South Africa: Covid-19 - Some Chronic Patients to Be Given Enough Pills for 3 or 4 Months

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Four provinces have made positive moves to announce that patients on chronic medicines will be able to have their scripts filled for as long as three or four months in order to minimise their exposure to possible COVID-19 infection in public spaces like clinics.

But in practice, it is unlikely that all patients will immediately be able to pick up a three-month supply of their medicines throughout all facilities by their next collection date. Officials from the National Department of Health say that in balancing stock levels and managing logistics in a time of COVID-19 lockdown multi-month script refills across the board will not be a reality, even though it is being assessed for implementation.

People receiving medication for hypertension, diabetes, and various respiratory conditions are among the population groups who are thought to have greater vulnerability to complications from contracting COVID-19. People with HIV and tuberculosis infection may also be at increased risk of getting seriously ill or dying - although this is not yet clear.

Keep to scheduled dates

"The biggest fear from patients has been that the facility where they usually pick-up their medicines will be closed due to the lockdown so we did see people flocking to some of their collection points after the president's announcement," says Maggie Munsamy, head of CCMDD (Centralised Chronic Medicines Dispensing and Distribution) at the National Department of Health (NDoH).

Munsamy says that the key message is for patients to continue to pick up their medicines from their preferred channel (clinics, fast lane, CCMDD or others) on their scheduled collection date. She confirms that post offices have been closed as a non-essential service during lockdown "for now" and patients affected by this temporary closure are being communicated to via SMS about alternative pick-up points and dates. This also applies to patients picking up their medicine parcels from collection points that have amended operating hours as a result of the lockdown.

"We have been planning for all these scenarios - including things like if an independent pharmacist gets sick and has to close for a few weeks or in the event of something like a COVID-19 contamination at any pick-up point," says Munsamy.

There are currently 3.2 million people registered on CCMDD and over 2000 registered collection points in the country. Munsamy says the extensive network means service providers have established communication channels with their patients. She adds that patients can also make use of the 0600 123 456 hotline and the department is working on targeted electronic communication to service providers and clinicians.

But Munsamy has cautioned that patients should not expect to necessarily be able to pick up a three months' supply of their chronic medicines at their next collection date.

"We are at the end of a financial year; we also have supply disruptions from India and China. We do have stock to cover us for one or two month refills but not for refill scripts for up to three or four months at a time. This is something that has been tabled at NDoH and as soon as stocks are stable we will assess and see what we can do," she says.

She adds however, that for clinicians and pharmacists who have stable stock "there should be no reason why they can't issue three-month refills".

Why multi-month dispensing makes sense

Multi-month medicine dispensing in a time of COVID-19 has been welcomed as an effective way to reduce the risk that patients with underlying conditions will be exposed to the COVID-19 virus.

Lynne Wilkinson of the International Aids Society says it is positive that at least four provinces have made the commitment to move in the direction of multi-month script refills. But she stresses that there is no time to waste.

"This is an outbreak, it's an emergency and the national department needs to be on top of its stock management - every day we delay is a day lost," she told Spotlight.

"It might not be immediately possible to have everyone on a three-month refill but we have to give people what we can - from new patients to stable patients. We just don't want people who have underlying conditions to be in facilities where there will likely be people infected with COVID-19," she says.

Wilkinson says during the drought in the Western Cape in 2018, facilities were able to give patients chronic medicines for up to four months at a time.

She says communication and stock management from a provincial level down to clinic level must be "exquisite" at this time to manage stock levels and to stop clinics from hoarding medicines.

She adds that in the case of HIV patients, they should be encouraged to switch to tenofovir/lamivudine/dolutegravir (TLD) treatment from tenofovir/ disoproxil/ fumarate/lamivudine/efavirenz (TLE). Wilkinson says TLD stock levels are in good supply compared to levels of Efavirenz-based combinations, making them an obvious choice as part of a Coronavirus disease response plan.

North West district leads the way

The Bojanala district in the North West was the first to respond to this issue on 19 March. In a circular it called for "all chronic patients to be given three months prescriptions in order to reduce crowding which needs to also be monitored in waiting areas. Further instructions will follow".

In the Western Cape draft guidelines indicate that in the case of patients on TLD, patients would be given up to four months' supply. However, the provincial guidelines also noted that "current medicine supply in the country is already compromised and further global stock-outs due to COVID-19 in China are expected". China, the initial epicentre of COVID-19, is a major producer and exporter of Active Pharmaceutical Ingredients (API).

The notice went on to state: "We therefore need to judiciously use stock we have at present whilst supporting patients to practise social distancing." It also flagged a shortage of stock of TEE (tenofovir/emtricitabine/efavirenz). The guidelines recommend, as a priority, a switch of eligible patients to TLD.

In Gauteng a notice issued by the provincial health authorities on 22 March called for a push to increase the number of chronic patients registered on CCMDD and for "patients to be provided with three months' supply of medication and repeat scripts for six months". The province also urged patients on chronic medication to make use of the Pelebox - the smart locker system for medicine collection that doesn't require entering a clinic or standing in a long queue.

KwaZulu-Natal's circular to staff was low on detail, but stated in order "to decongest health facilities during this period a two to three months' supply of chronic medication was to be issued".

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