Antiretroviral drug supply challenges in the era of scaling up ART in Malawi

Abstract

The number of people receiving antiretroviral treatment (ART) has increased considerably in recent years and is expected to continue to grow in the coming years. A major challenge is to maintain uninterrupted supplies of antiretroviral (ARV) drugs and prevent stock outs. This article discusses issues around the management of ARVs and prevention of stock outs in Malawi, a low-income country with a high HIV/AIDS burden, and a weak procurement and supply chain management system. This system for ARVs, paid for by the Global Fund to Fight AIDS, Tuberculosis and Malaria, and bypassing the government Central Medical Stores, is in place, using the United Nations Children’s Fund’s (UNICEF’s) procurement services. The system, managed by a handful of people who spend limited time on supply management, is characterized by a centrally coordinated quantification based on verified data from all national ART clinics, parallel procurement through UNICEF, and direct distribution to ART clinics. The model worked well in the first years of the ART programme with a single first-line ARV regimen, but with more regimens becoming available (e.g., alternative first-line, second-line and paediatric regimens), it has become more difficult to administer. Managing supplies through a parallel system has the advantage that weaknesses in the national system have limited influence on the ARV procurement and supply chain management system. However, as the current system operates without a central warehouse and national buffer stock capacity, it diminishes the ability to prevent ARV stock outs. The process of ordering ARVs, from the time that estimates are made to the arrival of supplies in health facilities, takes approximately one year. Addressing the challenges involved in maintaining ARVs through an efficient procurement and supply chain management system that prevents ARV stock outs through the establishment of a dedicated procurement team, a central warehouse and/or national buffer stock is a priority.

References WHO: Towards Universal Access: Scaling up priority HIV/AIDS interventions in the health sector: progress report 2010. World Health Organization; 2010. WHO: Antiretroviral Therapy for HIV Infection in Adults and Adolescents: recommendations for a public health approach. 2010 version. World Health Organization; 2010 Pasquet A, Messou E, Gabillard D, Minga A, Depoulosky A, Deuffic-Burban S, Losina E, Freedberg KA, Danel C, Anglaret X, Yazdanpanah Y: Impact of Drug Stock-Outs on Death and Retention to Care among HIV-Infected Patients on Combination Antiretroviral Therapy in Abidjan, Côte d'Ivoire. PLoS ONE 2010, 5(10):e13414. The Malawi Global Fund Coordinating Committee: CCM request for RCC Continued Funding (RCF). Lilongwe, Malawi; January 2011. Quick JD, Boohene N-A, Rankin J, Mbwasi RJ: Medicines supply in Africa. BMJ 2005, 331:709–710. Mtonya B, Chizimbi S: Systemwide Effects of the Global Fund in Malawi: Final Report. Abt Associates, Bethesda, Maryland, USA; September 2006. Harries AD, Schouten EJ, Libamba E: Scaling up antiretroviral treatment in resource-poor settings. Lancet 2006, 367:1870–1872. Harries AD, Schouten EJ, Makombe SD, Libamba E, Neufville HN, Some E, Kadewere G, Lungu D: Ensuring uninterrupted supplies of antiretroviral drugs in resource-poor settings: an example from Malawi. Bull of the World Health Organ 2007, 85:152–156. Government of Malawi: Ministry of Health. Malawi Antiretroviral Treatment Programme Quarterly Report. Results up to 31 December 2010. Lilongwe, Malawi; 18 March 2011. Libamba E, Makombe S, Mhango E, de Ascurra Teck O, Limbambala E, Schouten EJ, Harries AD: Supervision, monitoring and evaluation of nationwide scale-up of antiretroviral therapy in Malawi. Bull World Health Organ 2006, 84:320–326. Managing Drug Supply: the selection, procurement, distribution, and use of pharmaceuticals – Second edition., revised and expanded. Management Sciences for Health in collaboration with the World Health Organization, West Hartford, Connecticut, USA; 1997 Zere E, Walker O, Kirigia J, Zawaira F, Magombo F, Kataika E: Health financing in Malawi: Evidence from National Health Accounts. BMC International Health and Human Rights 2010, 10(27). Zachariah R, Van Engelgem I, Massaquoi M, Kocholla L, Manzib, Suleh A, Phillips M, Borgdorff M: Payment for antiretroviral drugs is associated with a higher rate of patients lost to follow-up than those offered free-of-charge therapy in Nairobi, Kenya. Transactions of the Royal Society of Tropical Medicine and Hygiene 2008, 102:288. Souteyrand YP, Collard V, Moatti JP, Grubb I, Guerma T: Free care at point of service delivery: a key component for reaching universal access to HIV/AIDS treatment in developing countries. AIDS 2008, 22(Suppl 1);S161–S168. United Nations Statistics Division—National Accounts Main Aggregates Database [http://unstats.un.org/unsd/snaama/resCountry.asp]. United Nations Foundation: The Pledge Guarantee for Health. [http://www.unfoundation.org/our-solutions/innovative-health-campaigns/pledge-guarantee-for-health/overview.html]. WHO: Antiretroviral Drugs for Treating Pregnant Women and Preventing HIV Infection in Infants: recommendations for a public health approach. 2010 version. World Health Organization; 2010.