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Table 1 Potential challenges and solutions to pharmacy-based PrEP delivery

From: Design of a care pathway for pharmacy-based PrEP delivery in Kenya: results from a collaborative stakeholder consultation

Delivery component

Challenges

Solutions: Pilot

Solutions: Scale up

Promoting pharmacy PrEP

• Most existing promotional materials from suppliers.

• Limitations on how pharmacies can advertise products/services.

• Health facilities may be reluctant to refer client to pharmacy PrEP if trying to reach target PrEP numbers.

• Word-of-mouth promotion (e.g., PrEP providers at health facilities)

• Tell clients seeking services indicating HIV risk-related behaviors (e.g., condoms, emergency contraception) about pharmacy PrEP

• Display posters within the confines of the pharmacy.

• NASCOP works with pharmacies to create PrEP materials for display.

• MOH national awareness campaign for pharmacy PrEP.

• PPB revises advertisement restrictions for PrEP.

• Pair pharmacies with health facility so pharmacy PrEP clients count toward the facility’s PrEP targets.

HIV testing

• No guidelines for rapid HIV testing at pharmacies, although ongoing.

• Only select pharmacies currently providing assisted HIV self-testing.

• Unclear if PrEP can be initiated based on an HIV self-test result.

• Counterfeit HIV self-tests.

• Select pilot pharmacies certified to do assisted HIV self-testing.

• Obtain special approval from regulatory agencies to offer HIV rapid testing at pilot pharmacies.

• MOH develops guidelines for HIV rapid testing at pharmacies (currently ~ 1/5th the price of self-tests at pharmacies).

• MOH limits PrEP delivery to pharmacies certified to do assisted HIV self-testing (Obtain self-tests through KEMSA?).

• PPB reclassifies HIV self-testing so treated like any other HIV test.

Counseling

• Pharmacy providers not trained on PrEP counseling.

• No private space at some pharmacies.

• Business approach of pharmacies, gets in the way of quality counseling.

• Existing counseling prompted by clients, not pharmacy providers.

• Train pilot pharmacies on PrEP counseling using NASCOP guidelines and materials.

• Private counseling space required for PrEP delivery at pharmacy.

• MOH implements pharmacy provider training requirement for PrEP delivery

• MOH customizes NASCOP training to fit the retail pharmacy setting.

Prescribing

• Pharmacy providers not trained on how to (and not allowed to) prescribe PrEP.

• What (cash) incentives do pharmacies have to provide PrEP if receive drug for free from NASCOP?

• Train pharmacy providers on how to prescribe using a checklist and remote clinician oversight.

• Charge small consulting fee for PrEP counseling and dispensing.

• Allow pharmacies to charge for HIV testing (necessary for prescription).

• PPB reschedules PrEP so that it can be sold without a prescription.

• Pharmacy providers purchase PrEP from a generic manufacturer.

• Pair pharmacies with CCC for oversight.

• Remote PrEP clinicians (MOH supported?) for remote oversight.

Dispensing

• Retail pharmacies do not have MFL codes to: 1) acquire PrEP through KEMSA, and 2) report dispensing.

• Current retail pharmacy records do not tend to track clients over time.

• Some clients move between pharmacies.

• Clients might not be able to afford 3-months PrEP at a time.

• Link pilot pharmacies with health facilities; have pharmacies use facility MFL code to obtain PrEP; then facilities reports the drugs dispensed.

• Set up unique tracking system for pilot.

• Have clients pay only for testing & a consulting/dispensing fee; PrEP drug free.

• Give pharmacies MFL codes.

• Use system similar to diabetes for tracking prescriptions over time (e.g., “PrEP card”).

• MOH provides free PrEP to pharmacies.

• MOH establishes minimum criteria that pharmacy providers must meet to deliver PrEP (e.g., completion of NASCOP PrEP training).

Oversight/ Referrals

• Many retail pharmacies lack formal connections to health facilities.

• Clinicians busy, often hard to reach.

• Cost of oversight? Who pays?

• Ethics – how do you know pharmacies will call clinicians when needed?

• Who is the clinician?

• Link pharmacies with specific health facilities.

• Have study-staff clinician on call.

• Monitor the frequency of calls and record the content.

• Create WhatsApp group for alternative mode of communication.

• NASCOP-supported PrEP clinician hotline?

• Include cost of oversight in the consultation/dispensing fee client pays to pharmacy.

Other

• Some pharmacies only have one staff member working at a time.

• Pharmacy providers may lack PrEP and HIV testing & counseling knowledge.

• Pharmacy providers may discriminate against clients, especially marginalized populations (e.g., MSM, FSWs).

• Currently, no regulations for pharmacy-based PrEP delivery.

• Pharmacy providers selected for this pilot will be trained on PrEP delivery and provided with a standardized checklist to walk them through PrEP prescribing.

• Pharmacy providers will be connected to a remote PrEP clinician who can answer any questions they have and receive referrals of complex clients.

• MOH establishes minimum criteria (e.g., possession of a private consultation room, completion of NASCOP training) that pharmacy establishments and providers must meet to deliver PrEP.

• MOH requires pharmacy-based PrEP providers to undergo a sensitization training on PrEP stigma/discrimination.

• MOH establishes guidelines for pharmacy-based PrEP delivery, including any price regulation and accountability mechanisms (e.g., in cases of client mismanagement).

  1. Abbreviations: FSWs female sex workers, KEMSA Kenya Medical Supplies Authority, MFL Master Facility List, MSM men who have sex with men, MOH Ministry of Health, NASCOP National AIDS and STI Control Program, PPB Pharmacy and Poisons Board, PrEP pre-exposure prophylaxis