High prevalence of stockouts of antiretroviral medicines in South Africa

One in five public health facilities in South Africa were unable to supply at least one antiretroviral (ARV) or tuberculosis (TB) drug on the day they were contacted by researchers, while over a third had had a drug stockout in the previous three months, according to a national survey published in PLOS ONE.

Between October and December 2015, the survey investigators contacted facilities by telephone to enquire about stockouts, which they defined as “a complete absence of a specific formulation and/or dosage of medicine at a given facility”.

Of the 2370 surveyed health facilities providing ARVs and TB medicines, 20% (485) reported a stockout of at least one ARV or TB-related medicine on the day of contact, while 36% (864) reported the same in the preceding three months. There were significant discrepancies from one province to another – for example, 74% of facilities in Mpumalanga reported stockouts in the past three months, compared to 12% in the Western Cape.

During the three months prior to contact, there were stockouts of the following medicines:

• At least one adult first-line ARV (11% of facilities)
• At least one adult second-line ARV (15%)
• At least one less commonly used ARV (11%)
• At least one paediatric ARV (9%)
• Nevirapine syrup used for the prevention of mother-to-child transmission (1%)
• At least one TB medicine (4%).

A total of 1475 different stockouts were reported in the previous three months, with between one and 14 medicines out of stock per facility. Of these 1475 stockouts, 73% (1082) were of ARVs for adults; 18% were of ARVs for children; 2% were of nevirapine syrup and 7% were of TB-related drugs.

Of the 1082 stockouts of adult ARVs, 29% were used as first-line treatment, 41% as second-line, and 29% were less commonly used ARVs. The main driver for the second line ARV stockouts was a national shortage of adult lopinavir/ritonavir that had been documented.

The investigators also wanted to collect information on how long stockouts lasted and their impact on patients’ treatment regimens.

For people whose lives depend on treatment, stockouts are unacceptable. But in this case, their duration was even more so, with 70% of stockouts lasting for over a month. Also, there were significant discrepancies between provinces. In the Western Cape, the province with the ‘shortest’ stockouts, 29% lasted less than a week and 33% over a month. In Mpumalanga, 1% lasted less than a week and 88% continued for more than a month.

The impact of each stockout was classified as high, medium or low by the authors.

• High impact (25% of cases): patients left the facility without any treatment or with an incomplete regimen.
• Medium impact (39%): patients were referred elsewhere or turned away; received drugs borrowed from another facility; switched to a less optimal regimen, but not necessarily provided with full supply of medicines, etc.
• Low impact (36%): switched appropriately to a different regimen, dosage or formulation; a full supply borrowed from another facility, etc.

The majority of staff who responded to the survey were nurses-in-charge (58%) and nurses (17%), rather than pharmacists (16%) and pharmacy assistants (9%). Following the research protocol, the researchers first tried to speak to pharmacy staff, before turning to nursing staff if they were not available. Pharmacists are likely to have a better knowledge and recall of stockouts, whereas nurses may be more aware of treatment switches and the clinical impact.

The survey fills an important gap: according to its authors, the current South African monitoring system does not provide transparent information on medicine availability and the true extent of the problem across the country was not known. The survey may be the first national stockout evaluation conducted in a resource-limited setting.

It rings alarm bells for South Africa, the nation with the highest number of people living with HIV and incidence of TB worldwide, a rising epidemic of multidrug resistant TB and, concomitantly, the world’s most ambitious antiretroviral treatment programme. But it should also raise concern among policymakers in other resource-limited countries.

Throughout the article, we are reminded of the terrible consequences of poor medicines management on people living with HIV: treatment interruptions due to disengagement from care, poor adherence, emergence of HIV or TB resistance (sometimes multidrug resistance), financial costs for those who must travel longer distances to get their medicines, etc. In other words, as a result of these stockouts, people living with HIV become even more vulnerable than they already are. For example, the “less commonly used ARVs” stockout rate of 29% is of particular relevance to those adults who have shown contraindications or resistance to the more widely prescribed drugs.

The authors remind us that more than a decade ago South African researchers found that “patients who claimed less than 80% of their prescription refills were three times more likely to die than those who claimed 80% or more”.