Cheaper drugs for HIV/AIDS in Africa: What happens next? Suggested strategies for distributing HIV drugs

by John Kiwanuka Ssemakula, April 09, 2001

Now that there is the prospect of cheap drugs becoming more available in Africa, it is important that the drugs reach the people who need them the most. The next step is to look at how African governments will ensure that life saving drugs get to the people who need them. How will governments ensure equitable access, availability, continued supply to meet the demand? The truth is that at the moment despite the significant reduction in the price of HIV drugs, at the moment only a very small number of HIV infected people will benefit. Already 6 countries have made low cost deal with drug companies to provide cheap HIV drugs. But the governments of these nations say they can only afford to provide treatment for only 1-2% of HIV sufferers. In Mali, 130,000 people are infected with HIV but only 600 will receive low-cost treatment. Ivory Coast, with almost 1 million HIV infected people, hopes to increase the number of people receiving treatment from 1,000 to 3,000 people in 2001. In Senegal with 180,000 infected people, the low-cost deal took effect in November 2000 and the numbers receiving treatment has doubled, from 100 to 200.

The debate will shift to focus on the existing health infrastructures and medicine supply systems. The health infrastructure in many African countries is in a woefully dilapidated state due to years of chronic under funding and neglect. There is an urgent need for increased investment to develop the healthcare infrastructure, but this should not act as an obstacle to delay the start of HIV drugs distribution. African governments should look for ways to implement HIV/AIDS drugs distribution as soon as possible using existing systems.

However this should also be taken as an opportunity to objectively analyse existing healthcare structures and processes in the context of the current environment. How can they be modified, or improved to deliver a better service to its citizens? What new techniques can be introduced to aid in the fight against HIV/AIDS and other diseases? New ways of thinking, new and innovative methods of healthcare delivery need to be evolved.

Whatever new strategies, innovative measures evolved to combat the HIV/AIDS epidemic, the means used to deliver life saving medicines to People Living with HIV/AIDS (PHAs) should be developed alongside existing traditional methods with an eye on the long term future development of healthcare delivery in Africa. It would be shortsighted to develop strategies to fight HIV/AIDS alone to the exclusion of other diseases and health problems assaulting Africa. The HIV/AIDS epidemic is the greatest tragedy to strike Africa in recent years. It threatens the lives of millions of people that Africa cannot afford to lose. African governments should do their utmost to save as many of their citizens.

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How will HIV/AIDS drugs be distributed to HIV/AIDS sufferers?

Before a program to distribute the drugs can be developed, a number of questions need to be answered.

Who will be responsible for distributing the drugs
How widely available will drugs be and who will get them?
How will patients be identified?
Where and when will people receive treatment?
How will a continued supply of drugs be maintained?
What will be the actual cost the HIV/AIDS drugs to the customers and the government?

In order for PHAs to benefit from the recent reduction in prices there must be an equitable distribution network and the supply must be maintained continuously. This is important for two reasons. Firstly, a constant supply will ensure that there will be no break in the PHAs schedule of treatment, reduce the possibility of drug resistance emerging which would render the drugs ineffective. Secondly a continuous supply prevents shortages that may lead to an increase in price and exploitation by unscrupulous persons wishing to make a profit (pharmaceutical companies notwithstanding).

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Who will be responsible for distributing the drugs?

The Multisectoral approach – In many African nations a large number of organizations are not only involved in the fight against HIV/AIDS but with many other health problems. Mobilization of religious and local community organizations, NGOs both foreign and local, as well as different segments of society to form part of the supply distribution network can help relieve the pressure on stretched government resources, by dispersing the responsibility among many organizations already involved in the fight against AIDS.

For this approach to work there will need to be a central coordinating body to ensure proper control and management of the logistics of supply. It will be important to make sure all participating organizations whether government or non-government are included in crucial discussions from the beginning. This body should have clear guidelines set out. It is important that it does not become part of a bureaucratic bottleneck in delaying distribution of medicines.

HIV drugs are prescription drugs, and therefore ideally should only be given out by qualified personnel such as doctors, pharmacists or the equivalent, but there is a chronic shortage of trained people that will require many years to correct. Therefore powers to do this will need to be devolved to people such as suitably qualified nurses, medical assistants and primary care workers. These people will have to receive appropriate training.

Another suggested way of increasing number of people involved in distributing drugs is to train shopkeepers and community members in pharmaceutical use. In many cases these people are already involved in selling medicines to the general public, albeit informally and are quite often the first point of contact for people seeking treatment. Training and education will have the effect of strengthening knowledge and improve the dispensation of appropriate medicines. School based teaching on the proper use of essential drugs that include HIV drug use will be another way of improving public knowledge about medicines.

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Methods of distribution

The two main methods of distribution used in most African countries for supplying medicines to the population are:
The Centralized Supply System and the Decentralized Supply System.

The Centralised Supply System has two main types the Central Medical Stores (CMS), which is the classical conventional drug supply system and the Autonomous Supply Agency System (ASAS) where management responsibility is devolved to an autonomous or semiautonomous board. The Centralised Supply Systems take up a lot of resources in terms of human, physical infrastructure, management, and communication systems. It involves bulk procurement of drugs into a central warehouse and then forward distribution from the warehouse to regional and district health facilities. This type of system involves considerable logistical problems with distribution and is costly. It has the following problems:

Prone to bureaucratic delays. Take too long to respond to changing local environments.
Not very flexible. It does not adequately reflect local demands or needs.
Management problems – Financial, warehouse and store management. The system requires a high level of qualifications, and there is a chronic shortage of skilled managers in many African nations
Transport problems
Security of drugs is an issue.

The Decentralized Supply System also has two main types: The Direct Delivery System (DDS) and the Primary Distribution System (PDS). In the decentralized approach the drugs are delivered directly by suppliers to customers who include regional and major healthcare centers. There are generally no middlemen, the government health purchasing board or office posts tenders to establish the price of the drugs, and also to establish whom the official supply agencies will be. Decentralization is supposed to improve the responsiveness, flexibility, quality and efficiency of health services and reduce the creation of bottlenecks in supply. The system depends on very good information and communication both within and between the healthcare system and the drug supply system to ensure there is a continued supply of medicines.

Benefits are:	Problems are:
Greater local involvement.	Lack of capacity
Greater public accountability and transparency	Lack of trained personnel
Increased flexibility and response to local conditions	Lack of finances, or inadequate financial structures at local level.
More rapid / accurate communications	Increased corruption, it makes it easier for local officials or special interests to profit locally (to be fair this can and does occur at any level)
Quicker adaptation to changing conditions	Increased cost – decentralized ordering means smaller order quantities that can lead to increased prices of drugs
Aims to promote an effective private sector distribution system.

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Which system is the best?
Each system mentioned offers benefits and has pitfalls. Each one must be chosen carefully before modifying or replacing the existing system and this should only be done after the existing system has been properly evaluated and analyzed for its strengths and shortcomings. This will depend on the local environment in each country. However the best approach is likely to be one that combines elements of both types of systems or integrates the two systems side by side.

Traditionally the centralized system has been used where the private sector was not well developed and where the medicines supply was via one main channel. But in recent years this has been associated with declining availability of drugs, poor erratic supply and an inability to cope with changes in medical practice as well as increased demand for healthcare services. The dwindling supply of medicines due to the decline in the healthcare system, has led to a parallel informal network of private clinics, shops, trading posts that sell drugs. The current system where the government is the main source and provider of medicines is not about to change especially when the private sector distribution system is still under developed. However the introduction of decentralised systems will help in promoting a more effective private sector distribution system.

Working with NGOs is also another way to increase the drug supply network. Worldwide NGOs are responsible for the distribution of 20% of the world’s supply of drugs. NGOs are also active in many healthcare projects in Africa including those concerned with HIV/AIDS. Incorporating these organizations into the drug supply network will greatly improve the capacity of distribution systems.

A possible solution
One possible solution is a hybrid system of public private partnership whereby the government sets up an autonomous public supply system that competes with private supply agencies, which are also given as much support and encouragement to perform, such as changes in government policy waiving restrictions or tariffs on the importation of essential medicines or certain class of drugs, will help in developing a better private sector distribution and in order to encourage the growth of a health drugs market. It will have the effect of introducing competition, thereby promoting lower prices. In the long term this will reduce the burden on government resources and make drugs more widely available.

A Hybrid drug supply network that integrates the public drug distribution system with the private drug supply systems and the NGO network.

To make the whole system more efficient and effective there should be “vertical” integration with other drug supply systems such as those providing other essential medicines for prevention programs such as TB and Maternal and Child Health programs.

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How widely available will drugs be and who will get them?

People who are infected with HIV/AIDS are meant to be the main beneficiaries of cheaper HIV drugs. Initially it is expected the availability and supply of drugs will be limited, so who will be prioritized? Priority for treatment must go to those with the greatest risk of transmitting infection such as HIV-infected pregnant women, sex workers. It is important know a lot more details about People living with AIDS, such as where they are found, their numbers and demographic characteristics such as age, gender and other factors.

Until now figures about the AIDS epidemic have been estimates, but if there is to be any hope of delivering drugs to the right people much more accurate and detailed information will be required. Without knowing how many HIV sufferers there are, where they are found, how fast the epidemic is growing governments will be unable to plan an effective program of distribution of HIV drugs, let alone cope with increases in numbers of infected people in the future. Improved surveillance, better monitoring and a greater commitment reporting on the epidemic will be needed.

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How will patients be identified?

HIV positive people can only be properly identified using HIV testing kits and this is also the only way to determine the actual numbers of people infected with HIV. This then means the availability and quality of HIV testing kits, and the speed with which HIV testing is done will have to be improved. People must be identified quickly so they can get on treatment quickly. HIV testing will have to be more wide spread, the kits will have to be made more widely available, even in rural areas, and their supply should be assured, so that they do not become a bottleneck in the whole program. The cost of HIV testing kits will have to be included in the whole program.

Promotional and Education campaigns will be required to ensure people will actually come forward to be tested and to receive treatment. For too long in many African countries HIV/AIDS has carried a stigma, which has not been helped by official denials of its existence. This coupled with the fact that there were no drugs available has prevented people from coming forward to be tested. A change in policy and attitude of many governments and the need to face up to the reality of HIV epidemic is required. Governments must face up to the fact they have a responsibility for leading the way in the fight to combat the HIV epidemic. HIV/AIDS sufferers must be assured that their rights will be protected, and that they will not be discriminated against.

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Educating the consumer

Antiretroviral drugs are taken as a cocktail, and they must be taken everyday without fail. Sufferers taking these drugs must follow a rigorous regimen and stick to it to ensure the maximum effect of the drugs. Patient compliance in long illnesses with long treatment times has often been shown to be poor. Another factor that may lead to noncompliance and breaking the rigorous pill-taking routine are the often unpleasant or debilitating side effects of the drugs used in combating HIV/AIDS. The danger is that patients will interrupt their treatment allowing resistance to the drugs to develop.

Vigorous campaigns to educate people on the correct methods of taking the drugs will have to be conducted. Leaflets or posters clearly displaying the different medicines, the combinations used, the recommended dosages will be helpful in informing people on how to use the drugs properly. Educating patients about what to expect when they start taking the drugs will be very important to ensure they stick with rigorous treatment schedules, and prevent the creation of drug-resistant strains that would spread worldwide. It will be very important to make people aware of the fact that these HIV drugs will have to be taken everyday without fail for the rest of their lives, otherwise resistance to the drugs will make them ineffective and the person will develop AIDS. People must be made to realize these HIV drugs are not a cure for HIV/AIDS.

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