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   Last updated: 19.07.02
4.2.F. Guidelines for treatment
Many governments have produced national treatment guidelines which are intended to improve rational drug use and encourage good practice in HIV-related treatment work. In addition, many NGOs/CBOs have developed their own treatment guidelines.

A prescribing manual - sometimes called a formulary - contains detailed information about each drug. This includes the dose, side effects, necessary precautions and other special requirements for using the drug. It is usually arranged in the same way as an Essential Drugs List, with the drugs listed alphabetically under the types of disease that they can treat.

Treatment guidelines provide information about different health problems and the necessary advice for treating them. They will tell health workers about diagnosis and management of health problems as well as what alternative treatments can be used. They do not usually give complete information about each drug, just what is necessary to use it - such as the dose and length of treatment.

These key resources – prescribing manuals and treatment guidelines, alongside Essential Drugs lists - can be used together to answer key questions about providing effective HIV-related treatment:

What drugs should we use?
Resources: Essential Drugs list, prescribing manual

How should we use the drugs?
Resources: prescribing manual

For what illnesses should we use the drugs?
Resources: treatment guidelines

The quality of treatment for people with HIV is improved if national treatment guidelines are developed with the participation of NGOs/CBOs who provide treatment on a daily basis. Their active involvement will ensure that the treatment needs of people with HIV are more accurately understood and are reflected in the advice given.

Realistic treatment guidelines will also provide better input for the national Essential Drugs List and prescribing manuals. This in turn will encourage improved availability and accessibility of drugs for HIV-related treatment.

Activity: Treatment Guidelines
Aim: To raise awareness about treatment guidelines and other important sources of information for rational drug use.

Instructions:
NB. Before starting this activity, the facilitator needs to collect some examples of prescribing manuals and treatment guidelines. If possible, this should include some local, national and/or international examples.
1. Explain the aim of the activity.
2. Ask participants what information they need in order to provide effective HIV-related treatment.
3. Ask participants to share their practical experiences in finding out this type of information.
4. Explain to participants what is meant by prescribing manuals (or formularies) and treatment guidelines [see previous page]. Show them some local, national and international examples.
5. Ask participants what national prescribing manuals and treatment guidelines are available to them and whether they are appropriate for their situation. Encourage the participants to ask each other questions and to make comments.
6. Discuss how NGOs/CBOs could help to improve national prescribing manuals and treatment guidelines for HIV-related work.
7. Facilitate a group discussion about what has been learned from the activity, based upon questions such as:
  • Why are national materials – such as treatment guidelines – important for NGOs/CBOs, alongside their own practical experiences?

  • How can NGOs/CBOs influence what is included in national prescribing manuals and treatment guidelines.


Facilitators’ notes:
  • Help participants to think positively about how to improve national prescribing manuals and treatment guidelines, rather just criticising the current weaknesses.


Example: information needed for effective treatment
At a skills building workshop, NGO/CBO participants brainstormed what information they need in order to provide effective HIV-related treatment. They then shared their experiences of finding out the information.

Participants were shown examples of local, national and international prescribing manuals and treatment guidelines. They then discussed what of these resources are available to them and whether they are appropriate for their situation. Some of their comments included that:

  • The Zambian EDL gives us an idea of what drugs can be used for each type of illness, but it doesn’t give us any idea of dosage.

  • National treatment guidelines would be very helpful but they are not yet available in Zambia.


Finally, the participants discussed how NGOs/CBOs could help to improve national prescribing manuals and guidelines. Their ideas included:

  • The Zambian National Formulary is a dictionary of drug treatment. This includes information on dosages and side effects. It should be more easily available and accessible.

  • The Zambian government is working on developing local treatment guidelines. NGOs/CBOs involved in providing care and treatment should be involved in the process of developing the treatment guidelines.


Afterwards, the facilitator led a group discussion about what had been learned from the activity. For example, participants agreed that national and international guidelines are important resources, but are only truly useful when combined with local experiences.

(Reference: Adapted from the workshop on “Access to HIV-Related Treatment”, Catholic Dioceses of Ndola and the International HIV/AIDS Alliance, Zambia, April, 2001.)

4.2.G. Fact sheet - Antiretrovirals
Drugs that directly combat the HIV virus – antiretrovirals (ARVs) – have not been available or accessible in most resource-poor communities because of cost and technical difficulties in using ARVs. However, prices of ARVs are reducing and easier ways are being found to use them.

Everyone involved in ARV treatment needs to be well informed about the drugs, the services that are needed to support their use, and the risks and benefits of using them.

Some NGOs/CBOs/PLHA groups are already involved in providing ARVs to relatively small numbers of people. Some donors and governments are looking for ways to provide ARVs to larger numbers of people - especially in countries with high HIV prevalence.

What are ARVs? There are three types of ARV drugs and each type of drug attacks the virus in a different way. These different types of drugs used in combination work to reduce the amount of virus (viral load) in a person’s body. This is HAART – highly active anti-retroviral therapy. Successful HAART helps a person to stay healthy and live longer. However, the drugs must be taken exactly as prescribed and for the rest of a person’s life. Many ARVs cause side effects and some strains of HIV are resistant to some of the drugs, so treatments must be carefully chosen and monitored with regular laboratory tests to ensure that they are effective and safe.

ARVs do not cure HIV – they only reduce its effects and prolong life.

In the special case of preventing mother-to-child HIV transmission (MTCT), just one or two drugs are used briefly to protect a child around birth from becoming infected by its mother’s HIV virus. This does not change the mother’s HIV status. HIV infection can also happen through breastfeeding or, if the mother is receiving HAART, the ARVs may pass in the mother’s milk with possible benefits to the child but also the risks of side effects. Treatment for mothers and babies is therefore specially challenging.

Types of ARVs Presently Available
(listed with generic and short chemical or generic abbreviations)

Nucleoside analogues (also called Nucleoside Reverse Transcriptase Inhibitors or NRTIs):

  • zidovudine (AZT)

  • didanosine (ddI)

  • zalcitabine (ddC)

  • stavudine (d4T)

  • lamivudine (3TC)

  • abacavir (ABV)


Non-nucleoside Reverse Transcriptase Inhibtors (NNRTIs)

  • Efavirenz (EFV)

  • Nevirapine (NVP)

  • Delavirdine (DLV)


Protease Inhibitors (Pis)

  • saquinavir

  • ritonavir

  • indinavir

  • nelfinavir

  • amprenavir

  • lopinavir


Support needed for ARV provision

ARV treatment should always take place within the continuum of care across the following (represented as circles centred on the person with HIV):

Person with HIV - Family - Community - Health system

The following support the safe and effective use of ARVs:

  • Good treatment information that is easy to understand – how it is used, the risks and benefits, maintaining and looking after drug supplies and, especially, understanding that not treating HIV is a better option than partial treatment which leads to development of resistant viruses and shortening of life.

  • Strong social support to help people to adhere to the treatment regime, to maintain access to prescribed drugs and to cope with side effects.

  • Preventing and reduction of stigma or discrimination so that people are not discouraged from using or helping with ARV treatment.

  • Integrated health systems which include treatment for TB, opportunistic and sexually transmitted infections and for other health problems – viral load is increased by the presence of other infections.

  • Trained counsellors and access to facilities for voluntary counselling & testing – the first important step in making a decision about ARV treatment.

  • Prescribers and health workers trained in clinical management of HIV/AIDS.

  • Laboratory services to provide checks on the level of HIV infection, through CD4 or similar tests (viral load tests are very expensive); testing for drug side effects is also important, such as liver function tests.

  • Supply services that can maintain adequate and uninterrupted supplies of ARVs and other HIV-related drugs, HIV test kits and laboratory materials. This means adequate funding to maintain all the above so that treatments are not interrupted.

  • Support when ARV treatment cannot be used and encouragement to follow the various other means of maintaining health and living with HIV.


4.3. Sourcing and looking after quality drugs
People often get supplies of drugs from a number of sources. Groups use many of the same sources. These include:

  • Local drug sellers, shops and markets.

  • Local pharmacies and chemists.

  • Health centres and hospitals.

  • Friends and family (sometimes using drugs that are left over from uncompleted treatment).

  • Donations from supporters.


When there are many sources, it can be difficult to be sure that all the drugs obtained are going to be safe to use. The quality and cost of drugs can vary widely, depending on their source. Even when reliable sources are available, the cost of drugs can limit where people get them. However, the quality is always more important than the cost. Low prices are attractive but, if the quality is bad, the drugs may be ineffective or even dangerous. This in turn means that treatment will not be successful, further illness may be caused and, in the end, the costs will be higher in both human and money terms.

You should therefore aim to get the best quality drugs you can at the lowest possible cost. This will allow you to get more drugs for your money, or to have more money to spend on other useful things. It will also mean that, if users of your services have to pay something for treatment, you will be able to charge them less.

A group can use money more effectively by buying good quality generic drugs. Usually the packaging is simpler and the drugs are not advertised – which reduces the costs of production and may reduce the selling price. Costs can also be controlled by protecting the quality of drugs through careful storage, good stock control and drug management from the moment of purchase through to when they are handed out for the patient to use for treatment.

4.3.A. Drug quality
Drug quality matters – bad drugs lead to bad treatment. Quality drugs are safe, effective and have guaranteed amounts of the stated active substance in them. The quality of a drug product depends on many stages in the production of drugs, but also on the drug management cycle. Everybody who has responsibility for a drug at some stage helps to ensure the good quality of the drug when it reaches the patient. Even the patients and their helpers have responsibility for storing and caring for their drugs to help them be effective.

The producer is expected to follow established procedures for good manufacturing practice, including testing at various stages in production. This includes the drug substances themselves, the extra ingredients such as water or sugar, the packaging and the labels.

Quality testing of drugs needs laboratory facilities expertise that are not easily available to NGO/CBO/PLHA group buyers – so it is not realistic to test each drug to see if it contains the correct ingredients. However, you can set up a system of quality assurance to help you ensure that the drug supplies you provide are of good quality by:

  • Only buying from recognised and trusted suppliers.

  • Checking the labelling and the containers to:

  • Make sure that labels are clear, including the drug name & strength, expiry date, batch number and manufacturer’s name and address

  • Make sure that the container is not broken and the lid fits tightly

  • Ensuring that drug products are not broken, discoloured, bad smelling.

  • Learning from other people about their experiences in obtaining drugs.


Good quality drugs
A good quality drug should:

  • Contain the correct amount of the active drug.

  • Contain the correct amount of other ingredients required to make the active drug usable in the form of tablets, syrup and ointment.

  • Be labelled clearly, showing the name and quantity of the drug, an expiry date, a batch number and the name and address of the supplier.

  • Not contain any contamination - such as dirt or fungus.

  • Be stored correctly so that it remains effective and safe to use until the expiry date.


4.3.B. Sources of drugs
Drugs in larger numbers (or bulk supplies) can be obtained from different sources. These include:

  • Government stores.

  • Private pharmacies or wholesalers.

  • Non-profit or low-cost international suppliers.

  • Donors and supporters.

  • Direct from drug companies.

  • Local shops or markets.


When buying drugs, it is important to consider the following points:

  • Competitive price: You should compare prices of different suppliers. It is important to remember that the cost of a drug is more than just the price you pay for the actual medicine. For example, there are "hidden costs" - such as transport, time, customs duty and taxes.


  • Good quality: Drugs should be good quality and be guaranteed to be effective and fit for use.


  • Continuous supply: Regular supplies of drugs are necessary, not just for long-term treatments such as TB, but also for a group's credibility - as people will not come if drugs are often not available. It is important to find suppliers who can guarantee regular supplies of frequently used drugs.


  • Delivery time: This can be anything from a few hours (if buying from a local pharmacy) to several months (if buying from overseas). If drugs are not delivered in time, it will make it much more difficult for a group to do its job and people's health may worsen as a result.


  • Long shelf life: When buying a large quantity of one drug, it is important to ensure that the drug will not expire before it is used. Try not to buy drugs with a short shelf life - as they might expire before they can all be used. The "shelf life" is the amount of time available before a drug is out of date or expires. The producer of the drug decides its expiry date. After this date, the producer will not guarantee the quality or effectiveness of the drug, and it might become less effective or even dangerous.


Drug donations

When there are few funds available, donations of drugs and medical equipment can provide very important resources for HIV-related treatment work, but only if they are carefully controlled and the donor clearly understands the needs of recipients. Practical experiences with donations often show that they can be inappropriate, costly and even dangerous if they are not managed properly.

When using donations it is important to think about some serious questions:

  • Can further supplies be obtained? For example, if you have received a three-month supply of an antiretroviral drug, what will you do when it runs out? Interrupting treatment will increase the chances of drug resistance - which might reduce the benefits of further treatment with antiretroviral drugs.


  • How will the side effects of the drugs be monitored? Most antiretroviral drugs cause side effects that are unpleasant or even dangerous. Some of these need to be monitored with complicated tests, such as liver function tests. Many health facilities do not have the equipment or expertise to carry these out.


  • Which drug would be the most beneficial? If you have a choice about which drugs are donated, think about which would give your patients the greatest benefit. For example, you may think a supply of an antiretroviral drug would be the most beneficial, but there are problems with these drugs. So, you may find that a drug to treat infections - such as fluconazole - would be of greater value.


It is important to establish good two-way communication between the donor and the recipient. Recipients should let donors know what they need, and not be afraid to say "no" if something inappropriate is offered or sent. Donors should listen carefully to what recipients tell them and act accordingly.

The recipient should inform the donor about:

  • Which drugs and equipment they require.

  • What alternatives would be acceptable if the exact drug or equipment is not available.

  • What quantities are needed or how many people they are meant to help.

  • What language would be most helpful on labels and instructions.

  • What - if anything - has been wrong with previous donations, and how they could be improved in the future.


The donor should:

  • Send drugs that are on the country's Essential Drugs List. If there is no national Essential Drugs List, the WHO Essential Drugs List should be followed.

  • If specialist drugs - such as antiretrovirals - are sent, they should only be sent to people whose doctors are skilled in treating HIV.

  • The recipient must know in advance which drugs are being sent and in what quantity.

  • The drugs should have at least one year of shelf-life when they are received, especially considering that donations can take several months to arrive.

  • Donations should be labelled in a language that the recipient understands.

  • Equipment should have instructions and information about spare parts.


Advantages and disadvantages of drug donations

Advantages of drug donations

  • Donated drugs and equipment can provide access to treatment which would otherwise not be possible - either because of lack of funds, or because the drugs are unavailabile in a particular country.

  • Donations can free up funds to be used in other ways, for example to buy other drugs or equipment.


Disadvantages of drug donations

? The donated drugs may not be required because you already have plenty in stock.
? The drugs are not on your Essential Drugs List - so you may not have access to enough information, skills or experience to use them effectively and safely.
? The drugs you receive are out of date, or they only have a short expiry date and cannot be used in time.
? Donated equipment is often sent without instructions or spare parts.
? Donations can cause unwanted and unexpected costs to recipients, such as import duties, transport costs, disposal costs for unwanted items, and time and labour to sort useful items from the unwanted ones.
? Drugs are labelled in a language you do not understand so you may not know what they are or how to use them.

Activity: Donations of drugs
Aim: To identify the advantages and disadvantages of donations of HIV-related drugs.

Instructions:
1. Explain the aim of the activity.
2. Divide participants into three groups.
3. Ask each group to identify the advantages and disadvantages of receiving a type of donation of HIV-related drugs. For example:
  • Group 1: Donation of antiretrovirals.

  • Group 2: Donation of drugs labelled in a foreign language.

  • Group 3: Donation of drugs close to their expiry date.

4. Ask each group to develop a list of strategies that they could use to improve the donation in future.
5. Bring everybody back together and ask the groups to present their results. Encourage the participants to ask each other questions and to make comments.
6. Facilitate a group discussion about what has been learned from the activity, based upon questions such as:
  • On the whole, are there more advantages or disadvantages to donations of HIV-related drugs?

  • How can an NGO/CBO/PLHA group refuse a donation while maintaining a good relationship with the donor?


Facilitators' notes:
  • Encourage participants to think critically about the disadvantages of donations rather than taking an "any help is good help" approach.

  • Encourage participants to focus on how they can create an active partnership with the donors of drugs, rather than being the passive "recipients" of support.


Example: for and against donations
At a skills building workshop, NGO/CBO participants brainstormed the advantages and disadvantages of donations of certain types of HIV-related drugs:

Antiretrovirals

Advantages
  • We don't have to pay.

  • The drugs can prolong the lives of people with HIV.

  • The drugs allow the patient to continue working.


Disadvantages
  • The supply is not sustainable.

  • Limited amounts of the drugs are sent.

  • If they are new drugs, we have no guidelines for using them.

  • Need to have access to clinical support.


Ways to improve the donation
  • Ask donors to give us training in using the drugs.

  • Ask for constant and adequate supplies.

  • Ensure access to clinical services.


Drugs labelled in a foreign language

Advantages
  • We don't have to pay.

  • It means we have some drugs to give to patients.


Disadvantages
  • We can't understand instructions.

  • We don't know how to use the drugs.

  • It takes time to find someone to translate.


Ways to improve the donation
  • Ask for good quality drugs with a long expiry date.

  • Overcome language problem by asking the donor to translate the information.

  • Ask donors to use English.


Drugs close to their expiry dates

Advantages
  • We get the drugs for free.

  • We don't have to look for drugs or purchase them.

  • It helps us to provide treatment.


Disadvantages
  • The drugs are not good quality or very effective.

  • The drugs may not be finished before their expiry date and cannot be kept for a long time.

  • The patient may feel unhappy and worry about using the drugs.


Ways to improve the donation
  • Check the expiry dates before receiving the drugs.

  • Have an agreement with the donor to send drugs with a long expiry date.

  • Make arrangements to dispense the drugs as fast as we can.


Afterwards, the facilitator led a group discussion about what had been learned from the activity. For example, participants agreed that NGOs/CBOs need to build strong two-way relationships with donors - so that they can be honest with them and get the type of drugs that are most useful.

(Reference: Adapted from a workshop on "Access to HIV-Related Treatment," Khmer HIV/AIDS NGO Alliance and the International HIV/AIDS Alliance, Cambodia, May 2001).

4.3.C. Storing drugs
Storing HIV-related drugs correctly is important because drugs are only safe to use until their expiry date if they have been stored in the right way. If they have not, they can become ineffective or unsafe.

When organising a drug store, all drugs should be stored in a systematic way. For example, they might be put in alphabetical order according to their generic name - such as aspirin, co-trimoxazole and paracetamol. It is good practice to keep "external" preparations - or drugs for use on the skin - on a separate shelf, because they can be dangerous if swallowed.

When you receive a new supply of a drug, look at the expiry date and then:
  • If the shelf life is longer than your current stock, store the new supply behind the older stock and use the old ones first.

  • If the shelf life is shorter than your current stock, put the new supply at the front. But always finish an open container before starting a new one.

  • If the drug has a short expiry date - such as six months or less - use a coloured marker to remind people to use it first and to keep checking the expiry date. This also applies to any other medical supplies that have an expiry date - such as laboratory tests, condoms, latex gloves or syringes.


Ideally, do not use a drug if it is past its expiry date. This is because the drug may have become less effective or even dangerous. The best way to prevent problems with expired drugs is to keep them to a minimum by good stock control. Then the time, effort, cost and danger of drug disposal will be kept as low as possible.

Disposal of expired drugs should be carried out in a way that makes it impossible to use the drug and reduces the risk of harm to anyone. In some countries, expired drugs are classified as toxic waste and there are regulations about disposing of them. High temperature incineration is a very effective way of destroying drugs, but is not always available. NGOs/CBOs with expired drugs should seek advice about safe disposal from the national drug enforcement agency, local hospital or pharmacist.

Storing HIV-related drugs
To look after drugs, it is important to keep them:

  • In as cool a place as possible. Keep them in a refrigerator if the label says so, or if it says that you should keep them at less than 10 degrees C (for example "store at 2-8 degrees C"). However, drugs can also be damaged if they are kept too cold, so do not allow them to freeze unless the label says they must be kept at temperatures below 0 degrees C.

  • Away from sunlight - by keeping them in a box or putting curtains at the windows.

  • Away from moisture - by keeping containers tightly closed and protected from water.

  • In a container that keeps out insects and other animals.

  • In a safe place that stops children or other people taking them.


4.3.D. Keeping records and ordering drugs
To carry out effective work on HIV-related treatment, it is important that the management of drugs is well organised. Keeping records and ordering drugs are important parts of this work.

Keeping stock records is very important for tracking which drugs are being well used and knowing when to reorder. An easy way to record how much of a drug is being used is to use stock cards. Some important points to remember are to:

  • Use a different card for each drug and each different strength of drug. For example, if you keep co-trimoxazole 120mg tablets for children and 480mg tablets for adults, you should use a separate stock card for each one.

  • Record the date and quantity of the drug and sign the stock card each time a supply is received or dispensed.

  • Record the expiry date of the drug each time a supply is received and make sure the oldest supply is used up first.

  • Keep a written running total of the quantity of the drug that is left. This should be the same as the actual quantity on the shelf.

  • Make regular stock checks, for example every month. This will ensure that stock records are accurate about how much is on the shelves. It will also prevent you from running out or building up unwanted stocks.

  • Keep drugs in a secure place so that people cannot take them away without permission or recording on the card.


Important things to think about when ordering drugs include getting the next supply. Always try to obtain the next supply of a drug before the present one runs out. This is especially important for vital items such as TB drugs.

It is also important to think about calculating how much to order. When buying large quantities of drugs or buying from suppliers who take a long time to deliver, the following information is needed to ensure that the correct quantity is ordered and treatments are not interrupted:

  • Average monthly use: This can be calculated by dividing the total amount issued by the number of months during which it was issued. For example, a stock card for aspirin tablets 300mg might show that 102 units of tablets were given out during the last 6 months. This means that the average monthly use is 102 divided by 6 - which comes to 17 units.


  • Delivery time: This is the length of time between making an order and receiving it. It is also called the "lead time." When buying drugs from the local town, the delivery time may be only one day. But when buying drugs from a far away supplier or requesting a donation, the delivery time can be anything from one to six months, or more.


  • Minimum stock level: This is the smallest quantity that should be in stock on the shelf. The level will depend on the delivery time. As a guide, you can calculate it by taking the average monthly use, multiplying it by the number of months required for delivery and then using your judgement to add a little extra in case the delivery is delayed or you suddenly need much more of the drug.


  • Re-order level: This is the minimum stock level plus stock used during the delivery time. Ordering when you reach this level will ensure that a drug does not run out before new supplies arrive.


  • Supply period: This is the amount of time between one order and the next. Smaller amounts of drugs can be ordered more often if supplies are readily available at a good price. But if supplies have to travel long distances or prices are discounted for larger quantities, it may be better to have longer supply periods and buy larger amounts at lower prices.


  • Order quantity. This will depend on how often an order is made. If it is every six months then the order quantity must be a six months supply. You should check each time an order is made to see if there is any variation in amounts used - according to the time of the year or circumstances - as this may affect how much is ordered.


  • Maximum stock level. This is the re-order level plus the order quantity. If the stock level is higher than the maximum, drugs might expire before you can use them.


  • Emergency supplies. If possible, it is advisable to keep an emergency supply of drugs - to use if there is a problem receiving the next supply or if demands increase. Usually, about one month's supply is sufficient. As usual, it is important to check the expiry dates regularly, and to replace any drugs with a short expiry time.


Example stock card for HIV-related treatment
A stock card needs to be designed in a clear and simple way, such as:

Item: ASPIRIN TABS 300mg
Unit: 1000 tablets
Minimum stock: 10 units
Maximum stock: 40 units
Re-order level: 20 units
Order quantity: 20 units

[The rest of the card is laid out in columns with headings:]

Date // Received from // Issued to // Amount received // Amount issued // Balance // Remarks // Signed

[and here are two sample entries:]

2/8/02 // Medical stores //--- // 20 //---// 20 // Expiry 8/04 // CG
4/8/02 //--- // Clinic 1 //---// 2 // 18 //--- // CG

A sample calculation for reordering drugs
The stock card shows 9,000 tablets of paracetamol, 500mg were used over the last 6 months. An order from a supplier takes 1 month to deliver and the supply period is 6 months.

From this information, you know that:

  • Average monthly usage is 9,000 tablets divided by 6 months = 1,500 tablets.

  • Delivery time = 1 month.

  • Supply period = 6 months.

  • Minimum stock level (amount used during the delivery time) is one month = 1,500 tablets.

  • Re-order level is minimum level plus stock used in one delivery time = 1,500 tablets + 1,500 tablets = 3,000 tablets.

  • Order quantity is the amount you use during a supply period, namely 1,500 tablets x 6 months = 9,000 tablets.

  • Maximum stock level is re-order level + order quantity, namely 3,000 tablets + 9,000 tablets = 12,000 tablets.


Reducing drug costs
There are several effective ways of reducing drug costs, but they depend on knowing exactly what drugs are needed and how much of each one is required. It is important to keep accurate records about the quantities of drugs received and dispensed. Buying small quantities of something that is used a lot can be very expensive compared to buying in bulk. However, it is not useful to order a large amount of a drug if only a small amount is needed – as this can result in quantities of expired drugs that have to be disposed of.

When ordering drugs, there are six important ways to reduce costs:

1. Buy generic drugs whenever possible.
2. Buy in large quantities when appropriate. For example, it may be possible for several small organisations to buy their drugs together.
3. Pay with cash rather than asking for credit.
4. Compare prices from different suppliers.
5. Buy tablets rather than capsules, syrups or mixtures – as they are usually cheaper. For children, tablets can be crushed and added to food.
6. Only use injections when the drug cannot be given any other way –they are usually more expensive and involve the additional cost of needles and syringes.

Activity: Managing drug supplies
Aim: To build skills in how to manage HIV-related drug supplies effectively.

Instructions:
1. Explain the aim of the activity.
2. Lead a brainstorm about the steps involved in ordering supplies of HIV-related drugs. Ask participants to think about what needs to be done to get the right drugs, in the right quantities, at the right time, at the right price, of the right quality and in the right place.
3. Divide participants into small groups.
4. Ask each group to summarise the steps that are necessary to achieve good drug supplies. Ask them to draw a timeline - to show in what order the steps need to occur.
5. Bring everybody back together and ask the groups to present their results. Encourage the participants to ask each other questions and to make comments.
6. Facilitate a group discussion about what has been learned from the activity, based upon questions such as:
  • What would happen if an NGO/CBO ran out of a drug?

  • What would happen if the steps for ordering drugs were carried out in the wrong order?


Facilitators' notes:
  • Encourage participants to be thorough in their thinking about this activity - paying attention not only to the quantity of drugs needed, but also issues such as quality and price.

  • Encourage participants to focus on simple and practical steps to manage the supply of drugs, rather than complex systems and processes.


Example: Managing drug supplies in Cambodia
At a skills building workshop, NGO/CBO participants brainstormed the steps needed to manage supplies of HIV-related drugs effectively. They then drew a timeline to show the cycle in which the steps need to occur:

1. Analysis
  • What drugs do we need?

  • Do we know how to use these drugs?

  • What quantity of each drug do we need?

  • Quality

  • Cost

  • Expiry date


2. Supply
  • Delivery time

  • Permission holder for buying drugs

  • Regular supply

  • Emergency supply (safety stock)

  • Control on how to use drugs

  • Quantity of use and duration of supply

  • Dispensing drugs to patients


3. Reorder
  • Time to reorder

  • Recheck the quantity (checking stock)

  • Get permission to reorder


Afterwards, the facilitator led a group discussion about what had been learned from the activity. For example, participants agreed that the steps for ordering drugs need to be carried out in the right order to prevent gaps in treatment - that might physically and psychologically harm people with HIV.

(Reference: Adapted from a workshop on "Access to HIV-Related Treatment," Khmer HIV/AIDS NGO Alliance and the International HIV/AIDS Alliance, Cambodia, May 2001.)

4.4. Providing drugs to people with HIV
We need to remember at this point that ensuring people have access to drugs is more than just making them available in the area where they live or come for treatment. People need to be able to afford the drugs that are available and they need to get them in a way which is suited to their individual needs – the drugs have to be dispensed correctly. They also need the right information about their drugs and there has to be a system of transport to get them and their drugs together so that they can use them for as long as they need them.

This key stage of treatment access therefore depends not only on the mechanical processes of moving drugs around and putting them in containers with labels and instructions. It requires good communication skills by health workers and encouragement for patients to make the best of their treatment and seek advice about any problems that arise with the treatment. Once again, the importance of interaction between human, financial and material resources is clear, especially in the field of treatment for HIV-related illness when people are faced with many social and economic challenges as well as their health problems.

4.4.A. Paying for HIV-related treatment
Since costs are a key element in whether people with low incomes can access HIV-related treatment, it is important to think about ways in which these costs can be met. Two important issues about paying for treatment include:

Cost sharing, which is used for health care in many countries. It involves people paying for some or all of the costs of their care and treatment. One of the most common ways is that people pay either a fixed amount for treatment or a proportion of the actual cost. This can help to improve the availability of drugs, but it can also cause some problems, such as:
  • Some people cannot afford to pay for treatment. This might mean that the poorest people have less access to treatment.

  • Health workers might prescribe unnecessary or expensive drugs to increase their NGO’s/CBO’s income.

  • Charging does not guarantee a good supply of the necessary drugs.


Cost counselling can be helpful for people who need HIV-related treatment. It involves helping people to think through difficult choices – such as how to balance the costs of illness and treatment with other daily living costs, such as food and education. Also, when unexpected or extra expenses arise, people may need help to work out priorities between their short and long-term needs. Support groups can help people to make these choices, especially if they understand people’s daily living needs and the costs and availability of treatment. NGO/CBO cost counsellors need to understand what is important to people, what their money problems are, and how this relates to needs for treatment.

Cost sharing for HIV-related treatment
Questions to consider before starting cost sharing for drugs include:
  • What will patients think about paying for their drugs?

  • How will you calculate the prices to charge patients?

  • Who will not have to pay for their drugs?

  • What will happen if people are unable to pay? Will treatment be refused to them?

  • How will the money be collected and managed?


Cost counselling for HIV-related treatment
Things to think about in relation to cost counselling include:
  • Not all illnesses need drug treatments. Simple home remedies are often enough and sometimes problems clear up without using any remedy at all.

  • Some treatments are not effective unless the full amount is taken regularly. Using treatments incorrectly can be wasteful as well as dangerous.

  • Often, people can afford only part of the full range of treatment recommended for them. They may need advice about which items are the most important and which they can leave out.


4.4.B. Drug information
NGOs/CBOs need information about drugs that is objective, accurate, and in simple language. The best information about treatment comes from people who can understand technical facts, but can communicate them to others in a clear way – as this helps people to understand and to make informed decisions about drugs.

It is important not to rely on advertising material for information about a drug – as it aims to persuade people to use the drug and often does not include everything that you need to know. This is especially the case in relation to side effects or alternatives that might cost less.

Information about drugs
Good information about a drug should include:

Effects of the drug:
  • Which symptoms will disappear or reduce, and when?

  • How important is it to take the drug?

  • What happens if the drug is not taken?


Side effects:
  • What unwanted side effects might occur?

  • How can people recognise side effects?

  • How long will side effects last?

  • How serious are the side effects?

  • What should be done if side effects happen?


Instructions:
  • When should the drug be taken?

  • What quantity of the drug should be taken?

  • How should the drug be taken?

  • How should the drug be stored?

  • How long should the treatment be continued?

  • What should be done in case of problems?


Warnings:
  • What should you not do? For example, if the drug can make you sleepy, you should not drive a vehicle or operate machinery.

  • What is the maximum dose? For example, some drugs are poisonous if you take too much of them.

  • Is it important to continue the treatment? For example, for anti-infective drugs (such as antibiotics and antifungals), drugs for long-term conditions (such as diabetes or heart disease) and antiretrovirals.


Getting further help:
  • When should you go back the to person who prescribed the drug?

  • When should you go back for help earlier than an arranged time? For example, this might be necessary if the condition worsens, does not get better as it should, or there are bad side effects.

  • What should you do with left-over drugs? For example, how to dispose of them safely.


4.4.C. Dispensing drugs
Drug dispensing is a very important job in HIV-related treatment work. People must receive the correct amount of the correct drug, with the correct instructions. If a mistake is made, it can be very dangerous, as well as being a waste of resources.

Giving the right information about the drugs is as important as dispensing the drug correctly. Information about drugs can be spoken, but people usually only remember two or three messages at a time. It is important to focus on the key messages for that particular drug. Ask the person receiving the drug to repeat the explanation back to you. This will show if they have understood the instructions and give you an opportunity to correct them if necessary, or give them extra information.

Written information can also be given. It needs to be clear and in language that the user finds easy to understand. For example:

"Take two tablets twice a day. It is best to take them with some food. So, take two tablets with your meal in the morning and two with your meal in the evening. You must take the tablets until they finish. If you get a skin rash, stop taking them and come back to see us as soon as possible."

Pictures can also help, but must be clear and easy to understand. For example, "Take two tablets twice a day - 2 in the morning and 2 at night" could be drawn as:

[Picture of two tablets with the sun shining and two tablets with the moon and stars.]

Steps for dispensing HIV-related drugs
It is important to:
  • Make sure you understand the prescription. Check with the prescriber if you are unsure.

  • Select the required drug from your store. Double-check the name of the drug, the strength and the "form" (such as whether it is a tablet, skin cream, injection or liquid medicine).

  • Calculate how much of the drug is needed. For example, 10ml of antibiotic syrup three times daily for five days will be a total of 150ml.

  • Count or measure the required amount. Do this on a clean surface, using clean measures or tools. Avoid touching drugs with your hands. For example, use a knife or a spoon to count tablets.

  • If you have labels, write one to show the name of the drug, the strength, the directions for use, the person's name (or code number) and the date.

  • Check again that you have dispensed the correct drug, the correct strength and the correct quantity.

  • Hand the drugs to the person, explain how they should take the drugs and give any other information that they need. This is a very important part of dispensing. If drugs are not taken correctly, the patient and the provider have wasted time and money.


Information required about HIV-related drugs
A person using or providing drugs needs to know:

  • How much of the drug to use.

  • How the drug should be used - such as swallowed, rubbed on the skin or inhaled.

  • How often the drug should be used.

  • For how long the drug should be used.

  • Whether the drug should be taken after food, before food, between meals or with water.

  • What to avoid when taking the drug - such as specific foods, alcohol, milk or other drugs.

  • Common side effects of taking the drug and what to do about them.

  • Possible effects on the child if the drug is taken by a pregnant or breast feeding mother.

  • What to do if the drug does not seem to work.


For example, both the person prescribing antiretroviral treatment and the person thinking of taking antiretroviral treatment would need to know:

  • Accurate information about drugs

  • Cost of drugs

  • Cost of laboratory tests for monitoring

  • Life long therapy

  • Not a cure

  • It can mean taking many pills

  • How to take the drugs - food, diet etc.

  • Side-effects

  • Interactions with other drugs - TB drugs

  • Possibility of resistance - may mean changing combination of drugs


Activity: Information-giving
Aim: To build skills in giving appropriate information when dispensing HIV-related drugs.

Instructions:
NB. Before starting this activity, the facilitator needs to develop two role-plays about dispensing drugs to a person with an HIV-related illness:
  • Role-play 1: Showing bad practice in dispensing HIV-related drugs.

  • Role-play 2: Showing good practice in dispensing HIV-related drugs.

The facilitator also needs to select people to act out the role-plays and to make sure that they are confident about their roles before the activity begins.
1. Explain the aim of the activity.
2. Ask the first group of actors to perform their role-play about bad practice in dispensing HIV-related drugs.
3. Facilitate a group discussion about what was wrong or unhelpful about the way the drugs were prescribed in the role-play. Encourage participants to ask each other questions and to make comments.
4. Ask the second group of actors to perform their role-play about good practice in dispensing HIV-related drugs.
5. Facilitate a group discussion about what was good or helpful about the way the drugs were prescribed in the role-play. Encourage participants to ask each other questions and to make comments.
6. Facilitate a group discussion about what has been learned from the activity, based upon questions such as:
  • What could be the results of bad practice in prescribing HIV-related drugs?

  • What are the 2-3 essential points of good practice that should always be remembered whatever the circumstances?


Facilitators' notes:
  • Encourage the actors not to "over-act" in the role-plays and to try to show the type of situations that might occur in real life.

  • Encourage participants to identify simple and practical messages about good practice - so that they can use them in their every day work on prescribing HIV-related drugs.


Example: Role-plays on drug dispensing
At a skills building workshop, NGO/CBO participants acted out a role-play to illustrate bad practice in dispensing drugs to people with HIV-related health problems:

Role play 1: A patient has finished her drugs, but tells the doctor that she has a stomach pain. The carer asks the doctor about the drugs, but he refuses to talk to her. He looks through his bag and gives several more drugs to the patient, quickly telling her how often to take them, but not checking to see if she has understood. Afterwards, the patient cannot remember the information and asks her carer what to do. Together they decide she should take one of each kind of tablet. The patient does this and develops a headache. When the doctor comes back again, he is angry. The carer tells him he should have explained better, but the doctor shouts at her and tells her it's none of her business.

The participants discussed the role play and noted that the doctor is not acting responsibly, does not do his job well, and does not seem to know what to do about side effects. They also noted that he should have not only information about drugs, but training in how to dispense them well.

The NGO/CBO participants then acted out a role-play to illustrate good practice in dispensing drugs to people with HIV-related health problems:

Role play 2: The doctor comes to see a patient with a chest infection and cough. The doctor examines him thoroughly, and lifts him up so that he can breathe and cough more easily. He asks what medicines the patient has already taken, and if he has had any previous treatment from elsewhere. The patient says no, because other health workers are afraid to come near him in case they catch the infection. The doctor explains carefully how to take the medicines, why the patient should take them, and when he should take them. He writes the information down, and gets the patient to repeat the instructions back to him. The doctor also asks the patient's wife to repeat the instructions in case the patient does not remember them clearly. He tells them what side effects to expect from the medicines and what to do about them. He also tells them about what other care is needed, such as sitting up when the patient needs to cough.

The participants discussed the role play and noted that the doctor has a good relationship with patient and family, a good way of explaining, and the patient trusts the doctor. They also noted that talking about side effects is important, otherwise, the patient might stop taking drugs when he should not.

Afterwards, the facilitator led a group discussion about what had been learned from the activity. For example, participants agreed that the results of bad practice vary from damaging the relationship between the treatment provider and patient to putting the patient's life in danger.

(Reference: Adapted from a workshop on "Access to HIV-Related Treatment," Khmer HIV/AIDS NGO Alliance and the International HIV/AIDS Alliance, Cambodia, May 2001.)

4.4.D. Managing transport for HIV-related treatment
Transport is vital for effective HIV-related treatment work. It is necessary both for enabling clients to access treatment and for moving supplies and skilled help to where they are needed. Transport is necessary to move supplies and people to the places where treatment is provided. It is also necessary for bringing drugs and other materials from sources of supply, whether from a local town or far away. One factor in deciding which suppliers to use will be whether they provide reliable transport for their goods.

The costs and difficulties of transport affects people's access to HIV-related healthcare. For example, if people with HIV need trained medical help, they must go to a clinic, hospital or other place where it is provided. Alternatively, the help must come to them - through a home visit. Either way, transport is required. Using transport takes time and requires money to purchase, maintain and repair vehicles, and to provide fuel. Even walking - which seems cost-free - requires fuel in the form of food and water.

An NGO/CBO might decide that it is important to have their own transport. The budget, costs, availability of spare parts and maintenance of a vehicle will have to be considered. A method of managing the transport will have to be planned, for example making timetables and keeping records of use and repairs. It will also be important to plan what will happen when a vehicle is worn out, damaged or needs to be replaced.

An NGO/CBO and their clients should aim to find the most cost and time -effective transport to suit their needs and resources. Factors to consider when deciding whether to take treatment to a client, or bring the client to the treatment may include:

  • How far are the clients from the treatment services?

  • Are there several clients in one area?

  • Does the NGO/CBO have reliable transport?

  • Is there good public transport for the clients to use?

  • Is there a suitable building for a clinic where clients could come?

  • If it is expensive to rent a building for a clinic, would it be better to spend the money on transport?


4.5. Training and management for treatment work
People are a key resource in HIV-related treatment work. Managing them requires planning - to make sure they have the appropriate skills, training, rewards and remuneration, management, support and supervision.

The skills and training required will depend on what tasks are to be done. Providing a service such as specialist treatment of infections will require different skills from providing basic essential drugs. However, all types of work will need people with a combination of technical and personal skills.

Training can start, update and develop the knowledge and skills of workers. It will help them to work more effectively and efficiently, and to be more confident. Training is beneficial for volunteers as well as paid staff. Resources for training will often be available - particularly through linkages with donors and government.

Active supervision and support are necessary to support training. Different people may need training on different things, depending on their work. Training may be needed for areas such as:

  • Technical skills

  • Personal attitudes

  • Team building and participative working

  • Management


In addition to providing training, it is important first to check that working conditions are acceptable and meet ethical and legal standards. For example, are the procedures for hiring, disciplining and dismissing people fair and legal? Taking care of these aspects makes good sense. Staff who are treated fairly will feel respected and supported by their employers. They will respond more readily to requirements for them to work hard and effectively.

Staff are paid a wage for their work. Volunteers are not usually paid, but might receive expenses for related costs, such as travel. Pay and rewards should be fair, but should also take into account what people value most. Employees might value additional benefits, such as food or help with transport. Recognition and praise from a manager and colleagues can also be rewards in themselves.

Volunteers are an important group of workers for many NGOs/CBOs. Some of them will be people with HIV themselves or affected by HIV/AIDS in some other way. The first step in recruiting volunteers is convincing community members that there is work to do and that voluntary help is necessary.

Good management and support involves good interpersonal skills and providing guidance to help people to do their work. A manager should collaborate with their team to identify needs, set objectives, plan, implement, review and evaluate their work. If possible, anyone responsible for organising the work or for managing other people should receive specific training in relevant areas. Clear management structures are also important - so that everyone knows who to report to and who to turn to if they have a problem.

Good management is not just about getting the job done. It also matters how the job is done. It includes motivating and encouraging all concerned, sharing responsibility and providing support.

Work in HIV-related treatment can be stressful. Good supervision can help in coping with this, but it must be confidential so that people can talk freely. Supervision can involve taking an objective look at how the work is progressing - for example asking whether drugs are being dispensed correctly. Supervision is more effective if it also takes into account what is happening to individuals. For example: Is someone having difficulty carrying out their work or do they have problems outside of work?

Managers should take responsibility to ensure that support and supervision are adequate - whether they are provided by themselves or fellow workers.
Regular meetings are another important way to support the management of a project and to prevent staff burnout.

Planning a training programme for HIV-related treatment
Key issues to consider when planning a training programme include:
  • Who needs the training?

  • What kind of training do they need?

  • Who can provide the training?

  • What methods of training should be used?

  • What material or financial resources will be required?

  • How will you monitor the effectiveness and value of the training?


Meetings for managing work on HIV-related treatment
Examples of meetings to help in the management of treatment work include:
  • Weekly case management meeting.

  • Monthly meeting with people receiving treatment.

  • Monthly staff meeting.

  • Regular retreats or parties.

  • An annual review and re-planning meeting.


4.6. Want to know more?
WHO Model List of Essential Drugs, December 1999.
- guidelines for development of national and other essential drugs lists for local use in resource-poor settings to address health needs of majority of people.

Guidance Modules on Antiretroviral Treatments. WHO and UNAIDS 1998.
- nine modules providing guidance on technical and policy aspects of ARV (antiretroviral) drug treatments for HIV

WHO Model Prescribing Information – Drugs Used in HIV-Related Infections. WHO. 1999.
- a manual providing guidance for prescribers, intended as a model for development of national formularies/prescribing manuals; covers all drugs for HIV-related opportunistic infections

Managing Drug Supply (Second edition). Management Sciences for Health in collaboration with WHO, 1997.
- a textbook about managing pharmaceutical systems covering selection, procurement, distribution, use of drugs, pharmaceutical policy, financing, organisation, management information systems, and human resources management.

Developing HIV/AIDS Treatment Guidelines. UNAIDS. May 1999.
- a resource summarising the principles and process for developing HIV/AIDS treatment guidelines.

How to Manage a Health Centre Store, Healthlink Worldwide, 1994.
- a guideline for running a health centre medical store, including ordering and storing essential drugs and supplies

Management Support for Primary Health Care – a practical guide to management for health centres and local projects. Paul Johnstone and John Ranken. 1994.
- principles and practice of health care management at local level, includes role of understanding communities and individual needs, methods and examples of management.

Basic Accounting for Small Groups. John Cammack, Oxfam (UK and Ireland). 1992.
- a manual about budgets, cash control, bank accounts, reports and auditing; designed for those with no previous experience of accounts.

Primary AIDS Care, Third Edition. Dr Clive Evian, 2000.
- a treatment manual, covers history and context of epidemic, progress of illness, testing, care for different stages of HIV infection, managing HIV-related conditions, needs of different population groups, counselling, care of pain and dying, HIV and health workers; written for South Africa, but applicable to many other countries, includes use of antiretroviral therapies.

Source: Access to Treatment Handbook
This is an extract from Mobilising NGOs, CBOs and PLHA groups for improving access to HIV/AIDS-related treatment: a handbook of information, tools and other resources, developed by the International HIV/AIDS Alliance with support from the World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS), published in this form in June 2002.

To view the whole publication follow this link.

To download this section, complete with graphics, in pdf format (which requires Adobe Acrobat software to read it) follow this link (file size 517 Kbytes).