Developing quality participatory pharmacy practice for children living with HIV/AIDS in Mbeya,Tanzania

 

Problem: 

Sub-Saharan Africa takes up a large share of population comprising people living with HIV/AIDS globally and studies have shown that Sub-Saharan Africa is home to 90% of children living with HIV/AIDS [i]

United Republic of Tanzania, a respective part of Sub-Saharan Africa, is estimated to have 1.4million people living with HIV/AIDS which contributes to an overall prevalence of 5.6% nationally of whom 160,000 are children living with HIV/AIDS, where this disease contributes to 86,000deaths and 1.3million orphans[ii]. Mbeya region of Tanzania is known to be one of the highest prevalent areas with HIV/AIDS in the country.
 
Accessibility to Antiretroviral Therapy is a component of Millennium Development Goals envisioned to prolong lives of people living with HIV/AIDS which has led to enablement of Antiretroviral Medicines upscale globally. Sadly, only 37% people eligible for Anti-Retroviral Therapy (ART) in Sub-Saharan Africa were able to access such service in 2009, although these numbers are even lower for children at 29% in the same year.[iii] For United Republic of Tanzania in 2010 just 32% of adult population eligible could access Anti-Retroviral Therapy, and for children this was at merely 17% of children eligible receiving ART (iii).
 
Of the twenty-two regions in Tanzania, Mbeya has an average 25% of total population illiterate[iv] and is ranked second region on the Food Poverty Rate, has 165/1000 Under-five Mortality Rate as well as being ranked tenth in stunting among other regions of Tanzania[v]. In fourteen districts where more than 14% children had lost either a mother or a father[vi] , Mbeya-Urban stands with 16.2% children orphaned in this way.
 
Baylor International Pediatric AIDS Initiative (BIPAI) is an organization which works globally to make lives better for children living with HIV/AIDS, and Mbeya is one of their intervening regions. Registered as Baylor Children’s Foundation, this organization works collaboratively with public referral hospitals to provide free healthcare services to children from infants till eighteen years of age. This Public-Private Partnership project has a separate building within compound provided adjacent to a public hospital and operates with separate resources to provide free HIV/AIDS (and TB) services for children.
 
Among resources actively invested into this structure are specialized pediatricians recruited from the United States of America who guide our practices into excellence of service provided. With dynamic training and knowledge sharing, human resources within Baylor makes it a Center of Excellence, and such learning is trickled down into our capacity-building efforts where human resources are invited from other public hospitals for training as well as our human resources conduct outreach activities to provide on-job-training.
 
Pharmacists are among scarce human resources in Tanzania with national ratio of 0.18 per 10,000 people, also indicating that almost two pharmacists serve for every 100,000people. Recent findings strongly suggest task-shifting being applied to local settings for implementation of HIV/AIDS scale-up in Africa[vii] being that other cadres involved in health care delivery system could take up multiple tasks in service delivery.
 
This implies that as we scale up delivery of Antiretroviral Therapy in Africa, tasks of pharmacists shall be handled by personnel other than pharmacist. Under such circumstances it becomes imperative that dispensers are equipped with appropriate tools to delivery optimal practice, especially for children who can easily be subjected to over-dosing, preventable illnesses, adverse effects, drug-interactions and unnoticed resistance to therapy. It is also of utmost importance that as service providers we comprehensively involve patients and their families in delivery of healthcare, which is a rare practice in Tanzanian pharmaceutical systems.

 

 


[i] UNAIDS Report on the Global AIDS Epidemic 2010; and UNAIDS unpublished estimates 2010.
[ii] UNAIDS, Joint United Nations Program on HIV/AIDS, http://www.unaids.org/en/regionscountries/countries/unitedrepublicoftanz...
[iii] Global report: UNAIDS report on the global AIDS epidemic 2010, p. 97
[iv] MBEYA DISTRICT SOCIO-ECONOMIC PROFILE, THE PLANNING COMMISSION DAR ES SALAAM/ MBEYA DISTRICT COUNCIL, http://www.tzonline.org/pdf/Mbeyadis.pdf
[v] National Bureau of Statistics, Household Budget , Survey 2000/01, Populations Census 2002 and Tanzania Demographic and Health Survey 2004/05.
[vi] Research and Analysis Working Group (2005), Poverty and Human Development Report 2005, Dar-es Salaam: Mkuki na Nyota Publishers. Available at http://www.repoa.or.tz/documents_ storage/PHDR_2005.pdf
[vii] Callaghan M. et al, eA isystematic review of task-shifting for HIV treatment and care in Africa, Human Resources for Health 2010, 8:8, http://www.human-resources-health.com/content/8/1/8

 

 

Intervention: 

Baylor Clinic started in Mbeya on February 2011 and during this time we adopted all pediatric HIV positive children from Mbeya Referral Hospital. To fulfill our vision of participatory and quality pharmacy practice provision at our center we involve patient/care-giver involvement in the dispensing process.

After verifying ART prescription, we question our patient/caregiver on how they have been using their ART. It is very essential to pose the question correctly to get the correct response. We usually avoid giving directions before learning on how these medications had been used previously. Interesting responses are received including identification of overdosing, and sometimes surprisingly, use of ART over a long period of time empowers patients to identify their accurate regimen and, given a chance, such participation helps in identifying their correct medications even sometimes correcting the dispensers’ errors.
 
Before dispensing more ART to patients we perform pill-counts for adherence at our clinic, and such count is confirmed at pharmacy department. During the process of pill-counts, we also assess the hygienic use of ART as many times patients return with extremely dirty pills.
When we identify dirty tablets (which have changed color from white to brown or even black with finger prints; even once tablets came back with chicken feathers), we usually retain these tablets for destruction by national protocol, and we counsel patient/care-giver on good hygiene practices at home including hand-washing. The dirty medications are then stored together with ART regimen change and expired/damaged medications are collected in a box for destruction.
 
Another significant change we have brought about is introduction of a dispensing algorithm which we use to give buffer amount ranging from one day to five days extra medications for them to return on their appointment days. We give limited buffer amounts to serve two purposes; one is that patients would return on their assigned dates and another is to provide for loss by dropping medicines or through vomiting. While dispensing extra amounts of ART, patients are consulted, not only informed upon amounts being dispensed relating to their assigned date of return.

 

As almost one in every four people in Mbeya region is illiterate (please refer to “problem”), we have patients who cannot understand written instructions. This becomes a problem when someone’s child has to begin ART and parent understands momentarily but then forgets the instructions. So, at our clinic we use crayons to draw instructions of every pill/suspension for them on a paper. We draw a sun and then a moon. Under “sun” (or “moon”) we draw how each pill is taken; so we draw half of the yellow pill and one whole white pill, for example.  For suspensions we draw a syringe and only draw a line with the number till which it is supposed to be measured. To distinguish syrups we shade the syringe drawn with color of the box.
 
After dispensing, and before patient leaves, patient/care-giver is requested to repeat directions of use for every ART dispensed. By doing so, any doubts and queries about use is addressed before they go home.
 
Results: 

Since we started we have more and more patients receiving care from our facility and our patients have increased. But more so perhaps a better result could be shown by the increase in number of patients receiving ART from our clinic who travel long distances across the region for our services. Our clinic has expanded to provision of ART as follows:

 

Also, our operational research on patients’ satisfaction survey of our patients/care-givers indicated that pharmacy services were graded highly as follows:  
Testimony to such high number of patients turning up for our service and their positive attire for pharmacy is because our services delivered at pharmacy are appreciated owing to the fact that pharmacy practice is patient-oriented and participatory.

 

Lessons: 

Dispensing ART through participatory approach with patient/caregiver could empower them creating a user-friendly environment and better compliance to prescribed regimes. To enable compliance dispensers should not merely “give” medications, but also recognize various clinical aspects related to use of the medication and their importance in patients’/care-givers’ enlightenment and resultant empowerment. Care displayed towards patient/caregiver is reflected through appreciation and gratification which is shown by positive attitude, and higher number of people travelling long distances with very little economic ability to visit us for healthcare.

 

Countries: 
Report Author(s): 
Nadiya Alnoor Jiwa, Yusuf Hussein, Kulwa Samson, Brenda Anosike, Michael Tolle
Organization(s): 
Baylor College of Medicine Children's Foundation Tanzania
ASSIST publication: 
no
Facebook icon
Twitter icon
LinkedIn icon
e-mail icon