Availability of antiretroviral drugs and associated factors : a comparison between Malta and Norway

Abstract

Newer antiretroviral drugs (ARVs) are recommended as first line agents because they are more tolerable in terms of adverse events, and achieve faster viral suppression. Discontinuation of antiretroviral treatment(ART) due to adverse effects was shown to be 4% (16/414) in patients on newer ARVs, compared to 14% (58/419) in patients on older ARVs.1 Following reports of limited availability of newer ARVs in Malta2, the aim of this study was to compare the availability of ARVs in Malta to Norway, adherence to ARVs, and determine the factors associated with availability of ARVs. Malta and Norway have the same prevalence of HIV (0.1%) but different incidence rates. Malta reported an HIV incidence rate of 14.5 per 100,000 population in 2016 compared to 4.2 per 100,000 population in Norway.

In this mixed-methods comparative cross-sectional study, data from the dispensing database at Mater Dei Hospital in Malta and the Norwegian Prescription Database was collected to determine the ARVs provided and the proportion of newer ARVs used in Malta and Norway. Using ARV refill dates from dispensing data, adherence to ART was determined using the proportion of days covered (PDC) method to investigate adherence as a factor associated with ARV availability. Using interviewer-administered questionnaires, face-to-face interviews were conducted with pharmacists in Malta and Norway responsible for ART provision to determine other factors associated with availability of ARVs.

ART was provided free of charge by the national health services in Malta and Norway. Up to 23.4% (N= 38605) of ARV prescriptions in Norway were for newer ARVs, compared to 4.9% of all prescriptions (N= 5657) in Malta. Patients in Malta and Norway showed comparable levels of adherence to ART. Seventy one percent (N=3991) of patients in Norway and 74% of patients (N= 265) in Malta had the desired adherence level at a PDC ≥ 95.0%. The 3 pharmacists involved in ART provision in Malta reported that challenges hampering availability of newer ARVs included an out-dated formulary, challenges in drug forecasting, and absence of HIV-allocated funding. In Norway and Malta, the high cost of ARVs compounded by the small market size affected provision of ARVs. Notwithstanding the high cost of ARVs, willingness-to-pay by the national health system was higher in Norway than in Malta. Pre-exposure prophylaxis (PrEP) was provided free of charge in Norway, and not provided in Malta. Interview respondents in Norway reported that the political will to provide the current standard of ART was high, while interview respondents in Malta reported the opposite.

Norway spends more money on ART, which could explain the higher availability of the newer more expensive ARVs as well as PrEP in Norway. Malta spends €4.5 per capita and 2.8% (€1.8 million) of the national pharmaceutical expenditure on ART, while Norway spends €12.26 per capita and 5.2% (€61,316,302) of the national pharmaceutical expenditure on ART. Increasing expenditure on ARVs, and providing newer ARVs and PrEP in Malta could reverse the increasing trend of HIV incidence in Malta.