ARV and TB medicine drug supply issues threaten South Africa’s ARV programme

HIV activist groups in South Africa are calling on the Minister of Health to address drug supply chain problems which are causing HIV and tuberculosis (TB) drug stock-outs in the country’s Eastern Cape province.

According to a report launched at the 6th South African AIDS Conference by a coalition consisting of the Rural Health Advocacy Project (RHAP), Doctors Without Borders (MSF), the Treatment Action Campaign (TAC) and SECTION 27, 40% of the 70 facilities surveyed by MSF and TAC during May 2013 in the Mthatha catchment area in the Eastern Cape province had experienced HIV and/or TB drug stock-outs. More than 100,000 people, on antiretrovirals (ARVs) or TB treatment, depend on 300 facilities served by the Mthatha depot.

Medical staff at 24% of the affected facilities were forced to send patients home without treatment because they experienced stock-outs of essential HIV and TB drugs. These stock-outs were reported to last, on average, 45 days at a time and have been ongoing since October 2012. The organisations estimated that at least 5494 adults were not able to take some of their ARVs and 561 children were sent home without treatment since September 2012 when the drug supply issues began.

Lamivudine (3TC), tenofovir, nevirapine, efavirenz, paediatric ARV formulations and Rifafour (a fixed-dose combination of four TB drugs) are the main medications affected.

“This situation is catastrophic. It means many thousands of people living with HIV have risked treatment interruption for months now. The stock-outs consequently undermine clinical benefits of life-saving ARV treatment. Over time, more deaths will occur as a result and the likelihood of increased drug resistance is significant,” says Dr Amir Shroufi, Deputy Medical Co-ordinator for MSF in South Africa. There have been a number of reports of patients receiving dual or even monotherapy in the Eastern Cape and Gauteng.

“I have been taking ARVs since 2008. Each year this [a stock-out] happens at least six times. I go to the clinic and they tell me there is no medication for me,” said a 36 year-old unemployed man who lives in a rural village in the Eastern Cape.

“It is very difficult for patients. We are telling them to adhere, but when they arrive at the clinic, which can take up to two hours to access by car in the rural Eastern Cape areas, they are told there is nothing for them and that they must come back another time,” said Vuyokazi Gonyela, the TAC Eastern Cape District Organiser.

On 10 October 2012, staff at Mthatha depot in the Eastern Cape staged a strike, following which 29 individuals were suspended, leaving the depot with only 10 working employees. Coupled with chronic supply chain issues, this precipitated widespread drug stock-outs in the region.

The survey followed an intervention by MSF and TAC volunteers during December 2012, which continued for three months, to respond to the burgeoning Mthatha depot crisis by supporting staffing, managing and ensuring drug delivery at the depot. This intervention helped to clear the backlog of drug orders and to bring the depot closer to normal levels of functioning.

“The MSF/TAC emergency intervention in the Mthatha depot from December 2012 to March 2013 has shown that it is possible to correct a disastrous situation with limited resources, even if the impact remains short-lived without large systemic changes and action from the provincial Department of Health”, said Gonyela, who led the intervention.

The main causes for the drug supply problems are the lack of an early warning system for facilities to be able to report potential shortages, drug suppliers failing to meet tender quotas, government failing to pay suppliers, and poor ordering practices at health facilities and medicine depots.

South Africa has one of the largest ARV programmes in the world with over 2 million people initiated on ARVs in the public sector. However, drug stock-outs are occurring across the country and are not limited to HIV and TB medication, but extend to other basic chronic medication such as hypertension (blood pressure) and diabetes medication, according to Dr Francois Venter, Deputy Director of the Wits Reproductive Health and HIV Institute (WHRI). This was reiterated by a number of healthcare workers attending the conference.

“The national Department of Health should create an emergency team to respond to stock-outs – given the extent, importance, and frequency of essential drugs stock-outs nationwide”, said John Stephens of SECTION27

The organisations are recommending that when stock-outs are identified, the underlying reasons must be established for each and appropriate action undertaken. The individuals responsible for the stock-outs must be clearly identified.

In response to the drug supply problems, the organisations have set up a civil society monitoring group which will focus on solving the drug supply problems and continue monitoring drug supply across the country.

“We are aware of the drug stock-outs across the country and share your concerns,” said Helecine Snyman, Head of Affordable Medicines at the South African Department of Health.