Country Assessment to Determine Factors Influencing the Cost, Availability and Distribution

of Acyclovir in Eight Sub-Saharan African Countries

Catherine Corbell* Andy Stergachis* Francis Ndowa** Patrick Ndase* Linda Barnes* Connie Celum*

*University of Washington **World Health Organization

Third International Conference for Improving Use of Medicines, November 15, 2011, Antalya, Turkey

Objectives

1. Assess the extent of implementation of WHO STI treatment guidelines about acyclovir and syndromic genital urinary disease (GUD) management in country-specific essential medicines lists and national STI guidelines.

2. Describe procurement and financing methods used by the Ministries of Health for the purchase of STI drugs, including acyclovir.

3. Assess cost and access to acyclovir at selected public and private pharmacies.

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Rationale

• Anticipation of potential beneficial effects of ACV in HSV trials for episodic treatment, suppressive therapy to prevent HIV acquisition/transmission/management.

• WHO interested in ACV for essential drug lists and recommendations of 2 WHO meetings in 2006.

• Access to STI drugs believed to be generally poor in SSA affected by costs/financing, erratic procurement and variable distribution – but not well documented.

Methods

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• Countries: Botswana, Kenya, Malawi, Uganda, Tanzania, South Africa, Zambia, Zimbabwe.

• Study period: July 2007-August 2007• Rapid assessment techniques:

• 29 structured in-person interviews with MoH officials and national STI program managers

• Visits to 28 public and 43 private health facilities to assess acyclovir cost & availability and conduct structured interviews with pharmacy workers

• Median price ratio determined by dividing the median retail cost of acyclovir 200 mg tablet by the median International Reference Price (IRP).

Results

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GUD Treatment Policy:• 4 of 8 countries adopted acyclovir as 1st line

syndromic GUD treatment in both EML and STI guidelines (Botswana, Malawi, Uganda, Zambia).

Acyclovir Procurement Policy:• Procured centrally for public sector by MoH or

central medical stores (CMS) for all countries except Zimbabwe.

• Stock-outs reported in 4 of 8 countries (Kenya, Tanzania, Zambia, Zimbabwe).

Results

Demand main factor driving availability and accessibility: Kenya, South Africa and Zimbabwe: STI guidelines recommend ACV as 2nd

line treatment of genital herpes leading to low prescribing. South Africa and Tanzania: Justification required for ordering of ACV from

CMS, which prolonged lead time and curtailed prescribing.Uganda: ACV expensive at CMS therefore not ordered by facilities. Inability

to order interpreted as low demand.Botswana: Demand escalated after ACV was included in syndromic

management.Lack of sufficient financial resources for purchasing acyclovir:

Zambia: ACV purchased at high prices due to insufficient financial resources for bulk procurement.

Zimbabwe: Foreign exchange problems hampered procurement.Botswana: Government unable to meet high demand for ACV; had to turn to

PEPFAR for assistance.

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Cost of AcyclovirAcquisition Cost of ACV in Public Sector: • Median IRP ranged from 0.74 to 1.95

– Publically Funded: USD 1.44 to 3.36 for 7-day course – Donor Funded: USD 1.05 to 1.26 for 7-day course

Cost and Access of ACV in Private Sector:• Median IRP was 5.85 to 9.76 times the median IRP

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Key Lessons

• Several African countries did not effectively implement WHO’s 2003 STI treatment guidelines.

• Purchasing through international donor organizations promoted access to ACV as it was less expensive than procurement through MoH.

• Retail cost of acyclovir in the private sector was higher than the median IRP, potentially making it unaffordable to many.

• Sampling and sample size study limitations.

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Implications

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• Changes to STI guidelines that require increased access to ACV should assess and address systems barriers to promote timely access to care for GUD.

• Strengthening public sector procurement and supply chains and public-private partnerships should include strategies for accessible and affordable GUD therapy.

• Successful implementation of guidelines requires guideline dissemination and training; effective drug procurement and coordinated distribution; and public education.*

*Lewis D. Sexually Transmitted Diseases. 2010;37:494-6

Future Research1. How to ‘Frappez Fort et Frappez Vite’ in treating

GUD effectively and potentially impacting HIV transmission?

2. New findings on reduction in plasma HIV-1 levels with high dose valacyclovir reinforce need to assess and mitigate barriers to access to GUD medicines.

3. Need to assess prevalence and factors associated with promoting access and affordability of medicines in anticipation of new evidence and guidelines.

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Thank You

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Wawaru C, Stergachis A, Ndase P, Barnes L, Ndowa F, Celum C. Sex Transm Dis. 2010 Aug;37(8):488-93.

stergach@uw.eduwww.globalmedicines.org