Multi-month supplies of HIV medications – recommended during lockdowns – are not authorised in many countries

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During the coronavirus pandemic, allowing people who are stable on their HIV treatment to collect enough medication to cover three or six months – therefore minimising unnecessary visits to healthcare facilities – is recommended by the World Health Organization (WHO), UNAIDS, the International AIDS Society, the Global Fund and PEPFAR. However, a third of countries do not permit prescriptions of three months or longer, according to a rapid analysis published by the O’Neill Institute for National and Global Health Law at Georgetown University.

Results were particularly poor in high-income countries.

Before the pandemic, WHO already recommended that clinically stable adults, children, adolescents and pregnant and breastfeeding women could benefit from multi-month prescriptions and refills. The need for this recommendation to be implemented has been made more urgent by social distancing.

"The greatest compliance is from countries supported by PEPFAR and those in southern and eastern Africa."

The O’Neill Institute reviewed national policy documents (national HIV treatment guidelines, differentiated service delivery guidelines, national HIV strategic plants, and pharmaceutical guidelines) for 126 countries to see if they allowed for three- or six-monthly dispensing of HIV medication for stable patients. They also looked at whether national policies clearly defined who is considered stable on antiretroviral therapy and therefore eligible. If national policy documents were not available, the researchers looked at secondary sources including PEPFAR, UNAIDS and WHO.

Of the countries with available data, only 63% and 23% permitted three- and six-monthly prescriptions respectively. The greatest compliance is from countries supported by PEPFAR and those in southern and eastern Africa.

Given the coronavirus pandemic, several countries have expanded the groups of patients eligible for multi-month dispensing. However, countries are not always in a position to implement stated policies. South Africa’s guidelines support three-monthly dispensing, but due to concerns about the supply chain and stockouts, prescriptions are for a maximum of two months.

High-income countries appear to be slower to implement multi-month prescribing. Of around 30 high-income countries surveyed, only 39% and 19% allow for three- and six-monthly prescriptions respectively.

Looking at the three criteria assessed (clear definition of stable patient, allowing three monthly and allowing six monthly refills), Australia, France and the United Kingdom were positively rated for all three. On the other hand, Belgium, Ireland and Spain failed on all three counts. The blockages are often related to insurance and health system regulations, rather than specific HIV guidelines.

“National policies on multi-month dispensing remain largely inadequate,” say the authors.