Self-initiation of antiretroviral therapy in the developing world: the involvement of private pharmacies in an HIV program

BACKGROUND Self-initiation to antiretroviral treatment (ART) exposes the patient to the risk of drug toxicity, poor adherence to treatment, and escalates the development of drug resistance. OBJECTIVES To determine the sources of antiretroviral (ARV) drugs by unregistered human immunodeficiency virus (HIV)-infected patients and the extent of ARV self-medication. METHODS Simulated clients were used to investigate availability and ARV dispensing practice in the private pharmacies in Dar Es Salaam, Tanzania. A total of 480 HIV-infected patients qualifying to start ART were interviewed to find out their previous use of ARV drugs prior to visiting the HIV clinics. Venous blood (2 mL) was collected from each patient who indicated not to have used ARVs in the past (n = 450). Blood samples were analyzed for the presence and levels of nevirapine (NVP). RESULTS Only 5.1% (23/451) of pharmacies were found stocking ARVs drugs, among which 4.0% were retail. Drug dispensers in nearly all (15/18) retail pharmacies which stocked ARVs were willing to sell ARVs without prescription. Out of 450 enrolled patients, only 2.7% (12) stated that they had been receiving ARV drugs from HIV clinics but interrupted the ART treatment due to various reasons. From 450 patients, only 10% had quantifiable NVP concentrations in the blood, despite stating in an interview that they had not recently used ARVs. CONCLUSION Prior use of ARV drugs outside HIV clinics was rare among patients attending those centers. However, the results show that some patients could access and use ARV drugs from private pharmacies without undergoing ART eligibility assessment in HIV clinics.