Although significant efforts have been made to address the affordability of antiretroviral therapy (ART) in recent years, affordability is only one aspect of access. In addition—

• Antiretroviral drugs (ARVs) must be consistently available at the facility level, geographically accessible, and supplied in a way that is culturally acceptable to the population served.
   
  
• Pharmaceutical management systems must be strengthened to expand access to ARVs and other HIV/AIDS-related drugs as well as to support the rational use of these drugs by prescribers, dispensers, and clients.
   
  
• Laboratory services must be capacitated to perform ART tolerance and outcome monitoring.
   
  

Several pilot and small-scale programs have demonstrated the feasibility of safely and effectively using ART in resource-poor settings in sub-Saharan Africa and Haiti.

However, there still is little experience or information available for program planners and implementers on how to introduce and scale up access to ART through building the capacity of existing health care systems.

Building Ownership and Capacity for ART

The Rational Pharmaceutical Management (RPM) Plus Program, in partnership with Family Health International's Implementing AIDS Prevention and Care (IMPACT) project and Population Council/Horizons, is working with the Government of Kenya, local partners, and stakeholders to implement an initiative for incorporating ARVs into the health care system in Mombasa, Kenya, as part of an existing care and treatment framework.

Key to this initiative is a collaborative, inclusive approach to building local ownership and local capacity for introducing and scaling up access to ART as an integral part of a comprehensive package of HIV/AIDS-related health services.

The program began ART delivery at the first of four sites, the Coast Provincial General Hospital (CPGH), in June 2003.

The ART program in Mombasa will provide valuable implementation and operations research on how to safely and effectively deliver ARVs and how to build the capacity of the existing system to expand access to treatment. It is expected that the lessons learned in Mombasa will feed back immediately to national policy makers and stakeholders for use in scaling up the program.

RPM Plus Role

The role of RPM Plus in this partnership is to help strengthen commodity management systems and laboratory services in support of the introduction of ART, and to conduct relevant formative research.

An essential component of starting and scaling up an ART program at the facility level is establishing standard operating procedures (SOPs) for all departments that contribute to ART care, including the pharmacy and the laboratory.

SOPs act as a standard for defining and monitoring the quality of service delivery and facilitating training efforts; they are critical to the successful rapid scale-up of safe and effective ART. However, few public institutions in developing countries have pharmacy and laboratory SOPs for existing services, meaning that there is no precedent of ART SOPs for implementers to draw upon.

RPM Plus has been providing technical assistance to CPGH in Mombasa to develop pharmacy and laboratory SOPs for the U.S. Agency for International Development (USAID)-supported ART program. These procedures have been developed in collaboration with the highly motivated staff of CPGH's pharmacy and laboratory departments, under the stewardship of the Hospital Management Team and the Provincial Medical Officer, Ministry of Health (MOH) for Coast Province.

Sharing SOPs in Draft Format

The SOPs are in the later stage of development; they are currently being tested and adapted at CPGH. While the SOPs were designed for the CPGH context, they build on existing Kenya MOH forms and systems. Because many health care institutions both inside and outside Kenya are seeking to rapidly start ART programs as part of an emergency response to HIV/AIDS, RPM Plus and CPGH are sharing the SOPs in draft format.

These SOPs are in the public domain and may be reproduced, published, or otherwise used. We request that the Kenyan Ministry of Health, the Coast Provincial General Hospital, USAID, and RPM Plus be cited as the source of the information and that any photo credits or bylines be similarly credited to the photographer, author, or the Kenyan Ministry of Health, the Coast Provincial General Hospital, USAID, or RPM Plus, as appropriate.