1. SUPPLY CHALLENGES IN PROVIDING ART FOR CHILDREN: The need for responsive supply chains Naomi Printz, Technical Advisor, John Snow, Inc. Amanda Ombeva, Technical Advisor, John Snow, Inc./Logistics Services Claudia Allers, Senior Technical Advisor, John Snow, Inc. XVII International AIDS Conference Mexico City 7 August 2008

2. Need for Responsive Supply Chains Multiplicity of choices in products –FDCs Paediatric FDCs (scored and dispersible), crushed/broken adult FDCs –Single formulation tablets and capsules –Liquids Same child  multiple formulations in one regimen Need to adjust dosages over time as child grows Recommended dosages also change Providers must do calculations and match kids needs with what is in the pharmacy New products continually emerging on market Policy changes

3. Liquid oral formulations will continue to be needed –Not all children able to take FDCs –Some drugs/regimens not yet available as FDCs  no zidovudine-based FDCs on the WHO prequalification list (July 2008) Liquids more difficult to manage –Relatively short shelf lives –Bulky and fragile –Some require cold chain Need for Responsive Supply Chains (2)

4. The Logistics Cycle

5. Responsive Supply Chains: Product Selection Develop strategy for determining criteria for including products in a national formulary –Should consider cost of implementation Establish a timeframe for periodically reviewing STGs Limit the number of formulations to be procured –Formulations should match the STGs

6. Responsive Supply Chains: Introducing New Products Coordinate the timing of procurement with program plans –Goods should not arrive in country until providers have seen and been trained in new guidelines, and implementation plans have been developed 1.Develop implementation plan 2.Verify that all products to be procured are registered in country 3.Disseminate dosing guidelines to sites prior to product arrival in country 4.Train providers on how to use new products

7. Responsive Supply Chains: LMIS Capture consumption, stock on hand, losses & adjustments, and patient by regimen data Data collected and reported by the LMIS should be regularly analyzed to –detect trends –help update forecasts – inform procurement and shipment schedules –facilitate inventory control All LMIS forms should contain blank spaces so that new products can be written in Calculating re-order quantities at the higher level can reduce burden on service providers

8. Responsive Supply Chains: Implementing Policy Changes Think about logistics from the beginning – in what logistics system will products be managed? –Adding co-trimoxazole to ARV drug logistics systems(?) –Implementing more efficacious PMTCT regimens –Changing laboratory guidelines and procedures (i.e. DBS collection)

9. Responsive Supply Chains: Forecasting and Quantification Review forecasts quarterly to make any necessary adjustments to anticipated consumption –Use as many data sources as possible to inform forecasts, including data from LMIS, HMIS, and program plans Use updated forecasts to adjust shipment schedules

10. Kenya: using an Excel-based tool to calculate resupply quantities for sites Calculations based on number of paediatric patients by regimen and by weight band Dosing guidelines for each weight band applied to the number of patients Total quantities expected to be dispensed for the next month calculated Order quantity includes maximum stock quantities and stock on hand

11. TOTAL QUANTITIES REQUIRED 1st Line RegimenAZT+3TC+NVP97% Single Drug Toxicity:AZT+3TC+EFV0.00% D4T+3TC+EFV3.00% D4T+3TC+NVP0.0% Data for each weight band Weight 3-5 kg8.0% 5-10 kg11.4% 10-15 kg15.0% 15 - 20 kg15.6% 20 - 25 kg25.0% 25 - 30 kg25.0% 30 - 40 kg0.0% Pediatric Forecasting Assumptions: Dosage Guidelines AZT Weight AZT60mg/3TC30 mg AZT60mg/3TC3 0mg/NVP50mg AZT300mg/3TC 150mg AZT300mg/3TC150m g/NVP200mg 3-5 kg22 5-10 kg33 10-15 kg55 15 - 20 kg55 20 - 25 kg66 25 - 30 kg 22 30 - 40 kg 22 Pediatric Assumptions: FDC vs Combined Liquid and Solid Formulations AZT Based FDC WeightAZT60mg/3TC30mg AZT60mg/3T C30mg/NVP5 0mg AZT300mg/3TC 150mg AZT300mg/3TC150m g/NVP2000mg 3-5 kg25% 0% 5-10 kg25% 0% 10-15 kg100% 0% 15 - 20 kg100% 0% 20 - 25 kg100% 0% 25 - 30 kg80% 20% 30 - 40 kg0% 100%

12. Responsive supply chains serve customers Customers: children and caregivers, providers and facilities Uncertain demand, constantly changing products, dynamic environment of paediatric ART  Communication between supply chain managers, ART providers, and program managers is critical Responsive supply chains ensure products are available whenever and wherever they are needed