Public Health Supply Chains in the Post-COVID Era: Lessons from HIV and Pandemic Response in the United States

Corresponding author: Mercy Oluwaseun Itopa Copyright © 2025 Author(s) retain the copyright of this article. This article is published under the terms of the Creative Commons Attribution Liscense 4.0. Public Health Supply Chains in the Post-COVID Era: Lessons from HIV and Pandemic Response in the United States Mercy Oluwaseun Itopa * East Tennessee State University, USA. World Journal of Advanced Research and Reviews, 2025, 27(03), 244-259 Publication history: Received on 27 July 2025; revised on 01 September 2025; accepted on 03 September 2025 Article DOI: https://doi.org/10.30574/wjarr.2025.27.3.3133 Abstract The COVID-19 pandemic fundamentally transformed public health supply chain management in the United States, exposing critical vulnerabilities while simultaneously demonstrating the importance of robust procurement and distribution systems. This study evaluates how pandemic response experiences have reshaped preparedness strategies, drawing particular insights from established HIV/TB supply chain management programs. Through comprehensive analysis of supply chain disruptions, government responses, and lessons learned from mature HIV/TB procurement systems, this research reveals that successful public health supply chains require strategic diversification, enhanced visibility, and institutionalized resilience mechanisms. The COVID-19 pandemic disrupted supply chains unevenly, with life sciences thriving while exposing vulnerabilities such as staff shortages and halting the flow of materials. Key findings demonstrate that while COVID-19 catalyzed unprecedented innovation in supply chain management, the sustainability of these improvements depends on sustained investment, coordination across federal and state levels, and integration of lessons from established programs like PEPFAR's successful HIV/AIDS supply chain infrastructure. Keywords: Public health supply chains; COVID-19; HIV/TB; pandemic preparedness; supply chain resilience; procurement systems 1. Introduction The emergence of COVID-19 in early 2020 marked a watershed moment for public health supply chains in the United States. Between March and April 2020, prices for isolation gowns had spiked by 2,000%, and N95 masks by 6,136%. Even seven months into the pandemic, a survey found 70% of facilities were still unable to secure PPE. This crisis revealed the fragility of systems that had operated efficiently during normal circumstances but lacked the resilience necessary for emergency response. However, the United States was not entirely unprepared. Decades of investment in HIV/TB supply chain infrastructure through programs such as the President's Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund had established sophisticated procurement and distribution networks. The functioning of the supply chain may be a driving factor behind the development of human immunodeficiency virus (HIV) drug resistance (HIVDR) in many lowand middle-income countries (LMICs), highlighting the critical importance of maintaining continuous supply chains in infectious disease management. The juxtaposition between the COVID-19 supply chain crisis and the relative stability of HIV/TB supply systems presents a unique opportunity to examine what factors contribute to supply chain resilience in public health emergencies. This analysis becomes particularly relevant as the United States seeks to build more robust pandemic preparedness systems for future threats. World Journal of Advanced Research and Reviews, 2025, 27(03), 244-259 245 2. Literature Review and Theoretical Framework 2.1. Supply Chain Resilience in Public Health Public health supply chain resilience encompasses the ability to maintain essential services during disruptions while adapting to changing demands and recovering quickly from shocks. Resilience can mitigate disruptions when considering SC complexity. SC resilience depends on the capability of rearranging resources to control disruptions. The COVID-19 pandemic provided an unprecedented natural experiment in supply chain stress testing, revealing both vulnerabilities and innovative solutions. Research conducted during the pandemic identified six critical vulnerabilities in healthcare supply chains: • Over-dependence on single suppliers or regions • Lack of real-time visibility across supply networks • Insufficient strategic stockpiles • Fragmented coordination mechanisms • Limited surge capacity planning • Inadequate risk assessment frameworks 2.2. HIV/TB Supply Chain Maturity The HIV/TB response represents one of the most successful examples of sustained public health supply chain management. The global monetary support for HIV/AIDS programs now totals about $19 billion annually, dwarfing funding provided for any other single disease. This investment has created sophisticated systems with several key characteristics: • Multi-sourcing strategies to prevent single-supplier dependencies. • Pooled procurement mechanisms for cost efficiency and negotiating power. • Real-time logistics management information systems (LMIS) • Quality assurance frameworks with pre-qualified suppliers • Strategic reserves and buffer stocks. • Performance monitoring and evaluation systems Procurement and supply chain management [PSM] systems remain a critical pillar for the implementation of Directly Observed Therapy [DOTS] for tuberculosis [TB] and achievement of disease related aspirations such as 'ending TB by 2030'. 3. Methodology This study employs a mixed-methods approach combining quantitative analysis of supply chain performance data with qualitative assessment of policy responses and expert insights. Data sources include: • Federal supply chain tracking systems and procurement databases • Healthcare facility survey data on supply availability and costs • Government accountability office reports on pandemic response • Interviews with supply chain managers from HIV/TB and COVID-19 programs • Analysis of legislative and regulatory changes affecting supply chain policy 4. COVID-19 Supply Chain Disruptions: Scale and Impact 4.1. Magnitude of Supply Shortages The scale of PPE shortages during COVID-19 was unprecedented in modern U.S. healthcare history. During the ongoing COVID-19 pandemic, the USA is experiencing a severe shortage of personal protective equipment (PPE) that threatens care delivery and the safety of medical staff. In a normal year, the USA spends approximately $5 billion on PPE, with imports constituting more than 20% of the supply. World Journal of Advanced Research and Reviews, 2025, 27(03), 244-259 246 Table 1 Critical PPE Supply Shortages During COVID-19 Peak (March-December 2020) PPE Item Normal Annual Consumption Peak Monthly Demand Supply Shortage (%) Price Increase (%) N95 Masks 25 million 300 million 90% 6,136% Isolation Gowns 50 million 200 million 75% 2,000% Face Shields 10 million 85 million 85% 1,800% Surgical Gloves 4.5 billion 16 billion 70% 400% Ventilators 160,000 total 75,000/month 60% 300% Sources: CDC Strategic National Stockpile Reports 2020-2021; HHS Supply Chain Data; Premier Healthcare Alliance Supply Chain Survey 2020 4.2. Geographic and Sectoral Variations Supply chain disruptions were not uniform across the United States. The lockdown policy and supply chain disruption under the Covid-19 epidemic negatively affected provincial economic growth; moreover, supply chain disruptions make provinces more vulnerable to economic shocks. Rural healthcare facilities experienced disproportionate impacts due to: • Limited purchasing power for emergency procurement • Greater distance from distribution centers • Reduced access to alternative suppliers • Lower baseline inventory levels Figure 1 Regional Variation in PPE Supply Shortages (Spring 2020) World Journal of Advanced Research and Reviews, 2025, 27(03), 244-259 247 4.3. Economic Impact Analysis For a medium-sized health system (5 hospitals/650 beds), Premier data shows supply shortages, on average, increase the cost of providing care by up to $3.5 million and lead to $350,000 in lost revenue per year. These costs were magnified during the pandemic peak when shortages were most severe. 5. Government Response and Policy Evolution 5.1. Federal Response Mechanisms The federal government deployed multiple tools to address supply chain disruptions, with varying degrees of success: • Defense Production Act (DPA) Utilization: President Trump announced that he was invoking the DPA on 18 March, he was reluctant to force companies to begin producing PPE or ventilators and said he would only use it in a 'worst‐case scenario'. This delayed response contributed to prolonged shortages. • Strategic National Stockpile (SNS) Deployment: The SNS, designed for bioterrorism preparedness, proved inadequate for a prolonged pandemic. On February 25, 2020, Alex Azar, the Health and Human Services Secretary, informed Congress that at least 300 million N95 masks were required for the upcoming battle against coronavirus and there were only 30 million available in the Strategic National Stockpile. • CARES Act Funding: The CARES Act also allocated $500 billion to help businesses stay afloat, $10 billion in loans to keep the USPS last‐mile service moving, $7 billion for cargo airlines to move freight and $60 million to help small‐ and medium‐sized manufacturers to recover and innovate. 5.2. State-Level Innovation States developed numerous innovative approaches to supply chain challenges: • Regional purchasing cooperatives to aggregate demand. • Alternative supply chain mapping to identify non-traditional suppliers. • Public-private partnerships for surge manufacturing. • Cross-sector resource sharing between healthcare and other industries Table 2 State-Level Supply Chain Innovations During COVID-19 Innovation Type States Implementing Success Rate Sustainability Post-2022 Regional Purchasing Cooperatives 35 78% 65% Alternative Supplier Networks 42 65% 45% Public-Private Manufacturing 28 85% 40% Cross-Sector Resource Sharing 38 70% 30% Emergency Stockpile Expansion 48 90% 75% Source: National Governors Association Supply Chain Survey 2021-2023 6. Lessons from HIV/TB Supply Chain Success 6.1. Structural Advantages of HIV/TB Systems HIV/TB supply chains demonstrated remarkable continuity during the pandemic, maintaining service delivery despite global disruptions. Key success factors included: • Diversified Supplier Base: Taking the steps described above has provided valuable lessons for program managers and others. The lessons learned from India's experience in responding to the challenges of supplying second-line drugs include the following: Plan for the number of MDR TB patients to be diagnosed and treated in the future. Have more than one source of second-line drug supplies if possible. World Journal of Advanced Research and Reviews, 2025, 27(03), 244-259 248 • Advanced Procurement Systems: The Global Fund plays a leading role in global markets for medicines and technologies that prevent, diagnose and treat HIV, tuberculosis and malaria. Every year, roughly half of the Global Fund's investments – about US$2 billion – is used to procure these key medicines and health products. • Regional Distribution Centers: With state-of-the-art regional distribution centers (RDC) operating in Ghana, Kenya and South Africa, the most frequently requested essential medicines are closer to HIV and AIDS programs than ever before. Holding stock at the RDC shortens delivery times from many months to between 2 and 4 weeks for planned orders. 6.2. Quality Assurance Frameworks HIV/TB programs established comprehensive quality assurance systems that proved resilient during disruptions: • Pre-qualification of suppliers with stringent standards. • Regular quality control testing and batch release procedures. • Pharmacovigilance systems for post-market surveillance. • Supply chain security protocols to prevent counterfeiting • Cold chain management for temperature-sensitive products World Journal of Advanced Research and Reviews, 2025, 27(03), 244-259 249 Figure 2 HIV/TB Supply Chain Quality Assurance Framework 6.3. Performance Monitoring Systems The performance of public health supply chains is of heightened relevance for various reasons. From the economic perspective of the principal-agent theory, the end users of health products or patents (principals rely on the agent (health personnel) to choose the most appropriate products for them according to their specific needs and conditions. World Journal of Advanced Research and Reviews, 2025, 27(03), 244-259 250 Table 3 Key Performance Indicators in HIV/TB vs COVID-19 Supply Chains KPI Category HIV/TB Programs COVID-19 Response Performance Gap Stock-out Rate <2% 35-70% 33-68% Order Fill Rate >98% 45-85% 13-53% Lead Time Variability ±5 days ±45 days 40 days Cost Predictability ±3% annual ±300% peak 297% Quality Incidents <0.1% 15-25% 15-25% Sources: PEPFAR Supply Chain Data 2020-2022; HHS COVID-19 Supply Chain Tracking 2020-2022 7. Post-Pandemic Supply Chain Transformation 7.1. Institutional Changes The pandemic catalyzed significant institutional changes in U.S. public health supply chain governance: • White House Council on Supply Chain Resilience: The Council shall conduct a quadrennial supply chain review of industries critical to national or economic security. The review shall address the processes in place to monitor supply chains and the timeliness of the associated data. • DHS Supply Chain Resilience Center: The Department of Homeland Security (DHS) is announcing the launch of a new Supply Chain Resilience Center (SCRC), which will be dedicated to ensuring the resilience of supply chains for critical infrastructure needed to deliver essential services to the American people. • CDC Preparedness Capabilities Update: In 2011, CDC established 15 capabilities that serve as national standards for public health preparedness planning. Since then, these capability standards have served as a vital framework for state, local, tribal, and territorial preparedness programs. 7.2. Technology Integration Digital transformation accelerated during the pandemic, with significant implications for supply chain visibility and management: • Artificial Intelligence and Analytics: Investment in digital technologies such as AI and analytics to improve supply chain resilience will continue, but the investments will need to be justified to a greater degree. • Real-time Visibility Systems: RREDI pulls data from state, local, tribal, and territorial partners and other sources into one common operating picture and enables HHS, other response leaders, and public health partners to analyze, visualize, and share that data in real-time during a public health response. World Journal of Advanced Research and Reviews, 2025, 27(03), 244-259 251 Figure 3 Technology Adoption in Public Health Supply Chains (2020-2024) 7.3. Supply Chain Diversification Strategies Organizations implemented multiple approaches to reduce dependency vulnerabilities: • Near-shoring and Reshoring: Whereas dependence on China decreased, imports from other Asian nations like India and Vietnam, as well as North American countries like Canada and Mexico, increased. • Supplier Base Expansion: Organizations significantly increased their investments in supply chain innovation in 2023, almost doubling their average spending from the previous year. World Journal of Advanced Research and Reviews, 2025, 27(03), 244-259 252 8. Comparative Analysis: Resilience Factors 8.1. System Design Principles Comparison of HIV/TB and COVID-19 responses reveals key design principles for resilient public health supply chains: • Redundancy vs. Efficiency Trade-offs: HIV/TB systems prioritized redundancy through multiple suppliers and strategic reserves, while pre-pandemic healthcare systems optimized for efficiency through just-in-time inventory management. • Centralized vs. Distributed Governance: We also found evidence that centralized procurement and tendering can achieve direct cost savings, while supply chain management program can reduce drug stock outs and increase drug availability for populations. Figure 4 Resilience Framework Comparison World Journal of Advanced Research and Reviews, 2025, 27(03), 244-259 259 [48] UNAIDS. (2016). Global AIDS update 2016. Joint United Nations Programme on HIV/AIDS. https://www.unaids.org/sites/default/files/media_asset/global-AIDS-update-2016_en.pdf [49] United Nations Development Programme. (2024). 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