With more than 20% of Lesotho’s population living with HIV, the need to scale up preventive measures has been recognized as crucial in the country’s fight against the disease. Although the estimated number of new HIV infections per year decreased from 30,000 in 2005 to 26,000 in 2013, the country has historically experienced low levels of HIV testing due to the shortage of HIV diagnostic supplies, the inadequate scale-up and accessibility of services, and widespread stigma associated with the disease.
Accelerating efforts to test key populations for HIV
According to the National AIDS Commission, only 42% of women and 24.7% of men in Lesotho knew their HIV status in 2009. Providing HIV testing and counselling (HTC) services is therefore essential for ensuring that individuals are aware of their HIV status, reducing the number of new infections, improving the quality of life for people living with HIV, and, ultimately, making strides towards an AIDS-free generation in Lesotho.
The government of Lesotho is committed to increasing the use of HTC services nationwide. A target for testing 60% of the population for HIV in 2014 was set by the National HIV and AIDS Strategic Plan (NSP) 2011/12-2015/16. To attain higher testing levels, the Ministry of Health (MOH) launched a two-week nationwide HTC Campaign on World AIDS Day 2014, while continuing to offer HTC through provider-initiated testing and counselling (PITC) at hospitals and health centers.
Limited availability of HIV Rapid Test Kits
After a nationwide distribution of HIV rapid test kits (RTKs) to health facilities in November 2013, the National Drug Service Organization (NDSO)’s monthly stock status reports estimated that the stock-on-hand of Determine HIV RTKs and Uni-Gold confirmatory tests would only last for two months. A central level stock-out of HIV RTKs was anticipated due to a lack of buffer stock at NDSO and a six-month lead-time for an expected Global Fund HIV RTK procurement.
In the three years prior to November 2013, the Lesotho health care system had been suffering constant stock-outs of HIV RTKs. Even when the country had available stock of HIV RTKs on hand, health staff at service delivery sites had to ration stock to ensure equitable HTC activities at all the sites. Additionally, the lack of quality data to be used in the quantification of HIV RTKs resulted in the inability of staff at NDSO to properly quantify need, making stock-outs inevitable. Because of this insight, the USAID-funded Systems for Improved Access to Pharmaceuticals and Services (SIAPS) Program anticipated that the level of available stock would pose a challenge in achieving the NSP target.
Maintaining central level stock levels to meet increased demand
As a key MOH partner in Lesotho’s HIV/AIDS response, SIAPS was concerned about the impact that a nationwide stock-out of HIV RTKs would have on HIV prevention, treatment and care. SIAPS worked with the MOH, the Global Fund Coordinating Unit (GFCU) and NDSO to conduct a quantification exercise and budget gap analysis of HIV RTKs in the first quarter of FY 2014.
Through a collaborative approach, stakeholders in Lesotho conducted an extensive quantification exercise and budget gap analysis. Data on the parameters required for the quantification exercise was obtained from the Supply Chain Management Technical Working Group (SCM TWG), while the rates of HIV RTK stock usage were extracted from the MOH’s Logistics Management Information System (LMIS). Information was also gathered from the NDSO and other published sources, including Management Sciences for Health (MSH)’s International Drug Price Indicator Guide 2010. Key assumptions related to the calculations were discussed with PEPFAR Lesotho, NDSO and MOH during various meetings in November 2013.
With SIAPS support, Lesotho’s MOH recognized that to safeguard the country from future stock-outs of HIV RTKs there was a critical need to procure additional stock of HIV RTKs, and requested an emergency procurement from PEPFAR. Through the procurement, the Government of Lesotho sought financial assistance from PEPFAR to scale up HIV testing in line with NSP targets. This procurement was estimated to cover the provision of test kits for HTC services over a period of at least 12 months.
With the emergency procurement of 210,400 HIV RTKs and 50,000 Uni-Gold test kits approved, hospital and health centers could continue to offer HTC services without the fear of running out of stock as they strived to reach the NSP target of testing at least 500,000 people between January and December 2014. The emergency procurement included provisions for both HIV RTKs and HIV confirmatory tests. Determine HIV RTKs are used at hospitals and health centers to screen patients for HIV. A positive test result by a Determine test kit requires the use of a Uni-Gold test to confirm the patient’s HIV status. In addition to including both Determine and Uni-Gold test kits, the procurement included a contingency provision of 75% – equivalent to nine months of stock – of the total supply to cover lead time and buffer stock, as well as an additional 10% of the total supply to cover possible wastage, including re-tests, loss, and expiry.
HTC services continue after emergency procurements
In January 2014, PEPFAR procured 2,104 Determine-100 pack HIV RTKs and 2,500 Uni-Gold-20 pack test kits for HTC at hospitals and health centers in Lesotho. Between January and December 2014, approximately 587,680 people were tested for HIV, exceeding the NSP target of 537,180 (60% of need) by about 50,500 people for 2014. This emergency procurement, which was made available in May 2014, averted a central level stock-out, allowing HTC services to continue uninterrupted throughout the year.
Hospitals and health centres in Lesotho have not experienced stock-outs of HIV RTKs since 2014. With enriched knowledge gained from the training and support provided through SIAPS, MOH staff is now equipped to conduct future quantification exercises efficiently and to accurately forecast product need. The MOH is working in close collaboration with SIAPS to review past forecasting and supply planning practices, and to conduct capacity building for harmonized and evidence-based multi-year quantifications of HIV RTKs and related products. Together, the MOH and SIAPS will proactively avoid any future need to issue another large emergency procurement.
By Pheello Pompong, SIAPS M&E and Communications Advisor; Dr. Almakio Phiri, SIAPS Lesotho Country Project Director; Andreas Fusi, SIAPS Laboratory Logistics Advisor; Katelyn Payne, SIAPS Project Associate; and Gabriel Daniel, SIAPS Principal Technical Advisor