Home delivery of antiretroviral drugs in Indonesia, Laos, Nepal and Nigeria: implications of COVID-19 experiences for post-pandemic decentralized ARV delivery


BACKGROUND: Confronted with COVID-19-imposed health facility closures and travel restrictions, HIV services in Indonesia, Laos, Nepal, and Nigeria introduced home delivery (HD) of antiretrovirals (ARVs) to ensure HIV treatment continuity.
A 2020 program review revealed HD to be feasible and acceptable across the four countries, with 19%-51% of eligible clients receiving ARVs through HD. We report on continued HD during in 2021, the pandemic's second year, and present implications for decentralized drug delivery (DDD) beyond emergency circumstances.
DESCRIPTION: Throughout 2021, all four countries continued the ARV home delivery mechanisms initiated in 2020. In Indonesia, the Jakarta Provincial Health Office continued to support Jak-Anter,a home-based ARV delivery system which utilizes ride-based apps and transport courier services. In Laos and Nepal, the HD conducted by community health workers continued, with the numbers of clients using the service varying with pandemic intensity. In 2021, in Indonesia, Laos, and Nepal, 29.8%, 47.0%, and 28.4% of individuals on ARVs in project-supported areas were on HD. In Akwa Ibom State, Nigeria, clients were progressively transferred to alternative DDD models, with HD limited to 12% of clients on ARVs in Mbo Local Government Area who could not go to the facility.
LESSONS LEARNED: Understaffing in health facilities, exacerbated by COVID-19 infection among health care providers, made ARV HD a valuable service alternative. Six-month dispensing allows HD to be practical and affordable but depends on consistent ARV stocks. In addition, the countries continuing ARV HD rely on donor funding and external technical assistance, and mechanisms for sustaining and scaling the approach without external support are not yet in place.
CONCLUSIONS: Policymakersand service delivery partners in the four countries support innovative community-based service delivery models to ensure service continuity in the COVID-19 era. While service delivery guidelines have been adjusted to support HD, national policy change is still needed to sustain the approach. New mechanisms for financing, supply chain management, staff training and supervision, and client sensitization are needed to implement HD at scale. Options for decentralized service delivery will be especially important for future service disruptions caused by other pandemics, natural disasters, or civil unrest.

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