Overcoming sample transportation challenges: Using FedEx to transport HIV early

infant diagnosis (DBS) samples from hard to reach areas to a central lab in Zimbabwe

Tumbare, E; Mahomva, A; Mthombeni, PZiMA Annual Congress

Elephant HillsAugust 28, 2014

Acknowledgements

Outline

Background Context Description Lessons learnt Challenges Other innovations Conclusions and recommendations

Background-Zim stats Total population: 13mil

(2012) PLHIV: 1,4mil; of whom

156, 718 are children 0-14years*

Adult HIV prevalence 15%* ANC HIV prevalence

16.1%* MTCT rate: 18% (Spectrum 2011); 8.8% from 2012 survey

New pediatric HIV infections are estimated at 6,843* (90% from MTCT)

Adult need for ART (2014) 955 922 Peads needing ART

(2012): 100 561

Sour11 & MOHCW HIV estimates 2012

Background

Zimbabwe’s ART program reached near universal adult access in 2013

Only 44% of 46 000 children in need of ART receiving it

Efforts needed to scale up Peads ART

Disparity Between Adult and Pediatric ART Coverage continues

Making the case for early infant diagnosis

Zimbabwe expects delivery of more than 60,000 HIV-exposed infants annually who need early HIV diagnosis.

Approx. 50% of HIV-infected infants die before second birthday, if untreated

Early treatment is critical in averting both high morbidity and mortality in pediatric patients

EID is the most critical step in identifying infected infants and linking them to care

Context

Zimbabwe EID program depends on one National Microbiology Reference Laboratory (2nd laboratory opened only recently in Mutare)

Until a few months ago, NMRL was responsible for processing specimens from approximately 1,440 EID sites.

Sample

Result

Issues

Centralized set-up requires efficient transportation and results dissemination system

MTR of PMTCT (2013), TAT for EID- DBS specimen collection to delivering results - 54 days [7.7 weeks]

One of the biggest barriers to early HIV diagnosis is sample and result transportation

Innovative methods to transport samples particularly from hard to reach areas are critical

Description

EGPAF sought strategies to address sample transportation challenges

Courier Connect was contracted initially in 2011

Later FedEx took over in 2012 Samples collected from 217 central

collection points and delivered to NMRL Results returned using same route

Map with FedEx sample collection points

Description

EGPAF receives feedback on sample pick-up rates through DFPs stationed in the districts

Summary information is collected through tracking

Monthly meetings between EGPAF and FedEx are held to discuss progress and address challenges

Lessons learnt

FedEx couriers now routinely collect samples from 217 points, which serve as central collection points for over one thousand sites throughout the country

Average specimen transportation time from facility to laboratory has declined from 2 months pre-FedEx use to 2 weeks

Return of results to collection sites has been reduced from about four months to two weeks

Number of specimens processed through the national laboratory increased from 20,609 in 2010 to 55,240 in 2013

HIV DNA PCR TESTS BY YEAR: 2010-2013

Scale Up of Paediatric ART in Zimbabwe 2004-2012

Challenges

Main challenge has been reaching the very hard to reach sites with poor/none existent road networks

Batching of samples Delays also with sample processing

within the lab Limited human resource Breakdown of machines Reagent stock-outs

Delays in return of results to caregiver

Other innovations

Engagement of EHTs and use of integrated sample transportation system

Use of GPRS (50 sites) SMS technology (>1000 sites)

Decentralization of EID labs

NMRLMash West, Mash Central, Mash East, Harare, Midlands

Mutare lab

Manicaland,

Masvingo

Mpilo lab

Bulawayo, Mat North, Mat South

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Future innovations

Testing at birth HIV-related mortality peaks at around 2–3

months of age Virological testing at birth might allow ART

initiation before peak mortality occurs

Point of care EID

EID and the private practitioner

Most private practitioners use private labs for PCR

Referral of clients for DBS collection at municipal clinics possible

Staff can be trained to collect DBS samples and deliver to local clinic/lab

Either way- early identification of HIV infection critical for early initiation on ART

Use of dosing wheels as job aides (available at EGPAF stand)

Conclusions and recommendations

Courier system proven to be a viable method of scaling up EID sample and result transportation

Decentralization needs to continue to further shorten EID TAT

Well defined SOPs are required to ensure timely disbursement of EID results from facilities to clients’ care-givers.

Final thought…………

It always seems impossible until its done- Nelson Mandela