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Civil society organisations call for an enquiry into the ongoing stock-outs of medicines

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Statement by the Treatment Action Campaign, the HIV Clinicians Society of Southern Africa, the Rural Health Advocacy Project, the Rural Doctors Association of Southern Africa, SECTION27 and Médecins Sans Frontières

10 May 2012

There have been ongoing shortages of antiretroviral medicines, specifically tenofovir (TDF) and abacavir (ABC) since March in facilities across South Africa. These shortages are compromising the health of patients taking these medicines. We call for urgent resolution of the shortages and for an enquiry into their cause.

TDF and ABC are both essential medicines. South Africa’s antiretroviral treatment guidelines provide for TDF in 1st and 2nd line treatment of adolescents and adults. ABC is provided for in 1st and 2nd line treatment of infants and children.

In response to the shortages, the Southern African HIV Clinicians Society (the Society) sent a letter to the Minister of Health on 29 March calling for an urgent investigation into the cause of these shortages. The Department of Health requested the Society develop clinical guidelines for health care workers experiencing TDF and ABC drug shortages. This guidance was shared with the Department of Health on 29 March 2012 and widely circulated across the country. To date, the guidance has not been adopted by the Department of Health as policy or officially communicated to provincial health departments, and facilities remain uncertain about whether they can follow the recommendations when faced with a drug shortage.

In the guidelines, the Society noted that they were only a short term solution and that shortages could harm patients' health:

“ARV treatment interruptions and suboptimal ARV therapy are associated with treatment failure and the development of viral resistance to available ARVs. Treatment interruptions are also associated with a number of health complications. Changing a patient back to stavudine (D4T), with its known side effects, could lead to increased rates of non-adherence and consequent treatment failure if not accompanied by careful counselling.”

The Rural Doctors Association of Southern Africa noted additional challenges with switching treatment:

"Ideally before substituting D4T for tenofovir a viral load test is done, in order to make sure that a patient’s viral load is suppressed. Unfortunately in rural areas the turnover time for viral load testing is too long, and therefore D4T will need to be substituted blindly for tenovofir. This means that in some of our patients resistance against D4T may develop."

TAC has received reports of medicine shortages in Mpumalanga, Gauteng, Limpopo and the Eastern Cape. However, more provinces are likely affected by what appears to be a national shortage.

  • In Gauteng, TAC received reports of ARV shortages in Daveyton Main, J Dumane, Poly Clinic and Chris Hani Clinics. In some facilities, patients are given only 7 – 11 days of ARVs at a time, forcing patients to repeatedly visit clinics repeatedly to retrieve their medication. 
  • In Limpopo, shortages of TDF have been reported Giyane Health Center at Shotong, Kgapane, Ratang, Mogapane and other clinics.
  • In Mpumalanga, Amsterdam CHC, Mayflower Clinic, Fernie 2, Diepdale Clinic, Embuleni Hospital, Baberton Hospital as well as facilities based in Nkangala district are facing shortages of TDF. Many of these shortages have been ongoing since January. Additionally, Mayflower Clinic, Fernie 2, Diepdale Clinic, Amsterdam CHC, Embuleni Hospital and Bethal Hospital have reported shortages of ABC. Healthcare workers from some of these facilities reported receiving a letter informing them not to initiate new patients onto ABC and requiring clinicians to write motivational letters when initiating new patients onto ABC.
  • TAC received reports of shortages of TDF at both depots in the Eastern Cape. Facilities in the KSD sub-district in the Eastern Cape are already widely affected; the district hospital, Zithulele Hospital and its clinics have already started substituting TDF with other drugs, but they are not alone. Other facilities are facing shortages and will also need to begin substituting treatment.

TAC has sent two letters to the Minister of Health demanding an urgent resolution of the shortages [letter 1, letter 2]. The organisation has not yet received a response. Earlier this week TAC received communication from the Department of Health that adequate supplies of TDF had been secured and would be distributed to provinces. However in follow-up investigations, it is clear that the supplies of TDF distributed to provinces are inadequate to meet the need. For instance, Umtata Depot in the Eastern Cape requested 70,000 tablet of TDF yet only received 10,000 tablets.

Switching patients onto sub-optimal treatment is not an acceptable solution as it increases the risk of default, resistance and other health complication.

Given the risk to patients’ health, we call on the Department of Health to urgently resolve the shortages. Stock shortages have become too commonplace in the health system. The Minister of Health must start an enquiry to find out the causes of the shortages and to stop them from recurring. Further, the Department of Health must issue a circular to provincial Departments of Health providing clear guidance to facilities on what to do when experiencing a drug shortage. Without a Department of Health endorsed policy, clinics and facilities remain reluctant to act.