Study design and study site

This was a qualitative study where we diverged into the exploratory aspects of pharmacists’ involvement in HIV care as there was no prior findings to rely on. Thus, to explore stakeholders’ understanding about pharmacist’s current role, potential roles, barriers and facilitators, we designed a qualitative study. The study sites included the organizations that are working for HIV/AIDS patients. Major organizations include: the office of National Centre for AIDS and STD Control (NCASC), Department of Drug Administration (DDA), Nepal Pharmacist Association (NPA), Nepal Pharmacy Council (NPC), Save the Children, Ministry of Health and Population (MOHP), and Logistic Management Division (LMD).

Ethical approval

Ethical approval (NHRC- Registration no. 834/2020 P) was obtained from Nepal Health Research Council (NHRC) before the data collection. Following the approval from NHRC, the study objectives were explained to the respondents, and written informed consent was obtained from each participant before the interview. In addition, permission was taken from the respondents to record the interview with an assurance of maintenance of confidentiality.

Study participants and their recruitment

Most of the study participants were the individuals working in the organizations related to HIV/AIDS. One of the authors (BKC) was involved in HIV/AIDS care sector in his earlier phase of career. Through him some key informants from the policy making level and from service provider level were identified initially. The official website of National centre for AIDS and STD control (NSASC) was also utilized to identify initial key informants, such as pharmacists involved in HIV/AIDS care delivery. Similarly, policymakers including the director of NCASC, the secretary of the Ministry of Health and Population, the director of the Department of Drug Administration, the Nepal Pharmacy Council, and the Nepal Pharmaceutical Association were identified via their respective institutional websites. On this basis, an initial list of key informants was compiled.

The second phase involved contacting the key informants via Facebook or in-person after scheduling an appointment. On Facebook, two NCASC-employed pharmacist informants were located and sent a message pertinent to the study’s objectives. Following their affirmative response, a formal appointment with the director of NCASC was scheduled. The purpose of the study was thoroughly explained to the director during the meeting, and a formal letter requesting the collection of data was submitted. After approval, appointments were requested from pharmacists and the NCASC director. Similarly, other policymakers were approached through formal appointment and the same procedure was followed. A total of 14 participants were interviewed. Two predetermined key informants did not participate because they deemed another informant to be more credible and referred them. The other informants were selected following snowballing technique. The respondents for this study are mentioned in Table 1.

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 1. Participants of the study.

https://doi.org/10.1371/journal.pone.0280160.t001

The appointments for interview were taken according to the informant’s convenience. Time and place for interviews were selected by the key informants. All the interviews were conducted face-to-face, and only interviewer and interviewee were present during interviews. At the end of each interview, the informants were asked for any potential informant. The contact number of the potential informants were sought, and they were contacted through telephone call. Then, appointment of the interview was taken. Four interviews were done after office hours in the cafeteria, one in the office canteen, two virtually via zoom, and seven during formal office hour in the key informant’s respective office.

Data collection

Interview guides were used to conduct the interviews. Three interview guides were developed both in English and Nepali: one for pharmacists (Appendix 1 in S1 File), one for policymakers (Appendix 2 in S1 File) and one for other healthcare professionals (Appendix 3 in S1 File). The interview guides were designed after an extensive literature review and series of discussions within the team. The interview questions focused on pharmacists’ perceived roles in HIV/AIDS care, their impact, the need for pharmacists, and perceived facilitators and barriers to pharmacist’s involvement in HIV/AIDS care.

A series of practice sessions were run prior to final data collection where the interviews were conducted with the supervisors to ensure proper delivery, intelligibility of the questions, and further refinement of the interview guide. After finalizing the interview guide, it was subjected to pilot testing where two interviews were conducted with relevant stakeholders. Necessary modification was done in the interview guide following the pilot testing. For instance, the question “There seems to be no role of pharmacist in Antiretroviral (ARV) related dispensing, counselling and adherence monitoring in Nepal, why do you think so?” was split to two questions “In the context of Nepal, who is involved in dispensing, counselling and adherence monitoring of ARVs?” and “In your opinion, is it necessary to involve Pharmacist in activities like dispensing, counselling, adherence monitoring related to ARVs?” The two pilot interviews were excluded from the final data analysis. Data was collected from March 2021 to June 2021. AS conducted all fourteen interviews. All the interviews were audio-recorded, and field notes were taken during the interview. The interviews ranged from 30 minutes to one hour. No further interviews were conducted after data saturation. When AS began to hear similar responses, data saturation was believed to have been reached, indicating that it was time to stop collecting data and begin analysing what had already been gathered [20].

Data analysis

To analyze the data, Braun and Clarke’s six step process—familiarizing with the data, generating initial codes, searching for themes, reviewing themes, defining and naming themes, and producing the report—was used [21]. To familiarize with the data, the audio-recorded interviews were transcribed verbatim by AS and all the transcripts were circulated among the team with the request to read thoroughly. After thorough readings, two authors (AS and KA) were assigned to do coding, and it was agreed that translation and back translation of the interviews conducted in Nepali language would be done after coding. Following these decisions, AS and KA independently coded the data, and all coded extracts from the interviews in Nepali language were translated into English by AS; and to ensure quality standard, some randomly selected extracts from the translated version were back-translated into Nepali by KA. Since very few and minor differences were observed in the two versions, English-translated version was considered appropriate. Initially, the coding process was done inductively, and after coding seven transcripts, all authors discussed the codes for emerging themes. Any discrepancies in the codes derived by AS and KA were settled unanimously, and the cluster of codes were prepared to figure out emerging themes. The emerging themes were clustered into Current role, Disagreement among stakeholders, Potential role, Barriers and Facilitators. On the basis of these themes, a framework was developed, and the remaining seven transcripts were coded. In the third stage, all the codes clustered into different categories were sorted to identify potential themes and subthemes. While reviewing and refining themes and subthemes all the compiled excerpts were re-read to determine if they appeared to form a logical pattern. A thematic map was also prepared to ensure that the themes and subthemes cohere, and they reflect meaning of the excerpts. Next to this stage, the themes were named on the basis of the value they captured. Then, they were defined. In the final stage, a report based on the themes and subthemes was prepared [22, 23].

Current roles

The theme—current roles—highlights the role of pharmacists in HIV/AIDS care provision in Nepal, and also entails the existing status of pharmacists in Nepal. Our findings indicate that pharmacists are currently involved only in central logistic management. All respondents directly involved in HIV/AIDS care reported that two central offices, NCASC and Save the Children, are responsible for the procurement and distribution of ARVs to various ART centers in Nepal. Pharmacists only participate in logistic management in these central offices. The respondents directly involved in care, both pharmacist and non-pharmacists identified the similar roles.

The following excerpts summarize the roles of pharmacists. One pharmacist stated “one of my roles is procurement, storage and supply chain management “#KI03. Another said “during procurement, we look over quality assurance and technical evaluation their main role is procurement and supply management” #KI02. Yet, the other revealed, “Our role or our job is not directly clinical, but is the procurement of HIV-related drugs, their successful storage and distribution” KI05. Summing up, it can be concluded that pharmacists are confined to non-clinical engagements.

Non-pharmacist respondents’ statements also substantiated what pharmacists stated. One said, “their main role is procurement, warehousing and supply management” #KI08. And, another respondent remarked, “After procurement, we ask the pharmacists to do the quality assurance” #KI09.

Only pharmacist respondents identified providing training on logistic management as their current roles whereas both pharmacist and non-pharmacist respondents highlighted providing support to the ART centers. As articulated by a pharmacist “We provide support to ART centers…. they reach out to us regarding the pediatric dose, so we calculate the dose….” #KI04. Another stated, “Sometimes, we calculate pediatric dose" #KI03. Here, two pharmacists specified supportive role as pediatric dose calculation, while non-pharmacist respondent just acknowledged their support to the ART centers vaguely, “Problems keep coming from the district. Even though we all tackle the problem together, they are the main ones. They are the first contact.” #KI12. The pronoun used here, “they,” refers to the pharmacists. The pharmacists being the “main ones” and “first contact” acknowledge the role of pharmacists but does not accredit the pharmacists exclusively.

To sum up, this theme shows the current roles of pharmacist in HIV/AIDS care delivery in Nepal is Logistics management, which involves procuring ARVs, ensuring their quality, warehousing them, managing the supply chain, ensuring a smooth flow of logistics, providing training, and support to the ART centers.

Additionally, despite the fact that the majority of informants (80%) were aware of the current number of pharmacists involved in HIV care, even the responsible pharmacists were unsure of the number. For example, one pharmacist said, “There are… wait… 1… 2 pharmacists” #KI03; and another stated, “there are 1, 2, 3….5 pharmacists now” #KI04. The responses, “There are… wait… 1… 2 pharmacists,” and “there are 1, 2, 3…5” may be revealing uncertainty of the pharmacists about the fellow members working in the same field. What they apparently speak is the existence of a very small number of pharmacists, and the insignificance given to pharmacists.

Disagreements among stakeholders

The theme- disagreement among stakeholders- highlights the existing dispensing and counselling practices on ARVs, and key informants’ opinions on the same.

Only the respondents directly involved in HIV/AIDS care were aware of the current ARV related dispensing and counselling practices. Dispensing and counselling were reportedly carried out by trained ART counsellors with nursing or public health background, or Health Assistants (HA) and Auxiliary Nurse Midwife (ANM). The respondents clearly stated the roles which is mentioned in the excerpts below:

• KI06: Dispensing and counselling are done by HA, the staff nurse. They are trained.
• KI01: PCL nursing dispenses. At some centers, there is Bsc. Nursing, BN, or those with public health degree…and in some places, there is HA. However, maximum there are either HA or staff nurse.

Pharmacist respondents’ statements presented above strongly point to the reality that they were the potential untapped resources for undertaking this responsibility.

There was a general disagreement among pharmacists and non-pharmacists respondents regarding the role of ARV related dispensing and counselling. Pharmacists were of the opinion that their involvement in ARV dispensing and counseling would create a positive impact in terms of increased adherence and better facilities. Pharmacists were adamant that the roles of dispensing and counseling are theirs, citing their respective expertise to support their claim. One pharmacist suggested “Others are not allowed to dispense or counsel. It is illogical…. there should be a pharmacist…. pharmacists have in-depth knowledge, and they can counsel patients accordingly” #KI14. And, another pharmacist stated “…pharmacist, we mean medicine expert… dispensing and counseling is the role of the pharmacist” #KI14. Both these assertions place pharmacists as the major responsible persons for ARV dispensing and counseling. Pharmacists also emphasized that their involvement in ARV dispensing and counseling would create a positive impact in terms of increased adherence and better facilities. One pharmacist said “pharmacist can deliver far more and better facilities to the patients” #KI01.

While majority of pharmacists revealed strong opinions of pharmacists regarding their potentially beneficial roles; some, however, were ambivalent. Respondents identified dispensing and counseling as pharmacist roles but did not deny that any trained individual could perform those duties as well. One pharmacist stated “if a specified person is well-trained, then we cannot argue that the person cannot perform well, but certainly, pharmacists are well-placed” #KI11

Non-pharmacist respondents in contrary to the pharmacist respondents held a contrary view. The respondents in public health felt that dispensing and counseling on ARV is not pharmacist’s role. “Absence of roles” “Absence of visible roles” and “Absence of a need for pharmacists in dispensing and counselling” were concurrent codes in their statements. One respondent said “This role is different. This role belongs to monitoring, evaluation, treatment, and care, and I do not think this is pharmacists’ role.” #KI09 The outright denial, which is a representative quote, can be considered as a manifesto of non-pharmacists’ take on the issue of dispensing and counseling on ARV.

Pharmacists were deemed superfluous in dispensing and counselling ARVs. Staff nurses and health assistants were the ones who took ownership of this role. One respondent asserted, “there are counselors plus staff nurses or those with a medical background …. I do not think pharmacists counsel the patient, most probably, counseling can be done only by the trained counselors.” #KI08. This excerpt demonstrates that the informant does not consider pharmacists to be medical professionals. It is implied that only those with a medical background are qualified to dispense and counsel, and pharmacists are ineligible.

Additionally, budgeting was cited another reason for not hiring a pharmacist in dispensing and counselling. One stakeholder quoted “There are 80 ART centers, and we have not been able to retain even doctors in all of them because of budgeting issue, so, lets’ not speak about others. So, one there is budgeting, and another there is no role visible role of the pharmacists.” #KI12 Here, the informant describes how budgeting has been an issue to retain professionals. The informant in the excerpt KI12 emphasized especially doctors quoting "even doctors" which clearly can be assumed that only doctors are considered important.

Potential roles

The theme—potential roles—spotlight the informants’ perspective on the roles that pharmacists can play in HIV/AIDS care delivery. The theme has two subthemes, a) logistics management, and b) pharmacovigilance and adherence monitoring.

Barriers

The theme- barriers- spotlight the hindrances to the pharmacists’ involvement in HIV/ AIDS care delivery in Nepal. It is further categorized into three subthemes, a) pharmacist-related weakness, b) government-related weakness, and c) society-related weakness.

Facilitators

The theme- facilitators- spotlight the perceived factors that facilitate the involvement of pharmacists’ in HIV/AIDS care delivery in Nepal. This theme contained two subthemes, a) pharmacist and b) organization.