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Section: Costa Rica
April 2010

Report on a Meeting in Costa Rica Focused on the Analysis of  a  Stock-out just prior to Easter week.

by   Richard Stern*

Four members of the Costa Rican Association of People Living with HIV/AIDS (ASOVIH/SIDA)  including the organization’s President Gustavo Chinchilla,  as well as  myself,  met with approximately 12 officials from the Caja Costarricense de Seguro Social (CCSS) yesterday afternoon , April 6th, 2010 in the offices of the CCSS.   Also present was Dr. Adrian  Vieto from the Health Ministry and National AIDS program. The CCSS is the supplier of all health care in Costa Rica.    Various physicians who work in all aspects of the “supply chain” in Costa Rica were present as well as Directors of the Hospitals which had been affected.    The stock-out which occurred just prior to Easter week,  was analyzed in detail and the causes  were reviewed. Apparently the problem was mostly related  to a breakdown of timely communication between Hospital authorities and the storage facility  where the medicines had already had arrived but had not been distributed.  The stock out affected several hundred PLWA who could not receive their AZT and 3TC on time. In many cases, there were given partial supplies and told to return at a later date.

In general the time framework for the stock-out seemed to be a maximum of perhaps a week, in terms of those PLWA who may have presented themselves at the HIV clinics  on or about  March 26th and could not  obtain needed medications. But by Tuesday, March 30th the medication had been delivered to  all hospitals. 

Costa Rica has provided  universal access to anti-retroviral access since 1997, following a decision by the nation’s Supreme Court ordering the CCSS to provide treatment for People Living with HIV/AIDS. Approximately 3,500 PLWA receive treatment here.   ARV access is completely free, and financing for treatment is not dependent in any way on the Global Fund or PEPFAR, but comes from the CCSS itself. 

Dr. Ubaldo Carrillo of the CCSS  was the chairperson for yesterday’s  meeting and generally explained the situation to  PLWA who were  present.  He expressed some concern about negative publicity which resulted from what was a relatively brief stock-out, but at the same time made what appeared to be a very  sincere commitment to improve communication between all personnel responsible for timely delivery of medications.  Dr. Albin Chavez, Director of Pharmacotherapy for the CCSS,   was also present at the meeting, and defended the record of the CCSS in terms of its continuous commitment to uninterrupted treatment, during the past 13 years.    (Dr. Vieto from the Health Ministry  commented that there were other reports of stock-outs, apparently extremely brief, in other hospitals during the past year but he was not specific in terms of the seriousness of these interruptions, and there was no further discussion of this.)  

Dr. Carrillo pointed out that these two medications (AZT and 3TC)  were in fact present in the two hospitals where the stock-outs occurred, but had  expired  and therefore could not be distributed.   He indicated that he would be investigating why there was a relatively large amount of expired medications on hand as this is not cost-efficient and is against the policies of the CCSS.   The expired medications could have resulted from unexpected changes in the numbers of  PLWA who needed these specific medications, which would be a best case scenario, or in a worst case scenario from poor planning on the part of authorities who ordered the medications. 

A follow up meeting was arranged for April 27th with all parties to be reconvened, and in the mean time, communication about any issues or problems can be channeled directly between  Gustavo Chinchilla or Rosibel Zuniga, from ASOVIH/SIDA, and Dr. Carrillo and his staff at the CCSS.

I commented that I was  impressed that,  within a very few days of this stock-out,   that a meeting of this magnitude  had been arranged in which 18 key stakeholders from government was well as Civil Society could be present, in order to analyze the situation and assure that the problem would be appropriately addressed.

I also raised the issue of “3rd line medications” such as Isentress ( the new integrase inhibitor from Merck) and Darunavir in cases where 2nd line treatment is failing. I pointed out that many Costa Rican PLWA have now been taking ARVs for well over ten years and that  more failures of 2nd line treatment are likely to occur as a greater number of PLWA continue to have more and more years on ARVs.   Dr. Vega from the CCSS indicated that there is now a pilot project in which the CCSS is purchasing raltegrevir (Isentress)  as treatment for 8 PLWA,  and also purchasing Darunavir (Prezista) for an additional 8 PLWA.   However, the cost of Merck’s  Isenstress is over $8,000 per year.  If a large number of PLWA were to eventually  need this or similarly priced  medications,  the high cost becomes a very serious obstacle .  Dr. Carrillo expressed concerned about the cost, and also indicated that Colombia is an example of a country where strong measures have been taken to obtain lower prices.   I commented that Civil Society must work collaboratively  with government in order to advocate for lower costs for newer “third line” medications. However, serious obstacles exist related to Free Trade agreements, and this must be dealt with. The issue of Compulsory Licenses also was brought up, but in terms of “political will” it is not clear how committed the Costa Rican government would be with regard to this issue. 

According to Dr. Vega (who works analyzing treatment protocols for PVVS), the CCSS has also negotiated the purchase of Tenofovir (Viread)  for 150 PLWA and apparently  treatment with Tenofovir  will begin very soon in Costa Rica.

I also raised the issue as to why the CCSS was still using AZT and 3TC separately as opposed  to Combivir or generic versions of AZT and 3TC in one pill as this issue affects adherence.   There was no significant follow-up  on the issue for the moment.  Dr. Albin Chavez did  mention that there are some cases of PLWA with Hepatitis where a AZT must be given separately from 3TC.   However, we did not have time to get into more detail about this issue or how many PLWA are affected by this.

Dr. Chavez also brought up the fact that Costa Rica will most likely  be purchasing a generic version of Abbot’s Alluvia (lopinavir + ritonavir)  from a pre-qualified Indian generic company, at a considerable savings and that he would be forwarding  pricing details as soon as possible.

In general, I can comment personally that I was impressed with the meeting and the commitment of officials from the CCSS. But I also feel that the response from the CCSS was partially  generated by appropriate, strategic,  and well organized pressure from Civil Society as represented by ASOVIH/SIDA.  Without this pressure, it is not clear that the response would have been exactly the same.  Gustavo Chinchilla  from ASOVIH/SIDA  spoke very eloquently during the meeting about the role and responsibility of ASOVIH/SIDA in terms of monitoring problems as they occur.  Other members of ASOVIH/SIDA who contributed significantly during the meeting were Edgar Briceño, Rosibel Zuniga, and Yadira Martin.  At the same time it can recognized  the CCSS has generally distinguished it as a model for economically self-sufficient universal access  on a regional level during the past decade.   

Perhaps some of the  “lessons learned” from this crisis  and from  the very thorough follow up which occurred can also be useful on a region wide level.


*Richard Stern
Asociacion Agua Buena
San Jose, Costa Rica
Tel/fax 506-2280-3548


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