Covid19 pandemic and a HCW strike action that also occurred at the time significantly affected hospital refill rates
for CIDRZ - How many patients used this model for PrEP? was the clinical model the same (how many facility visits per year? vs how many months of prep per refill?)
@Hannah Marqusee - Following the successful demonstration of the PPP, the Ugandan Ministry of Health has decided to scale up this model across the country. Under the expanded phase, only pharmacy HR will be used, and the cost for each client visit will be covered through either the client, Gov't, PEPFAR, or insurance service provider. Discussions are ongoing currently.
CIDRZ- did each pharmacy have a similar patient load? What was the effective per patient cost of the K1000 paid to the pharmacies?
@Clement, I think the model would work everywhere there is a pharmacy. We are in the process of mapping the locations of pharmacies in different countries and using this information to see how to advise on placement of services. In very rural areas, I think other models such as PODI etc can be used
@Justin, the biggest incentive in my view is that the stakeholders are put in the driving seat as far as implementation is concerned, they jointly conceptualize, implement and monitor CPARP as owners
The 60$ were they per person attended ?
@Moses Bateganya - A few clients have dropped out largely because they've changed residence and moved to rural areas. The others are females who get pregnant, and therefore have to return to facility-based care for comprehensive EMTCT services.
@Olubukola CPARP trained the community pharmacists on Pharmaceutical Care in HIV, SOPs and M&E tools for documentation. Their support staff were also trained on reduction of stigma and discrimination. The pharmacy must have a room for confidential counselling to participate in the program.
@Moses, yes sir we do have an integrated training package for pharmacists. We also have training for Community Pharmacy personnel on Confidentiality, Stigma and Discrimination
@Melchiade-The $60 is a monthly stipend
@Justin. In addition, feedback from some Community Pharmacies indicate that participation in CPARP provides an opportunity for them to render Quality ART services, increasing the scope of their service delivery to the Community
@Chima Ugwu - The clients come in on scheduled appointment days. A few (2%) tend to walk in unscheduled and this is largely due to unforeseen work-related engagements.
for CIDRZ. How did you come up with the 90 USD per month (which is now 60 USD)
@Andrew the Community Pharmacist spends an average of 10-20mins to provide refills and documentation per client. For the documentation, electronic and manual models are currently being explored. However, with the ongoing assimilation of all our clients on the electronic platform, we shall switch entirely to the electronic platform.
Pharmacist reported increased footfalls in terms of clients coming along with families and friends and buying other medications in addition to receiving their drugs for ART.
The CPD can be implemented in the rural area if there is a need (high numbers of patients + overcrowding at the facility) plus the availability of pharmacies in the rural area. From the literature review it was found that Community adherence groups were more effective in the rural area than in the urban area
Dr Mwanza Wa Mwanza
Thanks Clement for the question. the CPD model could be implemented in rural area as long there is existing community Pharmacies that meet the requirements
For all presenters - did you see trends in the type of patients that opted in to the model? were they higher income/formally employed or a mix? any age trends?
@Andrew Muranga - The nurse dispenser primarily attends to the PLHIV but whenever free he/she attends to the other regular pharmacy customers. The nurse works extended hours until 8:00pm when she locks up the cabin in which the ARVs are stored. In her presence, other pharmacy staff are also encouraged to serve the PLHIV. The dispenser has 100% control of the ARVs within the private pharmacy premises.
Dr Mwanza Wa Mwanza
Thanks Hannah, We did not have any PrEP client. the clinical models were different from this model. 4 facility clinical visits( 2 clinical and 4 pharmacy visits) PrEP was given monthly with a maximum of 3 month dispensation.
good presentation Bola,pls what is the incentive to the CPs in this model
In Nigeria IHVN. How much do you pay per month in a subsidy ?
To Bola and Peter, for states that transitioned between CDC and USAID, how did that affect reporting? were CPs able to maintain the same reporting systems (apps or paper)?
how is data from the CPs shared with the facilities especially the LMIS data
Dr Mwanza Wa Mwanza
Thanks Hannah, the work load was different from one pharmacy to another. We did not do the cost evaluation analysis since the model was stopped.
Bola pls how does the ARVs get to the Community pharmacists
@all presenters: is there any specific experience serving key populations? Are key populations also willing to be devolved to some of these private or community pharmacies?
CPARP pharmacies in Nigeria are now being used for distribution of HIV self test kits for their index clients and the general population..
Dr Mwanza Wa Mwanza
Thanks Melchiade, the 60$ was monthly incentive regardless of the number of clients seen.
@dorothy- is the HIVST subsidized by pepfar or for sale?
To all the presenters, your presentations were very educating and shows that CPARP is the way to go for clients satisfaction.
No, these are Ora Quick test kits that the community pharmacists bought from the Ora sure agent in country using their own funds following our discussions with them.
Dr Mwanza Wa Mwanza
Thanks Cathy, the 90$ was the amount that were paid to any volunteer working in the Health facility or at community level
In the Ugandan model - the pharmacies currently only provide ART, Septrin, Dapsone and INH/TPT at no cost. Plans are under way to expand this package to include HIVST, PEP, PREP especially for the KPs.
is there a maximum number of patients that can be attached to a pharmacy?
We are using a Hub and Spoke Model for the drug distribution. The community pharmacist receives their drugs from the hub facilities and report back too the hub facilities using the reporting tool every two months
@Olubukola Akinlade - The Ugandan model has set 1500 as the number of PLHIV per pharmacy. This translates to about 25 clients per day
What are the thoughts with regards to increased TB screening through these models?
initially there was a cap to avoid congestion. but with the 3MMD and 6MMD in Nigeria the cap has been removed. the clients can choose any pharmacy that is convenient to them.
Dr Mwanza Wa Mwanza
In our model (CPD) the maximum of number of clients /day was up to 50 clients with maximum of 1000 to 2000 clients based on the size of each community pharmacy.
@Bola; the testing in the Community Pharmacy is it the traditional HTS or Self-testing?
@ Moses. With the Nurse Dispenser model implemented, did you find the community pharmacist unwilling or unable to provide the refill services? Kindly share the projected and actual benefits of this method. Thanks so much.
Though a genuine concern, I don't think there is significant additional risk of loss of drugs from CPs as compared to loss from the HFs as long as there is due diligence and adequate control measures are put in place (including MoUs).
@Mubaina-the pharmacy staff are trained to screen for OIs including the refill. If they you suspect that the patient may have developed an OI then the patient is immediately referred back to health facility
@Mubiana. All clients devolved to receive refills in the Community Pharmacies are provided TB screening at each refill visit. This is part of a Chronic care screening that include screening for Chronic diseases, BMI, Nutrition counselling and Positive living.
Do you think that Community pharmacy is a good place for HIV testing ? I believe we are asking them more. The testing could be done at the health facility level and other places in the community level
@Moses Bateganya - There's no specific training package. The IDI-KCCA approach involves clinical placement in a busy clinical setting for 2 months so that the teams can acquire reasonable skills and knowledge in HIV care.
@Mubiana, Screening for TB is part of the chronic care screening provided by the pharmacists at each visit.
Clients also receive drugs for TPT as part of ART
Please share also country protocols on DDD if they are any
What has been the experience of KPs accessing community pharmacies? Is there a difference between uptake by KP and general population?
@ Levian. The community Pharmacists are trained in HIV counselling and testing. so they are fully equipped to carry out these services.
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Great presentations everyone! Very informative. Thank you!
So we have about 65% female on CPARP. Besides, 75% of our devolved clients are between 18-50yrs
thank you very informative.
Excellent presentations and DDD is the way to go
Thank you so much
Thank you everyone.
Thank you so much
Thank You everyone
Thank you, quite informative