Does centralized dispensing and distribution of medicines improve health outcomes? A retrospective cohort study in Ndola, Zambia

doi:10.21203/rs.3.rs-3408228/v1

Download PDF

Research Article

Does centralized dispensing and distribution of medicines improve health outcomes? A retrospective cohort study in Ndola, Zambia

https://doi.org/10.21203/rs.3.rs-3408228/v1

This work is licensed under a CC BY 4.0 License

Version 1

posted

You are reading this latest preprint version

Background

The global shift toward universal test and treat policy for individuals living with HIV has triggered an unprecedented surge in healthcare demand. In response, Zambia's government implemented a centralized dispensing and distribution intervention. Despite successful implementation, empirical evidence of its impact within Zambia remains lacking. This study aims to assess this intervention's utilization patterns and measure its effect on medicine collection rates, retention, and plasma viral load levels.

Methods

We conducted a retrospective cohort study by analysing programmatic data from 17,157 stable patients who received chronic antiretroviral therapy through the intervention across nine high-volume treatment facilities in Ndola, Zambia, from January 2018 to September 2021. We computed the annual ratios of the key health outcomes.

Results

Between January 2018 and September 2021, a total of 17,157 clients were enrolled, 75% of the total target during the implementation period. Out of those enrolled, there were more females 69% than males 31%, with most clients aged 20 years and above. The yearly rates of beneficiary medicine collection and retention consistently surpassed the benchmark, reaching 93% (90% CI: 85% − 100%) and 97% (95% CI: 95% – 99%), respectively. However, less than 1% of those ever-enrolled experienced escalated viral load levels warranting discontinuation from the program.

Conclusion

Our study establishes that implementing the centralized dispensing and distribution intervention in Ndola produced a notable positive impact on enrolled beneficiaries' critical health outcomes. This reinforces the intervention's viability as a scalable solution, holding potential for broader population-level benefits.

Differentiated Service Delivery

Innovation

Centralized Medicine Dispensing and Distribution

Retention

Viral Load Suppression

HIV/AIDS Service Delivery Models

Cohort Studies

The adoption of a universal test and treat approach as policy towards HIV/AIDS epidemic control in Zambia resulted in a significant number of individuals being diagnosed with human immunodeficiency virus (HIV) and subsequently initiated on antiretroviral therapy (ART). The surge in demand for healthcare services led to the overcrowding of primary health care facilities, compromising the quality of care. Such overcrowding in treatment centres created difficult conditions, such as prolonged waiting times and an intensified workload for healthcare providers, often causing poor patient retention in regular care. The implications of poor retention in healthcare are profound, spanning from treatment failure to elevated viral loads (VLs), which contribute to new HIV transmissions, heightened disease progression, and increased risks of mortality [1, 2].

To counteract the escalating demand in healthcare, the World Health Organization (WHO) recommends the integration of differentiated care models for stable individuals on ART, encompassing strategies to reduce clinic visits, streamline medication pickups, and enhance the convenience and accessibility of antiretroviral drugs (ARVs) [3]. Among these models, the decentralized drug distribution (DDD) of medicines outside healthcare facilities emerged as a promising avenue to extend treatment access through innovative modalities, aligning with the then ambitious 2020 UNAIDS 90:90:90 HIV treatment targets [3].

In 2017, the Government of Zambia (GOZ), in partnership with key stakeholders, introduced various differentiated service delivery (DSD) models to alleviate congestion within high-volume treatment facilities. A pivotal component of this initiative was the implementation of the centralized dispensing and distribution (CDD) concept, strategically designed to address impending overcrowding challenges within Ndola district.

A similar intervention has been undertaken in South Africa since 2015, yielding notable outcomes, including an increased client base for chronic medication, reduced patient waiting times, alleviated healthcare worker burden, improved accessibility to treatment, and enhanced patient experiences [4–6]. Additionally, annual primary care visits in South Africa saw a decline from 129 million in 2012/13 to 126 million in 2015/16, partially attributable to the CDD programme [7]. Notably, the success of the CDD programme in South Africa has been evident through its expanded reach among eligible beneficiaries, spanning health facilities and community-based establishments [8]. Despite these promising prospects, the question of cost-effectiveness relative to conventional or alternative modalities of chronic medication access, particularly in Zambia [9], remains largely unexplored. This crucial information is of paramount importance to decision-makers and potential donors, as innovative healthcare interventions such as the CDD programme often necessitate judicious resource allocation within the confines of limited healthcare resources [6].

Therefore, our study seeks to measure the effects of the CDD programme within the context of Ndola, a resource-constrained setting within the Copperbelt province of Zambia. Specifically, our assessment encompasses CDD service utilization by eligible patients, rates of medicine collection, beneficiary retention, and the programmatic implications for sustainable viral load suppression. By delving into these dimensions, we aim to contribute to the evidence-based healthcare delivery strategies amid a dynamic and evolving landscape of HIV/AIDS care, especially in low- and middle-income countries.

Study Design

This study sought to assess the effects of the CDD intervention on key health outcomes, conducted at intervals of twelve months over a span of four years from January 2018 to September 2021. To do this, we conducted a retrospective cohort study using programmatic data pertaining to a cohort of 17,155 stable patients who enrolled to receive chronic antiretroviral therapy (ART) within the framework of the CDD intervention. For complete and transparent reporting of a study on this intervention, we followed the StaRI and TIDieR guidelines [10,11].

Study Setting and Sample

The study was conducted within the framework of the CDD program, which operated across nine high-volume treatment facilities situated in the Ndola district. Ndola, a significant urban hub in Zambia's Copperbelt province, grapples with healthcare facility overcrowding. The district has 37 public health facilities [12], with approximately 32 accredited to provide comprehensive ART services to a population of approximately 624,579 [13]. Ndola's urban landscape attracts migrant laborers from diverse regions of Zambia and beyond, resulting in a densely populated area. Ndola is the home for approximately 64,765 PLHIV, with approximately 89% (equivalent to 57,925 PLHIV) of them actively enrolled in chronic ART [14].

Our study primarily focused on the CDD program, engaging a carefully selected cohort of patients from 9 high-volume treatment facilities. This cohort represented approximately 30% of individuals actively receiving ART in Ndola, amounting to 17,157 individuals out of the total 57,925 PLHIV on ART. Notably, Zambia's guidelines mandate ART initiation for all PLHIV, with participants initially receiving the fixed-dose combination of tenofovir disoproxil fumarate, lamivudine, and efavirenz (TLE) regimen and subsequently transitioning to the tenofovir, lamivudine, and dolutegravir (TLD) regimen in line with updated guidelines.

Key to the program's success were viral load measurements at 6 and 12 months post ART initiation, which were repeated every 12 months thereafter. The CDD program beneficiaries had 6-month clinical reviews at the treatment facility and 3-month ART refills from the central pharmacy, consistent with the country's multiple-month scripting and dispensing (MMSD) guidelines. The eligibility criteria that governed inclusion in the program included viral load results below 1000 copies/mL within the past 12 months, a minimum of 6 months on ART, age above 10 years with adherence to adult ART regimens, absence of AIDS-defining illnesses, and controlled comorbidities. Exclusion from the program included pregnant individuals, those with active tuberculosis (TB) symptoms, and those with uncontrolled conditions requiring frequent clinical consultations.

Beneficiaries of the CDD program underwent regular 6-month clinical reviews, and those consistently eligible had their ART prescriptions renewed for sustained participation.

Intervention Description: Centralized Dispensing and Distribution

A concise description of the CDD program was done using (TIDieR) [11] guidelines, we present. The CDD program was designed to address the needs of stable individuals with chronic conditions such as HIV, with the specific objective of alleviating the strain in the 9 high-volume treatment facilities. This objective included enrolling up to 70% (23,216/33,397) of eligible individuals currently receiving ART in those facilities while enhancing primary health outcomes such as treatment adherence, retention, and viral load suppression. This program embodies a structured triad consisting of originating treatment facilities, a central dispensing pharmacy, and a network of community-based medicine collection points. These components are seamlessly connected through an end-to-end information technology (IT) platform, orchestrating a well-defined set of processes, such as patient registration, prescription acquisition, centralized prescription processing, dispensing, medicine logistics, personalized collection, reverse logistics, and comprehensive data reporting.

Program Workflow

Potential beneficiaries receive program information through sessions led by healthcare professionals, including nurses and counselors. Informative pamphlets and prominently displayed posters at healthcare facilities provide additional insights. Eligibility criteria were established for precise targeting, followed by screening by qualified clinicians such as medical doctors, clinical officers, or nurses, ensuring enrolment of appropriate individuals. Clinicians validate eligibility, and upon confirmation, beneficiaries give informed consent and choose a preferred medicine Pickup Point (PuP). A clinician completes a prescription form, and beneficiaries receive an appointment card detailing dates and program specifics. Quality-assured prescription forms are digitally transmitted to the central pharmacy, ensuring accuracy and efficiency. Initial refills occurred at the treatment facility and are managed by pharmacists, pharmacy technicians, or dispensing nurses. Subsequent refills are overseen by the central pharmacy, involving validation, packing, and distribution to designated PuPs. Medicine parcels are stored securely at PuPs until beneficiaries receive them, adhering to strict identification protocols and tracked using a dedicated mobile application. Scheduled SMS notifications provide support, reminding beneficiaries of collection, upcoming reviews, and program updates. The CDD program introduces a comprehensive, technologically advanced approach to healthcare in Ndola, harmonizing diverse entities and logistical complexities. Through its integrated system, the program elevates patient care, ensuring improved treatment adherence, retention, and overall health outcomes.

Health Outcomes in the CDD Program

The quantification of the effects of the CDD program included the measurement and estimation of several key health outcomes, providing a comprehensive measure of its effectiveness. These outcomes were evaluated over the course of the program's implementation, offering insights into utilization, adherence, retention, and state of viral suppression rates.

Utilization Rate

The utilization rate of the CDD program was quantified as the proportion of eligible patients who successfully enrolled, thereby participating in the program at 12-month intervals. This metric was tracked throughout the program's implementation, offering a dynamic snapshot of patient engagement and program access while decongesting high-volume sites. The predefined utilization rate of the intervention included the achievement of enrolments up to 70% (23,216/33,397) of eligible individuals currently receiving ART from high-volume facilities.

Medicine Collection Rates

As a crucial proxy measurement of program adherence, medicine collection rates were defined as the proportion of medicine parcels collected by beneficiaries at their chosen PuPs in adherence to the prescribed collection schedule upon enrollment and with every encounter during prescription renewal. This rate was computed by dividing the number of successfully collected medicine parcels by the total count of prepared and scheduled parcels, presenting a quantified snapshot of patient commitment to timely medicine retrieval. Through this program, the standard from which to assess the success of scheduled medicine collection rates was preset at 90%, measured annually.

Beneficiary Retention Rates

Retention rates, a vital feature of program success, reflected the proportion of beneficiaries who maintained active engagement in the CDD program at successive 12-month intervals from their initial enrollment [15]. Computation of this rate involved subtracting the newly engaged beneficiaries within the current period from those remaining engaged at the period's conclusion, divided by the number of beneficiaries continuing from the preceding period. For this computation, we assumed uniform beneficiary engagement at the onset of each 12-month cycle. The resulting proportion represented beneficiaries continuously enrolled in the CDD program since 2018, sustaining engagement over successive 12-month spans until the program's conclusion in September 2021. This calculation excluded beneficiaries that were either reported as deceased or transferred out from their treatment facilities. The observed net retention rates were benchmarked against the targeted threshold of 95% and above, following WHO and UNAIDS benchmarks.

Sustained viral suppression rates

This pivotal metric gauged the proportion of patients persistently maintaining viral suppression throughout each viral load assessment post-enrollment while receiving ART through the DDD program. This critical indicator signified the program's impact on sustained positive health outcomes among participants, reflecting effective viral load management and treatment adherence. The standard for this outcome was based on the proportion of active participants remaining virally suppressed (i.e., < 1000 copies/ml) while on the intervention as defined by WHO.

Data Collection and Sources

Routine program data management included an integration of clinical, dispensing, and medicine logistics information obtained throughout the active prescription cycles. This array of information was drawn from several distinct sources, which included the electronic health records management system within the treatment facilities, known as SMARTCARE. Furthermore, the central pharmacy database, eRX, played a pivotal role in integrating and sourcing pertinent data from various sources. Complementing these sources was the mobile logistics application database, which augmented the comprehensive repository of information essential for this study.

Data Analysis

The examination of program effects was determined through a systematic quantification process. This involved the calculation of annual rates pertaining to program utilization as measured by the number of beneficiaries enrolling against the preset target, medicine collection, beneficiary retention, and the maintained status of viral load suppression while on the program over the period of program implementation. We determined net program effects, presented as the mean effects observed per annum. The outcomes were further summarized into presentation formats, encompassing two-way tables and visually informative charts using Microsoft Excel. We used descriptive analysis to describe participant characteristics upon enrollment in the CDD program.

Participant Characteristics

In our study, a cohort of 17,157 eligible patients were enrolled in the CDD program during the review period. Figure 1 summarizes the sampling process.

Most enrolled participants were female, accounting for 69% of the total beneficiaries (Table 1). Analysis of the age distribution revealed distinct patterns between male and female beneficiaries. Among male beneficiaries, enrolment appeared to increase with advancing age categories. Conversely, female beneficiaries exhibited a less regular distribution across different age bands, with a notable concentration (50% and above) in the 50 years and older age group. Our analysis revealed a consistent trend of higher enrolment propensity among beneficiaries aged over 30 years, indicating a preference for programme participation among the older cohort.

Table 1

Baseline characteristics of a cohort of beneficiaries enrolled in the CDD program.
Variables	Summary Statistics (N = 17157)
Sex	Male: n (%)	Female: n (%)
Sex	5362 (31)	11795 (69)
Age
10–14	13 (22)	47 (78)
15–19	31 (32)	65 (68)
20–24	81 (20)	329 (80)
25–29	256 (20)	1008 (80)
30–34	541 (25)	1610 (75)
35–39	906 (29)	2225 (71)
40–44	1012 (31)	2208 (69)
45–50	1127 (36)	2022 (64)
> 50	1395 (38)	2281 (62)
Baseline Viral Load
Target Not Detected	2553 (28)	6437 (72)
Less than 20	1689 (33)	3444 (67)
Between 20 and 999	1119 (37)	1913 (63)
More than 1000	0	0
Enrollments
2018	947 (28)	2454 (72)
2019	2160 (33)	4317 (67)
2020	1447 (30)	3352 (70)
2021	808 (33)	1672 (67)

A key attribute considered during beneficiary enrolment was viral load suppression. Despite the program's eligibility criteria stipulating enrollment only for individuals with suppressed viral load (VL copies ≤ 1000 copies/mL), an assessment of viral load levels revealed that the majority (52%) of beneficiaries had achieved undetectable plasma viral load levels from facility-based care, as denoted by TND (Table 1).

An Assessment of the Key Health Outcomes

Impact on Treatment Sites and Intervention Utilization Rates

At the program's conclusion in 2021, a substantial 51% reduction (17,157 out of 33,397) in patient load was observed across the nine high-volume treatment sites (Table 1). While annual program enrollments exhibited variation over the years, the cumulative enrollment of eligible beneficiaries surpassed the initial target, reaching 74% of the planned goal (23,216 beneficiaries). An encouraging trend emerged, reflecting a consistent positive linear growth in the preference for CDD program utilization by eligible beneficiaries over time. Our analysis of participants' characteristics and the outcomes of the CDD program provides valuable insights into the program's impact and effectiveness. These findings underscore the significance of age distribution, viral load suppression, and enrollment trends, contributing to a comprehensive understanding of the program's reach and success.

Medicine Collection Rates

Our assessment of medicine collection rates revealed interesting patterns. The data demonstrated that, on average, 93% (CI: 85% − 100%) of scheduled medicine parcels were successfully collected by beneficiaries at the designated PuPs over the course of the CDD program implementation (Table 2).

Table 2

Medicine parcel collection rates (N = 31,969)
Period	# Preparedⁱ	# Collectedⁱⁱ	Collection Rateⁱⁱⁱ
2018	3371	3369	99.94%
2019	12641	11787	93.24%
2020	12285	9695	78.92%
2021	7135	7135	100.00%
ⁱ Number of parcels scheduled for collection in the corresponding period
ⁱⁱ Number of parcels collected as scheduled in the corresponding period
ⁱⁱⁱ The proportion of parcels successfully collected as scheduled (i.e., on scheduled date and within 72 hours of scheduled date)

The highest collection rates, both registering at a perfect 100%, occurred in 2018 and 2021. However, a notable dip below the desirable level (90%) was observed in 2020, where the collection rate declined to approximately 79%. Confidence interval estimates suggest that the mean rates of medicine collection facilitated by the CDD program likely fall within the range of 85–100%. It is also worth noting that for approximately 7% of the total number of medicine parcels prepared and scheduled for collection, some beneficiaries encountered challenges in collecting their medicines as per the schedule, which stemmed from several factors, such as highly mobile patients due to work commitments, lack of understanding of collection schedules upon enrolment, forgetfulness, and inability to transmit SMS reminders due to incorrect contact numbers or poor network coverage in the region.

Beneficiary Retention Rates

The assessment of beneficiary retention rates revealed significant insights with implications for program evaluation. On average, an impressive 97% (CI: 95% − 99%) of beneficiaries remained engaged in the program annually (Table 3).

Table 3

Annual CDD beneficiary retention rates (N = 16,492)
Period	New^iv	Deregistered^v	Cumulative^vi	Retained^vii
2018	3401	42	3358	98%
2019	6477	214	9620	94%
2020	4799	280	14139	97%
2021	2480	127	16492	99%
^iv Number of beneficiaries newly engaged onto the CDD program in the corresponding period
^v Number of beneficiaries removed from the CDD program in the corresponding program
^vi Incremental number of beneficiaries remaining actively engaged onto the CDD program from the preceding period plus the newly engaged less the those who were removed in the corresponding period
^vii The proportion of beneficiaries remaining actively engaged on the CDD program from the preceding period after 12 months, assuming that all beneficiaries were engaged at the same time in the preceding periods

The program's exceptional retention rates of 98% and 99% were observed in both 2018 and 2021, respectively, surpassing the program's 95% target. However, certain circumstances led to the discontinuation of 663 beneficiaries. These included factors such as elevated viral load results (n = 19), transfers (n = 12), instances of mortality (n = 5), voluntary disengagement (n = 4), and challenges in maintaining contact despite multiple follow-up attempts (n = 623).

Maintenance of Suppressed Viraemic Status

Through our observation over the period of CDD program implementation, beneficiaries who had to be removed from the program due to elevated viral load results represented a fraction (less than 1%) of the cohort (19/17,157) ever enrolled. These patients’ prescriptions were not renewed for continued participation in the program by the attending clinicians during their scheduled clinical review.

The implementation of Zambia's HIV test and treat policy in 2016 led to a surge in disease burden within primary healthcare facilities. To address this challenge, DSD interventions, including the CDD program, were adopted. This study aimed to quantify the impact of the CDD intervention on key health outcomes within Zambia's context, focusing on a cohort of eligible beneficiaries enrolled in routine antiretroviral therapy (ART) services. Consistent with findings from other studies showcasing various DSD models, our results further emphasize the positive impact of the CDD program in effectively tackling a range of healthcare delivery challenges [1, 2].

Positive Impact on Healthcare Delivery

While displaying positive outcomes in addressing health system challenges stemming from a high disease burden over time, the CDD program's effectiveness was hampered by a slow rate of beneficiary enrollment, resulting in underutilization of its existing capacity, and missed opportunities for economies of scale. In comparison, South Africa (SA) managed to serve 2,069,039 beneficiaries under a similar model by 2018, with 76% of the beneficiaries collecting ART [8]. Notably, contextual disparities influenced Zambia's uptake rate. The novelty of the model in the context of Zambia necessitated capacity-building and operational adjustments. While this review did not delve into the reasons behind the slow uptake, common contextual factors likely hindered program utilization from both healthcare provider and patient perspectives. While our findings explicitly indicate a net positive influence on retention and viral suppression, it is notable that [8] similarly underscores the effectiveness of the CCMDD program in South Africa. This study reaffirms that PLHIV enrolled in the CCMDD program in South Africa consistently maintained a substantial level of viral suppression and retention in care. This robust outcome underscores that the program's implementation had no adverse implications for the HIV care outcomes within the cohort under review.

Challenges in Program Implementation

Given the CDD program's uniqueness in the context of Zambia, addressing change management and scepticism among both providers and patients toward the use of external PuPs and technological advances emerged as essential. This observation resonates with findings by [16], revealing that among others, barriers such as limited literacy about DSD models, ARV drug stock shortages, and supply chain inconsistencies impeded the adoption, implementation, and scaling of DSD models. Notably, at the outset, several stakeholders expressed reservations about potential patient loss from routine care and anxieties about stock leakage in the private sector network—a practice unprecedented in Zambia. These concerns were mitigated through targeted multistakeholder workshops, engagements, and sustained mentorship and training initiatives, as recommended by [17].

Similarly, as encountered in other healthcare interventions employing smart healthcare strategies [18] to improve efficiency, patient outcomes, and quality healthcare, the integration of technology into the CDD framework was not without challenges. These challenges encompassed deficient network infrastructure in certain areas of Ndola, hindering script acquisition at the site level. The situation was exacerbated by beneficiaries' unreliable access to mobile phones, which is a prerequisite for enrolment. Additional hindrances included delayed access to recent viral load results, causing substantial delays in eligible beneficiary enrolment. Notably, the efficacy of ART monitoring in Zambia has been hampered by various viral load testing challenges [19], where only approximately 40% of approximately 800,000 patients on ART received a viral load test in 2018 [20].

Over time, as the program gained traction and resonated with beneficiaries and healthcare providers, an insufficiency of conveniently accessible alternative PuPs emerged as an obstacle. This resulted in uneven utilization of designated PuPs, thereby compromising the program's overall effectiveness and reach. This underscores the importance of strategically disseminating suitable alternative PuPs to optimize program efficiency, such as the introduction of strategically located semiautomated medicine collection units. This strategic deployment aligns with [21], where the perception of more convenient PuP locations was recognized as a notable benefit of the CCMDD program's implementation in South Africa.

Enhancements to the Health System

Despite the relatively sluggish uptake, the data have illuminated potential enhancements to the health system resulting from the CDD program. These improvements are highlighted by a robust mean annual retention rate of 97% (95% CI, 95% − 99%) that persisted over four years of implementation. This finding aligns with established evidence concerning DSD models in general [15], wherein retention rates across various models typically surpassed the 80% threshold. Although the expansion of the CDD program in SA showcased its ability to enhance access to essential medications in resource-constrained environments [8], there is little evidence on its effects on patient-level clinical outcomes in Zambia [8]. Our review reveals a moderate positive linear relationship (correlation coefficient, r = 0.3), indicating that higher mean medicine collection rates (93%, 95% CI: 85% − 100%) are consistently linked to elevated mean retention rates (97%, 95% CI: 95% − 99%). While a correlation coefficient of 0.3 indicates an association between medicine collection and retention rates, other factors may contribute to variations in these variables.

Comparative Studies on Medicine Collection

In a study examining barriers and facilitators to medicine collection during a similar intervention in South Africa over a 6-month period (April to September 2017), 97.5% of 31,157 beneficiaries were classified as collectors, while 2.5% were noncollectors [2]. In our review, the data show a minor distinction, where only 3.8% of 17,155 beneficiaries initially could not collect as scheduled despite multiple standard track and trace attempts over four years. At the outset of the CDD program in 2014 in South Africa, successful collection rates were estimated at 88–92% based on uncollected medicine parcels [22]. Despite the shorter follow-up duration and parcel-based measurement in the observations by [2], the CDD program in Zambia consistently achieved a similar outcome (96.13%) over a longer 4-year period using verified collection data, showcasing its enduring impact. A contextual difference to consider is the frequency of prescription refills, with South Africa at two months and Zambia at six months. Notably, the CDD program's success in Zambia's collection rates is attributed to treatment support services, encompassing routine reminders, patient education, adherence support, and follow-ups through a call center.

Viability of the CDD Program for Zambia

We contend that this review substantiates the CDD program's viability for Zambia. Sustained viral load suppression mandates active engagement and adherence. Specifically, a routine VL result below 1000 copies/ml was required for continued participation, leading to almost 100% of beneficiaries maintaining viral suppression. With notably high retention rates (mean 97%), our findings suggest the CDD program's potential to significantly contribute to durable viral load suppression. While this review did not directly compare retention to alternative interventions in Zambia, existing evidence highlights routine care's lower retention rates (75% and 65%) in Lusaka, Copperbelt, Western, and Southern provinces [23, 24]. The imperative of retention for sustained viral load suppression underscores the importance of routine care.

Future Directions

Our data-driven framework and review of outcomes suggest several promising paths for future investigation. Given the limited follow-up duration, we recommend utilizing our findings as a reference point for employing simulation techniques. These techniques can help project the CDD program's long-term impact on health system costs and outcomes, encompassing quality-adjusted life years (QALYs). Such projections would provide valuable insights for a comprehensive cost-effectiveness analysis and a budget impact assessment, facilitating comparisons with existing programs or standard care in the context of Zambia. In addition, we suggest a structured subgroup analysis of the cohort to synthesize evidence on significant differences in outcomes among specific subgroups of the study cohort.

Furthermore, we advocate for a qualitative inquiry to delve into the underlying causes of the observed slow uptake from both patient and provider perspectives. Although our study highlights higher collection rates, an explanatory gap remains regarding missed appointments for scheduled PuP collections in approximately 7% of the cohort. An in-depth investigation is warranted to uncover the reasons behind these missed appointments.

Another critical area of investigation pertains to the changes in the patterns of distribution of viral load (VL) levels over time for actively engaged beneficiaries. Renewed prescriptions are linked to suppressed VL results. However, a lack of transactional data tracking individual VL changes with each renewed prescription impedes understanding in this realm. Exploring this aspect would enrich our comprehension of VL dynamics within the program. Finally, a comprehensive evaluation of dispensing efficiencies and the technological impact of the central pharmacy on the CDD program, guided by key operational indicators, is essential. This assessment would contribute valuable insights into program optimization and technological enhancements and needed adaptations of the intervention for Zambia.

Study Limitations

This study's analytical methods have limitations. It focused on specific facilities in Ndola, limiting generalization. Varying enrollment times hindered cohort tracking, leading to retention rates estimated based on the number of beneficiaries being removed from the program at different points in time during implementation. While positive effects were demonstrated within the framework of the CDD program, a lack of baseline data on standard care outcomes prevented direct assessment of the CDD program's impact pre- and postimplementation.

The CDD program's impact over the demonstration period highlights its potential to significantly influence key programmatic outcomes, from alleviating congestion at high-volume treatment sites to ensuring sustained beneficiary enrollment and facilitating scheduled medicine parcel collection. Its operational attributes offer viable solutions to address healthcare system challenges in Zambia, including potential cost savings through economies of scale. Collaborating with regulatory bodies to integrate unconventional pickup points (PuPs) is crucial for widespread implementation.

Strategically positioning and supporting the CDD program could establish it as a foundational element of the Zambian health system, enabling resource pooling for broad population benefits. This holistic and technologically advanced approach to healthcare delivery integrates entities and logistical intricacies, enhancing medicine accessibility and refining patient engagement. By assessing key health outcomes within the CDD program, a comprehensive understanding of its effects on patient engagement, adherence, retention, and viral suppression was achieved. This multifaceted evaluation contributes valuable insights to the broader landscape of HIV care delivery and informs strategies for optimizing patient-centred healthcare interventions.

AIDS Acquired Immunodeficiency Syndrome.

ART Antiretroviral Therapy

ARV Antiretroviral drugs

CCMDD Centralized Chronic Medicines Dispensing and Distribution

CI Confidence Interval

DDD Decentralized Drug Distribution

DSD Differentiated Service Delivery

ERES Excellence Research Ethics and Science

GOZ Government of Zambia

HIV Human Immunodeficiency Virus

HMIS Health Information Management System

IT Information Technology

MoH Ministry of Health

PLHIV People Living with HIV

PuP Pickup Point

QALYs Quality-Adjusted Life Years

SMS Short Message Service

StaRI Standards for Reporting Implementation Studies

TB Tuberculosis

TIDieR Template for the Intervention Description and replication

TLD Tenofovir, Lamivudine, and Dolutegravir

TLE Tenofovir disoproxil fumarate, Lamivudine, and Efavirenz

TND Target Not Detected

UNAIDS Joint United Nations Programme on HIV/AIDS

VL Viral load

WHO World Health Organization

Acknowledgements

We wish to acknowledge the project implementation teams in Right-to-Care Zambia and South Africa. Furthermore, we acknowledge the reviewers of this paper. We also wish to express gratitude to Right ePharmacy, the third-party organization supporting the implementation of the project, for providing programmatic data required for this report.

Funding

This work was made possible by the generous support of the American people through the United States Agency for International Development (USAID), under the terms of the Cooperative Agreement AID‐OAA‐A‐15‐00070. The contents are the responsibility of the authors and do not necessarily reflect the views of USAID or the United States Government. The funders had no role in the study design, data collection and analysis, decision to publish or preparation of the manuscript.

Authors and Affiliations

Right to Care, 1006 Lenchen Avenue North, Centurion, Pretoria, South Africa

Gaula Molaudi, Maotoe Thapelo, Akpan Francis, Banoo Shabir & Sanne Ian

Implementation Science Unit, Right to Care, 1006 Lenchen Avenue North, Centurion, South Africa.

Wose Kinge Constance, Mothibi Eula, & Chasela Charles

Department of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.

Wose Kinge Constance & Chasela Charles

Right ePharmacy, 1006 Lenchen Avenue North, Centurion, Pretoria, South Africa.

Dube Tawanda& Hendriksz Fanie

Right to Care, Plot 31C DG Office Park, Bishops Road, Kabulonga, Lusaka, Zambia.

Chibanda Ivin & Chirwa Ben

Clinical HIV Research Unit, Department of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

Sanne Ian

Contributions

MG, conceptualization of the study, design, data collection, data analysis and interpretation, and wrote the main manuscript; CWK, critically reviewed and rewrote the paper. IC and TD, managed program implementation in Zambia, provided the necessary commentary on setting and contextual issues of the study and the program. FH, FA, TM, SB, BC, EM, IS, CC provided technical oversight during program implementation and reviewed the manuscript. All authors read and approved the final manuscript.

Corresponding author

Corresponding to [email protected]

Ethics Declarations

Competing Interests

The authors declare no competing interests.

Ethical approval and consent to participate.

Adherence to ethical imperatives was upheld throughout this study, which was conducted in accordance with the Declaration of Helsinki. Approval for this research was secured as a subprogram within the overarching EQUIP project, implemented in Zambia under the auspices of the Excellence Research Ethics & Science (ERES) Converge Zambia (IRB No. 00005948). It is noteworthy that the data utilized in this study were carefully collated in an aggregated manner, thus safeguarding the confidentiality and anonymity of individual beneficiaries. Informed assent/consent was obtained from clients or their parents/or legal guardian.

Consent for publication

Not applicable.

Data Availability

The dataset supporting the conclusions of this article is available upon reasonable request from the authors and with permission from the Zambian Ministry of Health and Right-to-Care.

Fox MP, Pascoe S, Huber AN, Murphy J, Phokojoe M, Gorgens M, et al. Adherence clubs and decentralized medication delivery to support patient retention and sustained viral suppression in care: Results from a cluster-randomized evaluation of differentiated ART delivery models in South Africa. PLOS Med [Internet]. 2019 Jul 23 [cited 2023 Feb 27];16(7):e1002874. Available from: https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1002874
Hlongwana SI, Gray AL. Barriers and facilitators to medicine collection through the CCMDD programme at a Durban Hospital. Health SA Gesondheid Online [Internet]. 2022 [cited 2023 Feb 27];27:1–10. Available from: http://www.scielo.org.za/scielo.php?script=sci_abstract&pid=S207197362022000100036&lng=en&nrm=iso&tlng=en
Consolidated Guidelines on the Use of Antiretroviral Drugs for Treating and Preventing HIV Infection: Recommendations for a Public Health Approach [Internet]. 2nd ed. Geneva: World Health Organization; 2016 [cited 2022 Apr 21]. (WHO Guidelines Approved by the Guidelines Review Committee). Available from: http://www.ncbi.nlm.nih.gov/books/NBK374294/
Du Toit J, Dames S, Boshoff R. Centralised dispensing-an affordable solution. SA Pharm J [Internet]. 2008;75(10):18–20. Available from: https://0-hdl-handle-net.innopac.wits.ac.za/10520/EJC81874
Magadzire BP, Marchal B, Mathys T, Laing RO, Ward K. Analyzing implementation dynamics using theory-driven evaluation principles: lessons learnt from a South African centralized chronic dispensing model. BMC Health Serv Res [Internet]. 2017 [cited 2022 Apr 21];17(Suppl 2):724–724. Available from: https://doi.org/10.1186/s12913-017-2640-2
Johns B, Baltussen R, Hutubessy R. Programme costs in the economic evaluation of health interventions. Cost Eff Resour Alloc [Internet]. 2003 Feb 26 [cited 2021 Nov 30];1(1):1. Available from: https://doi.org/10.1186/1478-7547-1-1
Blecher M, Kollipara A, Maharaj Y, Mansvelder A, Davén J, Gaarekwe O. Health spending at a time of low economic growth and fiscal constraint. South Afr Health Rev [Internet]. 2017;2017(1):25–39. Available from: https://hdl.handle.net/10520/EJC-c80bbce33
Liu L, Christie S, Munsamy M, Roberts P, Pillay M, Shenoi SV, et al. Expansion of a national differentiated service delivery model to support people living with HIV and other chronic conditions in South Africa: a descriptive analysis. BMC Health Serv Res [Internet]. 2021 May 17 [cited 2023 Feb 28];21(1):463. Available from: https://doi.org/10.1186/s12913-021-06450-z
Roy M, Bolton Moore C, Sikazwe I, Holmes CB. A Review of Differentiated Service Delivery for HIV Treatment: Effectiveness, Mechanisms, Targeting, and Scale. Curr HIV/AIDS Rep [Internet]. 2019 [cited 2022 Apr 17];16(4):324–34. Available from: https://go.exlibris.link/31qLH9Wt
Pinnock H, Barwick M, Carpenter CR, Eldridge S, Grandes G, Griffiths CJ, et al. Standards for Reporting Implementation Studies (StaRI) Statement. BMJ Online [Internet]. 2017 [cited 2023 Aug 21];356(Journal Article):i6795–i6795. Available from: https://go.exlibris.link/J2LSp8rM
Hoffmann TC, Glasziou PP, Boutron I, Milne R, Perera R, Moher D, et al. Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide. BMJ [Internet]. 2014 Mar 7 [cited 2023 Aug 19];348:g1687. Available from: https://www.bmj.com/content/348/bmj.g1687
Ministry of Health. Master Facility List [Internet]. 2023 [cited 2023 Aug 22]. Available from: http://154.120.217.168:8081/mfl/frontend/web/site/index
Zambia Statistics Agency. ZAMBIA 2022 CENSUS OF POPULATION AND HOUSING [Internet]. 2022. Available from: website: www.zamstats.gov.zm
Ministry of Health. Zambian Health Management Information System [Internet]. [cited 2023 Aug 22]. Available from: https://dhis2.moh.gov.zm/hmis/dhis-web-commons/security/login.action
Long L, Kuchukhidze S, Pascoe S, Nichols BE, Fox MP, Cele R, et al. Retention in care and viral suppression in differentiated service delivery models for HIV treatment delivery in sub‐Saharan Africa: a rapid systematic review. J Int AIDS Soc [Internet]. 2020 [cited 2022 Apr 17];23(11):e25640-n/a. Available from: https://go.exlibris.link/SD2njlZh
Belay YA, Yitayal M, Atnafu A, Taye FA. Barriers and facilitators to the implementation and scale up of differentiated service delivery models for HIV treatment in Africa: a scoping review. BMC Health Serv Res [Internet]. 2022 Nov 28 [cited 2023 Aug 21];22(1):1431. Available from: https://doi.org/10.1186/s12913-022-08825-2
Bogart LM, Shazi Z, MacCarthy S, Mendoza-Graf A, Wara NJ, Zionts D, et al. Implementation of South Africa’s Central Chronic Medicine Dispensing and Distribution Program for HIV Treatment: A Qualitative Evaluation. AIDS Behav [Internet]. 2022 Aug 1 [cited 2023 Feb 27];26(8):2600–12. Available from: https://doi.org/10.1007/s10461-022-03602-y
Renukappa S, Mudiyi P, Suresh S, Abdalla W, Subbarao C. Evaluation of challenges for adoption of smart healthcare strategies. Smart Health [Internet]. 2022 Dec 1 [cited 2023 Aug 21];26:100330. Available from: https://www.sciencedirect.com/science/article/pii/S2352648322000642
Girdwood SJ, Nichols BE, Moyo C, Crompton T, Chimhamhiwa D, Rosen S. Optimizing viral load testing access for the last mile: Geospatial cost model for point of care instrument placement. PLoS One. 2019;14(8):e0221586.
Nichols BE, Girdwood SJ, Crompton T, Stewart-Isherwood L, Berrie L, Chimhamhiwa D, et al. Monitoring viral load for the last mile: what will it cost? J Int AIDS Soc [Internet]. 2019 [cited 2023 Aug 21];22(9):e25337. Available from: https://onlinelibrary.wiley.com/doi/abs/10.1002/jia2.25337
Bassett IV, Yan J, Govere S, Khumalo A, Ngobese N, Shazi Z, et al. Uptake of community- versus clinic-based antiretroviral therapy dispensing in the Central Chronic Medication Dispensing and Distribution program in South Africa. J Int AIDS Soc [Internet]. 2022 [cited 2023 Aug 21];25(1):e25877. Available from: https://onlinelibrary.wiley.com/doi/abs/10.1002/jia2.25877
Magadzire BP, Marchal B, Ward K. Improving access to medicines through centralised dispensing in the public sector: a case study of the Chronic Dispensing Unit in the Western Cape Province, South Africa. BMC Health Serv Res [Internet]. 2015 Nov 17 [cited 2023 Feb 27];15(1):513. Available from: https://doi.org/10.1186/s12913-015-1164-x
Scott CA, Iyer HS, McCoy K, Moyo C, Long L, Larson BA, et al. Retention in care, resource utilization, and costs for adults receiving antiretroviral therapy in Zambia: a retrospective cohort study. BMC Public Health [Internet]. 2014 Mar 31 [cited 2022 Apr 21];14:296. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3995515/
Mwale JC. Factors affecting retention in care of patients on antiretroviral treatment in the Kabwe district, Zambia. 2016; Available from: https://etd.uwc.ac.za/handle/11394/5251

No competing interests reported.

Download PDF

Version 1

posted

You are reading this latest preprint version

Does centralized dispensing and distribution of medicines improve health outcomes? A retrospective cohort study in Ndola, Zambia

Status:

Version 1

Abstract

Background

Methods

Results

Conclusion

Figures

Background

Methods

Results

Participant Characteristics

An Assessment of the Key Health Outcomes

Impact on Treatment Sites and Intervention Utilization Rates

Medicine Collection Rates

Beneficiary Retention Rates

Maintenance of Suppressed Viraemic Status

Discussion

Positive Impact on Healthcare Delivery

Challenges in Program Implementation

Enhancements to the Health System

Comparative Studies on Medicine Collection

Viability of the CDD Program for Zambia

Future Directions

Study Limitations

Conclusion

Abbreviations

Declarations

References

Additional Declarations

Status:

Version 1