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Exploring the delivery of antiretroviral therapy for symptomatic HIV in Swaziland: threats to the successful treatment and safety of outpatients attending regional and district clinics
  1. Gerry Armitage1,2,
  2. Ian Hodgson2,
  3. John Wright1,
  4. Kerry Bailey3,
  5. Estel Mkhwana3
  1. 1Yorkshire Quality and Safety Research Group, Bradford Institute for Health Research, Temple Bank House, Bradford Royal Infirmary, Bradford, UK
  2. 2School of Health, University of Bradford, Bradford, UK
  3. 3Good Shepherd Hospital, Siteki, Swaziland
  1. Correspondence to Dr Gerry Armitage, Bradford Institute for Health, Temple Bank House, Bradford Royal Infirmary, Duckworth Lane, Bradford BD9 6RJ, UK; gerry.armitage{at}


Aim To examine the safety and acceptability of providing antiretroviral therapy (ART) in a resource poor setting.

Design Two-stage observational and qualitative study.

Setting Rural hospital in Southern Africa.

Methods Structured observation using failure modes and effects analysis (FMEA) of the drug supply, dispensing, prescribing and administration processes. The findings from the FMEA were explored further in qualitative interviews with eight health professionals involved in the delivery of ART. To obtain a patient perspective, a stratified sample of 14 patients receiving ART was also interviewed.

Results Key vulnerabilities in the process of ART provision include supply problems, poor packaging and labelling, inadequate knowledge among staff and lack of staff. Key barriers to successful patient adherence include transport inconsistency in supply and personal financial difficulties. There is, however, strong evidence of patient commitment and adherence.

Implications and conclusion Medication safety is relatively unexplored in the developing world. This study reveals an encouraging resilience in the health system and adherence among patients in the delivery of complex ART. The vulnerabilities identified, however, undermine patient safety and effectiveness of ART. There are implications for drug manufacturers; international aid agencies funding and supplying ART; and local practitioners. FMEA can help identify potential vulnerabilities and inform safety improvement interventions.

  • Antiretroviral therapy
  • resource-poor settings
  • treatment effectiveness
  • patient safety
  • effectiveness

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  • Competing interests None.

  • Ethics approval Ethics approval was provided by the University of Bradford, School of Health Ethics panel.

  • Provenance and peer review Not commissioned; externally peer reviewed.