Acceptability and implementation considerations for community pharmacy–based delivery of pre-exposure prophylaxis and antiretroviral therapy in Dar es Salaam: a sequential explanatory mixed-methods design

Abstract

BACKGROUND: Community pharmacies (CPs) may provide a decentralized platform for refills of pre-exposure prophylaxis (PrEP) and antiretroviral therapy (ART). However, evidence on their acceptability and implementation requirements remains limited. This study assessed the acceptability of using CP for PrEP and ART refills and explored stakeholder perspectives on feasibility to inform potential scale-up in urban Tanzania. METHODS: A sequential explanatory mixed-methods design study of community pharmacies was conducted in Dar es Salaam, Tanzania. Quantitative surveys were first conducted among women engaged in transactional sex and people living with HIV (PLHIV) to assess the acceptability and feasibility of obtaining PrEP or refilling ART through CPs. These findings then informed qualitative data collection, which included in-depth interviews with women engaged in transactional sex (TS), pharmacists, pharmacy owners, and key informants such as policymakers, as well as focus-group discussions with PLHIV. Qualitative data were analyzed thematically to contextualize and explain the quantitative results. RESULTS: Nearly 74.2% of the 93 women engaged in TS expressed willingness to receive PrEP from CPs. Among PLHIV, 66.0% of the 341 participants reported willingness to refill ART at community pharmacies. Across both groups, major concerns included stigma related to HIV status or perceived sexual behavior and potential user fees. Qualitative findings (N = 27) highlighted perceived advantages of pharmacies such as proximity, shorter waiting times, flexible opening hours, and the ability to obtain services discreetly within routine care settings. However, participants emphasized that acceptability would depend on assured confidentiality, free or affordable treatment, private consultation spaces, and specialized HIV training for pharmacy staff. Stakeholders further identified regulatory and financing uncertainties, infrastructure constraints, workforce shortages, medication misuse risks, and the need for digital health record systems as implementation challenges. CONCLUSIONS: CPs were perceived as promising complementary platforms for PrEP delivery, particularly to improve prevention access among high-risk populations, and for ART refills mainly among stable clients. However, successful integration into national HIV programs will require robust regulatory frameworks, sustainable financing, provider training, and systems to safeguard confidentiality and continuity of care. Implementation research is needed to evaluate feasibility, impact, and safety.