Pharmacists combating HIV/AIDS in developing Commonwealth countries
In this article, Ann Lewis, Commonwealth Pharmacists Association adviser, outlines the progress of an ongoing CPA collaborative project that is empowering pharmacists in developing Commonwealth countries to build capacity into combating HIV/AIDS
The Commonwealth Pharmacists Association (CPA) is a non-governmental organisation whose membership includes professional pharmaceutical societies from 43 Commonwealth countries and approximately 800 individual members consisting of pharmacists, pharmacy students and other supporters representing all regions of the world and high, middle and low income countries.
The CPA promotes pharmacy throughout the Commonwealth to help improve the quality and range of services offered by pharmacists. Its strategic plan for 2003–07 included the following objectives:
- To work towards achieving the targets set out in the United Nations millennium development goals (MDGs) generally and specifically as they apply to health
- To promote the role of the pharmacist in public health through integration of treatment and prevention, with special reference to HIV/AIDS, malaria and tuberculosis
A major collaborative project over the past four years has focused on promoting the role of the pharmacist in strengthening the pharmaceutical services in Commonwealth countries and helping pharmacists build capacity to address HIV/AIDS. The CPA works closely with the Commonwealth Foundation and the Commonwealth Secretariat based in London.
In 2003 the Commonwealth Foundation funded a symposium and workshop in Ocho Rios, Jamaica, attended by over 200 pharmacists. This resulted in the formulation of the Ocho Rios Statement (PJ, 6 December 2003, pp783–4), which highlights the place of pharmacies in local communities, the ready and informal access to services that they offer to the public, and the desire of many pharmacists to work collaboratively with other health professionals and governments to enhance their role in public health — in particular to the prevention and management of HIV/AIDS.
It also identified opportunities for action at international, national and individual level and implementing strategies for working with consumers and communities, with governments and other stakeholders.
Since 2004, seven workshops funded by the Commonwealth Foundation have been held in member countries to examine initiatives that could be taken forward at national level. The main criteria for selecting countries were a commitment by the local member organisation to run the workshop and support from the local health ministry. A further workshop is to be held in India in March 2010.
|Participants in a student workshop that took place in Kenya |
The seven interactive workshops held in Botswana (May 2004), Namibia (June 2004), Kenya (December 2006), Sri Lanka (May 2007), Zambia (June 2008), Barbados (2009) and Uganda (2009) were facilitated by the Commonwealth Pharmacists’ Association and professional bodies in each of the countries.
In all these countries prevention of, and services for people with, HIV/AIDS is a public health priority. As well as some high prevalence rates, the incidence of new infections is also high.
In addition to being a major focus for public health policy, and health care provision and delivery in these countries, HIV/AIDS has huge economic and social implications for countries, people living with HIV, their communities and families.
Each workshop was linked with a symposium at which the latest epidemiological information, recent developments in approaches to prevention, care and treatment of HIV/AIDS, and key national policy and strategies were presented and discussed. The workshops were divided into two sessions.
At the first session, working in groups, participants identified the challenges in developing their role. The second session identified opportunities, potential barriers and solutions, and actions and needs for implementation.
A report was prepared following each of the workshops. These provided information on the operation and conduct of each event, discussions between experts and delegates and a statement of outcomes in which participants identified possible actions regarding the potential contribution of pharmacists as a profession to realising policy goals in the prevention and management of HIV/AIDS.
The statements for each of the countries and the reports for Barbados and Uganda have been published and are available by clicking the “Statements” option on the CPA website.
A role for pharmacists
The reports following the first five workshops (Botswana, Namibia, Kenya, Sri Lanka and Zambia) were analysed. The content of the five reports indicated that there were many similar themes and ideas arising. These were apparent from descriptions of both the operation and final statements derived from each of the five meetings.
At all meetings, participants identified aspects of pharmacy service provision that might be helpful in developing future services, in terms of possible opportunities for greater involvement emanating from within the profession and in the wider health care context. To a lesser extent, potential barriers to service development were also raised and discussed.
The analysis below aims to bring together the separate evaluations from each of the five countries to identify common perspectives, thus providing an overview from an international perspective of possible future involvement of pharmacy services in supporting health policy objectives regarding services for prevention and management of HIV/AIDS.
This involved identifying the following from each of the reports:
- Perceived strengths of pharmacy services that may facilitate a greater role in prevention and management of HIV/AIDS
- Potential opportunities for pharmacy services to enhance their role in the prevention and management of HIV/AIDS
- Weaknesses or barriers that might hinder the development of pharmacy services
- Perceived needs of pharmacies, pharmacists and staff if an enhanced role is to be realised
The meetings were attended by large numbers of the pharmacy profession and pharmacy personnel with a range of professional qualifications (Zambia over 200, Kenya 120, Sri Lanka over 100, Botswana 50). Only in Namibia were the numbers fewer than hoped (19 pharmacists).
The numbers of participants indicated the interest of large numbers of pharmacists in the topic of the meetings. At these meetings there was also diverse attendance of male and female pharmacists, and technicians of wide age ranges, and from public and private sectors. Attendees were also described as “grass-roots” pharmacists as well those in senior positions.
All meetings were attended by representatives of ministries of health, non-governmental organisations involved in the delivery of care for HIV/AIDS and other stakeholders, which suggested interest in the goals of these meetings and the potential wider involvement of pharmacy in service provision.
At all meetings (although there were some reservations among the Namibian delegates) the predominant message from the attendees was a belief that pharmacists have knowledge and skills that could be more proactively applied to the provision of care — both prevention and management — for HIV/AIDS.
Pharmacists also expressed a desire for a greater public health role with regard to the prevention and management of HIV/AIDS as well as a commitment to improve the health of the people living in the communities that they served.
At all meetings the high prevalence of HIV/AIDS was highlighted. In Botswana, prevalence rates for the 19–49 year age group were believed to be 35 per cent, which was a major contributor to the life expectancy of 40 years. Sri Lanka was one of the five countries with lower prevalence but there were concerns regarding potential escalation of rates of infection and the need to address this.
Specific vulnerable groups, such as girls and young women and rural populations were sometimes identified as at greater risk, and possibly a priority for the development and targeting of services. Mother-to-child transmission was also identified as an important focus for services. It was suggested that these groups may be also more regular clients at pharmacies.
It was also reported that the prevalence of HIV/AIDS in some countries was higher in urban areas, where pharmacies are more concentrated and, therefore, possibly well positioned to participate in public health initiatives.
The prevention and management of HIV/AIDS was a public health priority for all countries. In addition to the personal, health, social and economic consequences for individuals, HIV/AIDS accounted for costs to the wider economy, and for social and political agendas, as well as for a high proportion of hospital admissions: in Botswana this was suggested to be 60 to 70 per cent of inpatient beds.
All countries had policies and guidelines regarding the prevention and management of HIV/AIDS. Zambian policy for testing, treatment and pre-test counselling were cited as specific examples where pharmacists may be able to contribute. Zambia’s goal to make antiretroviral therapy (ART) available to all who need it was viewed as a huge task, currently being implemented through the public sector. Extending the programme to involve the private sector was raised as an option which could result it more effective implementation.
Partnerships between the public and private sectors were suggested at four of the workshops. The pharmacists expressed a desire to examine how these might operate to provide suitable facilities for implementation of services that were, for example, sustainable and cost-effective.
It was also suggested that the partnerships should include nomination of pharmacists to national and professional committees to work strategically with governments.
Opportunities for formal involvement of pharmacy services were believed to span national and local initiatives. Suggestions included participating in national and local awareness campaigns such as World AIDS Day. At a local level, referral to appropriate clinics and agencies for counselling and testing was seen as an opportunity in many countries. Participation in health promotion activities including display of leaflets, promoting safe sex, encouraging people to know their HIV status and undergo voluntary testing were also highlighted as opportunities.
It was also suggested that pharmacy services could have a role in treating opportunistic infections within guidelines agreed with a clinician. Other ideas included arranging talks in local communities and schools, media presentations, and providing information in local languages.
The place and presence of professional pharmacy in many local communities was also seen as presenting opportunities for effective involvement in public health provision. Delegates highlighted their accessibility to the public, their place as a focal point for primary care in many communities, the daily contact they had with clients, that their services were respected and that they commonly had the trust of patients.
They described their services as confidential and promoting equitable care, and said they had the knowledge and skills to provide easy-to-understand and up-to-date information. As described above under “Strengths”, the motivation and commitment of pharmacists to serve their local communities was also voiced.
A number of potential threats to pharmacy service developments were identified.
Despite the relatively large numbers of pharmacists and other staff attending the meetings it was unclear how representative the participants were of the wider populations of pharmacists, especially regarding their aspirations for a proactive approach to achieve an enhanced public health role. It is possible that the enthusiasm of delegates led to idealistic views for which the feasibility and practical implications had not been voiced or explored.
In Namibia the numbers of participants were lower and there were some doubts regarding wider interest in the topic and goals of the meeting; it was also noted that interactions between participants in the Namibian workshop were limited.
A small minority of participants in Sri Lanka believed that the views expressed by many at the workshop would not be shared by the majority of health professionals, especially the medical profession, and that departure from the “status quo” may present barriers to further involvement by pharmacists.
Many of the “needs” listed below, should they not be met, could be viewed as potential barriers to service developments. The positive attitudes of participants in most meetings resulted in their perception as needs rather than barriers. However, in Namibia more potential barriers to service development were raised.
For example, in other meetings where a lack of counselling skills among pharmacists was seen as an issue to be addressed, in Namibia it was seen as a barrier to potential developments.
For potential service developments to be realised, “needs” were identified at all the workshops. One of the most prominent of these was collaboration. Channels of communication and active collaboration at national and local levels and with a range of agencies and professionals were important. These included building of working relationships with politicians and officials in the ministries of health to enable pharmacists to contribute to policy development, promote advocacy with governments and also to assist governments in implementing pharmacy regulatory requirements.
The need to collaborate with other health professionals was seen as essential if pharmacists were to participate in multidisciplinary programmes. It was also recognised that new roles of pharmacy in the provision of care, that could be seen as a change to the status quo would require ongoing collaboration with medical professionals in particular if they were to be acceptable.
Formal collaboration between the public and private sectors would be necessary if public health initiatives commonly delivered by the public (and sometimes voluntary) sectors were to be extended to private practitioners.
Participants at all meetings also recognised a need for continuing professional development for pharmacists and other pharmacy staff. There was a need for ongoing relevant programmes, and ways of ensuring that pharmacists had access to up-to-date information.
Pharmacists needed to know and understand national and local initiatives and guidelines, including the policy context. However, it was also seen as contingent on pharmacists themselves to make sure that they took advantage of the training opportunities that were available to them.
Developments within pharmacies and the practices of pharmacists were also discussed. The need to provide a holistic and wellness approach to patients was raised: the provision of counselling areas, acquisition of skills in patient counselling and readiness to communicate with patients.
These represented approaches to practice that were not necessarily already in place. Other practice developments included maintenance of patient records by pharmacists and sharing them among health providers, and materials for pharmacists to undertake training of staff and education of clients. Participants wished to see high standards of practice and one of the workshops suggested establishing criteria for accreditation of pharmacies.
Engagement in pharmacy practice research was advocated in all meetings. This may include collecting evidence of pharmacy input, impact on medicines use and health outcomes. This activity was seen as important in enabling a continual evaluation of, and improvement in, the quality of services and care.
The successful implementation of strategies for the prevention and management of HIV/AIDS is dependent on the effective distribution and use of medicines. The feasibility of developing pharmacists’ contributions will depend on national and local factors, including the current level of development of the profession.
However, it is clear that there are many pharmacists in different countries who believe they could and should contribute more effectively to public health, especially in the management of HIV/AIDS. The workshops enabled an exploration of opportunities and potential barriers from the perspectives of stakeholders which included people from government representatives and policy makers down to grass-roots pharmacists serving their local communities. These issues need to be identified and addressed to ensure workable developments and solutions.
The workshops also demonstrated many common perspectives and concerns across countries as well as issues that may be country or context specific. These issues will be important in informing the development of collaborative public health initiatives between pharmacists, governments, and other health professionals that maximise the benefits for patients.
ACKNOWLEDGEMENTS The CPA acknowledges the support of the Commonwealth Foundation in providing funding for each of the workshops and also support received from the Commonwealth Secretariat. The CPA also acknowledges the contributions made by members of pharmaceutical societies in Botswana, Jamaica, Kenya, Namibia, Sri Lanka, Zambia, Barbados, Uganda and India in this collaborative project and the contribution of Paul Spivey in developing the Ocho Rios Statement.
Commonwealth Pharmacists Association facilitation team
Roger Odd, Great Britain
Betty Falconbridge, Great Britain
Ivan Kotze, South Africa
Raymond Anderson, Northern Ireland
Grace Allen-Young, Jamaica
Carolyn Bell, Australia
John Bell, Australia
Ann Lewis, Great Britain
Commonwealth Pharmacists Association,
Felicity Smith, professor of pharmacy practice, department of practice and policy, School of Pharmacy, University of London
Member associations and local contacts
Pharmaceutical Society of Jamaica
Pharmaceutical Society of Kenya
Pharmaceutical Society of Sri Lanka
Pharmaceutical Society of Namibia
Pharmaceutical Society of Botswana
Pharmaceutical Society of Zambia
Pharmaceutical Society of Barbados
Pharmaceutical Society of Uganda
Indian Pharmaceutical Association
*In office at the time of the workshop but has since relinquished office
Commonwealth Foundation, Marlborough House, Pall Mall, London SW1 5HY
Citation: The Pharmaceutical Journal URI: 10998951
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