Rationalization of the Pediatric Antiretroviral Formulary to Optimize Pediatric Antiretroviral Treatment in Malawi
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1 Rationalization of the Pediatric Antiretroviral Formulary to Optimize Pediatric Antiretroviral Treatment in Malawi Presented by: Nandita Sugandhi M.D. 6 th International Workshop on HIV Pediatrics July 18-19,2014 Melbourne, Australia
2 Consolidating procurement simplifies supply chains and increases demand Example: AZT+3TC+NVP regimen for kg weight band Product Fragmentation Multiple formulations procured for one regimen Difficult to achieve minimum batch size per product Product Consolidation Improve patient outcomes Limit supply risks, meet minimum batch size Decrease costs Syrups Singles FDC s Batch size per product Individual Order AZT Single 3TC Syrup AZT Single NVP Single AZT/3TC dual FDC AZT Syrup 3TC Syrup NVP Syrup AZT Single 3TC Single NVP Single AZT Syrup 3TC Syrup NVP Syrup AZT Single 3TC Single NVP Single AZT/3TC FDC (non-disp) Minimum batch size AZT/3TC/NVP triple FDC AZT/3TC/NVP triple FDC AZT/3TC/NVP triple FDC FDC s 2
3 In 2010, Malawi procured 23 different formulations, including ddi ARV Formulations procured in 2010 by Malawi: 3TC (150mg) 3TC (150mg) + AZT (300mg) 3TC (30mg) + ABC (60mg) 3TC (30mg) + AZT (60mg) 3TC (30mg) + AZT (60mg) + NVP (50mg)-Dispersible Tablets 3TC (30mg) + d4t (6mg) 3TC (30mg) + d4t (6mg) + NVP (50mg) 3TC (50mg/5ml) 3TC (60mg) + d4t (12mg) 3TC (60mg) + d4t (12mg) + NVP (100mg) ABC (20mg/ml) ABC (300mg) AZT (100mg) DDI (125mg) DDI (200mg) DDI (25mg) EFV (200mg)-Tablets EFV (50mg)-Capsules LPV/r (200/50mg) LPV/r ( mg / ml) LPV/r (100/25mg) NVP (200mg) NVP (50mg/5ml) 3
4 Malawi s Optimization Opportunities 1 Limit use of syrups Limit use of single tabs and capsules Replace 50mg EFV cap with EFV 200mg scored tablet Consolidate around one pediatric d4t FDC
5 Between 2010 and 2012 Malawi reduced the total number of pediatric ARV formulations procured from 23 to 8 ARV Formulations procured in TC (150mg) 3TC (150mg) + AZT (300mg) 3TC (30mg) + ABC (60mg) 3TC (30mg) + AZT (60mg) 3TC (30mg) + AZT (60mg) + NVP (50mg)-Dispersible Tablets 3TC (30mg) + d4t (6mg) 3TC (30mg) + d4t (6mg) + NVP (50mg) 3TC (50mg/5ml) 3TC (60mg) + d4t (12mg) 3TC (60mg) + d4t (12mg) + NVP (100mg) ABC (20mg/ml) ABC (300mg) AZT (100mg) DDI (125mg) DDI (200mg) DDI (25mg) EFV (200mg)-Tablets EFV (50mg)-Capsules LPV/r (200/50mg) LPV/r ( mg / ml) LPV/r (100/25mg) NVP (200mg) NVP (50mg/5ml) ARV Formulations procured in TC (30mg) + ABC (60mg)-Dispersible Tablets 3TC (30mg) + AZT (60mg) 3TC (30mg) + AZT (60mg) + NVP (50mg)-Dispersible Tablets 3TC (30mg) + AZT (60mg)-Dispersible Tablets 3TC (30mg) + d4t (6mg) 3TC (30mg) + d4t (6mg) + NVP (50mg) EFV (200mg)-Tablets LPV/r (100/25mg) 5
6 Assessing impact of Malawi s pediatric ARV formulary rationalization: Cost of AZT/3TC/NVP for a 10-14kg child Methodology: Product Pack Size Product Cost Shipping Cost Total Cost Daily Dose (10-14 kgs) Average Cost per Pack PPPY Cost UNITAID-CHAI Data Calculations For each item, PPPY costs were derived for the following cost components: product cost, freight cost, procurement fee, handling fee, insurance fee Lead times were defined as the number of days elapsed between procurement order date and the invoice date 6
7 Results of rationalization: Total unit cost savings of over 70% between 2010 and 2013 Data from CHAI-UNITAID Pediatric ARV Donation Program 7
8 Results of rationalization: Reduction in lead times Data from CHAI-UNITAID Pediatric ARV Donation Program 8
9 2013 IATT Optimal Paediatric ARV Formulary Drug Class Drug Formulation Dose NRTI AZT Oral liquid* 50 mg/5ml NNRTI EFV Tablet (scored) 200 mg NNRTI NVP Tablet (disp, scored) 50 mg NNRTI NVP Oral liquid* 50 mg/5ml PI LPV/r Tablet (heat stable) 100 mg/25mg PI LPV/r Oral liquid 80 mg/20 mg/ml FDC AZT/3TC Tablet (disp, scored) 60 mg/30 mg FDC AZT/3TC/NVP Tablet (disp, scored) 60 mg/30 mg/50 mg FDC ABC/3TC Tablet (disp, scored) 60 mg/30 mg FDC ABC/AZT/3TC Tablet (non disp, scored) 60 mg/60 mg/30 mg * Oral liquids to be used to provide infant prophylaxis for PMTCT
10 Acknowledgments and Thanks CHAI Marianne Gauval Vadim Shepel Umesh Warty UNICEF Atieno Ojoo UNITAID Virology Education 10
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