Trying to solve ARV supply woes

From the day Lenny (not her real name) was diagnosed HIV positive, she opted to get her life-prolonging antiretroviral (ARV) drugs from overseas - a vote of no-confidence in Indonesia's sclerotic supply system. "I heard from my friends that hospitals often ran out of ARVs, so I became paranoid," she said.

Years later, she still hears the same stories from people living with HIV, even in Jakarta, the capital, and considers herself lucky that she can afford to get her drugs sent directly from abroad: "The government should really fix the system [of distributing ARVs] as well as the health care system," she said.

Once treatment begins, it is vital there are no interruptions to the therapy, otherwise resistance to the medication develops and patients have to start taking more expensive second-line drugs.

Just over 8,000 people in a population of 223 million are on treatment in Indonesia, according to the latest figures. The government provides free first-line drugs - nevirapine, stavudine, lamivudine, zidovudine and efavirenz – produced under licence by the state-owned pharmaceutical company, Kimia Farma. Financing by the Global Fund to Fight AIDS, Tuberculosis and Malaria covers the costs of importing second-line medicines.

Caught up in the red tape

Supply or distribution problems have dogged the free ARV programme since it was launched in 2004. Every three months or so, the country's largest AIDS e-network, AIDS-Ina, is inundated with complaints over the latest shortages, and the situation seems to be worsening.

The supply of efavirenz recently dried up, leading to a demonstration by about 50 HIV-positive people in front of the office of the health ministry's AIDS sub-directorate. Around 60 percent of people living with HIV are thought to use efavirenz.

Dyah Erti Mustikawati, head of the AIDS sub-directorate, said complicated customs and import duty requirements had caused second-line drugs to be stuck at the airport; moreover, Kimia Farma imports the chemical compounds to produce first-line drugs, which can also be held up by bureaucracy.

Beyond the red tape, there is the issue of funding. "As the country's financial state is worsening, there has been a budget cut for ARVs. Out of Rp75 billion (around US$8.2 million) proposed in this year's state budget, only Rp38 billion (US$4.3) has been disbursed," Mustikawati said.

Nobody gives enough attention to this ARV problem, and nobody dares to discuss it at the ministerial level.

An AIDS activist, who declined to be named, said the main problem with ARV availability was the dysfunction of the supply-chain management system, from national forecasting and drug purchasing to the accuracy of the inventory data held by hospital pharmacies.

"Some officials at the health ministry are indeed working hard to solve these problems, but the ministry is overwhelmed with other issues, such as bird flu, dengue hemorrhagic fever, tuberculosis and malaria," he said. "Nobody gives enough attention to this ARV problem, and nobody dares to discuss it at the ministerial level."

There have been attempts at reform, such as special phone or fax lines for hospital supply requests, but stock management problems persist.

"I've heard reports that hospitals are often late in submitting their reports to the ministry, making the ministry unable to work on the exact needs for ARVs every month," said AIDS campaigner C. Supriyadi, who participated in the protest outside the ministry of health's office. "Distribution can also be stuck in many places, such as the ministry itself, or the Kimia Farma warehouse."

Indonesia, the world's largest Muslim country, has an HIV prevalence rate of 0.16 percent - roughly 250,000 people. The epidemic is concentrated in high-risk groups, such as injecting drug users, sex workers, and men who have sex with men, but the conditions exist for infection to cross into broader society.

HIV-positive activists have urged the government to work more closely with the National AIDS Commission, UN agencies and major donors to provide cheaper ARVs - drugs from Kimia Farma, for example, are more than twice the cost of those provided by the Clinton Foundation - to improve ARV supply.

Mustikawati said the ministry was working on a proposal to secure additional funding for drug purchases, and to decentralise distribution. "In the near future, we will also reduce central government's burden, and health ministry offices in the region will be in charge, particularly on buffer stock provision so that hospitals can have easier and faster access to the medicine."

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