Unplugging bottlenecks in ARV distribution

In West and Central Africa, large amounts of money are spent on buying antiretroviral (ARV) drugs but weak distribution systems mean many HIV-positive patients never get them, said speakers at the 15th International Conference on AIDS and STIs in Africa (ICASA) in Dakar, Senegal, last week.

Approximately half of all international funding invested in the fight against AIDS is used to buy "inputs", including ARVs, HIV tests, and medication for opportunistic infections.

This is the figure noted in a study carried out jointly by the UN children's fund, UNICEF, the World Health Organisation, and the French organisation, ESTHER (Ensemble pour une solidarité thérapeutique en réseau/Network for Therapeutic Solidarity in Hospitals), which works to improve access to quality treatment for people living with HIV and AIDS in developing countries.

Presenting the study findings at ICASA, Eric Mercier, UNICEF's regional HIV/AIDS advisor, said part of the reason these items did not always make it to patients was that national systems for purchasing and managing stocks were unable to keep up with constantly increasing demand: between 2001 and 2005 the number of patients on ARVs in sub-Saharan Africa increased sixteen-fold.

Karim Diop, from the STI/HIV division of the Senegalese Ministry of Health, noted that aside from the vital medical importance of ARVs, they also had "a strong emotional significance" to patients, and should be available at all times.

Numerous actors

Mercier said the problems in supply-chain and distribution systems in West and Central Africa were similar in many countries, but "what varies is the intensity of the issues."

One of the major glitches was a lack of coordination between people at various stages of the chain, some of whom were working outside a country's regulatory framework. The Democratic Republic of Congo's Minister of Health, Mwami Auguste Mopipi, said this could destabilise distribution.

"We have various actors showing a great keenness to help, but this also poses problems for us, as we do not manage their orders or what they are bringing into the country," he said. "We have a set distribution chain, we try to coordinate and standardise, but the problem is we don't know if partners are ready to agree to State control."

Poorly identified needs

Another common obstacle was the lack of reliable data on the required quantity of ARVs and other AIDS-related medicines, which meant stocks could run out, or expire and have to be destroyed. A lack of flexibility in supply procedures often meant emergency orders could not be placed, so unexpected shortages took a long time to be resolved.

Caroline Damour, an ESTHER pharmacist who worked on the study, said it was hard for countries to help each other in emergency situations, partly because it would arouse suspicion amongst donors, but also because no forms of credit had been set up for this purpose.

Although the responsibility of partners was important, this should not overshadow the country's responsibility. "The country needs to be aware if it is facing a break in supplies, because it is often very hard to make [emergency deliveries]; sometimes it takes three weeks for the problem to be flagged, and then it takes more time to go through the [formalities]," she said.

Various solutions

The study emphasised that these issues can and should be resolved to increase access to HIV/AIDS treatment. UNICEF's Mercier pointed out that "Managing ARVs is a complex issue, and the problem of breaks in supplies was anticipated. However, it is possible to take measures to prevent this."

Senegal's Diop said the government had responded to bottlenecks by integrating ARV distribution into its national, and later regional, distribution systems for essential medication. This standardisation of stock management had greatly reduced breaks in supplies.

There were still hurdles to overcome, Diop acknowledged, such as how information was communicated, and providing more training for managers and pharmacists, but the system was working.

Nigeria, which faces considerable geographical and demographic obstacles, decided to outsource various parts of its distribution chain to partners - public, private, national and international - selected for their skills in the areas of product selection, supplying, stocking and distribution.

Not everyone has approved, with some arguing that existing national systems should be strengthened, rather than implementing parallel systems. But Collins Ndukwe, supply and logistics officer at the Nigerian National Agency to Combat AIDS (NACA), said ARV distribution to 120 treatment centres around the country had improved.

"We lost our grant from the Global Fund to Fight AIDS, Tuberculosis and Malaria [in 2006], because we couldn't get the medication to the right place at the right time. We had to make sure this didn't happen again and now with the system we have in place, we have [a very good reputation] with the Global Fund," he said.

Mercier said the challenges of distributing ARVs had highlighted similar problems with other medicines, and that the solutions could be applied to entire systems. "Thanks to [funding by] the Global Fund and others, HIV brings about an opportunity to resolve not just HIV issues, but other systemic issues."

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