CONTENTS
Chapters
- The Toll of STDs
- Reducing the Toll of STDs
- Managing STDs
- Diagnostic and Treatment Tips
- Getting Services to the People
- Getting People to Services
- Promoting Prevention—Condoms and Monogamy
HIGHLIGHTS
Population Reports is published by the Population Information Program, Center for Communication Programs, The
Johns Hopkins School of Public Health, 111 Market Place, Suite 310, Baltimore, Maryland
21202-4012, USA
Volume XXI, Number 1
June, 1993 |
Supplying Drugs
Lack of drugs is currently one of the main barriers to
effective STD services in developing countries. To ensure a
reliable supply of effective drugs, programs need to:
- Order the right drugs
- In sufficient quantity and
- At a low price and
- Distribute them efficiently.
Ordering the right drugs. Programs need to know the
prevalence of specific STDs in the population that they serve. To
assess national STD trends, programs collect information from a
sample of clinics—often called sentinel surveillance—and/or
require all clinics to report STD cases.
Such surveillance also needs to identify drug-resistant
strains of STDs. Drug resistance is fostered by ineffective
treatment—for example, not using enough drug to cure patients
completely. In this way STD pathogens are exposed to the drug and
given an opportunity to mutate into resistant strains.
Penicillin-resistant strains of gonorrhea now account for 25% to
80% of cases (3, 100, 151, 296).
Buying enough at low prices. The cost of drugs forces
governments to buy less than they need or to buy drugs that are less expensive
but also less effective. Drugs for gonorrhea treatment are especially
expensive because of the high prevalence of strains resistant to older,
inexpensive drugs such as penicillin and tetracycline (see Table
3). Drugs should cure 95% or more of
patients (329). Some programs, however, use drugs that cure only 85% to
95% of cases for initial treatment at primary health clinics and save
the more effective drugs for referral clinics. Unfortunately, many people
who are not cured by the initial treatment may not go to the referral
clinic (329). Programs should distribute the most effective drugs to the
clinics where patients first seek care.
To buy STD drugs in the quantities necessary, governments
need to:
- Buy in bulk to obtain volume discounts. In a US
chlamydia treatment program, for example, drugs bought
in bulk cost 60% to 80% less than single doses (304).
To buy in bulk, governments need to establish standard
treatment guidelines so that all providers treat STD
patients with the same drugs. Drugs recommended in the
guidelines must be on the national essential drug list,
of course.
- Get competitive bids. Prices from one supplier, whether
a distributor or manufacturer, may be three or four
times higher than prices from another (175).
- Allocate more funds to buy drugs, and seek donor
funding. Research showing the link between HIV
transmission and other STDs has persuaded governments
to increase spending on drugs or to buy drugs with
money for AIDS control (114, 162).
Asking patients to pay may be acceptable in some settings.
The STD program in Mozambique charged a small fee that covered
the cost of drugs but not the cost of distribution and taxes
(21). The many STD patients seeking care from pharmacists and
other private providers clearly are willing to pay. Still, in
some situations charges may deter patients from seeking care.
There is little information on how charges affect use of STD
services. One study in Nairobi, Kenya, reported a 60% decline in
attendance at an STD clinic when patients were charged about
US$1.75 for diagnosis and treatment, less than half a day's pay
for most city households (200).
Distributing drugs efficiently. Distribution of STD drugs
can be improved by:
- Decentralizing to speed delivery. In Zimbabwe drugs
were shifted from one central warehouse to warehouses
in five of the eight provincial capitals. This change
cut the time that primary health clinics must wait for
orders from six months down to between four and six
weeks (155, 162).
- Monitoring supplies. Primary care clinics need to keep
track of drugs to prevent theft and stockouts. Supplies
may need to be ordered two to nine months in advance
(155). Health care providers generally lack training in
drug supply management. In Ghana, Swaziland, Tanzania,
Zimbabwe, and other countries, in-service courses teach
such skills (154, 257).
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