JOHANNESBURG, 13 July 2010 (PlusNews) - In a bid to ease pressure on South Africa's over-burdened public health sector, the government has given hospitals and clinics permission to give patients on HIV/AIDS treatment a three-month supply of their antiretroviral medication (ARVs).

In a recent memo the Department of Health said there was no legal barrier to supplying patients with multiple months of treatment, and it could lighten the burden on the health sector; an estimated 700,000 patients are currently receiving ARV treatment through monthly visits to public health facilities.

Patients could also benefit. New research from the Reproductive Health and HIV Research Unit (RHRU), in Johannesburg, found that most patients who defaulted on treatment did so because they were unable to get time off work for monthly clinic visits. Poor adherence to ARVs can lead to drug resistance, necessitating more expensive second-line treatment and limiting future treatment options.

"Imagine spending one out of every 25 work days collecting tablets at the clinic," said Dr Francois Venter, president of the Southern African HIV Clinicians Society and head of RHRU's HIV management cluster.

Patients also defaulted because they had to travel long distances to reach clinics and could not afford transport costs, said Catherine Tomlinson, a senior researcher at the Treatment Action Campaign (TAC), a local AIDS lobby group. "Allowing people to get three months of medication at a time will remove these barriers to treatment and improve adherence," she told IRIN/PlusNews.

Venter said a limited amount of research had shown that decreased interaction with health workers might negatively affect adherence in a small number of patients, but most would benefit from the move. Tomlinson said selected clinics in Western Cape Province had started giving patients three-month supplies of ARVs and were seeing improved adherence.

Managing more drugs

Only stable patients will be eligible to receive the extended supplies of ARVs. Venter said this would most likely include patients who had been on treatment for more than six months, were free of serious drug side effects, and had undetectable viral loads.

The department of health cautioned facilities to evaluate their supply chain management and drug storage capacity before making a decision about whether or not to start issuing three-month supplies of the drugs.

Supply chain management has been a long-standing challenge in the public health sector, which is currently experiencing shortages of the first-line ARV, tenofovir, the TAC said. In revised treatment guidelines issued by the health department earlier this year, tenofovir was meant to replace stavudine (D4T), which has been associated with serious side effects in some patients.

Yet tenofovir shortages in the Eastern Cape district of Lusikisiki meant that patients started taking D4T and were then switched back and forth between the two drugs, said the TAC's Noloyiso Ntamehlo.

Andy Gray, a pharmacist and senior lecturer at the department of therapeutics and medicines management at the Nelson R Mandela School of Medicine, University of KwaZulu-Natal, said part of the problem was a lack of information management.

"Most health facilities operating at the point of care are working with paper-based systems," he told IRIN/PlusNews. "There have been attempts to strengthen supply chain management, which has seen the computerisation of the management of larger stocks of drugs in the country, but most of South Africa lacks any coherent computerised system."

A recently released government report also highlighted supply chain shortcomings, which have made forecasting drug demand and supply extremely difficult, especially in the context of South Africa's huge ARV treatment programme.

The report, commissioned by former Health Minister Barbara Hogan after a serious ARV shortage in Free State Province in 2009, noted that most provincial supply chain processes - including pro-active planning, stock control and distribution - need improvement.

Gray said a shortage of pharmacists, especially in rural areas, to schedule drug orders and deliveries, and monitor drug stocks, was compounding such problems.

The TAC has urged government to procure fixed-dose combination ARVs, which deliver three ARV drugs in a single pill and can be dispensed by pharmacy assistants, as one way of addressing the shortage of pharmacists.