PEPFAR

The Laboratory’s Key Role in Scale-Up and Sustainability

Seema Meloni, Ph.D., M.P.H.Harvard School of Public Health

AIDS 2012: Turning the Tide Together

25 July 2012 AIDS PreventionInitiative Nigeria

GETTING TO 6 MILLION: LESSONS FROM THE TRACK 1.0 PEPFAR PROGRAM

“Strengthening national health laboratory systems in

resource-poor countries is critical to meeting the United

Nations Millennium Development Goals.”

Birx D, de Souza M, Nkengasong JN. The interaction of health and laboratory systems, clinical research, and service delivery. Am J Clin Pathol. 2009; 131:849-51.

PEPFAR

The Harvard PEPFAR Track 1.0 Program Experience in Nigeria

Notes from the Field

GETTING TO 6 MILLION: LESSONS FROM THE TRACK 1.0 PEPFAR PROGRAM

Overview: Harvard PEPFAR Nigeria

• 2000: Through Bill & Melinda Gates Funding, Harvard has been working with multiple hospitals and prevention programs in Nigeria

2004 2005 2006 2007 2008 2009 2010 20110

20,000

40,000

60,000

80,000

100,000

120,000

140,000

160,000

180,000 Cumulative in HIV Care

Current in HIV Care

Cumulative on ART

Current on ART

• 2004: In collaboration with AIDS Prevention Initiative in Nigeria (APIN), PEPFAR HIV care and ART activities started at 6 tertiary hospitals

• 2005-2012: Expanded to a total of 32 ART sites and 64 PMTCT sites

GETTING TO 6 MILLION: LESSONS FROM THE TRACK 1.0 PEPFAR PROGRAM

Objectives of the Harvard PEPFAR Nigeria Lab Program

1. Integrate within the Federal Government of Nigeria health system plan

2. Develop state-of-the-art laboratory services for multiple service tiers

3. Provide cost-effective, accurate, and high-quality laboratory service

4. Develop sustainable continuous training program to support partner sites

5. Build program-wide quality system for lab diagnosis and/or monitoring

6. Support electronic data capture of all laboratory records

GETTING TO 6 MILLION: LESSONS FROM THE TRACK 1.0 PEPFAR PROGRAM

Jos University Teaching Hospital

GETTING TO 6 MILLION: LESSONS FROM THE TRACK 1.0 PEPFAR PROGRAM

Laboratory Network & Infrastructure

• Tertiary Laboratories: 11 labs in 6 states• Secondary Laboratories: 15 labs in 7 states• Primary Laboratories: 45 (in progress)

Lab Equipped

Training complete

Internal QA/QC

EQA program

Serology (HIV, HBV, HCV) X X X CAP 2007

CBC X X X Cross-site

Chemistry X X X CAP 2007

CD4- flow X X X UK-NEQAS (2006)

Viral Load X X X Harvard (2006)

Infant DNA PCR X X X CDC (2007)

GETTING TO 6 MILLION: LESSONS FROM THE TRACK 1.0 PEPFAR PROGRAM

Training

• Three tertiary labs have been designated training centers for hands-on workshops and training sessions

• Training model relies on tiered system– Tertiary institutions responsible for training satellite sites

• Standardized training guidelines across program

Jos University Teaching Hospital

Abnira Medical Center

Solat Women’s Hospital

Jenvak Hospital Tundun Wada

Nassarawa Medical Center

Pankshin General Hospital

PHC Amper

PHC Kabwir

FCE Clinic

Seventh Day Adventist

PHC Amo Katako

PHC Zabolo

PHC Jengre

Barakin Ladi General Hospital PHC Maikatako

PHC Dorowa Babuje

PHC Sho

Panyam Cottage Hospital

PHC Kerang

PHC Mangu

PHC Gindiri

Vom Christian Hospital

PHC Riyom

PHC Ganawuri

PHC Chugwi

Plateau State, Nigeria: Model for Satellite Development

GETTING TO 6 MILLION: LESSONS FROM THE TRACK 1.0 PEPFAR PROGRAM

Lab Hematology ChemistryCD4 or CD4% Viral Load DNA PCR

Drug resistance Genotype

ABUTH 8430 7056 8594 3951 395 JUTH 20833 20902 22622 14185 4801 90LUTH 12312 12348 12966 6692 2445 NIMR 18173 18458 18469 8669 3294 66UCH 8384 12897 15761 8069 2155 20FMCM 15718 16216 17003 3578 964 OLA 4290 4392 4365 2610 204 UMTH 9762 6237 9606 4753 690 UNTH 8863 8825 8870 2996 500 Eleta 812 788 811 Ogbomosho 1173 1011 1014 Ijebu-Ode 2062 1232 2336 Sacred Heart Lantoro 1392 1452 1437 FMC Nguru 250 220 1315 SSH Maiduguri 711 3 780 Shendam 1610 1150 1602 Solat 999 655 1393 Adeoyo 3424 3274 3333 Total 119,198 117,116 132,277 55,503 15,448 176

Volume of Laboratory Tests Performed in 2011

PEPFAR

The Harvard PEPFARLaboratory Master Trainer and

Site Support Programin Botswana

Notes from the Field

GETTING TO 6 MILLION: LESSONS FROM THE TRACK 1.0 PEPFAR PROGRAM

Laboratory Master Trainer & Site Support Program Team

Laboratory Master Trainer Corps

1 Lab Master Trainers (assigned by Government)

6 BHP-PEPFAR LabMaster Trainers

Train site-level lab personnel as site Master Trainers

Coordinator (Director of the National HIV Reference Laboratory)

GETTING TO 6 MILLION: LESSONS FROM THE TRACK 1.0 PEPFAR PROGRAM

2002-2004: 2 Labs with CD4 and Viral Load Capabilities

NHHRL

BHHRL

BHHRL – BotswanaHarvard HIV Reference Laboratory

NHHRL – NyangagbweHospital HIV Reference Laboratory

GETTING TO 6 MILLION: LESSONS FROM THE TRACK 1.0 PEPFAR PROGRAM

2005-2008: 21 Laboratories with CD4 Capabilities

FacsCalibur

FacsCount

CD4 Equipment

Partec CyFlow

Coulter

FacsCount at a Clinic

GETTING TO 6 MILLION: LESSONS FROM THE TRACK 1.0 PEPFAR PROGRAM

2005-2008: 8 Laboratories with Viral Load Capabilities

Roche Taqman 48Cavidi ExaVir Load

Viral Load equipment

Equipment available – no space

GETTING TO 6 MILLION: LESSONS FROM THE TRACK 1.0 PEPFAR PROGRAM

Effect of Decentralization of LabsN

umbe

r of T

ests

GETTING TO 6 MILLION: LESSONS FROM THE TRACK 1.0 PEPFAR PROGRAM

Challenges• Upgrades and updates needed

– Early renovations and equipment need replacement– More trained engineers needed to keep up with numbers – New kits = adapted logistics and trainings

• Big sites cannot continue to support the increasing demand

• Bridging gap between care providers and the laboratories to ensure data are appropriately used in course of care (Birx et al, 2009)

PEPFAR

Acknowledgements

This work was funded by the U.S. Department of Health and Human Services, Health Resources and Services Administration.

P. Kanki (PI) R. MarlinkJ-L. SankaléD. HamelB. ChaplinH. RawizzaA. Dieng-SarrG. EisenC. SmithM. O’MalleyC. ChangH. ReyesN. UlengaL. DinicJ. HosseiniU. IjeomaE. KochC. WenA. WeissP. BurnsM. Farhani

R. MurphyK. ScarsiK. HurtB. TaiwoC.Achenbach

P. OkonkwoT. JolayemiJ. SamuelsE. OfucheB. BanigbeS. OchigboR. OlaitanP. AkandeT. OyebodeB. AkinyemiO. EberenduC. O’MartinsJ. AdeolaI. AbbasA. Obakeye

I. AdewoleD. OlaleyeJ. IdokoS. SagayO. AgbajiO. IdigbeD. OnwujekweC. OkanyR. NkadoW. GashauH. MuktarJ. AbahC. ChukwukaS. AkanmuF. Ogunsola

All our colleagues at the PEPFAR sites in Nigeria and

Botswana.

And, most importantly, the patients

J. MakhemaT. GaolatheM. Mine