Essential Hiv/Aids Medicines and Diagnostics in Uganda

APRIL 2014 UGANDA COALITION FOR ACCESS TO ESSENTIAL MEDICINES

ACCESSIBILITY OF ESSENTIAL HIV/AIDS MEDICINES AND DIAGNOSTICS IN UGANDA

A HEPS-Uganda

HEPS-Uganda – Coalition for Health Promotion and Social Development – is a non-profit, health consumer organisation that advocates for the right to health, focusing on access to affordable essential medicines for the poor and vulnerable people.

UCAEM

Uganda Coalition for Access to Essential Medicines (UCAEM) was born in 2000 out of a need to promote access to essential medicines for all Ugandans, particularly the poor and vulnerable. Coordinated by HEPS-Uganda, UCAEM consists of civil society advocates and advocacy organisations that have since worked together through joint campaigns, research and stakeholder engagement to promote good health through access to essential medicines. ACCESSIBILITY OF ESSENTIAL HIV/AIDS MEDICINES AND DIAGNOSTICS IN UGANDA

APRIL 2014

UGANDA COALITION FOR ACCESS TO ESSENTIAL MEDICINES

i acknowledgements

HEPS Uganda and Uganda Coalition for Access to Essential Medicine are grateful to the following individuals and institutions for their contribution to the completion of this work:

Survey Manager Mr Denis Kibira

Data Collectors Paul Akankwasa Prima Kazoora Muhammad Lubega Thomas Obua Joseph Magusho Francis Abura Alice Tumwesigye James Achol Kenneth Mwehonge Winnie Wednesday Jona Karungi Connie Kazoora

Project Coordinator Mr Kenneth Mwehonge

Advisory Committee Mr Morries Seru Mr Thomas Obua Dr Ebony Quinto Dr Namagala Mr Muhammed Lubega

Report Authors Mr Denis Kibira Mr Richard Hasunira

Printing New Enterprise Publications

Financial Support Hivos

ii foreword

he national response to HIV/AIDS is beginning to get back on track. Access to treatment Tis expanding rapidly, particularly for HIV-positive mothers. For the third year in the row, Uganda AIDS Commission and Ministry of Health are reporting declining infections and AIDS-related deaths. These are good signs and they are in line with trends at the global level, where UNAIDS has reported expanded access to treatment, and reducing infections and deaths.

To sustain and build on these gains, it is important to ensure that existing clients are not lost to follow-up or default on treatment, the current pace of enrolment is maintained, and from increased treatment enrolment, particularly good health for people living with HIV, andthat reduced equity in transmission access is achieved. attributable All these to suppressed are important viral load if we among are to people maximize enrolled benefits for treatment.

diagnostics,As results from as well this as work inequity show, in it access. may be Availability a challenge of tomedicines achieve forthese children benefits is extremelywhen the poor;treatment access effort to treatment is being among undermined adolescents by is low;pockets and medicineof stock-outs availability of both is overall medicines and lower in rural areas.

We need to maintain and strengthen the current momentum by ensuring that key HIV medicines are available and accessible to all PLHIV without discrimination, at all accredited treatment sites at all times, wherever these sites may be located. This needs to be accompanied by measures for retention, including addressing stigma, expediting adoption of new treatment guidelines, and to accelerate access to testing and counselling services, given that a large proportion of PLHIV – and may be in need of care – do not know their status.

Good reading,

Rosette Mutambi (MS) Executive Director HEPS-Uganda

iii ABBREVIATIONS AND ACRONYMS

MDGs Millennium Development Goals UNAIDS United Nations Joint Programme on AIDS ART Anti-retroviral treatment ARV Anti-retroviral (medicines) PLHIV People Living with HIV PMTCT Prevention of Mother to Child Transmission HCT HIV counselling and testing HC Health Centre UCAEM Uganda Coalition for Access to Essential Medicines HAI Health Action International HEPS Coalition for Health Promotion and Social Development MOH Ministry of Health WHO World Health Organisation

iv TABLE OF CONTENTS

Acknowledgement ...... ii Foreword ...... iii Abbreviations and acronyms ...... iv Executive summary ...... vii

1. BACKGROUND ...... 1 1.1 Status of HIV and TB treatment ...... 1 1.2 Rationale and objectives of the survey ...... 2

2. METHODOLOGY ...... 4 2.1 Design ...... 4 2.2 Study population, sample size, selection criteria ...... 4 2.3 Study tools ...... 5 2.4 Medicines list ...... 6 2.5 Personnel ...... 7 2.6 Data Collection , validation, entry, analysis and management ...... 7 2.7 Limitations of the study ...... 7 2.8 Ethical considerations ...... 7

3. DISCUSSION OF FINDINGS ...... 8 3.1 Availability of ARVs ...... 8

3.1.2 Comparison of availability of First line treatment ARVs in 3.1.1 urbanAvailability Vs. rural ARVs facilities for first ...... line treatment ...... 98

3.1.4 Second line and third line adult ARVs ...... 11 3.1.53.1.3 AvailabilityTrends in availability comparison of firstof adult line second ARVs in line the ARVs public in sector urban .. 10 and rural facilities ...... 12

3.1.7 Second line and third line paediatric ARV treatment ...... 14 3.1.83.1.6 ARVsAvailability for prevention of first line of mother-to-childARVs for children HIV ...... transmission .... 1413

3.2 Availability of medicines for TB and other opportunistic infections 15 3.2.1 Medicines for treatment of TB ...... 15 3.2.2 Availability comparison of TB medicines in urban and rural facilities ...... 16 3.2.3 Medicines for treatment of other opportunistic infections ... 17

3.3 Availability of essential laboratory supplies and services ...... 18 3.3.1 Availability of HIV test kits ...... 18 3.3.2 Availability of laboratory services ...... 18

v 3.4 Logistics management ...... 19 3.4.1 Human resource capacities ...... 19

3.4.43.4.2 ExpiredManagement medicines information at health system facilities ...... 2120 3.4.53.4.3 Stock-outsSupply system ...... 2120

4. CONCLUSIONS AND RECOMMENDATIONS ...... 22 4.1 Conclusions ...... 22 4.2 Recommendations ...... 23

REFERENCES ...... 24 ANNEX I: Availability of ARVs ...... 25 ANNEX II: List of health facilities surveyed ...... 27

vi EXECUTIVE SUMMARY

Introduction

An estimated 162,232 Ugandans living with HIV were newly enrolled on antiretroviral therapy (ART) in the 12-month period to 30 September 2013, bringing total active enrolment Progressto 570,373. Report On the highlights basis of athe gap latest in the treatment retention guidelines of ART clients. from WorldIn addition, Health equity Organisation is yet to be(WHO), achieved access in standsaccess, atwith only children 40% of andeligible adolescents people. The being 2013 particularly HIV and AIDS disadvantaged. Uganda Country

HEPS Uganda, through Uganda Coalition for Access to Essential Medicine (UCAEM), has undertaken this survey to assess progress and identify gaps in access to HIV and TB treatment as well as in the logistics management of HIV and TB medicines, and diagnostics. It is a follow up of three earlier surveys that have been conducted since 2009. facilities accredited by Ministry of Health to provide ART in in four regions of Uganda (Central, Eastern,The survey Western, was conducted and Northern). in 118 Apublic, basket private of 67 essentialand private-not-for-profit medicines for tuberculosis (PNFP) health and

RARTesults was surveyed: 57 ARVs and 10 anti-tuberculars.

• Of the 57 medicine formulations assessed by the survey, a total of 14 medicines were not found in any of the facilities surveyed. Most of the medicines that were not found in the surveyed facilities were monotherapies. This suggests that patients are receiving combination therapies, which reduces the pill burden and hence increasing chances of adherence.

• The triple combination therapy of Zidovudine+Lamivudine+Nevirapine was the most

atavailable one third medicine, of treatment found sites in 69% which of indicates public facilities, that universal 70% of access private to facilitiestreatment and is still67% a of challenge. mission facilities. Hence, even the most available medicine was not available

• First line ARVs were more available in urban facilities compared to rural facilities.

the public sector. The difference was most pronounced in the private sector and least pronounced in • remained relatively stable over the last six years but on the day of data collection for thisAvailability survey, one of in first three line facilities combination did not have Zidovudine+Lamivudine+Nevirapine this key medicine in stock at all. has

• Availability of double combination Tenofovir+Lamivudine has grown from complete

that the highly toxic combination of Lamivudine+ Nevarapine + Stavudine (commonly knownunavailability as Triomune) in 2011 has to phased62% of out facilities completely in this as survey. it was notAt thefound same, at any results treatment show site.

vii • The most available adult second line medicines were the combinations

but overall, availability of second line and third line medicines was lower than that of Atazanavir+Ritonavir 300mg+100mg and Lopinavir+Ritonavir 200mg+50mg tablet,

• firstAvailability line medicines. of medicines for children remains was very poor. The only triple combination medicine available Lamivudine+Nevirapine+Stavudine was in less

facilities. than 3% of public facilities; in none of the private facilities; and only 8% of mission • The most available second line combination medicine for children was Lopinavir +

Ritonavir cap 100mg+25mg, which was available in 51% of public facilities, 23% of private facilities and 17% of mission facilities. Abacavir 60mg tablet was only found in the public sector (26%). Third line medicines were only available in the private • sector (8%).

On eMTCT medicines, the preferred first line treatment for pregnant mothers, Tenofovir+ Lamivudine+ Efavirenz 300mg+300mg+300mg, was available in only • 26%Medicines of public for TBfacilities; treatment 62 of initiation private facilities phase (Rifampicin/ and 50% of missionIsoniazid/ facilities. Pyrazinamide/

Ethambutol tab/cap 150mg/75mg/400mg/275mg) were the most available TB medicine, found in 81% of facilities in the public sector, in 77% of facilities in the • private sector, and in 60% of the facilities in the mission sector. medicines for treatment of opportunistic infections in PLHIV, were most available in theCotrimoxazole mission sector 480mg/960mg and lowest inand private Fluconazole sector. All200mg, mission two facilities of the most reached important in this

• survey had Cotrimoxazole tab 480mg.

ofThe other most kinds available of diagnostic HIV diagnostic kits – kitsStatpack were andDetermine, Unigold which – was was lower. available in 90% of public facilities, 94% of private facilities, and in 95% of mission facilities. Availability •

In comparison with results from the 2011 survey, the availability of CD4 cell count chestincreased x-ray to remained 75% (from low 13% while in that 2011), of ZN renal sputum function smear tests tests (from reduced. 18% in 2011) to 57%, and liver function tests (from 11% in 2011) to 44%. However, availability of •

Stock cards were available in 92% of the facilities reporting. Nine facilities (8%), of • which five were public sector facilities, did not have any stock cards. facilities that responded to the question. Eight of the above facilities were from the publicConsumption sector. record books/dispensing logs were not available in 19 of 115 (17%)

• premises on the day of the survey. This proportion was lower than the proportion There were 49 facilities (50%) that reported to have some expired medicines on their

• registeredSixty two per in the cent 2011 of facilities survey (61%).reported to have ever experienced a stock out of ARVs

and only 43% of these could have replenishment within a week after a stock out but viii 28% took between one to three months. 1. baCKGROUND

1.1 status of HIV and TB treatment UNAIDS estimates that 35 million people were living with HIV in the world at the end the countriesof 2013. Thewith vast the majorityheaviest ofburden these ofpeople HIV; –it aboutis among 24.7 the million three or top 70% countries – were –in along sub- Saharan Africa (UNAIDS 2014). And within the sub-Saharan Africa region, Uganda is among

Nigeria and South Africa, that account for almost half (48%) of all new infections in the region (UNAIDS 2014).

The 2011 Uganda AIDS Indicator Survey reported HIV prevalence among adults aged between 15 and 49 years at a national average of 7.3%. The latest estimates by Ministry of Health HIV/AIDS(MOH) indicate remains a total a huge of 1,618,233 national and people global living public with health HIV in challenge. 2013, comprising of 1,441,285 adults and 176,948 children below 15 years (UAC 2014). These figures demonstrate that Yet, there are signs that the HIV response is beginning to gain ground on the pandemic.

UNAIDS (2014) has reported the lowest levels of new HIV infections this century, at 2.1 million. In the last three years alone new HIV infections have fallen by 13%, and AIDS- related deaths are at their lowest since the peak in 2005, having declined by 35%. New HIV infections among children have fallen by 58% since 2001 and dropped below 200,000 for Atthe the first national time in level,the 21 Ministry most-affected of Health countries estimates in basedAfrica, onwhich Spectrum include projections Uganda. indicate remainthat AIDS-related high, the trend deaths over have the steadily last three declined years sincealso shows 2011, froman impressive 72,928 in decline, 2011 to from 70,262 an in 2012, and then to 61,298 in 2013 (UAC 2014). And even though the country’s infections a remarkable reduction in new infections among children has also been achieved; from estimated 162,294 in 2011 and 154,589 in 2012, to 140,908 in 2013. Over the same period,

27,660 in 2011; to 15,411 in 2012, and to 9,629 in 2013. toUNAIDS the life-saving (2014) attributes medicines, the bringing latest gains the globalagainst number the HIV of pandemic people accessing to progress anti-retroviral in access to HIV treatment over the recent years. In 2013, an additional 2.3 million people gained access therapy (ART) to nearly 13 million by the end of 2013 (UNAIDS 2014). In sub-Saharan Africa, almost 90% of people who tested positive for HIV went on to access ART, and research shows that up to 76% of people on ART in the region have achieved viral suppression, whereby they are unlikely to transmit the virus to their sexual partners (UNAIDS 2014).

In Uganda, an estimated 570,373 people were active on HIV treatment as of 30 September Option2013, withB+ programme 162,232 (or has 28%) been scaled of them up beingrapidly, enrolled and as part in the of this 12-month scale-up, period the number October of accredited2012-September ART sites 2013 has alone. catapulted. The elimination of Mother-to-Child Transmission (eMTCT)

1 The eMTCT programme officially went country-wide in October 2012 and by the end of that 1,478year, the by numberthe end ofof accreditedthe year. Consequently, ART sites reached the eMTCT 532, from programme 407 a year reached earlier. an In estimated2013, the 1,726,177increase was mothers phenomenal: of known the and number documented of sites HIV reached sero-status 1,073 and by providedthe end of ARVs June for and eMTCT then to 71.7% of the positive mothers (123,754 or 7.2%) of women reached by the programme Thein 2013 past (UAC few 2014). years of progress in the treatment response, also came with changes on the policy front: the National AIDS Policy 2010; the National Strategic Plan (NSP) 2011- which2015; theincluded National targeted Prevention interventions Strategy for (NPS) key populations. 2011-2015, and the Health Sector Strategic Investment Plan (HSSIP) 2011-2015 have helped strengthen the overall national response,

1.2 rationale and objectives of the survey E millionven ofthen, the thereestimated are still 35 milliongaps in peoplethe treatment living with effort. HIV Accessglobally to dotesting not knowand counselling, their HIV- positivewhich status. is key At tothe accessing country level, treatment, the proportion is still limited. of adults UNAIDS aged 15-49 (2014) who reports have ever that been 19 whotested are for of HIV unknown and received HIV-positive the results status increased who therefore, from 12.7% cannot t in access 2004/05 treatment. to 65.8% in 2011 among women; and from 10.8% to 44.9% for men. But this still leaves out a lot of people of HIV-exposed infants (born to HIV-positive mothers) did not receive ARVs for eMTCT in On eMTCT, close to one third of HIV-positive mothers (28.3%) and close to two thirds (63.3%)

2013, largely due to low institutional delivery, estimated by the Health Sector Strategic and AndInvestment while overallPlan (HSSIP) ART enrolment mid-term review has tremendously at 41% (UAC increased 2014). over the past few years, reaching 69.4% of eligible people by the end of September 2013 on the basis of the 2010 WHO guidelines for ART, this proportion falls to a mere 40% (UAC 2014) when viewed on HIVthe basis and AIDS of latest Uganda (2013) Country WHO Progressguidelines Report for ART, also meaning highlights that a moregap in than the halfretention of Ugandans of ART clients.who needed In a cohort HIV treatment of clients, by retention the end ofon September ART at 12 months2013 were after not initiation receiving was it. estimatedThe 2013

Inat 83% addition, in September equity is 2013. yet to be achieved in access to HIV treatment, with children and adolescent being particularly disadvantaged. On the basis of the 2010 WHO ART guidelines (350 CD4 T-cells/ul and below), adult coverage of ART was estimated at 73% at the end of September 2013, which was closer to the 2015 national target of 80% than the coverage proportion for children (44%) was.

2 And when analysed on the basis of the 2013 WHO ART guidelines (500 CD4 T-cells/ul), the gap between adult ART access and ART access among children remains wide, that is 45% access rate for adults and 30% for children. Retention on ART was also higher for adults in An2013 assessment (84%), compared of adolescent to children access (73%) to HIV (UACtesting, 2014). care and treatment services conducted in

1,020 facilities in 2013 revealed that only 17% of adolescents living with HIV were enrolled in care; and that just 29% of the estimated ART-eligible adolescents were receiving ART (UAC 2014). While access to cotrimoxazole prophylaxis among adolescents was relatively Somegood (80%), of the only barriers 48% tohad access accessed to ART CD4 havetesting. been documented as limited access to HIV counselling and testing, shortage and stock-outs of medicines, HIV-related stigma at the community and healthcare levels, over-subscribed service points, among other factors.

In the survey of accessibility to, and management of, HIV and TB medicines and diagnostics, that some accredited facilities experienced stock-outs; the policy of phasing out Stavudine conducted by Uganda Coalition for Access to Essential Medicines (UCAEM) in 2011, found shortage of ARVs for second-line treatment, for infants and children, for prevention of mother-to-child40mg due to its high transmission side-effect of profileHIV (PMTCT), was yet toand be forfully AIDS-TB implemented; co-management; there was anand overall that there was a shortage of HIV prophylaxis medicines.

HEPS Uganda, through UCAEM, has undertaken this survey to assess progress and identify gaps that need to be closed in order to sustain the new momentum against the HIV epidemic.

1) To assess the availability of key HIV and TB medicines and diagnostics in Uganda. The2) specific To identify objectives challenges of this to survey accessibility were: of key HIV and TB medicines and diagnostics in Uganda; 3) To examine the logistics management of HIV and TB medicines, and diagnostics.

3 2. METHODOLOGY

2.1 design

he study used a quantitative approach. The survey was conducted using a standardized Tmethodology which has been co-developed by WHO and HAI1. The survey utilizes quantitative approaches to describe availability and prices of medicines and logistics management. (See annex section for the data collection tools).

2.2 study population, sample size, selection criteria

he survey was conducted in four regions of Uganda (Central, Eastern, Western, Tand Northern). The four regions were chosen as a representation of the diversity in epidemiological and geographical characteristics of the country.

The survey was conducted in three sectors: public, private (PFP) and mission (NGO/PNFP).

dataAll three points contribute for analysis. a significant2 proportion of health services in the country. The standard WHO / HAI methodology recommends 30 outlets per sector for a survey to achieve enough In each of the four regions, the main regional hospitals, district hospitals and sub-district health facilities were selected to represent the public sector. Private pharmacies were selected purposively within 5km of each of the selected public facilities while using the

official list of registered pharmacies fromSee annex the Uganda 1 for list National of facilities Drug). Authority. Urban areas were described as towns with a population of more than 50,000 and rural areas are at least 10 km away from the urban centres. ( characteristics to public sector equivalents (e.g mission hospitals of similar size and capacity toThe the mission regional, facilities district were and sub-districtpurposely selected, hospitals specifically in the region). targeting This was facilities to ensure with that similar the data collectors get reliable access.

Data were collected from a total 118 health facilities accredited to provide ART, with sectors represented according to their relative sizes. Out of the total facilities reached, 61 were accredited ART facilities was used to select the facilities. public, 17 private and 40 mission (private-not-for-profit, PNFP). The official list of MOH

1 www.haiweb.org/medicineprices 2 It is noted that a number of validation studies (in addition to the 9 pilot studies) were done during the original process of methodology development. The most important validation was on the sampling frame where it was found that sampling more regions, and those in areas greater than one days car travel from the capital, and in each area from more outlets a greater distance from the main hospital produced the same results as using the standard sampling frame. The adequacy of collecting data on just the originator brand and lowest priced generic equivalent was also studied – again it was found there was no significant difference in the results. The volatility of MSH prices (used as an external bench-mark) have also been studied and little volatility has been found. A paper on validation has been published, and is cited as Madden JM, Meza E, Ewen M, Laing RO, Stephens P, Ross-Degnan D. Measuring medicine prices in Peru: validation of key aspects of WHO/HAI survey methodology. Rev Panam Salud Publica. 010;27 (4):291–9. 4 Table 1: Facilities surveyed

Sector Location Total Urban Rural Public 28 33 61 Private 14 3 17 Mission 22 18 40 Total 64 54 118

2.3 study tools

standard WHO/HAI tool for assessing medicine availability was used to collect and A analyze relevant data on AIDS/TB medicines and diagnostic from selected ART centres/ facilities. Key informant guide interviews and focus group discussions were used to document case studies about access to HIV/AIDS treatment among ART care service providers and HIV infected individuals.

5 2.4 Medicines list anti-tuberculars. A basket of 67 essential medicines for tuberculosis and ART was surveyed: 57 ARVs and 10 Table 2: List of medicines surveyed Isoniazid (INH) 300mg tab/cap Lamivudine + Stavudine TABLET 150mg + 40mg

Rifampicin 150mg tab/cap Lamivudine & Zidovudine Tablet 150mg+300mg Ethambutol (ETH) 400mg tab/cap Lamivudine, Nevirapine & Stavudine Tablet 150mg +200mg +30mg Pyrazinamide (PZA) 400mg tab/cap Lamivudine, Nevirapine & Stavudine Tablet 150mg +200mg +40mg Isoniazid/ Ethambutol 150mg/ 400mg tab/cap Lamivudine, Zidovudine & Nevirapine Tablet 150mg + 300mg + 200mg Rifampicin/ Isoniazid tab/cap 150mg/75mg Lamivudine/Stavudine + Efavirenz 150/40mg & 600mg Rifampicin/ Isoniazid tab 60mg/ 30mg Lamivudine/stavudine + efavirenz tablet 150/30mg & 600mg Rifampicin/ Isoniazid tab/cap 300mg/150mg Lamuvidine/ zidovudine + efavirenz tablets 150/300+600mg Rifampicin/Isoniazid/Pyrazinamide tab 60mg/30mg/150mg Lopinavir + ritonavir capsule 133.3+33.3mg Rifampicin/Isoniazid/Ethambutol tab/cap 300mg/ Lopinavir/ritonavir tablet 200/50 mg 150mg/400mg Rifampicin/Isoniazid/Pyrazinamide/Ethambutol tab/cap Lopinavir + ritonavir oral solution 80 + 20 mg 150mg/75mg/400mg/275mg Streptomycin inj. 1g Lopinavir + lopinavir oral solution 80 + 20 mg Cotrimoxazole tab 480mg Nelfinavir mesylate tablet 250mg Fluconazole tab 200mg Nevirapine tablet 200mg Abacavir Tablet 300mg Nevirapine Oral Suspension 50mg/5ml ABACAVIR + LAMIVUDINE TABLET 600+300mg mg Ritonavir oral solution 80mg/ml Abacavir Sulphate + Lamivudine + Zidovudine Tablet Ritonavir capsule 100mg 300mg + 150mg + 300mg Atazanavir So4 Capsule 150mg Stavudine capsule 15mg Atazanavir So4 Capsule 200mg Stavudine capsule 20mg Didanosine Capsule 25mg Stavudine capsule 30mg Didanosine Tablet 50mg Stavudine capsule 40mg Didanosine Tablet 100mg Tenofovir disoproxil fumarate tablet 300mg Didanosine Tablet 150mg Zidovudine capsule 100mg Didanosine tablet 200mg Zidovudine tablet 300mg Didanosine capsule 250mg Zidovudine oral solution 10mg/ml Didanosine capsule 400mg Tenofovir/lamuvidine+ Nevirapine 300mg/300mg+150mg Didanosine power for oral solution 2g/100ml Tenofivir/Lamuvidine+ Efavirenz 300mg/300mg+600mg Efavirenz capsule 50mg Zidovudine/Lamivudine 60mg/30mg Efavirenz tablet 600mg Abacavir/Lamivudine 60mg/30mg Indinavir capsule 400mg Lamivudine Oral Solution 10mg/Ml Lamivudine tablet 150mg Lamivudine + Stavudine TABLET 150mg + 30mg

Lamivudine tablet 300mg LAMIVUDINE ORAL SOLUTION 50mg/5ml

6 2.5 personnel

The survey team consisted of a survey manager, a pharmacist, who was responsible for setting up and conducting the survey, supervising the data collectors, analyzing the data, and writing the report. The data were collected by 12 research assistants, three per region. For each region, the team of data collectors consisted of one pharmacist or pharmaceutical technologist and one social scientist/ public health professional.

An Advisory Group guided the survey process through supporting the survey manager in ofsetting MoH upPharmacy and conducting Division, the AIDS survey; Control providing Programme, feedback and onMedical the survey Access findings Uganda and Limited draft (MAUL).report. The advisory group for this survey was composed of a total of five representatives

2.6 data Collection , validation, entry, analysis and management

survey manager. Data collectors were provided with introduction letters from Ministry of Before field data collection, survey personnel participated in training/briefing led by the (DHO) before starting data collection. The collected data were delivered to the survey managerHealth. At at the HEPS district, Secretariat data collectors in Kampala. introduced themselves to the District Health Officer

The survey manager checked all the data collection forms for completeness and accuracy. Questionable entries were validated by contacting either the data collector or the health facility or both.

Data analysis was completed using the customized WHO/ HAI Excel workbook, which was used to generate tables, graphs were generated for report.

2.7 Limitations of the study

Although the four regions in which data were collected were selected as a representative cross section of the country, the sampling procedure does not take into account differences in prevalence of HIV across different regions of the country. in addition, the study did not explore the cost and prices of the medicines, which may also affect accessibility. 2.8 ethical considerations information on availability of the medicines in the facilities. The information obtained did notThere relate were to noART ethical clients issues or their of records, patient and clinical hence confidentiality ethical clearance as the was survey not considered collected necessary.

7 3. disCUSSION OF FINDINGS

3.1 aVailability of ARVs

3.1.1 Availability ARVs for first line treatment Of the 57 medicine formulations assessed by the survey, a total of 14 medicines were not found in any of the facilities surveyed. Most of the medicines that were not found in the surveyed facilities were monotherapies.

The triple combination therapy of Zidovudine+Lamivudine+Nevirapine was the most combination,available medicine, which foundposes anin 69%access of challenge public facilities, to this key 70% medicine of private for facilitiesHIV clients and receiving 67% of treatmentmission facilities. at these Put sites. differently however, at least 30% of the facilities did not have this

The double medicine combination of Zidovudine+Lamivudine was available in 69% of public facilities, 54% of private facilities and 67% of mission facilities. The double medicine combination of Tenofovir+Lamivudine was found in 62% of public facilities, 70% of private facilities and 50% of mission facilities. programme.Preferred first line treatment Tenofovir+Lamivudine+Efavirenz for pregnant mothers was found in 26% of facilities which may impact on the implementation of the eMTCT Unlike previous years, the triple combination therapy of Lamivudine+ Nevarapine + Stavudine

(commonly known as Triomune) which was phased out by MoH due to toxicity profile of Stavudine was not found in public sector. More findings are summarised in the table below.

8 Table 3: Availability of adult first line ARVs Public Private Mission Medicine Overall Urban Rural Overall Urban Rural Overall Urban Rural % % % % % % % % %

Lamivudine + Stavudine tab 150mg+ 0% 0% 0% 8% 10% 0% 0% 0% 0% 30mg Lamivudine + Stavudine tab 150mg+ 0% 0% 0% 15% 20% 0% 8% 25% 0% 40mg Lamivudine +Zidovudine tab 69% 75% 65% 54% 60% 33% 67% 75% 63% 150mg+300mg Lamivudine + Nevarapine + 0% 0% 0% 0% 0% 0% 0% 0% 0% Stavudine tab 150mg+200mg+30mg Lamivudine, Nevirapine&Stavudine 0% 0% 0% 0% 0% 0% 0% 0% 0% tab 150mg+200mg+40mg Lamivudine, Nevirapine&Stavudine 3% 0% 4% 0% 0% 0% 8% 0% 13% tab 30mg+50mg+6mg Lamivudine, Zidovudine&Nevirapine 69% 69% 70% 69% 80% 33% 67% 75% 63% tab 150mg+300mg+200mg Lamivudine + Stavudine + Efavirenz 0% 0% 0% 0% 0% 0% 0% 0% 0% 150mg + 40mg + 600mg Lamivudine + Stavudine + Efavirenz 3% 6% 0% 0% 0% 0% 0% 0% 0% 150mg + 30mg + 600mg Lamivudine + Zidovudine + Efavirenz 0% 0% 0% 0% 0% 0% 0% 0% 0% 150mg + 300mg + 600mg Tenofovir disoproxil fumarate tab 0% 0% 0% 0% 0% 0% 0% 0% 0% 300mg Tenofovir/Emtricitabine tablet 300 8% 6% 9% 15% 20% 0% 8% 0% 13% mg/200 mg Tenofovir/Lamivudine/Efivarenz tablet 26% 31% 22% 62% 70% 33% 50% 25% 63% 300mg/300mg/300/mg Tenofovir/Lamivudine tablet 300 62% 63% 61% 62% 70% 33% 67% 75% 63% mg/300 mg Zidovudine tab 300mg 44% 50% 39% 15% 20% 0% 17% 50% 0%

• Most of the medicines that were not found in the surveyed facilities were monotherapies. This suggests that patients are receiving combination therapies, which reduces the pill burden and hence increasing chances of adherence.

• Even the most available medicine, the triple combination therapy of Zidovudine +Lamivudine+Nevirapine was not available in all facilities which indicates that universal access to treatment is still a challenge.

3.1.2 Comparison of availability of First line treatment ARVs in urban Vs. rural facilities First line ARVs were more available in urban facilities compared to rural facilities. The

In the private sector, the combination Zidovudine+Lamivudine+Nevirapine for instance, was difference was most pronounced in the private sector and least pronounced in the public sector. available in up to 80% of the urban facilities and in only 33% of rural facilities.

9 Figure 1: Comparison of urban vs. rural availability of two key first line ARV combinations by sector

With the combinations Zidovudine+Lamivudine+Nevirapine and Tenofovir+Lamivudine available in only one third of rural private facilities, access to HIV treatment remains uneven. The low availability of ARVs in rural private facilities is an indicator of skewed access to HIV treatment in this sector, and calls for further investigation of the reasons behind this phenomenon.

3.1.3 Trends in availability of first line ARVs in the public sector relatively stable over the last six years but on the day of data collection for this survey, one inAvailability three facilities of first did linenot have combination this key medicine Zidovudine+Lamivudine+Nevirapine in stock at all. has remained

Availability of double combination Tenofovir+Lamivudine has grown from complete

Theunavailability availability in of 2011 the combination to 62% of facilities Lamivudine+ in this survey.Nevarapine + Stavudine (commonly known beforeas Triomune) phasing has out diminished completely over in this time, survey. from 80% of facilities in February 2008, to 41% in September 2008, to 21% facilities in October 2010, to 5% of facilities in December 2011,

10 Figure 2: Trends in availability of First line ARVs in Public Sector

• The phasing out of the toxic combination of Triomune is a positive development that means ART clients are receiving safer and more tolerable medications.

3.1.4 Second line and third line adult ARVs The most available adult second line medicines were the combinations Atazanavir+Ritonavir

300mg+100mg and Lopinavir+Ritonavir 200mg+50mg tablet. Atazanavir+Ritonavir 300mg+100mg was found in 64% of public facilities, 38% of private facilities and 50% of mission facilities. Lopinavir+Ritonavir 200mg+50mg tablet was available in 59% of public Availabilityfacilities, 69% of theof private surveyed facilities second and line 52% and of third mission line ARVsfacilities. are summarised in table below.

11 Table 4: Availability of adult second line and third line ARVs Medicine Public Private Mission Overall Urban Rural Overall Urban Rural Overall Urban Rural % % % % % % % % % Abacavir tab 300mg 38% 63% 22% 8% 10% 0% 17% 0% 25% Abacavir + Lamivudine tab 13% 19% 9% 23% 30% 0% 50% 50% 50% 300mg + 600 mg Atazanavir So4 Cap 150mg 0% 0% 0% 0% 0% 0% 8% 25% 0% Atazanavir So4 Cap 300mg 0% 0% 0% 8% 10% 0% 8% 0% 13% Atazanavir/Ritonavir 300/100 64% 81% 52% 38% 40% 33% 50% 50% 50% mg Didanosine tab 200mg 0% 0% 0% 0% 0% 0% 0% 0% 0% Didanosine cap 250mg 0% 0% 0% 0% 0% 0% 8% 25% 0% Didanosine cap 400mg 0% 0% 0% 0% 0% 0% 8% 25% 0% Duranavir 300 mg 0% 0% 0% 0% 0% 0% 0% 0% 0% Etravine 100 mg 0% 0% 0% 8% 10% 0% 0% 0% 0% Indinavir capsule 400 mg 0% 0% 0% 0% 0% 0% 0% 0% 0% Lopinavir + ritonavir cap 100 51% 63% 43% 23% 20% 33% 17% 0% 25% mg/25 mg Lopinavir/ritonavir tab 59% 69% 52% 69% 80% 33% 58% 75% 50% 200/50mg Nelfinavir mesylate tab 250 3% 6% 0% 0% 0% 0% 0% 0% 0% mg Raltergravir 400 mg 3% 6% 0% 15% 20% 0% 0% 0% 0% Ritonavir Capsule 100 mg 5% 6% 4% 15% 20% 0% 8% 0% 13% Saquinavir 500 mg 3% 6% 0% 8% 10% 0% 0% 0% 0%

• The availability of second line and third line ARVs was relatively low for key medicines, and some facilities did not have second line medicines at all.

3.1.5 Availability comparison of adult second line ARVs in urban and rural facilities of second line treatment between urban and rural and this was highly marked in the private The comparison of availability of second line treatment showed a big difference in availability sector. For instance, in the private sector, Lopinavir+Ritonavir 200mg+50mg, which was found in 80% of urban facilities, was available in only 33% of rural facilities.

12 Figure 3: Comparison of urban vs. rural availability of second line ARVs by sector

While availability of second line medicines is overall lower in rural facilities, rural private sector. facilities are worse off, which reflects greater inequality in access to treatment in the private 3.1.6 Availability of first line ARVs for children Availability of medicines for children remains was very poor. The only triple combination medicine available Lamivudine+Nevirapine+Stavudine was in less than 3% of public facilities; in none of the private facilities; and only 8% of mission facilities. The most available ARV is Nevirapine oral suspension 50mg/5ml, which was available in 49% of public facilities, 38% Tableof private 5: Availability facilities, and of infirst 58% line of paediatric mission facilities. ARVs across sectors PUBLIC PRIVATE MISSION Medicine Overall Urban Rural Overall Urban Rural Overall Urban Rural % % % % % % % % % Efavirenz tab 50mg 3% 0% 4% 8% 10% 0% 0% 0% 0% Efavirenz tab 100 mg 10% 0% 17% 0% 0% 0% 8% 25% 0% Lamivudine oral solution 50mg/5ml 0% 0% 0% 0% 0% 0% 0% 0% 0% Lamivudine oral solution 10mg/ml 0% 0% 0% 0% 0% 0% 8% 25% 0% Lamivudine, Nevirapine&Stavudine 0% 0% 0% 0% 0% 0% 8% 0% 13% tab 60mg+100mg+12mg Lamivudine, Nevirapine&Stavudine 3% 0% 4% 0% 0% 0% 8% 0% 13% tab 30mg+50mg+6mg Nevirapine tab 50mg 28% 31% 26% 0% 0% 0% 42% 25% 50% Nevirapine oral suspension 49% 50% 48% 38% 40% 33% 58% 75% 50% 50mg/5ml Stavudine cap 15mg 0% 0% 0% 8% 10% 0% 0% 0% 0% Stavudine cap 20mg 0% 0% 0% 0% 0% 0% 0% 0% 0% Zidovudine cap 100mg 3% 0% 4% 0% 0% 0% 0% 0% 0% Zidovudine oral solution 10mg/ml 5% 13% 0% 0% 0% 0% 0% 0% 0%

13 Management of HIV in children remains a major gap in the national response. Paediatric ARVs have remained poorly available over the years, which undermines the eMTCT programme as well as access to HIV treatment by children.

3.1.7 Second line and third line paediatric ARV treatment The most available second line combination medicine was Lopinavir + Ritonavir cap

100mg+25mg, which was available in 51% of public facilities, 23% of private facilities and 17% of mission facilities. Abacavir 60mg tablet was only found in the public sector (26%). TableThird line6: Availability medicines wereof children only available second inand the third private line sector ARV treatment (8%). across sectors Medicine Public Private Mission Overall Urban Rural Overall Urban Rural Overall Urban Rural % % % % % % % % %

Abacavir Tab 60 mg 26% 25% 26% 0% 0% 0% 0% 0% 0% Atazanavir So4 Cap 150mg 0% 0% 0% 0% 0% 0% 8% 25% 0% Didanosine cap 25 mg 0% 0% 0% 0% 0% 0% 0% 0% 0% Didanosine tab 50mg 0% 0% 0% 0% 0% 0% 8% 25% 0% Didanosine tab 100mg 0% 0% 0% 0% 0% 0% 8% 25% 0% Didanosine powder for oral 0% 0% 0% 0% 0% 0% 8% 25% 0% solution 2g/100ml Etravine 100 mg 0% 0% 0% 8% 10% 0% 0% 0% 0% Lopinavir + ritonavir cap 100 51% 63% 43% 23% 20% 33% 17% 0% 25% mg/25 mg Lopinavir + lopinavir oral 15% 19% 13% 8% 10% 0% 8% 0% 13% solution 80 + 20 mg Ritonavir oral solution 80mg/ml 0% 0% 0% 0% 0% 0% 0% 0% 0% Ritonavir Capsule 100 mg 5% 6% 4% 15% 20% 0% 8% 0% 13%

HIV-positive children have not been adequately been catered for in terms of second line be leading to high treatment default rates and hence requiring a higher availability of medicines as well. It is possible that low availability of first line paediatric ARVs could eMTCTsecond programme.line drugs. Availability of both first line and second line paediatric ARVs needs to be improved for better management of HIV in young ART clients and for a more effective 3.1.8 ARVs for prevention of mother-to-child HIV transmission Ministry of Health has rolled out Option B+ for mothers across the country, meaning that all

HIV-positive expectant mothers are started in ART for life. The preferred first line treatment for pregnant mothers, Tenofovir+Lamivudine+Efavirenz 300mg+300mg+300mg, was poorly available particularly in the public sector. This combination was available in only 26% of public facilities; 62 of private facilities and 50% of mission facilities. low, even though it was the most available paediatric ARV. This medicine was available in Availability of Nevirapine oral suspension 50mg/5ml used in HIV-exposed infants was overall

49% of public facilities, 38% of private facilities and 58% of mission facilities. 14 Transmission of HIV from mother to child is one form of infection that can be eliminated, as the experience of other countries has shown. The success of the eMTCT programme in butUganda in overall will require provision major of otherimprovements ARVs and in paediatric the availability ARVs. of specific medicines such as the combination Tenofovir+Lamivudine+Efavirenz and Nevirapine oral suspension 50mg/5ml,

3.2 aVAILABILITY OF MEDICINES FOR TB AND OTHER OPPORTUNISTIC INFECTIONS 3.2.1 Medicines for treatment of TB The appropriate management of TB is important because it is a common opportunistic infection for people living with HIV (PLHIV) and one of the leading causes of death among PLHIV. Medicines for TB treatment initiation phase (Rifampicin/Isoniazid/Pyrazinamide/ facilitiesEthambutol in the tab/cap mission 150mg/75mg/400mg/275mg) sector. The only other medicine were that the was most fairly available, available in was 81% the of facilities in the public sector, in 77% of facilities in the private sector, and in 60% of the were poorly available, particularly mono-therapies. duo-combination Isoniazid/Ethambutol 150mg/400mg tab/cap. Otherwise, other anti-TBs Table 7: Availability of anti- TB medicines across sectors Public Private Mission Medicine Overall Urban Rural Overall Urban Rural Overall Urban Rural % % % % % % % % %

Isoniazid 300mg tab/cap 3% 7% 0% 8% 10% 0% 10% 25% 0% Rifampicin 150mg tab/cap 3% 7% 0% 8% 10% 0% 0% 0% 0% Ethambutol 400mg tab/cap 14% 14% 14% 8% 10% 0% 10% 25% 0% Pyrazinamide 400mg tab/cap 6% 14% 0% 0% 0% 0% 10% 25% 0% Isoniazid/Ethambutol 150mg/400mg 81% 79% 82% 62% 80% 0% 70% 75% 67% tab/cap Rifampicin/Isoniazid tab/cap 0% 0% 0% 8% 10% 0% 0% 0% 0% 150mg/75mg Rifampicin/Isoniazid tab/cap 6% 14% 0% 8% 10% 0% 30% 0% 50% 300mg/150mg Rifampicin/Isoniazid/ 81% 86% 77% 77% 90% 33% 60% 75% 50% Pyrazinamide/Ethambutol tab/cap 150mg/75mg/400mg/275mg

The fact that the combination Rifampicin/Isoniazid/Pyrazinamide/Ethambutol tab/cap available anti-TB is a positive development because it reduces reliance on monotherapies and150mg/75mg/400mg/275mg, their attendant heavy pill burden. used in the initiation stage of treatment, was the most

15 3.2.2 Availability comparison of TB medicines in urban and rural facilities Anti-TB medicines were generally more available in the urban areas compared to rural areas. The comparison in the public sector was almost even in both urban and rural facilities. Only one medicine Rifampicin/Isoniazid tab/cap 300mg/150mg was not available in mission urban facilities compared to 50% availability in mission rural facilities.

However, there was a marked difference in availability in the private sector: Rifampicin/ Isoniazid/Pyrazinamide/Ethambutol tab/cap 150mg/75mg/400mg/275mg was available in 90% urban and 33% in rural facilities. Rifampicin/Isoniazid tab/cap 300mg/150mg was available in 10% in urban and none of rural facilities, Isoniazid/Ethambutol 150mg/400mg tab/cap was available in 80% in urban and none of the rural facilities surveyed.

Figure 4: Comparison of availability of TB medicines in urban and rural facilities

• The poor availability of anti-TB medicines in rural private facilities poses equity challenges, given the high prevalence of HIV-TB co-infection among PLHIV across the country. The standard combination of anti-TB medicines should ideally be available in all facilities accredited to provide ART to promote access and adherence to treatment.

16 3.2.3 Medicines for treatment of other opportunistic infections for treatment of opportunistic infections in PLHIV, should ideally be available in all facilities atCotrimoxazole all times. Cotrimoxazole 480mg/960mg is used and inFluconazole primary prophylaxis 200mg, two against of the mostpneumocystis important pneumonia medicines (PCP) in immune-compromised individuals particularly PLHIV, who are at increased risk. It is also used for HIV prophylaxis for PLHIV awaiting enrolment on ART.

Fluconazole is an antifungal antibiotic used to prevent fungal infection in people with weak immune systems caused by cancer treatment, bone marrow transplant, or immune- compromising conditions like HIV. Fluconazole 200mg was most available in mission facilities (80%), followed by public facilities (58%) and then private facilities (40%). pneumonia and fungal infections respectively, need to be available in all accredited facilities toCotrimoxazole slow the pace 480mg/960mg at which HIV-positive and Fluconazole people progress 200mg to AIDS, are usedthe stage to preventwhere they or need treat ARVs. mission sector and lowest in private sector. All mission facilities reached in this survey had Availability of Cotrimoxazole 480mg/960mg and Fluconazole 200mg was highest in the

Cotrimoxazole tab 480mg. In private facilities, Cotrimoxazole tab 480mg was available in 69% of the facilities. Availability was at 67% in public facilities.

17 3.3 aVailability of essential laboratory supplies and services

3.3.1 availability of HIV test kits

ofThe diagnostic most available kits – HIVStatpack diagnostic and Unigold kits were – was Determine, lower. which was available in 90% of public facilities, 94% of private facilities, and in 95% of mission facilities. Availability of other kinds Rural private facilities, disadvantaged in most medicines, were impressive in diagnostics; all facilities had all three kinds of diagnostic kits surveyed – Determine, Statpack and Unigold.

Sector Medicine Public Private Mission Overall Urban Rural Overall Urban Rural Overall Urban Rural Determine 90% 93% 88% 94% 93% 100% 95% 91% Statpack 70% 68% 73% 82% 79% 100% 60% 50% Unigold 49% 46% 52% 65% 57% 100% 25% 18%

• The availability of all three kinds of HIV diagnostic kits in all rural private facilities is impressive. However, there is need to verify that availability of kits in rural private facilities, where HIV tests may be provided at a fee, is not as a result of low uptake of testing services. • • The relative differences in availability of Determine in comparison to other kinds of diagnostics is a concern as it may imply that some facilities may not be in position to provide HIV confirmatory and tie-breaker tests.

3.3.2 availability of laboratory services The survey assessed the availability of a range of tests conducted in monitoring the side equipmenteffects of ARVs,from thediagnosis previous of TB,survey. and PLH eligibility for antiretroviral therapy (ART), among other purposes. The findings indicate a tremendous improvement in availability of testing

In comparison with results from the 2011 survey, the availability of CD4 cell count increased to 75% (from 13% in 2011), renal function tests (from 18% in 2011) to 57%, and liver function tests (from 11% in 2011) to 44%. However, availability of chest x-ray remained low and reduced further from 32% in 2011 to 27% in this survey. Availability of ZN sputum smear tests reduced from 100% to 60% as is shown in table below.

18 Table 8: Availability of laboratory services in facilities Type of test Public Mission Private Total (n=118)

CD 4 Tests 48 30 10 88 Renal function tests 28 27 12 67 Liver function tests 22 19 11 52 Anemia 48 29 12 89 ZN Sputum smear 41 18 12 71 Chest X-ray 13 10 9 32

• For services not available at the facility, patients samples are either transferred to external laboratories (40% of 102 facilities) or patients are referred to other facilities (54%). In cases where referral facilities are far and few between, access to essential laboratory services may be a challenge to clients.

3.4 LOGISTICS MANAGEMENT

On aspects of logistics management, the survey explored the available human resource capacity and functionality of logistics management systems.

3.4.1 Human resource capacities

On the background of stores personnel , out of a total of 118 facilities surveyed, 23% of stores in-charges were either pharmacists or pharmacy technicians. However, 16% did not Tablehave health-related 9: Background qualifications. of stores personnel Designation Public Mission Private Total

Pharmacist 3 4 1 8 Pharmacy technician 10 6 3 19 Doctor 0 0 0 0 Clinical officer/medical assistant 4 4 1 9 Nurse 9 8 4 21 Nursing assistant (trained) 7 2 1 10 Other health professional 22 10 1 33 Other non-health 7 6 6 19 Total 62 40 17 119 training is required to ensure adequate medicines management. Given that majority of stores personnel did not have any medicines management qualification,

19 3.4.2 Management information system The availability of key logistics forms in keeping records was assessed: stock cards; requisition and issue vouchers; and consumption reports. These logistics forms are used to manage stock, determine quantities required to order, and prevent pilferage.

On availability of stock cards, 114 facilities responded to this question of which the stock sector facilities, did not have any stock cards. cards were available in 105 facilities (92%). Nine facilities (8%), of which five were public One hundred and nine facilities responded to the question on availability of requisition and issue vouchers and of these, six did not have the forms. Two facilities were in the public sector and three were in the private sector. that responded to the question. Eight of the above facilities were from the public sector. Consumption record books/dispensing logs were not available in 19 of 115 (17%) facilities medicinesOf the facilities respectively. that reported to have stock cards, all had stock cards for ARVs, but 27% and 24% of the reporting facilities did not have stock cards for HIV diagnostics and anti-TB Stores personnel were asked how they learned to complete the logistics forms. The responses were not mutually exclusive and some respondents cited more than one way. Just over half hadof the done respondents self-study. (58%) had learned to complete logistics forms through formal training; 44% reported to have received on-job training at their respective facilities; while some 9% • The overall findings indicate that although a high number of facilities reported to have tools for management of logistics, effort is required to improve logistics management for especially HIV diagnostics and anti-TB medicines.

3.4.3 Supply system for the supplies. For one quarter of the surveyed facilities, supply quantities are determined byMost a higher-level of the facilities facility. surveyed (74%) operate a pull system for supplies; they place orders

Table 10: Supply mode for ARVs at surveyed facilities Mode of supply Public Mission Private Total (n=113)

The facility determines its orders (pull 43 29 12 84 system) The higher facility determines facility order 16 9 4 29 (push system)

20 The majority of the facilities (69%) place orders every two months and 73% receive supplies fourevery weeks two months.after placing However, the order only to 54% receive knew a delivery. they were supposed to receive ARVs and diagnostics bimonthly. On re-supplies of ARVs, 47% of the facilities reported it took one-to- 3.4.4 Expired medicines at health facilities premises on the day of the survey. This proportion was lower than the proportion registered There were 49 facilities (50%) that reported to have some expired medicines on their at their premises, while four reported that they destroyed them. in the 2011 survey (61%). Twenty four facilities reported that they stored expired medicines Table 11: Handling of expired antiretroviral medicines at surveyed facilities Action Public Mission Private Total (n=83) Store them at the facility 16 5 3 24 Transfer them to higher facility 20 10 8 38 Transfer them to NDA 3 2 1 6 Destroy them 1 3 0 4 Other 5 4 2 11

• The guidelines for dealing with expired medicines should be clarified, communicated and adhered to by all health facilities that experience medicine expiries. Facilities destroying expired medicines should have adequate capacity for doing so.

3.4.5 Stock-outs Sixty two per cent of facilities reported to have ever experienced a stock out of ARVs and replenishmentonly 43% of these of medicinescould have was replenishment done majorly within by borrowinga week after from a stock another out but facility 28% or took by referringbetween onepatients to three to other months. facilities. In instances when there were stock-outs, patients’ refills/

21 4. Conclusions and recommendations

4.1 CONCLUSIONS

• Universal access to treatment is still a challenge. Even the most available triple combination medicine Zidovudine+Lamivudine+Nevirapine was not available in all facilities.

• Not many monotherapies for ART were found in the surveyed facilities. This may suggest that patients are receiving combination therapies which reduces the pill burden and may increase chances of adherence.

• The low availability of ARVs in rural private facilities is an indicator of skewed access to HIV treatment in this sector, and calls for further investigation of the reasons behind this phenomenon.

• The phasing out of the toxic combination of Triomune is a positive development that means ART clients are receiving safer and more tolerable medications.

• The availability of second line and third line ARVs was relatively low for key medicines, and some facilities did not have second line medicines at all.

• Management of HIV in children remains a major gap in the national response. Paediatric ARVs have remained poorly available over the years, which undermines the eMTCT programme as well as access to HIV treatment by children.

• HIV-positive children have not been adequately been catered for in terms of second line

be leading to high treatment default rates and hence requiring a higher availability of secondmedicines line as drugs. well. It is possible that low availability of first line paediatric ARVs could

• The trends in availability of medicines for opportunistic infections show an erratic availability over the years and a considerable number of facilities do not have especially medicines for opportunistic infections which may increase the rate at which PHAs progress from HIV to AIDS.

• therefore training is required to ensure adequate medicines management. Majority of stores personnel did not have any medicines management qualification and • adhered to by all health facilities that experience medicine expiries. Facilities destroying expiredThe guidelines medicines for dealing should withhave expiredadequate medicines capacity should for doing be clarified,so. communicated and

22 4.2. RECOMMENDATIONS

• Government (Ministry of Finance, Ministry of Health and Parliament) should ensure universal access to ART and TB medicines especially in rural private facilities through

• increased financing for medicines and strengthen supply chain management. ARVs to improve management of HIV in young ART clients. Ministry of Health should improve availability of both first line and second line paediatric • For the success of the eMTCT programme, Ministry of Health should improve the availability

Nevirapine for children. of specific medicines such as the combination Tenofovir+Lamivudine+Efavirenz and • Ministry of Health should provide continuing refresher and on-job training to stores personnel in order to improve medicines management.

23 References

HEPS Uganda, May 2009. Essential AIDS and TB medicines and diagnostics in Uganda: An assessment of availability and management

HEPS Uganda, September 2008. Essential AIDS and TB medicines and diagnostics in Uganda: An assessment of availability and management

UAC (2014): HIV and AIDS Uganda country progress report; 2013.

UNAIDS (2014): UNAIDS Gap Report. http://www.unaids.org/en/resources/ campaigns/2014/2014gapreport/gapreport/

24 Annex I

Availability of ARVs across sectors Public Private Mission Medicine Overall Urban Rural Overall Urban Rural Overall Urban Rural % % % % % % % % % Abacavir tab 300mg 38% 63% 22% 8% 10% 0% 17% 0% 25% Abacavir + Lamivudine tab 300mg 13% 19% 9% 23% 30% 0% 50% 50% 50% + 600 mg Abacavir Tab 60 mg 26% 25% 26% 0% 0% 0% 0% 0% 0% Atazanavir So4 Cap 150mg 0% 0% 0% 0% 0% 0% 8% 25% 0% Atazanavir So4 Cap 300mg 0% 0% 0% 8% 10% 0% 8% 0% 13% Atazanavir/Ritonavir 300/100 mg 64% 81% 52% 38% 40% 33% 50% 50% 50% Didanosine cap 25 mg 0% 0% 0% 0% 0% 0% 0% 0% 0% Didanosine tab 50mg 0% 0% 0% 0% 0% 0% 8% 25% 0% Didanosine tab 100mg 0% 0% 0% 0% 0% 0% 8% 25% 0% Didanosine tab 150mg 0% 0% 0% 0% 0% 0% 8% 25% 0% Didanosine tab 200mg 0% 0% 0% 0% 0% 0% 0% 0% 0% Didanosine cap 250mg 0% 0% 0% 0% 0% 0% 8% 25% 0% Didanosine cap 400mg 0% 0% 0% 0% 0% 0% 8% 25% 0% Didanosine powder for oral solution 0% 0% 0% 0% 0% 0% 8% 25% 0% 2g/100ml Duranavir 300 mg 0% 0% 0% 0% 0% 0% 0% 0% 0% Efavirenz tab 50mg 3% 0% 4% 8% 10% 0% 0% 0% 0% Efavirenz tab 100 mg 10% 0% 17% 0% 0% 0% 8% 25% 0% Efavirenz tab 200 mg 51% 63% 43% 31% 30% 33% 25% 25% 25% Efavirenz tab 600mg 72% 75% 70% 62% 70% 33% 67% 75% 63% Etravine 100 mg 0% 0% 0% 8% 10% 0% 0% 0% 0% Indinavir capsule 400 mg 0% 0% 0% 0% 0% 0% 0% 0% 0% Lamivudine tab 150mg 51% 75% 35% 23% 30% 0% 17% 0% 25% Lamivudine oral solution 50mg/5ml 0% 0% 0% 0% 0% 0% 0% 0% 0% Lamivudine oral solution 10mg/ml 0% 0% 0% 0% 0% 0% 8% 25% 0% Lamivudine + Stavudine tab 0% 0% 0% 8% 10% 0% 0% 0% 0% 150mg+ 30mg Lamivudine + Stavudine tab 0% 0% 0% 15% 20% 0% 8% 25% 0% 150mg+ 40mg Lamivudine +Zidovudine tab 69% 75% 65% 54% 60% 33% 67% 75% 63% 150mg+300mg Lamivudine + Nevarapine + 0% 0% 0% 0% 0% 0% 0% 0% 0% Stavudine tab 150mg+200mg+30mg Lamivudine, Nevirapine&Stavudine 0% 0% 0% 0% 0% 0% 0% 0% 0% tab 150mg+200mg+40mg Lamivudine, Nevirapine&Stavudine 0% 0% 0% 0% 0% 0% 8% 0% 13% tab 60mg+100mg+12mg Lamivudine, Nevirapine&Stavudine 3% 0% 4% 0% 0% 0% 8% 0% 13% tab 30mg+50mg+6mg Lamivudine,Zidovudine&Nevirapine 69% 69% 70% 69% 80% 33% 67% 75% 63% tab 150mg+300mg+200mg Lamivudine + Stavudine + Efavirenz 0% 0% 0% 0% 0% 0% 0% 0% 0% 150mg + 40mg + 600mg Lamivudine + Stavudine + Efavirenz 3% 6% 0% 0% 0% 0% 0% 0% 0% 150mg + 30mg + 600mg

25 Lamivudine + Zidovudine + 0% 0% 0% 0% 0% 0% 0% 0% 0% Efavirenz 150mg + 300mg + 600mg Lopinavir + ritonavir cap 100 mg/25 51% 63% 43% 23% 20% 33% 17% 0% 25% mg Lopinavir/ritonavir tab 200/50mg 59% 69% 52% 69% 80% 33% 58% 75% 50% Lopinavir + lopinavir oral solution 80 15% 19% 13% 8% 10% 0% 8% 0% 13% + 20 mg Nelfinavir mesylate tab 250 mg 3% 6% 0% 0% 0% 0% 0% 0% 0% Nevirapine tab 200mg 72% 81% 65% 69% 80% 33% 50% 25% 63% Nevirapine tab 50mg 28% 31% 26% 0% 0% 0% 42% 25% 50% Nevirapine oral suspension 49% 50% 48% 38% 40% 33% 58% 75% 50% 50mg/5ml Raltergravir 400 mg 3% 6% 0% 15% 20% 0% 0% 0% 0% Ritonavir oral solution 80mg/ml 0% 0% 0% 0% 0% 0% 0% 0% 0% Ritonavir Capsule 100 mg 5% 6% 4% 15% 20% 0% 8% 0% 13% Saquinavir 500 mg 3% 6% 0% 8% 10% 0% 0% 0% 0% Stavudine cap 15mg 0% 0% 0% 8% 10% 0% 0% 0% 0% Stavudine cap 20mg 0% 0% 0% 0% 0% 0% 0% 0% 0% Stavudine cap 30mg 0% 0% 0% 0% 0% 0% 0% 0% 0% Stavudine cap 40mg 0% 0% 0% 0% 0% 0% 0% 0% 0% Tenofovir disoproxil fumarate tab 0% 0% 0% 0% 0% 0% 0% 0% 0% 300mg Tenofovir/Emtricitabine tablet 300 8% 6% 9% 15% 20% 0% 8% 0% 13% mg/200 mg TenofovirLamivudine/Efivarenz 26% 31% 22% 62% 70% 33% 50% 25% 63% tablet 300mg/300mg/300/mg Tenofovir/Lamivudine tablet 300 62% 63% 61% 62% 70% 33% 67% 75% 63% mg/300 mg Zidovudine cap 100mg 3% 0% 4% 0% 0% 0% 0% 0% 0% Zidovudine tab 300mg 44% 50% 39% 15% 20% 0% 17% 50% 0% Zidovudine oral solution 10mg/ml 5% 13% 0% 0% 0% 0% 0% 0% 0%

26 Annex II

LIST OF SURVEYED HEALTH FACILITIES

Northern Region PUBLIC PRIVATE MISSION Gulu Regional Referral hospital Akakanyero pharmacy Gulu LACOR Hospital Awach Health Centrer IV MEDIZONE PHARMACY Health TASO Gulu Lalogi Health Centre IV Gulu Independent Hospital Medicines Sans Frontier Anaka Hospital AAR Attiak Health Center IV St Mary’s Hospital Lacor 5th Division Acholi PII Hospital (Pader) Pajube Health Centre IV (Pader) Atanga Health Centre IV Gulu Miltary 4th Division JCRC Gulu Reg REF Hosp Anaka Hospital (NWOYA) Koch Goma Health Centre III (Nwoya) Pabbo Health Centre III (Amuru) Barr Health Center III Bobi Health Centre IV Agwata Health Centre III (Dokolo) Bata Health Centre III Lira Regional Referral Hospital Lira Medical Centre Pag HCIV Lira Ogur Heealth Center IV Feliesta pharmacy Lira Ngeta Mission Amach Health Center IV ODOKOMIT PHARMACY DOKOLO Health Center IV PHARMA HEALTH LTD Amai community Hospital MANAV PHARMACY LTD LIRA PAG Health Centre IV Ayago Health Centre IV Amuca SDA Health Centre III Ngetie Health Centre III Alebtong Health Centre IV Amach Health Centre IV Apala Health Center III Barapwoo Health Centre III Abako Health Centre III

Western Region

Mbarara University Teaching Hospital Mayanja Memorial Nursing Home Nyakibale Hospital (NGO) (NGO) Rushere Hospital Mbarara community Hospital Kisiizi Hospital (NGO) Bwizibwera Health Center IV Mbarara Municipal Council Clinic Comboni Hosspital Ibanda Hospital James Finlays- Ankole Estate clinic Ibanda Hospital (Bushenyi) Kitagata Hospital Bushenyi Medical center Ruharo mission hospital Ishaka Adventist Hospital Mbarara diagnostic center TASP Mbarara Nyamuyanja HC IV-Isingiro BD Pharmaceuticals Ltd. (Quality MJAP Mbarara Chemicals) Nyakishenyi HC IV Zee Pharmacy Holly Innocents Children Hosp Kambuga Hospital – Kanungu Multiple Pharmacy (Mbarara) Karoli Lwanga Hosp – Rukungiri Ishongorero HC IV – Ibanda TASO Rukungiri Nyakisenyi HC III Rukungiri Bushenyi HC IV – Bushenyi Ankole Tea Estatte

27 MMC HC IV – Mbarara Rukungiri HC IV – Rukungiri Kinoni HC IV – Mbarara Ndeija HC III – Mbarara Itojo Hospital – Ntungamo Kebisoni HC IV – Rukungiri Kyamuhunga HC III – Bushenyi Ruhoko HC IV – Ibanda North Kigezi HC IV – Rukungiri

Eastern Region

Kamuli Hospital Nile Breweries - Jinja St. Francis Hospital-Buluba Jinja Regional Referral Hopital International Medical Center - Jinja Naminage HCII Kamuli Walukuba Health Centre IV Rana Medical Centre Kolonyi HCIV Buwenge Health Centre IV Rana Medical Centre Jinja Kamuli Mission Hospital Pallisa Hospital Family Hope Clinic – Jinja Kakira Hospital (NGO) Kibuku Health Centre IV St. Anthony Hospital – Tororo Mbale Regional Referral Hospital Busolwe Hospital (NGO)- Tororo Bududa Hospital TASO Jinja Magale Health Centre I CHRISCO HCIV (Mbale) Tororo Hospital Magale HCIV (Bubulo) Pallisa TC HC III AIC – Jinja Budaka HC IV Nabulola Community Medical Centre – Busia Tororo Hospital Kabasa Memorial Hsp – Busolwe Budadiri HC IV Kaucho HC III Magale HC IV Kolonyi HC IV Chrisio HC III – Manafwa Buwenge HC IV Mpumudde HC IV – Jinja

Central Region

Mulago National Referral Hospital SAS Foundation Clinic Namugoona Orthodox Hospital Kawempe Health Centre IV Kadic Medical Center Rubaga Hospital (NGO) Makerere University Hospital Case Medical Center Mengo Hospital (NGO) Kisenyi Health Center IV St. Balikudembe Market Clinic Nsambya District Hospital (NGO) Butabika Hospital KIMS Medical Center Kibuli Hospital (NGO) Entebbe Grade B, Hospital Kampala Medical Chambers Kiubi Hospital Wakiso Health Center IV International Hospital Kampala Mildmay Hospital (NGO) Namayumba Health Centre IV Kitante Medical Center Nkozi Hospital (NGO) Gombe Hospital Victoria Medical Center Nagalama Hospital Kawolo Hospital St. Catherines Clinic – Lumumba Nyenga Mobilie Hospital Avenue (NGO) Mukono Health Centre IV TASO Mulago

HEPS-UGANDA Coalition for Health Promotion and Social Development 351A, Balintuma Road, Namirembe P.O. Box 2426, Kampala, Uganda Tel: +256-414-270970 Email: [email protected]