Arriving early in the morning to receive their HIV medications and beat the crowds, patients visiting resource-limited health facilities are often greeted by long lines. This was a problem experienced in some of the busiest health centers in Lusaka, Zambia, in 2014.
While Zambia’s rate of HIV/AIDS prevalence is declining (12.9% in 2015 compared to 14.3% in 2007), largely due to improved access to lifesaving antiretroviral medication (ARVs), it remains a major health concern, with 1.2 million people living with the disease. Ensuring that patients remain on HIV treatment is critical to not only saving the lives of those impacted, but curbing the spread of the disease. Unfortunately, crowded health facilities and long lines in urban areas of Zambia were a reality for many, and thought to be a deterrent that was compromising adherence to continued medical care.
In 2014, the Zambian government requested a formative assessment to better understand the contributors to congestion in HIV treatment facilities in Lusaka. The initial assessment (in just 8 of Lusaka’s 56 facilities) showed that in the facilities visited, many stable patients were leaving their visits with only a 1- or 2-month supply of antiretroviral drugs. Only 46% of stable HIV treatment patients in these sites were receiving a 3-month refill supply of ARVs, despite it being national policy for stable adult patients. There was a great deal of variation in where and how the 3-month policy was being implemented. Often, pharmacist concerns about running out of drugs were standing in the way of the policy being implemented for all patients who qualified.
After digging into the underlying reasons for congestion at the HIV treatment facilities, the Ministry of Health (MOH), CHAI, and the Centre for Infectious Disease Research in Zambia (CIDRZ) worked together to develop an intervention that would make it easier for patients without complications to receive their 3-month supply of ARV drugs at one time, rather than having to return monthly to treatment facilities. The MOH requested an impact evaluation of the intervention to generate evidence on ways to address congestion at health facilities.
As a first step of the intervention, the MOH sent a memo to all HIV treatment sites in the district of Lusaka reminding them of the 3-month ARV refill policy. The evaluation team then selected 16 sites to conduct the evaluation. The first 8 sites continued business as usual, while the second group of 8 sites received additional support including drug forecasting, a pharmacist job aide, checklists, and health staff training in quality improvement techniques.
The evaluation team compared the proportion of stable patients that received 3-month ARV refills in the 8 control sites to those in the 8 intervention sites. After 3 months of additional support, the 8 sites with the extra support had an additional 15% of patients receiving the 3-month supply of ARVs. Sites had fewer daily appointments and patient wait time decreased.
Our findings showed that when done correctly and with the appropriate interventions, a more patient-centered service delivery schedule of 3-month prescription refills for stable patients is viable. Moreover, these types of low-cost interventions can be replicated elsewhere to help improve access to lifesaving ARV treatment and ensure that patients continue with treatment.
Zambia has been a leader in expanding its HIV program to provide treatment to all who need it. Solutions like this one help improve the experience of visiting health facilities for the patient and ease the daily burden on health care workers, both of which contribute to a healthier population.
