ARV supply issues cause treatment interruptions in a UK clinic
Simon Collins, HIV i-Base
An email question to the i-Base treatment information service in September reported ARV stock-outs in the UK that resulted in patients having to interrupt HIV medication due to problems in drug supply. 
This case related to drug delivery services contracted to Healthcare at Home to be delivered to the HIV clinic in Taunton. Supply problems had been ongoing for several months.
Any UK clinic should be able to contact the closest hospital pharmacy where ARVs are routinely stocked. Between-clinic support should have been arranged in time to ensure continuous supply, even if this required a courier service that was later invoiced to the contractor.
It is difficult to understand why a UK clinic would allow problems to develop to the point that this happened not just once, but several times.
BHIVA guidelines are clear about risks from treatment interruptions. The first instance should have been a red flag for arranging an emergency interim solution that worked. Instead, the lack of supply seems to have been minimised as a problem, with one email referring to a “temporary disruption” in “a small number of patients”.
Taunton stopped stocking ARVs after contracting all medicines to Healthcare at Home, including being delivered back to the clinic for patients to collect. These problems occurred even when prescriptions were ordered several weeks in advance.
No senior manager at the Taunton clinic elevated this to either a regional or national commissioning level. At the very least, an emergency plan should have been rapidly established at the hospital after the first case of non-delivery.
An additional two further cases of treatment interruptions occurred after patients attended the clinic to collect pre-ordered medications and were sent home with nothing.
Responses from within the hospital have been limited, with no hospital manager willing to respond formally.
A lack of response from Jo Cubbon, the Chief Executive, and Selina Riggs, the lead commissioner for HIV for the South West Specialist Commissioning Group, led to this issue being raised directly by community representatives on the Clinical Reference Group (CRG) and to commissioners at NHS England.
It is difficult to decide whether it was more disconcerting to hear that some commissioners were aware of an ongoing problem and yet had not resolved it or that some were unaware of such serious faults in the services that they are ultimately responsible for commissioning.
Importantly, within weeks of the alert, Taunton reversed its earlier policy and now stocks ARVs at the hospital. We have heard from patients that this has improved the service. It is still unclear why this was not done months ago.
It is essential to raise this supply issue as a treatment alert because of a concern that this might happen in other clinics, especially given pressure within the NHS to privatise services.
Partly due to the intervention by i-Base, these incidents have now been formally classified as serious events. An interanl investigation is now expected to take several months. Until this is resolved, these patients should be formally contacted to explain the process. This should include an applogy.
While services at Taunton have now been changed, the situation should never have arisen in the first place.
It highlights the need for continuous ARV supply to be clarified as a key commissioning standard that should be audited.
Anyone in a similar situation, should either raise it at the highest level in their hospital, or contact i-Base if you would like us to do so on your behalf.
This incident itself would also have been appropriate for an MP to raise as a question in parliament.
i-Base online Q&A service. Stock-out and non-delivery of ARVs in Taunton in the UK (and subsequent comments). 19th September 2014.