Recently there have been a series of worrying reports in the press on stock outs or near stock-outs of Antiretroviral drugs (ARVs) in the following countries: Swaziland, CAR, Malawi, Mozambique, DRC, Nepal, India, … and the list only seems to grow.

The consequences for patients and health workers are dire. Rationing initiation jeopardizes the lives of  people waiting for ARVs, as opportunistic infections and death peak. Necessary treatments have to be interrupted or their initiation delayed, with not only individual deterioration of health status, but also an increasing risk of drug-resistance. Second line ARVs increase the drugs bill with a factor of approximately five and damage public health due to the possible increased spread of resistance towards the first line regimen in a population. In some places, due to the limited availability of ARVs,  patients even have to wait until someone dies in order to take their treatment slot.

There is also an unnecessary additional burden for the patient and the health system when a patient has to go (far) more often to the clinic for a refill of a lower quantity of drugs and this typically in settings with critical shortages of health workers. The low stocks impose costly and inefficient coping mechanisms on patients and health systems. In addition the performance and credibility of HIV programs are seriously undermined. Patients who were told over and over again in the past how important adherence is (by their health workers) are now let down by the health system as it fails to assure continuity of ARV availability; patient-health worker relations suffer and the trust in the health system goes down.

Supply management, forecasting and efficient distribution are obvious challenges. It is complex to organize logistics in difficult circumstances to remote places, relying on limited staff  and in often very fragile health systems. However, mitigation mechanisms should be in place in any complex system. In this case, they are mostly absent though, probably due to a lower priority or funding limitations. Somewhat hidden behind the reported countrywide stock outs of ARV,  smaller stock outs at regional, district or health structure level are also a reality in many settings, but they get far less attention. In many countries the central level does not have sufficient “buffer” stocks to react adequately to these calls for help. However, often the central level also just pays little attention to urgent requests from clinics that face shortfalls.

In the current “austerity” environment with decreased resources for ARVs by donors (PEPFAR, World Bank, Global Fund), sufficient stock levels or appropriate enforcement of the supply systems are – obviously – growing concerns. Buffer stocks and emergency funds for mobilizing funds swiftly to avoid stock-outs are therefore urgently needed. Within a shrinking overall budget for HIV action, increased prioritization of assuring medical consumables related to ARV and other life-saving HIV treatment (OI drugs, laboratory reagents and diagnostic tests) is needed, otherwise supply chains will face dramatic problems in the next months. If funding gets tight, continuity is harder to assure and strategic buffer stocks will probably shrink, while in fact more robust buffer stocks are needed in response to the increased problems reported.

Stock out problems affect not only ARV availability, obviously. In many countries, patients face stock outs of many other essential drugs on a daily basis. But until recently, ARV supply seemed to be a fortunate exception. Nowadays less countries seem shielded from stock outs through rapid mobilization of buffer stocks and bridge funding. Heightened public awareness and close monitoring by activists seem less effective in preventing situations whereby patients lack necessary drugs. In other words, the increasing number of reports on ARV stock outs might be a sensitive predictor of overall deterioration, heralding worsening problems in supply systems for essential drugs in general. This is a sobering thought in times where health systems strengthening seems to be the ‘number one’ priority in global health.

Stock outs of ARVs might thus very well be a critical indicator of performance of health systems, as well as a concrete measure of international responsibility, political will and accountability towards  users.

Mit Philips (ITM and MSF), Marc Biot (MSF, recently returned from Mozambique) & Marielle Bemelmans (MSF, recently returned from Malawi)

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