Country ownership and sustainability of Nigeria's HIV/AIDS Supply Chain System: qualitative perceptions of progress, challenges and prospects.

BACKGROUND: The emergency response phase to HIV epidemic in Nigeria and other countries saw to the deployment of donors' resources with little consideration for country ownership (CO) and sustainability. The progress that has been made in the fight against the pandemic has however precipitated a paradigm shift towards CO and sustainability. With the decline in donors' funding, countries must continually evaluate their readiness to own and sustain their HIV response especially the supply chain system (SCS) and bridge any observed gaps. This study assessed the current understanding of CO and sustainability of Nigeria's HIV/AIDS SCS, established progress that has been made, identified challenges that may be hampering CO and possible recommendations to address these challenges. It also explored opportunities that the country can leverage on. METHODS: We conducted a cross sectional descriptive study through semi-structured interview of twelve purposefully selected key informants involved in HIV/AIDS supply chain management. Transcribed qualitative data were analyzed using a thematic approach. RESULTS: Among other submissions, respondents acknowledged that CO involves non-government stakeholders. Key CO and sustainability achievements were: development of national strategic plans and policy documents, establishment of coordinating structures, allocation of funds for some logistics activities at the state level and payment of salaries of government staff, institution of pre-service training, use of logistics data for decision making and the unification of the hitherto parallel HIV/AIDS supply chains. Challenges included: inadequate domestic funding, bureaucratic bottlenecks and inadequate manpower at the health facility level. Respondents recommended more political commitment and increased government funding, exploration of alternative sources of funding, improved accountability, effective healthcare workforce planning and local manufacture of HIV commodities. Existing structures and programmes that the country can leverage on included: Nigeria Supply Chain Integration Project, National Health Insurance Scheme and the private sector. CONCLUSIONS: Nigeria has made some progress towards achieving CO and sustainability. The country however needs to address financial and human resource gaps through innovative resource mobilization and effective workforce planning. As other countries plan for CO and sustainability, it is important to secure political buy-in and adopt a working definition for CO and sustainability while resource mobilization and workforce planning should be prioritized.

Adherence to On-Time ART Drug Pick-Up and Its Association with CD4 Changes and Clinical Outcomes Amongst HIV Infected Adults on First-Line Antiretroviral Therapy in Nigerian Hospitals.

Medication adherence is a major determinant of antiretroviral treatment (ART) success. Promptness in medication refill pick-ups may give an indication of medication adherence. This study determined medication refill adherence among HIV positive patients on ART and its association with treatment outcomes in HIV treatment centers in Nigeria. This retrospective multi-center cohort study involved a review of ART refill records for 3534 HIV-positive patients aged 18-60 years who initiated first-line ART between January 2008 and December 2009 and were on therapy for ≥18 months after ART initiation. Drug refill records of these patients for 10 consecutive refill visits after ART initiation were analyzed. The first ten consecutive refill appointment-keeping rates after ART initiation ranged from 64.3 % to 76.1 % which decreased with successive visits. Altogether, 743 (21.1 %) patients were deemed adherent, meaning they picked up their drugs within 7 days of the drug refill appointment date on at least nine out of ten refill visits. The adherent group of patients had a mean CD4 cells increase of 206 ± 6.1 cells/dl after 12 months of ART compared to 186 ± 7.1 cells/dl reported among the nonadherent group (p = 0.0145). The proportion of patients in the adherent category who showed no OIs after 12 months on ART (81 %) was significantly higher when compared to the proportion in the non-adherent category (23.5 %), (p = 0.008). The multivariate analysis showed that the odds of being adherent was 2-3 times more in patients who had a baseline CD4 count of less than 200 cells/dl compared to those with a baseline CD4 of >350 cells/dl. (AOR 2.43, 95 % CI 1.62-3.66). In addition, for patients with baseline CD4 cell count of 201-350 cells/dl, the odds of being adherent was found to be 1.9 compared to those with baseline CD4 of greater than 350 cells/dl (AOR 1.93, 95 % CI 1.27-2.94). Pharmacy refill data can serve as an adherence measure. Adherence to on-time drug pickup on ≥90 % of refill appointments was associated with a better CD4 count response and a reduction in the presence of opportunistic infections in ART patients after 12 months of treatment.

Assessment of satisfaction with pharmaceutical services in patients receiving antiretroviral therapy in outpatient HIV treatment setting.

BACKGROUND: The patient's perception and satisfaction are increasingly considered as a useful factor in the assessment of competency of health care providers and quality of care. However, these patient focused assessments are largely ignored when assessing health care outcomes. OBJECTIVE: The study assessed the perception and satisfaction of patients receiving antiretroviral therapy (ART) with pharmaceutical services received in outpatient HIV treatment settings. SETTING: Seventeen HIV treatment centres in Nigeria. METHODS: This cross-sectional survey included 2,700 patients randomly selected from 26,319 HIV patients on ART, who received pharmaceutical services in the study setting. A study-specific Likert-type instrument was administered to the participants at point of exit from the pharmacy. Midpoint of the 5-point scale was computed and scores above it were regarded as positive while below as negative. Chi-square was used for inferential statistics. All reported p values were 2-sided at 95 % confidence interval (CI). MAIN OUTCOME MEASURE: Patient satisfaction with pharmaceutical services. RESULTS: Of 2,700 patients sampled, data from 1,617 (59.9 %) were valid for analysis; 62.3 % were aged 26-40 years and 65.4 % were females. The participants had received pharmaceutical services for a mean duration of 25.2 (95 % CI 24.3-26.1) months. Perception of participants regarding the appearance of pharmacy was positive while that regarding the pharmacists' efforts to solve patients' medication related problems was negative. The participants' rating of satisfaction with the waiting time to access pharmaceutical services was negative; the satisfaction decreases with increasing waiting time. However, the satisfaction with the overall quality of pharmaceutical services received was rated as positive; 90.0 % reported that they got the kind of pharmaceutical services they wanted; 98.2 % would come back to the pharmacy if they were to seek help again and would recommend services to others. The level of satisfaction was found to be associated with educational status of the participants (p = 0.006) unlike age, sex, marital and employment status. CONCLUSION: The satisfaction with overall quality of pharmaceutical services received by participants was positive. Longer waiting times resulted in lower patient satisfaction. High patient load may be the cause of the long waiting time and the inadequate duration of interaction between pharmacist and the patient.

The incidence and types of medication errors in patients receiving antiretroviral therapy in resource-constrained settings.

PURPOSE: This study assessed the incidence and types of medication errors, interventions and outcomes in patients on antiretroviral therapy (ART) in selected HIV treatment centres in Nigeria. METHODS: Of 69 health facilities that had program for active screening of medication errors, 14 were randomly selected for prospective cohort assessment. All patients who filled/refilled their antiretroviral medications between February 2009 and March 2011 were screened for medication errors using study-specific pharmaceutical care daily worksheet (PCDW). All potential or actual medication errors identified, interventions provided and the outcomes were documented in the PCDW. Interventions included pharmaceutical care in HIV training for pharmacists amongst others. Chi-square was used for inferential statistics and P<0.05 indicated statistical significance. RESULTS: Of 6,882 participants, 67.0% were female and 93.5% were aged ≥ 15 years old. The participants had 110,070 medications filling/refilling visits, average (± SD) of 16.0 (± 0.3) visits per patient over the observation period. Patients were followed up for 9172.5 person-years. The number of drug items dispensed to participants was 305,584, average of 2.8 (± 0.1) drug items per patient. The incidence rate of medication errors was 40.5 per 100 person-years. The occurrence of medication errors was not associated with participants' sex and age (P>0.05). The major medications errors identified were 26.4% incorrect ART regimens prescribed; 19.8% potential drug-drug interaction or contraindication present; and 16.6% duration and/or frequency of medication inappropriate. Interventions provided included 67.1% cases of prescriber contacted to clarify/resolve errors and 14.7% cases of patient counselling and education; 97.4% of potential/actual medication error(s) were resolved. CONCLUSION: The incidence rate of medication errors was somewhat high; and majority of identified errors were related to prescription of incorrect ART regimens and potential drug-drug interactions; the prescriber was contacted and the errors were resolved in majority of cases. Active screening for medication errors is feasible in resource-limited settings following a capacity building intervention.

Improving pharmacy practice through public health programs: experience from Global HIV/AIDS initiative Nigeria project.

BACKGROUND: The use of medicines is an essential component of many public health programs (PHPs). Medicines are important not only for their capacity to treat and prevent diseases. The public confidence in healthcare system is inevitably linked to their confidence in the availability of safe and effective medicines and the measures for ensuring their rational use. However, pharmacy services component receives little or no attention in most public health programs in developing countries. This article describes the strategies, lessons learnt, and some accomplishments of Howard University Pharmacists and Continuing Education (HU-PACE) Centre towards improving hospital pharmacy practice through PHP in Nigeria. METHOD: In a cross-sectional survey, 60 hospital pharmacies were randomly selected from 184 GHAIN-supported health facilities. The assessment was conducted at baseline and repeated after at least 12 months post-intervention using a study-specific instrument. Interventions included engagement of stakeholders; provision of standards for infrastructural upgrade; development of curricula and modules for training of pharmacy personnel; provision of job aids and tools amongst others. A follow-up hands-on skill enhancement based on identified gaps was conducted. Chi-square was used for inferential statistics. All reported p-values were 2-tailed at 95% confidence interval. RESULTS: The mean duration of service provision at post-intervention assessment was 24.39 (95% CI, 21.70-27.08) months. About 16.7% of pharmacies reported been trained in HIV care at pre-intervention compared to 83.3% at post-intervention. The proportion of pharmacies with audio-visual privacy for patient counseling increased significantly from 30.9% at pre-intervention to 81.4% at post-intervention. Filled prescriptions were cross-checked by pharmacist (61.9%) and pharmacy technician (23.8%) before dispensing at pre-intervention compared to pharmacist (93.1%) and pharmacy technician (6.9%) at post intervention. 40.0% of pharmacies reported tracking consumption of drugs at pre-intervention compared to 98.3% at post-intervention; while 81.7% of pharmacies reported performing periodic stock reconciliation at pre-intervention compared to 100.0% at post-intervention. 36.5% of pharmacies were observed providing individual counseling on medication use to patients at pre-intervention compared to 73.2% at post-intervention; and 11.7% of pharmacies had evidence of monitoring and reporting of suspected adverse drug reaction at pre-intervention compared to 73.3% at post-intervention. The institution of access to patients' clinical information by pharmacists in all pharmacies at post-intervention was a paradigm shift. CONCLUSION: Through public health program, HU-PACE created an enabling environment and improved capacity of pharmacy personnel for quality HIV/AIDS and TB services. This has contributed in diverse ways to better monitoring of patients on pharmacotherapy by pharmacists through access of pharmacists to patients' clinical information.

Knowledge and attitudes of HIV-infected patients on antiretroviral therapy regarding adverse drug reactions (ADRs) in selected hospitals in Nigeria.

PURPOSE: The study evaluated the knowledge and attitudes of HIV-infected patients on ART regarding ADRs following routine patient counseling and education in selected hospitals in Nigeria. MATERIALS AND METHODS: From 36,459 HIV-infected patients on ART in the 36 selected hospitals, a study-specific instrument was administered to 3,650 patients in a cross-sectional study. Patients were provided counseling and education on ADRs before and after commencing ART. Factor analysis was performed using principal components extraction. Item score means above midpoint (3.7) on a 5-point scale were regarded as positive attitudes and below as negative attitudes. A chi-square test was used for inferential statistics; P<0.05 was used to determine statistical significance. RESULTS: The mean questionnaire return rate was 47.5%. Data from 2329 (63.8%) participants were analyzed, 63.1% females and 34.4% aged 25-34 years old. A total of 80.1% participants accepted to have been counseled on ADRs; 65.8% knew that all medicines cause some kind of adverse effects; 55.1% knew the adverse effects of their medicines; 60.8% knew what to do when they suspect ADRs and it included mainly reporting to the healthcare provider (88.1%). However, only 31.9% had experienced ADRs previously. The knowledge of ADRs was associated with gender and educational and employment status of the patients (P<0.05). A total of 95.6% reported self-efficacy to ART. Majority of the rated attitude score means were >3.7 which denotes positive attitudes to ADRs. Three extracted factors accounted for 73.1% of cumulative variability. All attitude items had very significant loadings of ≥0.5. CONCLUSION: Overall, participants reported good knowledge and positive attitudes to adverse effects of their medicines compared to what was reported previously. The patient counseling and education on drug therapy provided to patients may have contributed to these findings and are highly recommended.

Assessment of side effects coping practices of HIV-infected patients receiving antiretroviral therapy.

PURPOSE: The study assessed coping practices to HIV treatment side effects among HIV-infected patients receiving antiretroviral therapy (ART) in selected hospitals in Nigeria. METHODS: In a cross-sectional study, Side Effects Coping (SECope) instrument was administered to 3650 HIV-infected patients receiving ART in 36 hospitals. Patients were provided pre-treatment information on side effects of antiretroviral drugs. Factor analysis was performed using principal components extraction with varimax rotation. Factors selected for rotation had eigenvalues >1. Mean scale scores above midpoint of 3.18 on five-point scale were regarded as positive coping practices and below as negative practices. Chi-Square was used for inferential statistics; P < 0.05 used to determine statistical significance. RESULTS: Mean of SECope instrument return rates was 47.5% (95%CI, 37.1-57.9). Data from 2329 (63.8%) participants were analyzed: 63.1% females and 63.9% aged 25 to 44 years old. The mean SECope scale score (±SD) was 3.18 (±0.80); mean subscale scores (±SD) were 3.52 (±0.20) positive emotion focused coping, 2.82 (±0.18) information seeking, 2.57 (±0.30) social support seeking, 2.34 (±0.39) taking side effect medications, and 4.43 (±0.10) non-adherence. Five extracted factors accounted for 67.2% of cumulative variability. All items had very significant loadings of 0.50 or greater. All subscales except positive emotion focused coping were associated with age (p < 0.05). Non-adherence and information seeking subscales were associated with employment status (p < 0.05). Taking side effect medications was associated with educational status (p < 0.05). CONCLUSION: The study reported positive coping practices in positive emotion focused coping and non-adherence subscales. Non-adherence as a coping strategy was not significant contrary to previous research finding.

Improving Monitoring and Reporting of Adverse Drug Reactions (ADRs) in HIV positive patients on Antiretroviral Therapy (ART) in Nigeria.

Under-reporting of ADR may be associated with poor knowledge, attitudes and practices to pharmacovigilance. This study evaluated knowledge, attitudes and practices of healthcare professionals about ADR monitoring and reporting following interventions. This longitudinal study included 36 healthcare professionals participating in ART program in a tertiary hospital. Interventions included group training on pharmacovigilance (PV) and provision of ADR reporting forms amongst others. Assessments were conducted at months 0 and 6 post-interventions using study-specific Likert-type instruments. Mean attitude scores above midpoint of 3.6 on 5-point scale were regarded as positive and below as negative. P<0.05 used to determine statistical significance. Mean age of participants was 36.6 (95%CI, 34.5-38.7) years; 61.1% males; 44.4% doctors, 13.9% pharmacists, 19.4% nurses, 8.3% laboratory scientists, 8.3% record officers and 5.6% welfare officers. None had received training on PV previously. Mean knowledge test score increased from 53.6% (95%CI, 44.6-63.6) at pre-intervention to 77.1% (95%CI, 72.8-81.4) at post-intervention with a mean change of 146.9% (95%CI, 60.5-233.3; p=0.000). Mean rated attitude scores increased from 3.6 (95%CI, 3.4-3.8) at pre-intervention to 4.2 (95%CI, 4.0-4.4) at post-intervention; the difference was statistically significant (p=0.000). 75.8% reported that ADR reporting forms were not readily available at pre-intervention compared to 18.2% at postintervention; 15.2% had reported ADR previously at pre-intervention compared to 69.7% at post-intervention; 12.1% reported providing information regarding ADRs and its management always at pre-intervention compared to 45.5% at post-intervention; these differences were statistically significant (p<0.05). Lack/inadequate knowledge, unavailability of reporting forms and negative attitudes were barriers identified; and addressing them resulted in significant improvement in this setting. Scaling up these interventions to other hospitals can better the situation of under-reporting of ADRs in Nigeria.

Health-Related Quality of Life and CD4 Cells Status of Patients Receiving Antiretroviral Therapy in Nigeria

Background: The goals of antiretroviral therapy (ART) are to improve patient's health-related quality of life (HRQOL) and restore immunologic function among others. Objectives: The study evaluated HRQOL and CD4-cells response of HIV-infected patients at months 0 and 6 of receiving ART in Maitama District Hospital Abuja, Nigeria. Methods: HRQOL of a cohort of 150 HIV-infected patients was evaluated at months 0 and 6 of receiving ART using Medical Outcomes Study Short Form-36 (MOS SF-36) which has 8 domains. These include physical functioning, physically and emotionally related role limitations, social functioning, pain, energy/fatigue, emotional well-being and general health. A paired samples t-test was used to compare the HRQOL scores and CD4 cells count of participants at months 0 and 6. Wilcoxon's signed-ranks test was used to compare HRQOL of male and female participants. At two-tailed test, p value of <0.05 was considered significant. Results: The mean age (±SD) of the 150 participants at ART initiation was 34.3 ± 8.4 years; 59.3% were females. The mean (±SD) HRQOL of participants increased significantly from 71.9% ± 20.9 at ART initiation to 89.7% ± 10.6 after 6 months of ART (p<0.05). The change in all SF-36 domains was statistically significant (p<0.05) except for the domains of role limitation due to emotional problems, social functioning and pain. The improvement in the mental component score (MCS) was significant (p<0.05) unlike that of the physical component (PCS). The difference in the HRQOL of male and female participants at months 0 and 6 was not significant. The mean CD4 cell count (±SD) increased from 185.7 ±91.0 cells/mm3 at month 0 to 199.0 ±104.7 cells/mm3 after 6months of ART; though this increase was not statistically significant. Conclusion: There was significant improvement in the mean HRQOL scores of participants which was not associated with significant improvement in the CD4 cells status after six months of ART. The evaluation of HRQOL alongside the clinical and immunological parameters when monitoring treatment outcomes is recommended