Implementation of South Africa’s Central Chronic Medicine Dispensing and Distribution Program for HIV Treatment: A Qualitative Evaluation

Abstract

We used the Practical, Robust Implementation and Sustainability Model to evaluate implementation of South Africa’s Central Chronic Medicine Dispensing and Distribution (CCMDD) program, a differentiated service delivery program which allows clinically stable HIV-positive patients to receive antiretroviral therapy refills at clinic- or community-based pick-up points. Across ten clinics, we conducted 109 semi-structured interviews with stakeholders (pick-up point staff, CCMDD service providers and administrators) and 16 focus groups with 138 patients. Participants had highly favorable attitudes and said CCMDD decreased stigma concerns. Patient-level barriers included inadequate education about CCMDD and inability to get refills on designated dates. Organizational-level barriers included challenges with communication and transportation, errors in medication packaging and tracking, rigid CCMDD rules, and inadequate infrastructure. Recommendations included: (1) provide patient education and improve communication around refills (at the patient level); (2) provide dedicated space and staff, and ongoing training (at the organizational/clinic level); and (3) allow for prescription renewal at pick-up points and less frequent refills, and provide feedback to clinics (at the CCMDD program level).

Roles, Barriers, and Recommendations for Community Health Workers Providing Community-Based HIV Care in Sub-Saharan Africa: A Review

“… 56 While this intervention has been effective in decongesting clinics, 57 , 58 it faces many challenges such as inadequate feedback about patients not picking up their medication as well as the absence of clinical monitoring and adherence support. 59 The delivery of ART by CHWs to patients' homes could be a valuable alternative since it includes monitoring and support but, notwithstanding the benefits, also presents numerous challenges. These are not only logistical, such as incorrect delivery addresses, recipients not being at home, and the need for deliveries outside of CHW catchment areas, but are also of an ethical nature.…”

Essential health services delivery in South Africa during COVID-19: Community and healthcare worker perspectives

“…Whilst 43% of countries reported disruptions in prescription renewals for chronic medications and challenges with essential medicine (27,30), our study participants did not perceive much of a difference in medicine availability when compared to pre-COVID-19. The CCMDD program, initiated in 2014, saw rapid scale-up for chronic patients (45)(46)(47)(48) and was well-received by both HCWs and CMs due to increases in efficiency and convenience and decreases in patient load and financial impact on patients (46). Nevertheless, service delivery and utilization were negatively impacted by the fear of contracting COVID-19 as expressed by HCWs and CMs.…”

Opportunities and considerations for the design of decentralized delivery of antiretroviral therapy for female sex workers living with HIV in South Africa

“…Recent implementation evaluation research surrounding the CCMDD program for stable adults living with HIV in South Africa found it to reduce stigma, but cited patient-level and organizational-level barriers (i.e. inadequate education about CCMDD, inability to access treatment on designated dates, challenges with communication and transportation, treatment packaging, rigidity of CCMDD rules, and insufficient infrastructure) [30]. Additional research is needed to assess whether these barriers and challenges exist in DSD implementation strategies aimed to support the unique needs of FSW living with HIV and what mechanisms and contextual considerations are needed to overcome DSD implementation among populations at increased risk for suboptimal HIV treatment outcomes.…”

“…Decentralized treatment provision (DTP), a DSD strategy that includes community-based provision of ART, may address barriers to ART linkage, uptake, and retention among FSW [23][24][25][26][27] and leverages priorities for community-based, nurse-led ART care and treatment distribution [28]. DTP at select pick-up points (i.e., designated pharmacy queues, churches, and schools) has been implemented as part of the South African National Department of Health response since 2014 through the Central Chronic Medicine Dispensing and Distribution (CCMDD) program, but it has been limited to virologically suppressed adults living with HIV and on treatment for a sustained period; the CCMDD does not address the unique needs of marginalized populations or those not virally suppressed [29,30]. This is despite evidence across sub-Saharan Africa that community-based ART distribution for key populations (including but not limited to FSW) has been found to be as effective as facility-based care and resulted in similar HIV clinical outcomes [31].…”