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 Prevention Initiative 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:

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 2000: Through Bill & Melinda Gates Funding, Harvard has been working with multiple hospitals and prevention programs in Nigeria 2004: In collaboration with AIDS Prevention Initiative in Nigeria (APIN), PEPFAR HIV care and ART activities started at 6 tertiary hospitals : 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)XXXCAP 2007 CBCXXXCross-site ChemistryXXXCAP 2007 CD4- flowXXXUK-NEQAS (2006) Viral LoadXXXHarvard (2006) Infant DNA PCRXXXCDC (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 LabHematologyChemistry CD4 or CD4%Viral LoadDNA PCR Drug resistance Genotype ABUTH JUTH LUTH NIMR UCH FMCM OLA UMTH UNTH Eleta Ogbomosho Ijebu-Ode Sacred Heart Lantoro FMC Nguru SSH Maiduguri Shendam Solat Adeoyo Total119,198117,116132,27755,50315, Volume of Laboratory Tests Performed in 2011

PEPFAR The Harvard PEPFAR Laboratory Master Trainer and Site Support Program in Botswana Notes from the Field

GETTING TO 6 MILLION: LESSONS FROM THE TRACK 1.0 PEPFAR PROGRAM Laboratory Master Trainer & Site Support Program Team 1 Lab Master Trainers (assigned by Government) 6 BHP-PEPFAR Lab Master Trainers Train site-level lab personnel as site Master 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 NHHRL BHHRL BHHRL – Botswana Harvard HIV Reference Laboratory NHHRL – Nyangagbwe Hospital HIV Reference Laboratory

GETTING TO 6 MILLION: LESSONS FROM THE TRACK 1.0 PEPFAR PROGRAM FacsCalibur FacsCount CD4 Equipment Partec CyFlow Coulter FacsCount at a Clinic

GETTING TO 6 MILLION: LESSONS FROM THE TRACK 1.0 PEPFAR PROGRAM Roche Taqman 48 Cavidi 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 Labs Number of Tests

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. Marlink J-L. Sankalé D. Hamel B. Chaplin H. Rawizza A. Dieng-Sarr G. Eisen C. Smith M. O’Malley C. Chang H. Reyes N. Ulenga L. Dinic J. Hosseini U. Ijeoma E. Koch C. Wen A. Weiss P. Burns M. Farhani R. Murphy K. Scarsi K. Hurt B. Taiwo C.Achenbach P. Okonkwo T. Jolayemi J. Samuels E. Ofuche B. Banigbe S. Ochigbo R. Olaitan P. Akande T. Oyebode B. Akinyemi O. Eberendu C. O’Martins J. Adeola I. Abbas A. Obakeye I. Adewole D. Olaleye J. Idoko S. Sagay O. Agbaji O. Idigbe D. Onwujekwe C. Okany R. Nkado W. Gashau H. Muktar J. Abah C. Chukwuka S. Akanmu F. Ogunsola All our colleagues at the PEPFAR sites in Nigeria and Botswana. And, most importantly, the patients J. Makhema T. Gaolathe M. Mine