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Every minute and a half around the globe, nearly one child is born with HIV, according to the United Nations Children’s Fund (UNICEF). The global program estimates that without diagnosis and treatment, one third of HIV-infected infants will die before the age of 1, and almost half of infected infants will die during their second year of life.
With advances in molecular testing, infants can be tested and treated with antiretroviral therapy (ART). But in Africa, establishing a molecular lab in which to run the tests comes with many challenges such as staff retention, cost inefficiencies, and slow turnaround times (TAT).
One person who is working hard to overcome these challenges is biomedical scientist, Dr. Charles Kiyaga. Kiyaga works within the Central Public Health Laboratories (CPHL) in the Ministry of Health as the national coordinator for the Uganda Early Infant Diagnosis (EID) program. He helped establish the EID program in 2006 to test HIV exposed infants and help improve outcomes for their health. The program has tested more than 250,000 babies to date. Since its inception, UNICEF and the African Society for Laboratory Medicine (ASLM) have recognized his many innovations in the state-of-the-art molecular lab at CPHL.
Efficiency in One Lab
In a 2009 program review, Kiyaga and his team realized the program was very expensive and not sustainable. Testing was being conducted in eight regional laboratories, which led to high overhead costs and long TAT, among other issues.
In 2011, they consolidated and opened one centralized EID lab. Kiyaga also implemented a sample transport system that directed all samples to the central lab through a network of hubs. Laboratory TAT was reduced from 30 days to only two days, and overhead cost per test was reduced from $22 to $5 per test. The centralized lab is estimated to save up to $4.1 million by 2014.
With eight labs originally, six of which were operating with manual equipment, they faced challenges with volume distribution. Some labs received more samples than they could efficiently run and therefore always had backlogs. Other labs received very few samples and therefore had to wait for days or weeks in order to have sufficient samples for a run. All of these factors contributed to long TAT.
According to Kiyaga, the centralized EID molecular lab is very efficient in that it receives sufficient sample volumes to run every day. Samples arrive, they are loaded into an automated machine, and they have results by end of the day. The lab became the sole testing center for all exposed infants in the country, and is testing more than 8,000 samples per month.
As a result of improved laboratory efficiency and TAT through lab consolidation, patient outcomes and patient retention also improved. The number of HIV-positive infants that were initiated on ART went up from 23 percent up to 57 percent. That is an improvement of 34 percent.
Another benefit they realized with one central lab is staff retention. A molecular lab needs highly trained, well-paid and motivated employees in a controlled working environment. According to Kiyaga, “By setting up one centralized testing lab, with all samples coming to one place, you don’t need redundant manpower, and you can therefore pay them well. They are well-utilized in a controlled environment and it brings down the cost of labor.”
Another benefit of EID lab consolidation was the centralized data capture in an elaborate database that stores all of the patient bio and testing data. Hewlett Packard (HP) donated high-capacity servers to the EID centralized laboratory and also donated 160 GSM printers to be installed at hubs. The massive-capacity server enables huge data storage, manipulation and commutation capabilities that has enabled the database to be web-based and posts relevant data analytics on specific dashboards for national stakeholders, implementing partners, and district leaders. The GSM printers placed at the hubs enable printing of respective hub results from the central data center based at the EID lab in real time, further reducing the TAT lost in sending results through the courier. All these benefits have been realized by centralizing the testing in one laboratory.
Infrastructure is also a big challenge that many African countries need to overcome when building a molecular lab. Utilities, power, equipment and facilities can be optimized when centrally located to ensure everything is available, controlled and functioning properly. “It is better to have a limited number of labs that you can use optimally than many labs,” he says.
In 2009, UNICEF recognized the EID program as most innovative in the world among similar programs.
UNICEF conducted a review of five countries to uncover the main issues, see how some countries were dealing with these issues, and then determine what were the lessons others could use to improve their situations.
At that time, Kiyaga’s program had developed and piloted many innovative methods after a country review earlier in the year revealed massive losses of the tested babies through the EID cascade. The innovations, codenamed “EID System Strengthening,” had six components that included:
1. Integration of routine care into the EID process
2. Establishment of one “EID care point” where all testing, care and follow-up of HIV-exposed infants was centralized
3. Establishment of a written referral system to improve linkages between entry points throughout the facility, the EID care point, and ART clinic
4. Improvement of tracking tools to follow infants longitudinally and monitor care indicators
5. Strengthening and standardizing counseling at all points in the EID process
6. Improvement of capacity for active follow-up of lost infants.
“Our program was seen to be innovative because we addressed many challenges before the UNICEF review and implemented many new approaches,” said Kiyaga. “By 2010 we analyzed our pilot and had even better outcomes.”
In 2012, the EID program had another chance to share their continuing innovations. According to Kiyaga, the African Society for Laboratory Medicine (ASLM) asked countries to submit innovative programs for review. The ASLM analyzed submissions from different countries and they found Kiyaga’s program to be better than all other similar programs in Africa.
“By that time we had even more innovations than we did in 2009 – lab consolidation, centralization of the lab, and the sample transport network,” he said.
Kiyaga received the award for best practice in EID programming, and in April 2013 he was appointed the ASLM Ambassador for Uganda. In this position, he will sit on the board that plans and makes strategies for the continent to improve health services through laboratory diagnostics.
“We will plan different projects in technology and innovation — and where they should be done — in order to optimize technology on the continent,” said Kiyaga. “I also want to make sure Uganda benefits from these new approaches.”
Kiyaga is always looking for ways to improve lab services and testing. Beyond HIV testing for exposed infants, he eventually wants to do viral load testing and sickle cell screening for neonates. He believes that once they have a stable infrastructure, more molecular tests beyond HIV will be possible.