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Integrating HIV Commodity Supply Chains to Prevent Mother to Child Transmission Scale Up in Nigeria.

Author(s) Chioma Nwuba1, Sunday Aguora2, Ogubuike Inmpey3, Elvis Okafor4, Okechukwu Agbo5, Vincent Ihaza6.
Affiliation(s) 1HIV/AIDS, Supply Chain Management Systems, John Snow Inc., Enugu, Nigeria, 2HIV/AIDS, Supply Chain Management Systems, John Snow Inc., Abuja, Nigeria, 3HIV/AIDS, Supply Chain Management Systems, John Snow Inc., Enugu, Nigeria, 4HIV/AIDS, Supply Chain Management Systems, John Snow Inc., Abuja,Nigeria, 5HIV/AIDS, Supply Chain Management Systems, John Snow Inc., Enugu, Nigeria, 6HIV/AIDS, Supply Chain Management Systems, John Snow Inc., Enugu, Nigeria.
Country - ies of focus Nigeria
Relevant to the conference tracks Health Systems
Summary Reduction in the rate of mother to child transmission of HIV in Nigeria depends on the availability of antiretroviral (ARV) drugs and HIV test kits in sufficient quantities at service delivery points.
The challenge of multiple storage and distribution channels for HIV commodities, late submission of reports, coupled with low commodity delivery coverage of rural clinics has led to pregnant women travelling long distances to access ARV treatment at urban hospitals.
Integrating existing supply chain management systems to prevent stockouts of essential commodities is crucial for preventing new HIV infections among children and for improving the lives of HIV positive pregnant women in Nigeria.
What challenges does your project address and why is it of importance? Globally, the gap for pregnant women receiving antiretroviral (ARV) medicines for the prevention of mother to child transmission (PMTCT) of HIV is 80% and Nigeria alone accounts for 32% of this gap. In addition, Nigeria has the largest number of children acquiring HIV infection with nearly 60,000 children infected with HIV in 2012 alone.
Thus, ensuring that all pregnant women receive access to HIV testing services and anti-retroviral treatment if tested positive is a priority for achieving PMTCT targets in Nigeria. The current system for collection and transmission of logistics management information system (LMIS) reports, from service delivery points at rural clinics to the central medical store, are complex and labor intensive. As a result, report submission is often delayed, leading to stockouts of critical HIV/AIDS commodities and a reduction in the number of pregnant women who have access to the much needed life-saving antiretroviral treatment.
In addition, multiple storage and distribution channels are often uncoordinated, and this has resulted in stockouts of commodities at some health facilities when there are excess stocks at other facilities.
How have you addressed these challenges? Do you see a solution? In order to improve access to HIV testing services and antiretroviral drugs for HIV positive pregnant women, at 471 rural clinics in five focus states, the USAID funded SCMS project of John Snow Inc. in Nigeria implemented the following data driven interventions: Integrated existing parallel HIV/AIDS commodity management system in the region to form a unified system for procurement, storage and distribution of commodities.
 Integrated collection and analysis of LMIS reports with already existing data collection systems thus facilitating timely report submission which informs resupply decisions to health facilities offering PMTCT services.
 Established an axial storage location within the region for storage & distribution of HIV/AIDS commodities to health facilities.
 Strengthened capacity and skills of community health workers on logistics management of HIV/AIDS commodities through on-site training and mentoring on the use of logistics management information system (LMIS) tools, standard operating procedures, good storage practices and quality improvement processes for efficient delivery of PMTCT services
 Introduced simplified reporting forms to aid community health workers in the collection and timely submission of accurate consumption and requisition reports.
 Initiated bi-monthly cluster review meetings which provides a forum for community health workers to have access to continuing education on the management of HIV commodities, review logistics management information reports, share best practices and address challenges.
 Increased collaboration with government agencies and implementing partners to support LMIS report collation and to address stock imbalances through timely inter facility transfer and redistribution of commodities to avert stockouts and reduce wastages due to expiration.
 Commenced monitoring and supportive visits to monitor quality of services delivered and strengthen the performance of health workers at service delivery points.
 Challenges and issues identified at service delivery points are shared with health facility management teams and the regional technical working group who proffer and implement solutions to address these challenges.
How do you know whether you have made a difference? At the end of six months, the reporting rate for ARV drugs increased from 28.7% to 60% while that of HIV test kits increased from 30.4% to 63.7%.
Due to improved availability of rapid test kits, the number tested for HIV increased from 39,044 before intervention to 79, 384 after intervention. Subsequently, the quantity of test kits ordered increased by 98.5% post intervention.
Integration of all existing HIV/AIDS commodity management systems in the region has resulted in improved commodity security of HIV test kits and ARV drugs thus ensuring continuous availability of these commodities for HIV positive pregnant women and children. Furthermore, the introduction of a simplified HIV commodity reporting form which harmonizes collection of data on ARV drugs and HIV test kits has made it easier for community health workers in rural clinics offering PMTCT services to report consumption of commodities and to make requisitions for re-supply.
The cluster review meetings have improved quality of logistics data as well as the collection and timely transmission of such data required for resupply decision making, resulting in increased availability of HIV-related commodities and improved quality of care.
Have you or the project mobilized others and if so, who, why and how? The outcome of our interventions and lessons learned were adopted during the implementation of the third phase of the HIV/AIDS Supply Chain Unification Project , which covered seven states in the South Western region of Nigeria. It integrated all existing HIV/AIDS commodity management systems in the region aimed at improving commodity security in the supply of HIV rapid test kits and ARV drugs. We commenced by convening a stakeholders meeting with the state ministry of health, implementing partners and other relevant agencies on the need to harmonize the warehousing and distribution of HIV commodities to all service delivery points. The importance of HIV testing services especially for pregnant women and the outcome of treatment interruptions due to stock-out of essential ARV drugs was discussed.
Health workers at service delivery points were trained on the logistics management of HIV/AIDS commodities, use of standard operating procedures, logistics management information system (LMIS) tools and good storage practices.Bi-monthly reports on consumption and requisition of commodities are reviewed during cluster review meetings thus ensuring that commodity requests sent to the central level more accurately reflect health facility needs and, consequently, decrease the occurrence of stock imbalances (under/over stocking) which could result in stockouts or wastage due to expiration and damage.
When your donor funding runs out how will your idea continue to live? This program was executed in collaboration with the Federal/State Ministry of Health (HIV/AIDS Division), National Agency for the Control of AIDS and relevant stakeholders of each participating state. Government ownership and leadership of the program is facilitated through the Procurement and Supply Management Technical Working Group (PSM TWG) which is government driven and has representatives of each participating state as members.
This group conducts regular on site monitoring and supportive visits to health facilities in the region where they review performance of the supply chain system at various facilities, assess program implementation, identify and addresses challenges relating to the management of health commodities and quality improvement of supply chain processes in the region.
The government driven PSM TWG also advocates for funding support from respective state governments while seeking ways to improve overall program efficiency.Furthermore, to facilitate ownership and sustainability, each state is actively involved in the collection, transmission of LMIS reports and inter facility redistribution of commodities to health facilities within their states through the state logistics management team.
Working closely with relevant key stakeholders, we hope to achieve government’s leadership and ownership of the project in three to five years from now.

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