A severe shortage has emerged in Kenya of discounted supplies of two antiretrovirals (ARVs) produced by leading pharmaceutical company Bristol-Myers Squibb (BMS). This may point to more general problems in the supply of medicines, which are likely to emerge in other regions as efforts are made to expand access to ARVs.
The immediate issue, identified by Médicins Sans Frontières (MSF), is a severe shortage of low-cost supplies of the drugs ddI (didanosine) and d4T (stavudine). According to the Kenya Coalition for Access to Essential Medicines, a survey of seven district hospitals revealed that six of the hospitals were either completely out of stock of both drugs, for 2-6 months prior to the survey, or experienced irregular supply shortages. Phillips Pharmaceuticals, BMS’s distributor in Kenya, was unable to fill an order from MSF on 25 February.
"These shortages are unacceptable given the nature of ARV therapy for HIV: correct dosing, rigorous adherence to scheduling and absolute compliance are all paramount factors that affect outcomes ... of treatment. Positive results cannot be achieved without a guaranteed drug supply," the Coalition said in a letter to BMS. The Coalition called on BMS to follow the example of GlaxoSmithKline and Merck in setting up local buffer stocks to enable them to meet variations in demand.
Last year, the pharmaceutical company announced price reductions for their antiretrovirals used by public institutions and NGOs. The cost of Videx 25mg and Zerit 30mg decreased by 51 percent and 98 percent respectively. "But price reductions without consistent drug supplies are dangerous," the Coalition said.
Attempts to deal with the current shortages included pharmacists dispensing Videx 100mg tablets with a razor blade for patients to slice a tablet into four for their 25mg dosage, the Coalition said. Other patients were being forced to switch to alternative medicine.
While MSF had been able to order drugs from France for MSF patients, with BMS later promising to refund the difference in price, local doctors and medical facilities did not have this option, said Daniel Berman of MSF’s Access to Essential Medicines Campaign.
"The supply crisis in Kenya is basically considered resolved at this point," Bristol-Myers Squibb spokesperson, Robert Laverty, told IRIN’s PlusNews. He added that the company had been working with local distributors to solve the problem.
"This is news to us as we sent the letter two weeks ago and the problem still exists," a member of the Coalition told PlusNews on Tuesday 9 April.
Problems with demand as well as supply
At the end of March, the ten major HIV treatment centres in Nairobi and the leading national non-profit drug distributor, Mission for Essential Drugs and Supplies (MEDS), met with BMS and Merck to discuss this problem. They identified a series of factors making it hard to forecast demand, contributing to irregularities in drug availability.
These included:
- patients collecting drugs for up to six months in one go, rather than monthly.
- some patients collecting drugs from more than one centre using the same prescription, or even photocopies, with no system for tracking this behaviour.
- a rapid increase in the number of patients being put on ARV therapy, beyond the capacity of some treatment centers to dispense the treatments – although extra staff were being employed.
- patients seeking to fill prescriptions in Kenya from surrounding countries including Somalia, Rwanda, the Democratic Republic of the Congo and Tanzania, either directly or by seeking treatment in Kenya and obtaining drugs in Kenya.
- "an element of suspected fraud" – though difficult to prove – "where prescriptions come from unregistered medical practitioners [or] chemists".
Additional issues include education and training needs among pharmacists and among patients. Pharmacists perceive that "most patients are not willing to listen to instructions on how to use their medication." Low-cost drugs are being supplied to patients by the hospitals at minimal profit margins, which means that although there is goodwill and recognition of the need for training, there is no money to support it.
The International HIV/AIDS Alliance has produced a Handbook on Access to treatment, which includes planning exercises on developing and maintaining reliable drug supplies.
A recent report by researchers from Boston University, commissioned by WHO’s Essential Drugs and Medicines unit, includes an evaluation of Kenya’s MEDS agency; follow this link to read it.