“Operating…without regulations”: Conflicting sentiments towards the utility and relevance of community retail pharmacy-based antiretroviral therapy (ART) distribution in rural Uganda

Community retail pharmacies are promising venues for expanded delivery of HIV commodities, but there is scant evidence of their utility and relevance alongside well-established antiretroviral therapy (ART) refill models in Africa. We qualitatively explored the perceived relevance and utility of pharmacy ART dispensing in south-central Uganda. Between October 2024 and April 2025, we purposively recruited persons living with HIV enrolled in community- or facility-based ART refill models (“clients”) and HIV service providers (“clinicians”) for in-depth interviews, exploring perspectives on pharmacy-based ART dispensing. Guided by the Theoretical Framework of Acceptability, we used hybrid thematic analysis to discern salient implementation determinants of a hypothetical pharmacy ART dispensing model in rural Uganda. While articulating potential advantages to pharmacy ART dispensing (e.g., accessibility and convenience, enhanced anonymity during medication refill events, continued decongestion of overcrowded HIV clinics), clients ( n = 26) and clinicians ( n = 29) weighed these benefits against potentially intractable constraints, namely: (i) unmet needs for private, confidential, and stigma-free encounters at pharmacies; (ii) pharmacist misconduct, including potential exploitation of clients, in an under-regulated environment; (iii) inability for pharmacies to offer wraparound services (e.g., adherence counseling, screening for opportunistic infections); (iv) suboptimal pharmacist competencies to dispense ART; (v) medication management/storage and documentation practices incompatible with ART dispensing requirements; and (vi) challenges linking pharmacy ART dispensing outcomes into public sector-managed clinical information systems. Building client trust in pharmacies, expanding regulatory frameworks for pharmacies, and strengthening systems of accountability and transparency will be imperative to acceptable, scalable implementation of pharmacy ART dispensing models in Uganda.