Empty Shelves, Come Back Tomorrow: ARV Stock Outs Undermine Efforts to Fight HIV

White flag with red logo of Doctors Without Borders/Médecins Sans Frontières (MSF) against sunny blue sky

© Valérie Batselaere/MSF

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Despite considerable investments in supply chain reforms, wide-spread medicines stock outs negatively constrain patients’ ability to have access to their medication. Limited availability of antiretroviral drugs (ARVs) caused by dysfunctional supply chains impedes patient initiation and adherence and poses a major barrier to win the global fight against HIV.

Secured access to antiretroviral treatment (ART) is critical for the realization of the "90-90-90" objectives, to initiate 90 percent of diagnosed patients and obtain viral suppression in 90 percent of those on ART. Scale-up is critical, as studies have proven the benefits of starting ART as early as possible, leading to the World Health Organization (WHO) recommending universal treatment for all HIV positive patients. Optimal adherence is essential to ensure individual treatment success and limit viral resistance. Realizing the importance of accessible ART regimens for scale-up of initiation and retention in care demands a greater understanding of the magnitude of the access problem and of existing methods to ensure efficient ART provision.

This report details four case studies of sub-Saharan African countries with different HIV burdens and variable supply chain models, comparing those models in terms of robustness and flexibility to deliver ART. Context-specific methodologies to actively measure patient access and solve stockouts are proposed. Innovative approaches and initiatives are presented and assessed based on their effectiveness in improving ART access and simplifying ART delivery for people living with HIV.

The analysis conducted in the four selected countries shows that, due to diverse logistical, managerial, and legislative challenges, country programs fail to offer consistent and timely supplies of ARVs to their patients. None of these countries routinely collect data on ART availability in all facilities that would allow a fast response to stockouts. In South Africa, Mozambique, and the Democratic Republic of Congo (DRC), the lack of regular "last mile delivery" poses a chronic problem. The necessary medicines are regularly not available to patients at a health facility despite sufficient stocks being present in the country. In Malawi, ARVs reach the last mile but the system does not have the flexibility needed to allow patients to access ARVs in their community. Finally, acute widespread stock outs of ART are exacerbated in all countries due to critical events such as ART regimen switches and scale-up.

Whatever their cause, stockouts have a negative impact on patients’ motivation or ability to stay in care, which does not only compromise their health and well-being but also adds to the spreading of resistant virus strains. In contexts where health structures are congested, understaffed, and unequipped for necessary scale-up, stockouts undermine both patients and health workers trust in the system. Although supply chains exist for the purpose of serving the patients’ needs, currently there are little examples of country chains that are adapted to the patient’s reality and are open to their demands.

Access to multiple months refill (MMR) becomes indispensable to allow easy access for growing numbers of increasingly healthy patients and decongest health facilities. To date, few countries have shown their supply to be robust and flexible enough to provide MMR without stockouts. Where human resources are limited, patients successfully participate in medicines distribution and refills through community ART delivery if national legislation allows it. Patients, civil society, and community-based organizations have also taken a role in monitoring and resolving stockouts, providing the much-needed last level data, while holding the health system accountable. However, many struggle to find the funding and support necessary to perform this role.

Innovations and evidence to guide supply chain reform exist, and governments and donors are investing in context-specific approaches, but little is documented and examples are isolated. Sporadic regional collaboration through sharing of emergency supplies is used as a stop-gap measure, but this occurs only on an ad-hoc basis and often when stockouts are already visibly impacting the patients.

Despite its optimized status compared to supply chains of other disease groups, ARV supply chains in the analyzed countries still rely on overly complex, rigid, and non-adapted procedures with diffuse accountability. The countries were chosen based on data available to MSF in those locations, but it is likely that similar scenarios exist in comparable contexts.

  • In DRC, in most sites a bureaucratic four-level system persists, not reaching the last mile and with limited visibility of stock levels, resulting in widespread facility stock outs. National stockouts in critical periods of treatment changes have resulted in long-lasting facility stockouts with an important impact on patients. Without effective alert and response systems, upcoming regimen transitions and scale up plans pose a major stock out risk.
  • In Malawi, a solid two-level push system has managed to reach the last mile, and routinely a three-month supply is provided to all stable patients. But quarterly data collection does not allow an instant facility stock visibility and response, with stockouts occurring in times of regimen scale-up. Legislation does not allow for task shifting of ART distribution to lay cadres for further decentralization.
  • In Mozambique, there is no funded regular last mile delivery and stockouts are seen at facility level. National stockouts occur, depleting national buffer stocks in the absence of a defined emergency procurement mechanism. An ambitious supply chain restructuring plan was approved, but currently there is no earmarked funding to implement it.
  • In South Africa, the fragmented ART supply chain, managed by the provinces, allows limited visibility of facility stock levels and no regular last mile delivery. Chronic stockouts are widespread, although major provincial differences exist. Occurring national stockouts with a nationwide impact could be prevented or solved by overriding patent barriers.

This report highlights facility medicines stockouts as a regional problem with a negative impact on the health of patients. Urgent action to establish supply chain systems that deliver is essential in order to successfully treat growing patient numbers. We call on national and global actors to prioritise adapting the supply chain to respond to the patients’ realities, needs, and demands as a condition to provide a quality response against the HIV epidemic.

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Hermenegilda. Albazine’s Health Center. Maputo, Mozambique.
Andre Francois