using m-health strategies to improve laboratory data management in pmtct programs m-health satellite...
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Using m-health strategies to improve laboratory data management in PMTCT programs
m-health satelliteWashington, July 23, 2012
Financing overview: Malawi is expecting a funding gap in the near term, but significant worsening after 2013, unless additional funding is secured
Large numbers of HIV-infected children continue to get infected despite increasing access to PMTCT
• Access to PMTCT services has expanded markedly in recent years
• UNAIDS estimates that ~350,000 pediatric HIV infections have been prevented since 1995
• But…at best, we are preventing only 20-25% of new infections annually
• In 2010, there were an estimated 390,000 new pediatric infections
• More than 1,000 infants are newly infected each day
• In the absence of treatment, mortality in these infants is very high – approaching 50% by age 2
Source: UA report 2011, Newell et al. Lancet 2005
Financing overview: Malawi is expecting a funding gap in the near term, but significant worsening after 2013, unless additional funding is secured
We need to improve performance and strive for “eMTCT”, but we also must do a better job of treating the children already living with HIV
0.1M 0.1M 0.2M 0.3M 0.4M 0.5M 1.3M 1.9M 2.8M 3.8M 4.9M 6.2M
21% 23%
42%
51%
2005 2006 2007 2008 2009 2010
Adults Receiving ART
Children Receiving ART
Coverage % - Children
Coverage % - Adults
Adapted from: UA report 2011
Financing overview: Malawi is expecting a funding gap in the near term, but significant worsening after 2013, unless additional funding is secured
On the continuum of care for HIV positive mothers and children, infant diagnosis is essential for infant treatment and program monitoring
Opt A/B
ART
HIV Ab test
CD4 for ART
eligibility
Infant Diagnosis
ART monitoring in mothers and
children
Infant diagnosis is essential to monitor progress towards eMTCT and identify infected infants
Financing overview: Malawi is expecting a funding gap in the near term, but significant worsening after 2013, unless additional funding is secured
But, infant diagnosis requires virologic testing using DNA-PCR
• All HIV exposed infants have maternal HIV antibodies so infant diagnosis requires virologic testing
• DNA PCR identifies the DNA of the virus in cells but requires many steps including extraction, amplification and detection of HIV DNA
• Use of innovative blood collection methods such as Dried Blood Spots (DBS) has enabled many national programs to offer this test by using sample transport to link peripheral sites to central labs
Financing overview: Malawi is expecting a funding gap in the near term, but significant worsening after 2013, unless additional funding is secured
Using DBS and sample transport, in many countries, EID testing has scaled up rapidly in recent years
6,437
17,520
35,000+
0
5,000
10,000
15,000
20,000
25,000
30,000
35,000
40,000
2007 2008 2009
Number of DNA PCR tests performed, by year
Number of Sites providing EID 145 (29%) 285 (44%) 550 (58%)
Number of sites providing PMTCT 507 646 947
Uganda example
Financing overview: Malawi is expecting a funding gap in the near term, but significant worsening after 2013, unless additional funding is secured
But scale up of EID has not translated to scale up of infant treatment due to high rates of LTFU – especially between testing and results return
244
15098
570
50
100
150
200
250
300
350
Given PCR Test(Pos only)
Received PCR Results (Pos
only)
Enrolled into Care/ Treatment
Currently Active in Care/
Treatment
Infant Retention Cascade at 3 Regional Referral Hospitals in UgandaSept 2007 – Feb 2009
39% of positive infants never
received results 35% of positive infants receiving
results were never enrolled into care 42% of positive
infants in care & treatment were lost
Source: CHAI/MOH Uganda 2011
Postnatal PMTCT visits are linked to EPI at 6 and 10 weeks. If the turn around time is too long, EID results are not there when mothers return
Kangemi Health Center – NairobiTotal TAT 39 days
14 days 5 days
6 days
Batchsent to lab
Sample Tested
Results Dispatched
18 days
DBS drawn for PCR
Birth 6 wks 10 wks
Caregiver returns for
results
5 days
6 days
GSM Printers were used to reduce turnaround time from availability of result to delivery to clinic
14 days 5 days
6 days
Batchsent to lab
Sample Tested
DBS drawn for PCR
Birth 6 wks 10 wks
Caregiver returns for
results
5 days
6 days
What’s next after the SMS printers?? An “EID-ecosystem” to leverage the SMS network and build a real time national database of test results
A Public-Private partnership between HP, NASCOP and Safaricom resulted in the creation of a real time, online database to track EID nationally
EID sample received at
lab
Sample information entered into data terminal
Auto SMS to clinic confirming receipt and providing batch number
Information instantly
enters NASCOP’s
data “cloud”
Sample processed and result entered into data terminal
Auto SMS sent to clinic with result
Paper result dispatched to clinic
Safaricom supports the auto
SMS function
This wireless “ecosystem” enables >2,000 facilities to have access to all data & test results over SMS and web in real time AND allows program staff to review national, regional and site level performance
HP provided & supports servers
EID data can be accessed through a web interface http://www.nascop.org/eid
EID data can be accessed through a web interface http://www.nascop.org/eid
What lessons have we learned, what challenges remain?
• PPPs work! The support of CHAI, HP and Safaricom has created a highly effective system
• Building trust with partners was critical. Although it took a while to bring partners on board and overcome concerns of data sharing, the benefits of being able to access and view real time information is apparent to all
• With transparency comes accountability. Lab performance is closely tracked and problems can be addressed very quickly
• Clinics and providers are empowered by seeing their performance and having access to this technology
• The national EID data system helps us track progress better than ever before, but EID is a clinical service not only a programme monitoring tool. When a test is positive it is essential to link that child to treatment and this remains a challenge in many settings