1. 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, P ZiMA Annual Congress Elephant Hills August 28, 2014

2. Acknowledgements

3. Outline  Background  Context  Description  Lessons learnt  Challenges  Other innovations  Conclusions and recommendations

4.  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

5. 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

6. 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

7. Context  Zimbabwe EID program depends on one National Microbiology Reference Laboratory (2 nd 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

8. 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

9. 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

10. Map with FedEx sample collection points

11. 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

12. 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

13. HIV DNA PCR TESTS BY YEAR: 2010-2013

14. Scale Up of Paediatric ART in Zimbabwe 2004-2012

15. 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

16. Other innovations  Engagement of EHTs and use of integrated sample transportation system  Use of GPRS (50 sites)  SMS technology (>1000 sites)

17. Decentralization of EID labs NMRL Mash West, Mash Central, Mash East, Harare, Midlands Mutare lab Manicaland, Masvingo Mpilo lab Bulawayo, Mat North, Mat South 17

18. 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

19. 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)

20. 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.

21. Final thought………… It always seems impossible until its done- Nelson Mandela