djamieson Big gains in treatment of children living with HIV

Treatment rates for pediatric patients have always lagged behind adults, but now programs like PEPFAR’S ACT Initiative show this doesn’t have to be the case

 

by David Jamieson, PFSCM Senior Supply Chain Advisor

 

In May, we reported on new opportunities to test babies and young children for HIV at, or close to, the clinic where they see their doctor. In this blog post, we look at how results from PEPFAR’s Accelerating Children’s Treatment (ACT) program show that, with the right policies and a focused approach, rates of treatment of children living with HIV (CLWH) could be as good as those for adults.

When Ambassador Deborah Birx of PEPFAR launched the $200 million ACT initiative in August 2014, the aim was to double pediatric treatment rates in nine African countries in just two years, which would bring 300,000 new patients on antiretroviral (ARV) treatment.

By September 2016, the number of children on treatment worldwide had grown to an estimated 900,000with 561,000 patients on treatment in the ACT countries. Even more importantly, the number of children on treatment continues to grow, proving that the ACT program and other initiatives are creating sustained change.

Across the nine ACT countries, the number of children on antiretroviral treatment (ART) has increased by 44%. In Kenya, an estimated 73% of CLWH are now on treatment; in Zimbabwe, the figure is even higher at 80%, showing that the goal of 90% of known CLWH being on treatment is achievable.

Globally, PEPFAR now supports nearly 1.1 million children (0-19 years old) on ART — a 97% increase since 2014.

Though ACT, PEPFAR and the Children’s Investment Fund Foundation focused efforts in high-risk areas, working with local implementers to identify babies, children, and adolescents with HIV and to get them onto treatment without delay, often within a day.

Other barriers tackled included:

  • Training and job aids to overcome health care providers’ lack of confidence in treating pediatric patients.
  • Advocating to change restrictive treatment access policies.
  • Improving the child-friendliness of the medicines — some pediatric solutions tasted bad, making it difficult to get very young children, who could not swallow pills, to take the medicines.

The supply chain for ARVs: A critical component

PEPFAR tasked PFSCM, through the Supply Chain Management System project, with ensuring that the drugs would be available at the health facilities when needed. Identifying CLWH and encouraging parents and caretakers to start children on treatment is an enormous effort. If stock levels were not properly maintained at clinics, all the effort would be in vain.

Managing the supply chain for CLWH is challenging because it involves more drugs than for adults, the formulations change as children grow, and, in many countries, the total requirements are small. It is also necessary to strike a balance between preventing stockouts and not overstocking, which could result in products expiring before being used.

Globally, PFSCM engaged in two important supply chain initiatives. We became founding members of the Pediatric ARV Procurement Working Group (PAPWG), an effort to pool the requirements for pediatric ARVs to create and manage sufficient demand to keep the market attractive to suppliers. By coordinating the demand of major purchasers — such as PFSCM and the Global Fund to Fight AIDS, Tuberculosis and Malaria — with demand from smaller countries, supply became more consistent and flexible.

PAPWG results are described on PFSCM’s website and in a paper published on the Global Fund’s website. The PAPWG — now known as the ARV Procurement Working Group (APWG) and chaired by PFSCM’s Director of Global Supply Chain Wesley Kreft — has expanded to include adult formulations in low demand.

To address the challenge of multiple pediatric ARV formulations, PFSCM also joined a team from the UNICEF Inter-Agency Task Team (IATT) for the Prevention and Treatment of HIV Infection in Pregnant Women, Mothers and Children to draw up an optimal formulary of pediatric ARVs. From more than 65 approved pediatric ARVs, the team created a formulary that currently includes 10 optimal formulations, as well as a list of a further 10 limited-use products.

The IATT team has also advocated for and supported the development of small pellets that young children can take in soft food to replace the bad-tasting liquid for Lopinavir/Ritonavir, an ARV essential in treating very young children.

What’s next

To build on the achievements of PEPFAR’S ACT program and the other recent progress, the global community is continuing to innovate. Current initiatives include:

  • Start Free, Stay Free, AIDS Free: The ACT Initiative’s lessons are key to UNAIDS’ Start Free, Stay Free, AIDS Free framework — a super-fast-track approach to ending AIDS among children, adolescents, and young women by 2020. The framework is based on the fundamental principle that everyone living with HIV should have access to ART.
  • DREAMS: To address the high risk of contracting HIV for girls and young women, PEPFAR — in collaboration with private sector partners the Gates Foundation, Girl Effect, Johnson & Johnson, Gilead Sciences, and ViiV Healthcare — is driving the ambitious Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe (DREAMS) Partnership.

The global community should also:

  • Continue to update and promote the use of the pediatric ARV optimal formulary.
  • Develop child-friendly effective medicines.
  • Support introduction of new products.

PEPFAR’s 2017 report states: “Saving the lives of children with HIV is not only the right thing to do; it is the smart thing. By treating children early in their HIV infection, they can stay healthy and thrive. Healthy children who can pursue their dreams will grow economies, create jobs and strengthen their communities for decades to come.”

We can’t say it any better, and will continue to do all we can to ensure supply chains support increased treatment for children.


Based on UNAIDS 2017 report of 2.1 million children living with HIV, of whom 43% are on treatment

Now is the time to take testing of newborns
closer to their mother

Pilots have shown that early infant diagnosis
can be moved closer to point of care

by David Jamieson

 

We have known for years that if babies born with HIV do not receive treatment, more than 50 percent will die before their second birthday, but we also know that when treated, they can grow into healthy adults. Until very recently, a big challenge has been reaching mothers and their new babies soon enough, testing baby, and getting the results back to mom. Reliable diagnosis could only be completed in larger laboratories, meaning blood samples had to be transported to the lab, kept fresh for testing, and then the results returned — by which time, mother and baby were probably back in their village and might never get the result.

Photo credit: Fabrice Duhal

Recent work by WHO, CDC, and UNITAID means that this is all about to change. WHO and CDC have pre-qualified two point-of-care (POC) instruments: the Alere™q and the Cepheid GeneXpert® (both are and WHO Prequalified). And UNITAID is funding an Early Infant Diagnosis (EID) Consortium, initially to pilot test POC EID in Kenya, Malawi, Mozambique, Tanzania, South Africa, and Zimbabwe, and then to scale up the model if the pilot proved the concept.

The great news is that, yes, the pilot was successful, and as the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) reports, now is the time to accelerate scale-up and usage. UNITAID’s EID Consortium, EGPAF, Clinton Health Access Initiative (CHAI), UNICEF, and Médecins Sans Frontières (MSF) are now working with local governments and stakeholders to get the rollout moving, but we can all be involved.

Although these new instruments get a lot closer to mother and baby, it is not practical to put a machine in every location. The experience of the rollout of CD4 POC instruments is that many lay idle for long periods because of low demand. With EID, it will be important to learn the lessons from CD4. One thing that is clear is that to accelerate EID, we will need multiple inputs from many stakeholders.

How PFSCM can contribute to scaling up POC EID

PFSCM has always been firmly committed to improving the care, detection, and treatment of the youngest patients. Drawing on our expertise in managing global supply chains and optimizing laboratory networks, our contribution will be to ensure that the supply chain doesn’t let these patients down; that smart network design places these new instruments where they will make the most difference; and that results get back to mom and her health caregivers at the earliest opportunity. Specifically, we can:

  • Use software and GIS technology to design smart networks of laboratory-based instruments and POC diagnostics to reach as many mothers and babies as possible;
  • Consolidate supply chains to deliver complete packages of commodities needed for each and every test; and
  • Apply our expertise in data management and mobile technology to get the results back to mother and baby quickly.

The growing success of PMTCT (prevention of mother-to-child transmission) means that fewer babies are being born with HIV, but for those who are, EID is essential. And PFSCM can help ensure that pediatric antiretrovirals (ARVs) are available to treat babies born with HIV. (We will cover pediatric treatment in subsequent blog posts.)

PFSCM strongly supports the goal of an AIDS-free generation, and the three “frees” — start free, stay free, AIDS free.

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Noor Al-Gallas Antimicrobial resistance and supply chain: A neglected relationship

Delegates at the 68th World Health Assembly in May 2015 endorsed a global action plan to tackle antimicrobial resistance (AMR), directing the world’s attention toward AMR as an acknowledged serious threat to global health. The recent World Antibiotic Awareness Week campaign further raised AMR awareness, aiming to encourage best practices among the public, health professionals, and policy makers. WHO’s overarching message for the campaign was that “antibiotics are a precious resource and should be preserved. They should be used to treat bacterial infections, only when prescribed by a certified human or animal health professional. Antibiotics should never be shared or saved for the future.”

This threat of AMR has not developed overnight. WHO attributes it to the overuse and misuse of antimicrobial drugs everywhere in the world, which causes infectious organisms to adapt and become resistant to the antimicrobial drugs that were designed to kill them. The Center for Disease Dynamics, Economics & Policy’s report, “The State of the World’s Antibiotics, 2015,” suggests that 20 percent to 50 percent of global antibiotic use can be classified as inappropriate. “Inappropriate” is largely defined as prescribing and usage when no health benefit is possible, prescribing the wrong antibiotic, prescribing the wrong dosage, or patients’ poor adherence to a prescription.

The supply chain component. In the African region, there are two significant AMR-related supply chain challenges, according to WHO. Stockouts of essential medicines and antibiotics can lead to increased circulation of counterfeit or substandard antibiotics. While overall supply is a challenge, it is clear that increased appropriate prescribing and usage would decrease the burden of stockout.

The second and more urgent challenge is a lack of laboratory reagents and consumables, which makes proper testing, diagnosis, and treatment difficult or impossible, even when appropriate laboratory equipment is available. Physicians then face the hard decision of treating patients using antimicrobial agents to the best of their knowledge rather than based on an accurate diagnosis from test results. Addressing this gap in the supply chain of diagnostic tests can make the difference between appropriate use of antibiotics and overuse or inappropriate use.

The availability of diagnostic tests is only one part of the equation. WHO has also asserted that AMR is not monitored in low-resourced countries because they often lack a surveillance network or data system to collect and analyze the results of diagnostic tests, making it harder to identify the profile of infectious agents and their distribution in certain regions. Without data collection and analysis, properly monitoring prevailing infectious profiles and identifying new emerging ones is ever more challenging.

A starter package to address AMR. Diagnostic tests and a data collection system are a potential “starter package” for developing countries to jump-start the efforts to tackle AMR. Such an approach would encourage public health policy makers to enforce AMR surveillance, and would enable physicians to access diagnostic tests before prescribing antimicrobial agents.

WHO also calls for strengthening health systems, including diagnostic laboratories. Ensuring a strong supply chain of reliable diagnostic tests, reagents, and consumables is one of the key factors for creating a sustainable, strong diagnostic laboratory system.

During the last decade, we have observed the role of strong supply chains in addressing and managing the availability of diagnosis and treatment of HIV/AIDS, malaria, and TB; ensuring the availability of reproductive health commodities; and responding to other health challenges in the developing world. Making diagnostic tests and treatment available for these health burdens has helped to save millions of lives in the developing world.

The same consideration for the necessity of a strong supply chain is now urgently needed in addressing the significant risk of AMR.

Amna-Noor Al-Gallas, MD, MA
Global Health Expert
Market Dynamic Committee Strategic Advisor
Procurement Operations Manager—NPU


Rich Owens World AIDS Day — December 1, 2016

 

heroeslogoADear friends,

This is PFSCM’s 11th year commemorating World AIDS Day. We have come a long way since 2005 in helping to ensure essential commodities are affordable and readily accessible to those who need them.

In 2005, an HIV diagnosis was still a death sentence for many people in developing countries. Now, around 55% of adults living with HIV have gained access to antiretroviral (ARV) medication. To reach the UNAIDS “90-90-90” targets by 2020 and reduce the HIV epidemic to a low-level endemic disease by 2030, the number of people living with HIV and on ARV treatment must rise from the current level to close to 30 million by 2020. Those who start treatment early are expected to live a normal lifespan.

2016 marked many accomplishments of the people, organizations, and countries engaged in the fight against AIDS. Consider these notable highlights:

  • AIDS-related deaths have fallen 45% since the peak in 2005.
  • New HIV infections among children have declined by 50% since 2010.
  • More than 18.2 million people are accessing ARV therapy. 9.2 million of them are receiving ARV treatment through Global Fund-supported programs, with steady increases each year.
  • PEPFAR is supporting lifesaving ARV treatment for more than 9.5 million men, women, and children worldwide. In 2015, SCMS procured 80 percent of all ARVs directly funded by PEPFAR.
  • PEPFAR has directly supported 8.9 million voluntary medical male circumcision procedures (VMMC) for HIV prevention, assisted in large part by SCMS deliveries of VMMC kits. By pooling procurement across many countries and buying in large volumes, SCMS negotiated a 30% reduction in VMMC kit prices since they were first procured.

We are tremendously proud of the work PFSCM has done to assist in the fight against AIDS — on behalf of the US Government through the Supply Chain Management System (SCMS); on behalf of the Global Fund to Fight AIDS, Tuberculosis, and Malaria thr0ugh its Pooled Procurement Mechanism (PPM); and on behalf of all our other clients and collaborators.

  • Through SCMS and PPM, PFSCM has procured $4.78 billion of lifesaving commodities — ARVs, essential medicines, laboratory commodities, and more.
  • PFSCM delivered these commodities to 91 countries, including some of the hardest-to-reach places in the world.
  • PFSCM has contributed to driving down ARV costs per patient from $1,500 in 2005 to as low as $80-$90 today.
  • We have also helped 41 countries build the capacity of their supply chains, working to make them sustainable and to increase local ownership.
  • Looking forward, today PFSCM launches a new web site focused on how we contribute to the ambitious targets for tackling HIV and AIDS and support other health supply chains through innovation and high-quality performance. You can see the new site here: www.pfscm.org

Today, on World AIDS Day, we celebrate the achievements of PFSCM’s supply chain heroes and the many, many individuals dedicated to the fight against AIDS. Tomorrow, we get back to work. There is no time to lose and much left to do if we are to meet the ambitious goals of the global community to turn the tide and defeat AIDS by 2030. Achieving an AIDS-free generation requires dedication, planning, daring, and innovation, continuing onward from today.

With our best wishes,

rich-signature                         gordon-signature

Richard C. Owens, Jr.                     Gordon Comstock
Director                                              Director, Global Supply Chain

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President of MSH reflects on 10 years of progress

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Jono Quick, President of Management Sciences for Health, one of the key partners, along with JSI, on the SCMS project, looks back on 10 years of work strengthening global health supply chains for people living with HIV/AIDS.  This video is part of a collection of reflections we are highlighting as we look back on the legacy of SCMS and what it has meant to its many stakeholders and beneficiaries.



djamieson Dare to Innovate – Meeting the Supply Chain Challenge of 90-90-90

PFSCM IAS luncheon flyer FINAL 2UNAIDS’ ‘‘90-90-90’’ strategy calls for 90% of people with HIV to be diagnosed, 90% of those diagnosed to be on anti-retroviral therapy (ART) and 90% of those on ART to achieve sustained virologic suppression. Additionally, growing numbers of countries are adopting the universal test and treat model, in which all people diagnosed with HIV receive ART regardless of CD4 level.  It is widely recognized that these strategies will challenge public health systems in resource-limited settings, including global and local supply chain systems.

For supply chains, each of the ‘‘90s’’ presents complications and challenges in getting to 90-90-90 by the 2020 target date. Ensuring that 90% of people with HIV know their status will require a large increase in access to HIV tests, often in unconventional settings. The number of people living with HIV and on treatment must rise from the current level of around 17 million to close to 30 million by 2020, a near doubling of the demand for anti-retroviral (ARV) drugs.  Similarly, monitoring those on treatment means an unprecedented scale-up of viral load testing.

The Partnership for Supply Chain Management (PFSCM) will host a luncheon and panel discussion at the International AIDS Conference in Durban, South Africa to discuss the procurement, supply chain and logistics challenges in reaching each of the 90-90-90 targets (see below for event details).  Funding will obviously be key, and innovative solutions and reforms to the supply chain in developing countries will be essential, but we believe it can be done.

It is important that the fight against HIV continues to be led by governments, primarily through the Ministry of Health, but also include Ministries of Finance and Trade or similar institutions, to set policy and goals, although it is not necessary for the response to be solely from the public sector.  The private sector and voluntary and community groups also have much to offer.  This is especially true for supply chains.

The commercial private sector is already essential to combating HIV, whether by producing drugs, diagnostics and other health commodities or by transporting those products from the manufacturer to the countries heavily affected by the pandemic.  But there is much more that the private sector, for-profit, and not-for-profit organizations can do, especially in supporting and extending in-country supply chains to the so called “last mile,” before the drugs get to patients.  There are also many lessons we can learn from the commercial sector in creating and sustaining flexible, responsive supply chains that keep essential goods in constant supply.  We are confident that the supply chain can respond as needed, but it won’t be easy and will need dedication, planning, daring, and innovation.

The supply chain challenges and opportunities in treating all those living with HIV and reaching the 90-90-90 targets are further discussed in a new paper from PFSCM published in the Journal of the International AIDS Society entitled “The 90 90 90 strategy to end the HIV Pandemic by 2030: Can the supply chain handle it?”

If you are at the International AIDS Conference in Durban, please join us for lunch and the panel discussion on Wednesday, July 20, 12:45-14:00 at the Rainbow Terrace Restaurant of the Hilton Hotel.  We look forward to seeing you there!


PFSCM Lifesaving health supplies reach patients despite pre-electoral violence

Photo NIYONIZIGIYE Jean Claude

Pictured: Jean Claude Niyonizigiye, HIV supervisor in the sanitary district, south zone of Bujumbura, showcasing products that fight against HIV.

How can people living with HIV/AIDS continue to get the life-saving medical supplies they need in a country undergoing political unrest?  Thanks to the preparedness of the Supply Chain Management System (SCMS) and its partners in Burundi, operating under such unstable conditions barely affected the availability of and access to supplies for much-needed treatment.

Civil unrest erupted in Burundi on April 26, 2015, just before the elections, and political tensions continue to this day. Due to protests, as well as ambushes, assassinations, and a thwarted coup d’état, most parts of the city have been inaccessible.

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djamieson Adult ARV supply market for developing countries adapts to new WHO guidelines, but challenges remain

“Tenofivir and zidovudine-based products, including fixed-dose combinations, are in good supply, although there are some challenges with the zidovudine active pharmaceutical ingredient (API) market out of China. Demand for stavudine-based products is dropping fast and suppliers are exiting the market for these products.”

These were the conclusions from a recent visit to India and China by the PFSCM procurement strategy team. Continue reading


bimans SCMS helps ensure uninterrupted treatment to patients after a fire destroys the pharmacy of the regional hospital in Divo

On the night of December 17, 2014, a short circuit fire engulfed the pharmacy of the regional hospital in Divo, one of the hospitals that provide medical services to the more than 1 million inhabitants in the Loh-Djiboua region in Côte d’Ivoire. Despite the quick response and joint efforts of the neighboring population, $43,000 worth of general medicines and $54,000 worth of ARVs were destroyed. Though the laboratory equipment was recovered, it was deemed no longer functional due to fire damage.

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