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HIV drug and supply stock-outs in Latin America

2011; Elsevier BV; Volume: 11; Issue: 11 Linguagem: Inglês

10.1016/s1473-3099(11)70301-2

1474-4457

Omar Sued, Casey Schreiber, Nora Girón, Massimo Ghidinelli,

HIV, Drug Use, Sexual Risk

When stocks of HIV drugs and supplies run out, unplanned treatment interruptions lead to increased risk of HIV drug resistance, treatment failure, and death.1Pasquet A Messou E Gabillard D et al.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: e13414Crossref PubMed Scopus (99) Google Scholar In the early days of antiretroviral therapy (ART) programmes, management of HIV supplies outside of national systems was considered acceptable by governments to facilitate scale-up2Harries AD Schouten EJ Makombe SD et al.Ensuring uninterrupted supplies of antiretroviral drugs in resource-poor settings: an example from Malawi.Bull World Health Organ. 2007; 85: 152-155Crossref PubMed Scopus (39) Google Scholar, but this approach is proving difficult to sustain.3Schouten EJ Jahn A Ben-Smith A et al.Antiretroviral drug supply challenges in the era of scaling up ART in Malawi.J Int AIDS Soc. 2011; 14: S4Crossref PubMed Scopus (48) Google Scholar In May, 2011, the Pan American Health Organization (the regional office for the Americas of WHO) undertook a survey of national AIDS programmes in 12 countries to characterise stock-outs or episodes where there was a risk of stock-out affecting antiretroviral HIV supplies in Latin America (table).TableResults of a Pan American Health Organization survey of stock-out episodes in Latin AmericaAgency contactedRisk-of-stock-out episodes*Total number of episodes reported from January, 2010, to April, 2011.Stock-out episodes*Total number of episodes reported from January, 2010, to April, 2011.Laboratory supply stock-out episodes*Total number of episodes reported from January, 2010, to April, 2011.Drugs affectedEl SalvadorISSS and NAP (Ministry of Health)122Didanosine (100 mg), ritonavir (100 mg)HondurasNAP (Ministry of Health)221Didanosine (100 mg), didanosine (200 mg)NicaraguaNAP (Ministry of Health)325Efavirenz (200 mg), indinavir sulfate (400 mg), tenofovir disoproxil fumarate (300 mg), nevirapine (200 mg), abacavir (300 mg)PanamaPharmaceutical services (Ministry of Health)163Zidovudine intravenous (10 mg/mL)ParaguayPRONASIDA100Stavudine (30 mg)BoliviaNAP (Ministry of Health)110Efavirenz (200 mg), lamivudine (150 mg)+zidovudine (300 mg)+nevirapine (200 mg)ChileNAP (Ministry of Health)500Efavirenz (600 mg), abacavir (60 mg)+lamivudine (30 mg), nevirapine (200 mg), nevirapine (50 mg/5 mL), raltegravir (400 mg)VenezuelaNAP (Ministry of Health)34370Abacavir (600 mg)+lamivudine (300 mg)ColombiaNAP (Ministry of Health)26344Lamivudine (150 mg)+zidovudine (300 mg)Dominican RepublicCOPRESIDA600Didanosine EC (400 mg), didanosine EC (250 mg), didanosine EC (125 mg), lopinavir (200 mg)+ritonavir (50 mg), tenofovir disoproxil fumarate (300 mg), lamivudine (150 mg)+zidovudine (300 mg)PeruSupply-chain coordinator (Ministry of Health)200Didanosine EC (400 mg), saquinavir (200 mg)GuatemalaSupply-chain coordinator (Ministry of Health)762Lamivudine (30 mg)+stavudine (6 mg)+nevirapine (50 mg)ISSS=Instituto Salvadoreño de Seguridad Social. NAP=National AIDS Programme. PRONASIDA=Programa Nacional Del Sida de Paraguay. COPRESIDA=Comisión Presidencial del Sida. EC=enteric-coated.* Total number of episodes reported from January, 2010, to April, 2011. Open table in a new tab ISSS=Instituto Salvadoreño de Seguridad Social. NAP=National AIDS Programme. PRONASIDA=Programa Nacional Del Sida de Paraguay. COPRESIDA=Comisión Presidencial del Sida. EC=enteric-coated. Stock-outs occur when there are insufficient HIV drugs and supplies, resulting in interruption to treatment programmes. Risk-of-stock-out episodes happen when emergency measures have to be implemented to avoid antiretroviral interruption. From January, 2010, to April, 2011, 67% of countries surveyed reported antiretroviral stock-outs, all reported antiretroviral risk-of-stock-outs, and 50% reported stock-outs of HIV laboratory supplies. Of the 90 stock-out events, the products most severely affected were coformulated zidovudine plus lamivudine (13%), coformulated abacavir plus lamivudine (9%), abacavir (8%), lamivudine (6%), saquinavir (6%), tenofovir (6%), lopinavir (4%), raltegravir (4%), and fosamprenavir calcium (4%). Stock-out events occurred most frequently from November, 2010, to February, 2011, and lasted on average for 40 days each. The most common causes were delays in the bidding process (29%) or acquisition (13%), distribution problems (10%), or difficulties with drug production (9%). Response measures that were implemented included emergency purchases (46%), changing providers (15%), or changing regimens (11%). There were 89 episodes when risk-of-stock-out was imminent in the same period. Reasons included delays in delivery from the manufacturer (31%) or in acquisition (26%), forecasting problems (10%), and delays in the bidding process (10%). 51% of episodes needed emergency purchases and in 14% of cases loans were requested from other countries. The 17 episodes of laboratory supplies stock-outs included no rapid tests in 41% of cases, no CD4 cell count in 35%, and no viral load in 18%, resulting in the discontinuation of services in 88% of cases. In a third of these episodes, services for prevention of mother-to-child transmission were affected. Problems were attributed to delays in acquisition (64%), difficulties with estimated needs (18%), delays in the bidding process (12%), and no delivery by manufacturers (6%). Despite the important limitations of this survey, the information presented shows that HIV drug and supply stock-outs are crucially affecting public health services in Latin America. Furthermore, the region needs to address several challenges to sustain ART services, such as complex patterns of antiretroviral use, well established programmes based on individualised approaches rather than standardised treatments, increased use of second-line and third-line drugs, high cost of treatments,4Arán-Matero D Amico P Arán-Fernandez C Gobet B Izazola-Licea JA Avila-Figueroa C Levels of spending and resource allocation to HIV programs and services in Latin America and the Caribbean.PLoS One. 2011; 6: e22373Crossref PubMed Scopus (19) Google Scholar the decline of external resources (eg, The Global Fund to Fight AIDS, Tuberculosis and Malaria), and the departure of technical partners (eg, The William J Clinton Foundation). To scale up treatment effectively in Latin America and to transition into a new generation of more efficient, sustainable ART programmes, as recommended by the Treatment 2.0 initiative,5Hirnschall G Schwartländer B Treatment 2.0: catalysing the next phase of scale-up.Lancet. 2011; 378: 209-211Summary Full Text Full Text PDF PubMed Scopus (45) Google Scholar an efficient mechanism for the procurement and supply of antiretrovirals needs to be established and built into existing health systems. A dialogue for new regional policies between international agencies, activists, and countries is needed to build a new long-term perspective in the changing landscape of HIV in this region. We declare that we have no conflicts of interest. We thank James Fitzgerald and Victoria De Urioste from the PAHO Essential Medicines and Technologies Area and all of the PAHO consultants and national AIDS programmes involved in collecting the information.