Dispensing Antiretrovirals During Covid-19 Lockdown: Pathways to Health System Resilience in Uganda

Abstract INTRODUCTIONAlthough there is an emerging evidence base on the impact of Covid-19 pandemic on access to health services in low-and middle-income countries, the related notion of health system resilience has received little empirical attention. The objective of this study was to explore health system resilience at the sub-national level in Uganda with regard to strategies for dispensing of antiretrovirals during Covid-19 lockdown restrictions.METHODSWe conducted a qualitative case-study of eight districts from Eastern Uganda (Mbale, Sironko, Manafwa, Bulambuli, Bududa) and Western Uganda (Kabarole, Kyegegwa, Kyenjonjo) purposively selected due to having a relatively high HIV burden. Between June and September 2020, we conducted key informant interviews with district health team leaders (n=9), with ART clinic managers (n=36), representatives of PEPFAR implementing organizations (n=6) and six focus group discussions with recipients of HIV/AIDS care (48 participants). Qualitative data were analyzed using thematic approach.RESULTSFive broad strategies for distributing antiretrovirals during ‘lockdown’ emerged in our analysis: accelerating home-based antiretroviral therapy (ART) deliveries,; extending multi-month dispensing from three to six months for stable patients; leveraging the Community Drug Distribution Points (CDDPs) model for ART refill pick-ups at outreach sites in the community; an increased reliance on health information systems, including geospatial technologies, to support ART refill distribution in unmapped rural settings. District health teams reported benefiting from the Covid-19 outbreak response funding to deliver ART refills to homesteads in rural communities.CONCLUSIONAlthough Covid-19 ‘lockdown’ undoubtedly impeded access to facility-based HIV services, it unraveled new possibilities and innovations in the distribution of antiretrovirals in the predominantly rural settings of our case-study districts. Further research is recommended to evaluate the potential of home-based deliveries as an alternative differentiated ART delivery model in Uganda and other countries with a high HIV burden.