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4g. HIV/AIDS, TB: Improving Providers Prescribing and Dispensing
National Evaluation of Medicines Dispensing within Brazilian AIDS Program
Problem statement: Pharmaceutical services concerningfor People Living with HIV and AIDS (PLWHA) are fundamental for the Brazilian response to the epidemic. However, little is known about service performance and user satisfaction in pharmacies that dispense medicines necessary for this treatment.
Objectives: To evaluate the quality of pharmacies that dispense medicines for opportunistic infections and antiretrovirals in Brazil, focusing on aspects of service performance and user satisfaction within the public sector
Design: Cross-sectional study; a pharmacy services (PS) sample was selected according to a proportional probability based on the number of patients usually attended. Data from direct observation (based on check lists, document consultation) and interviews of professionals and users were collected. The entire process involved interactions with main stakeholders, as civil society, national and local health managers, and policy makers.
Setting: PS within the public sector distributed in 19 municipal districts, in 10 Brazilian states; a probabilistic sample of patients was calculated so as to be an estimate of the target states and the set of states.
Study population: 29 PS were visited and 101 health professionals and 1412 patients were interviewed
Outcome measure(s): Performance and satisfaction indicators were organized in 3 dimensions: accessibility, availability, and adequacy to technical standards. Satisfaction scores ranged from 0 to 100, based on a psychometric instrument.
Results: In relation to accessibility, the average time spent (from home to PS) was 68.4 min, and the average waiting time was 10.9 min; 81.1% of the checked list of medicines was available. No expired medicine was found. In terms of adequacy to technical standards, 61.9% of the stock register was confirmed by counting; 60% of the items checked for environmental quality were adequate; 20.5% of users were oriented by the pharmacy attendant and 50.8% of attended prescriptions were complete. In terms of patient satisfaction, the worst evaluated dimension was accessibility, 67.2 (SE ± 0.9). Within this dimension, choice of care provider and time spent received the lower scores, 39.7 (± 2.2) and 58.4 (± 1.6), respectively. Service organization was the best evaluated component, 90.0 (± 0.7). The best estimated dimension was ARV availability, 77.4 (± 1.5). The adequacy average score was 73.4 (± 0.8). Within this dimension, the component interpersonal aspects showed the worst result, 70.8 (± 1.0).
Conclusions: Strengths and weaknesses of the Brazilian AIDS Program were identified, allowing feedback to stakeholders in many ways (meetings, publications, and Internet). As 1 of the results of this process, a working group was established at the national level, including representatives from state-level programs, civil society, and the evaluators group, aiming to set strategies related to problems identified.
Funding source: Information not provided
Promoting Rational Use of ARVs in HIV/AIDS Clinic in Tanzania
Management Sciences for Health, Tanzania, United Republic of
Problem statement: Tanzania has made significant progress in scaling up antiretroviral therapy (ART) to eligible people living with HIV/AIDS. However, little is known about current medicines use practices in ART clinics.
Objectives: To assess current medicines use practices in ART clinics and identify areas needing improvement
Design: This was just a rapid assessment conducted to explore current medicines use practices related to ART from February to April 2010. Data was collected through document review, dispensing encounters, retrospective prescriptions review, and qualitative interviews with dispensers and prescribers to understand factors influencing medicines use practices.
Setting and study population: The assessment involved 51 public and private ART facilities at the district and primary health care levels. The selection of district was based on the HIV prevalence rate and on the needs identified by National AIDS Control program and other partners supporting the ART program.
Intervention(s): The assessment was meant to identify gaps and help in selection of appropriate interventions to promote rational use of HIV/AIDS related medicines.
Outcome measure(s): Percentages of availability of key medicines, of facilities with selected guidelines available, and of dispensers providing adequate information to patients on how to use medicines
Results: Availability of pediatric ARVs was found to be low compared to adult formulations. Of the 141 dispensers involved in handling ARVs, only 18% had pharmaceutical training; guidelines for the management of HIV/AIDS were available in 82% of the sites visited. However, many dispensers were not up to date with the current recommended ART default first-line regimen, or criteria for Co-trimoxazole prophylaxis; 80% of visited facilities did not have SOPs for good dispensing practices or for patient medication use counseling. Generally, dispensers did not provide adequate information to patients on how to use ART medicines; 75% of facilities had forums that meet regularly to monitor patient treatment progress, but few reported having a DTC in place. Only 16% of facilities indicated that their staffs are trained on adverse drug reaction (ADR) reporting. ADR forms were available in 22% of visited sites and underreporting of ADR was observed.
Conclusion: Regular training and on-site support is crucial with emphasize on rational use of medicines. DTCs need to be strengthened and used in promoting appropriate use of ART medicines. The assessment highlights the need to strengthen the pharmacovigilance system for ART by ensuring the availability of ADR reporting forms and ensuring that staff are well trained on ADR reporting.
Funding source: USAID through Strengthening Pharmaceutical Systems (SPS) Program
Role of Private Pharmacies in TB Control in Egypt
Ministry of Health, National TB Control Program,Egypt
Problem Statement: Egypt has a significant private health care sector with over 50% of all utilization and expenditure on health care occurring in the private sector. This study is aiming at investigating the current pattern of anti-tuberculosis drug use in the private pharmacies in Egypt, the prescribing practices of the physicians referring their cases to the private pharmacies for purchasing the drugs, and the feasibility of engaging the private pharmacists in identifying TB suspects and their referral to the nearest TB medical unit (MU) for diagnosis. A cross-sectional survey was conducted whereby pharmacists/pharmacists assistants in a representative sample of private pharmacies were interviewed using a questionnaire.
Objectives: (1) To describe the current pattern of anti-TB drug use in the private pharmacies in Egypt; (2) to determine the proportion of private pharmacies those have anti-TB treatment (ATT) in different geographical areas; (3) to evaluate the prescribing practices of the physicians referring their cases to the private pharmacies for purchasing the drugs; (4) to evaluate the knowledge, attitudes and practices of the private pharmacists towards TB; (5) to evaluate the case load of TB suspects and patients that purchase ATT from the private pharmacies; (6) to evaluate the feasibility of engaging the private pharmacists in identifying TB suspects and their referral to the nearest TB MU for diagnosis.
Setting and Study Population: The study was carried out in a representative sample of all Egyptian governorates. A representative sample of private pharmacies in the country was included in the study. The estimated sample size n is calculated, using simple Gaussian theory eligibility criteria. Private pharmacists and/or other personnel working in the pharmacies were enrolled according to the following inclusion criteria—pharmacies that have been open for at least three months whether registered or not which consented to participate in the study. Exclusion criteria was those pharmacies that had been open for at least three months but did not consent to participate in the study.
Funding Source: Global Fund to Fight Against AIDS, Tuberculosis and Malaria
Trends in Antiretroviral Drugs Prescribing at Public Health Facilities in Ethiopia: Compliance to Treatment Guidelines
1Management Sciences for Health/Strengthening Pharmaceutical Systems, Ethiopia; 2Management Sciences for Health/Strengthening Pharmaceutical Systems, Ethiopia
Problem statement: Treatment guidelines (TGs) provide a standardized and simplified guide and are designed to help practitioners make appropriate therapeutic decisions specific to the clinical circumstances. In Ethiopia, the treatment guideline for antiretroviral therapy (ART) was revised in March 2008. Since then, there has not been a systematic assessment of antiretroviral (ARV) prescribing patterns and compliance of prescribers to the new treatment guideline.
Objectives: To investigate trends in the prescribing of ARV drugs in public health facilities and the level of compliance to treatment guidelines
Design: A retrospective descriptive study based on reports received from ART health facilities in the past three years
Setting: ART pharmacies of selected public hospitals and health centers providing free ART services in different regions of Ethiopia
Study population: 154 health facilities comprising 70 hospitals and 84 health centers
Intervention(s): Following the revision of antiretroviral treatment guidelines, health care providers were given training on the new guidelines followed by supervision and mentoring support to reinforce ART prescribing as per the new protocol.
Outcome measure(s): Trends in ARV drug prescribing, percentage of patients on the preferred first-line regimen, percentage of patients on tenefover versus stavudine-based regimens, percentage of patients on a regimen that are not in the guidelines
Results: Analysis of the regimen profiles over the 3-year period indicated that the proportion of patients on preferred first-line regimen increased from 32% in 2008 to 49% in 2010. Conversely, patients on an alternative first-line regimen decreased from 66% in 2008 to 48% in 2010. Proportion of patients on TDF-based regimen increased from 0.68% in 2008 to 12% in 2010, whereas those on D4T-based regimen decreased from 65% in 2008 to 48% in 2010. Although the new treatment guidelines recommend TDF-based regimen as the preferred first option, the proportion of patients on this regimen is still very low (12%). The shift of patients to TDF-based regimens appears to be faster in health centers (0.03% to 2.48% to 8.15%) compared to hospitals (0.95% to 12% to 14%) in 2008, 2009, and 2010, respectively. The percentage of patients on regimens that are not recommended by the guidelines increased more than 5-fold between 2008 and 2010 (0.02% and 0.11%, respectively).
Conclusions: Compliance to ART guidelines is found to be quite low. A significant number of patients are on alternative first-line regimens, though improvement was observed during the study period. High proportion of patients, including newly enrolled ones, are still on D4T-based regimens and this poses particular safety and adherence concern. So, additional interventions are required to improve ARV drugs prescribing practice and possibly to review the ART guidelines.
Funding source(s): PEPFAR/USAID
Findings from Integrating CVD Risk Factors Screening and Services Among HIV Clients in Resources Constrained Setting
1FHI/Arlington; 2FHI/Kenya; 3FHI/Ghana
Problem Statement: There is mounting evidence demonstrating that 1) People Living with HIV (PLWHA) - whether or not on antiretroviral treatment (ART) - have an increased vulnerability to cardiovascular (CVD), certain cancers, diabetes, and depression; and 2) ART itself can increase risk factors for CVD and diabetes. As HIV treatment programs continue to scale up, people infected with HIV will be living longer and be at an increased risk of acquiring CVD.
Objectives: To pilot-test the feasibility of integrating the screening of CVD/diabetes risk factors with HIV services in a resource-limited setting; to describe the prevalence of CVD/diabetes risk factors among patients in existing HIV sites, and to provide patients indentified with CVD/diabetes risks with services or referrals.
Design: Adults accessing HIV counseling and testing (HCT), HIV care and/or treatment at the pilot sites were screened for CVD/diabetes risk factors using a behavioral risk assessment tool and measurement of body-mass index (BMI) and blood pressure. Those
patients in HIV care and/or treatment were additionally screened for lipid and blood sugar levels.
Setting: The intervention, in collaboration with the Kenyan Ministry of Health and Kenya Cardiac Society, took place in five public health facilities providing HIV services in Kenya.
Study Population: The population included adult patients accessing HCT, care and/or treatment in the selected pilot sites. A total of 4,027 individuals were screened for CVD/diabetes between September 2009 to September 2010: 1023 HCT clients, 952 HIV + clients in care (not on ART), and 2052 HIV+ clients on ART.
Intervention: CVD/diabetes screening, referral and limited treatment services were integrated into HIV services in 5 public health facilities.. The service providers were trained in behavioral and biological CVD/diabetes risk assessment. The sites were equipped with materials to screen patients for blood sugar, blood pressure, and lipid levels. Appropriate behavioral and biomedical interventions and referrals were provided to patients at risk or suffering from CVD/diabetes.
Policy: The government of Kenya will use results from this CVD/HIV integration pilot to inform the national HIV strategy.
Outcome Measure: Blood sugar; Cholesterol; Blood pressure; Body-mass index (BMI)
Results: The integration of CVD risk assessment in existing HIV services is feasible, and perceived positively by service providers, clients, and the government of Kenya. Among patients on ART, 20% on a first line treatment regimen had high blood pressure (HBP), versus 98% of those on second line ART. Blood pressure among was higher among patients who were on ART for three years or more. The prevalence of diabetes and high cholesterol was low among all patients.
Conclusions: Integration of CVD/diabetes to HIV service is feasible. The finding corroborates recent studies demonstrating the association between HIV and CVD; and CVD and ART.
Funding Source: FHI