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). |