Evidence
Alert

Community-based medicine collection improves access to lifesaving HIV treatment in South Africa

A programme in South Africa is successfully shifting the location of treatments for long term conditions from the clinic to the community. It is the largest programme of its kind in the world and a new study highlights the benefits to people living with HIV.

The programme is called Centralised Chronic Medication Dispensing and Distribution (CCMDD) and it moves treatment closer to where people live.

One of the first studies to assess CCMDD suggests that it is overcoming barriers to people receiving antiretroviral therapy (ART). ART suppresses the virus in people with HIV and stops progression of their disease. It also prevents them passing the virus on to others.

The findings suggest that CCMDD allows quicker and more convenient collection of ART, normalises HIV treatment, and reduces disruption to other aspects of peoples’ lives.

The authors say their findings support the rollout of community-based programmes for delivering ART as a way of ensuring that people receive lifesaving treatment.

What’s the issue?

ART allows people living with HIV to live a largely normal life with a normal life expectancy. More than 23 million people worldwide take ART. A further 14 million in low- and middle-income countries are still in need of treatment. Efficient systems to deliver ART to patients and support life-long engagement with HIV care are essential.

Standard clinic-based care has been linked with long waiting times, a lack of confidentiality, and restricted opening hours. This may discourage people from engaging with treatment.

Over one million people are registered with the CCMDD programme. They collect ART from community pick-up points – such as pharmacies – instead of receiving all their treatment at clinics. It was designed to reduce the demand on clinics and empower patients by moving treatment closer to their homes.

CCMDD was first rolled out in 2016. But it has not been formally assessed before now. This study asked patients and healthcare workers what they thought about the service and examined how they engaged with it.

What’s new?

The research took place in eThekwini, a district of South Africa which includes Durban. Around 15 to 20% adults there are living with HIV. Interviews and focus group discussions in 2018 involved 55 people living with HIV and eight healthcare workers.

The researchers analysed transcripts of these discussions to look at factors that influence people’s engagement with HIV care.

Their analysis suggests that CCMDD addresses many of the problems with ART provided by clinics. CCMDD is successful in overcoming barriers by:

  • allowing quicker and more convenient ART collection
  • normalising HIV treatment
  • reducing disruption to other aspects of patients’ lives, such as employment.

The research also revealed problems with the CCMDD programme. Some patients said they received inferior care at private pharmacies compared with paying customers. Some were concerned about inadvertently revealing their HIV status.

Other issues reported by patients and healthcare workers included delays in receiving reminder texts, medication not being ready at the pickup point, inflexible opening times, and difficulty registering for the service. The researchers said that some of these issues have since been resolved.

Why is this important?

The research supports the continued rollout of CCMDD across South Africa. Its findings are being fed back to local and national managers to improve the programme as it continues to expand and adapt.

The authors suggest such measures could include:

  • better regulation of private pharmacies to ensure confidentiality and flexible collection times
  • a wider timeframe within which ART can be collected by patients
  • taking steps to reduce HIV-related stigma in society.

Where HIV treatment is still delivered in clinics, this research suggests that care could be improved by extending opening hours, and by training staff to be more respectful towards their clients and more aware of the need for confidentiality.

The authors believe that expanding community-based ART delivery programmes around the world may help to drive engagement in HIV care.

What’s next?

The research team has shared their findings with the managers of the CCMDD programme from the South African government and a South African non-governmental association, the Health Systems Trust.

Further work is now needed to find out whether people in the CCMDD programme have better health outcomes than people who are treated in clinics. The cost-effectiveness of the programme also needs investigating. Plus – this study was carried out in a single urban clinic. More work may be needed to see whether CCMDD is as effective in rural areas.

The authors are also keen to examine the role CCMDD can play in responding to COVID-19. The programme may be able to help relieve pressure on clinics and reduce the risk of transmission. Some of the implementation problems described in the paper are being resolved as part of the response to COVID-19. Pickup points now have more flexible opening hours and collection windows have increased from two to 14 days before unclaimed medication is returned to the clinic.

You may be interested to read

The full paper: Dorward J, and others. Understanding how community antiretroviral delivery influences engagement in HIV care: a qualitative assessment of the Centralised Chronic Medication Dispensing and Distribution programme in South Africa. BMJ Open. 2020;10:e035412

Official website of the CCMDD programme

Other examples of differentiated care programmes, similar to the CCMDD programme, e.g. DifferentiatedCare.org

News article about how COVID-19 is putting pressure on medicine supply in South Africa

Funding

This study was funded by the US National Institute for Health, the South African Department of Science and Technology and the Wellcome Trust. One author was supported by the NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance.

Commentaries

Study author

We hope this research will help to make sure CCMDD is implemented as effectively as possible and in a way that is more empowering for the client.

Our message backs up other research on these types of programmes. It says that there are many benefits, but the more flexibility built into the system, the better. Stigma is a deep-rooted issue and we need to think about how we can maintain the confidentiality of people living with HIV.

In the UK, we have efficient home delivery of medication, but HIV treatment is still predominantly managed by doctors in hospitals. In South Africa, everything is managed by primary care nurses. It may be that the UK could move towards HIV care delivered more in primary care.

Another strength of the CCMDD programme in South Africa is the use of telecommunications. Patients receive text messages and can call a hotline if they have problems. These kinds of systems could be useful for other countries.

Jienchi Dorward, Honorary Associate Scientist, CAPRISA, Durban, South Africa, and Clinical PhD Fellow in Primary Healthcare, University of Oxford

Researcher

This research highlights the need for changes to practice in pharmacies involved with CCMDD. Discrimination against people with HIV, and all public clients, needs to be addressed. Government regulation will be helpful to ensure this and also to make sure that private companies monitor all aspects of delivery discrimination properly.

People with HIV need to re-contact clinics if they have signs of illness and the paper emphasises that this may be delayed or not happening sometimes in relation to CCMDD. Ongoing training for nurses working in clinical HIV settings, as well as for pharmacists and workers at community-based organisations, will be necessary to ensure they stress this to everyone with HIV.

The research suggests that people with HIV may miss basic medical oversight and not receive ongoing ART advice in CCMDD settings. However, community-based organisations and pharmacies could both expand provision in these areas.

Health policy shifts will be needed for CCMDD to be extended as far as is practicable.

These findings are directly relevant to people with digital capital ie SMS notifications in urban and rural settings in middle-income countries with robust public health provision. I am fairly confident that they also apply in rural settings in middle-income countries, and in both urban and rural settings in low-income countries, where distance from clinic may be even more difficult to bridge. However, in these settings, CCMDD is somewhat more difficult if digital access is low and clinic healthcare provision limited.

The study also demonstrates the usefulness of qualitative insights and the theory of practice framework in mapping the complexities of programmes such as CCMDD and how they interact with other aspects of people with HIV’s lives.

Corinne Squire, Professor of Social Sciences, University of East London

Conflicts of Interest

None declared.