Feasibility of HIV point-of-care tests for resource-limited settings: challenges and solutions

Co-creation of a novel approach for improving supply chain management for SARS-CoV-2 point of care diagnostic services in Mopani District, Limpopo Province: nominal group technique

Introduction

Effective supply chain management (SCM) of point-of-care (POC) tests for diseases like severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) requires active participation from diverse stakeholders, government entities, and regulatory bodies. The responsibility for overseeing various aspects of POC tests, including procurement, quality assurance, storage, inventory management, distribution, and human resource capacity, lies with national, provincial, and local levels of government. This study aimed to collaboratively develop an innovative approach to enhance SCM for SARS-CoV-2 POC diagnostic services in resource-limited settings, using the Mopani District in Limpopo province, South Africa, as a case study.

Methods

Key stakeholders were invited to participate in an online workshop using purposive sampling. The study employed the nominal group technique (NGT) for data collection, which consisted of two phases. Phase 1 focused on identifying barriers in the supply chain of COVID-19 rapid tests, while phase 2 aimed to devise strategies to overcome the priority barriers identified in phase 1. Participants used a Likert scale of 1-5 to rank barriers and strategies, and an overall ranking score was calculated for each. The participants were provided with the results of the ranking exercise for their feedback.

Results

Eleven key stakeholders from national (n = 1), provincial (n = 4), and local government (n = 2) levels, research entities (n = 3), and non-governmental organizations (n = 1) took part in the study. Participants identified significant barriers in the supply chain, such as the availability of testing kits, unknown demand, information on SCM during a pandemic, methods of controlling stock, and procurement processes. Strategies suggested by key stakeholders included monitoring stock levels and optimizing stock visibility systems to improve test availability, enhancing information visibility and consistent data updates to address unknown demand and improve SCM during a pandemic, employing data capturing and digitization for effective stock control, and implementing demand planning and standardized procurement processes at the national level to enhance stock procurement.

Discussion

The successful collaboration with key stakeholders, facilitated by the NGT, resulted in the co-creation of a novel approach to enhance SCM for COVID-19 diagnostic services in resource-limited settings. This study holds the potential to support the provision of COVID-19 diagnostic services in such settings. A recommended follow-up study would assess the feasibility of implementing this approach.

Navigating Quality Assessment Hurdles in Clinical Laboratory Services: A Comprehensive Review in Resource-Limited Settings

External quality assessment is the process of evaluating the performance of a laboratory and the competence of professionals. Participation in EQA and standardizing the quality of laboratory services are a mandatory requirements for accreditation. This review is aimed at identifying and discussing challenges that hinder the effective implementation of an EQA program in countries with resource limited setting. To obtain abundant information, articles were identified by searching the literature publishedin English using the National Library of Medicine, PubMed, Science Direct and AMC digital library databases. The articles identified in the references were manually searched and included. After the article was identified, it was imported to Endnote version 8.1 and exported to Microsoft Word for citation. Based on this review, the major identified challenges that hinder the implementation of an EQA program include the high cost of control materials, malfunction and lack of maintenance for equipment failure and breakdown, a knowledge gap among laboratory professionals, noncommutability of control samples, and difficulty in assigning target values. In addition, failing to participate in EQA and failing to take corrective action are the major challenges identified. As a result, applying to an EQA program in resource-limited counties was highly challenging. To attain high performance in the laboratory and to provide quality laboratory service for patient care, the EQA supplier and the user laboratory must pay attention to these issues and take appropriate corrective actions for ongoing quality improvement and accreditation.

Evaluating supply chain management of SARS-CoV-2 point-of-care (POC) diagnostic services in primary healthcare clinics in Mopani District, Limpopo Province, South Africa

Access to point-of-care (POC) diagnostics in resource-limited settings, where laboratory-based diagnostics are limited, depends on efficient supply chain management (SCM). This study evaluated the SCM for SARS-CoV-2 POC diagnostic services in resource-limited settings to determine the effect of SCM on accessibility to SARS-CoV-2 POC tests and to identify barriers and enablers of accessibility to SARS-CoV-2 diagnostic services in Mopani District, Limpopo Province, South Africa. We purposively assessed 47 clinics providing POC diagnostic services between June and September 2022. One participant per clinic completed an audit tool developed by the authors with guidance from the World Health Organization and the Management Sciences for Health guidelines. The audit tool evaluated the following SCM parameters: selection, quantification, storage, procurement, quality assurance, distribution, redistribution, inventory management, and human resource capacity. Percentage rating scores between 90-100% indicated that the facility was compliant with SCM guidelines, while rating scores < 90% indicated non-compliance. The clinic audit scores were summarized and compared across clinics and sub-districts. Clinics had compliance scores ranging from 60.5% to 89.2%. Compliance scores were the highest for procurement, redistribution, and quality assurance (all 100%), followed by storage (mean = 95.2%, 95% CI: 90.7-99.7), quantification (mean = 89.4%, 95% CI: 80.2-98.5), and selection (mean = 87.5%, 95% CI: 87.5%-87.5%). Compliance scores were the lowest for inventory management (mean = 53.2%, 95% CI: 47.9%-58.5%), distribution (mean = 48.6%, 95% CI: 44.6%-52.7%), and human resource capacity (mean = 50.6%, 95% CI: 43.3%-58.0%). A significant correlation was found between compliance score and clinic headcount (r = 0.4, p = 0.008), and compliance score and ideal clinic score (r = 0.4, p = 0.0003). Overall, the 47 clinics audited did not comply with international SCM guidelines. Of the nine SCM parameters evaluated, only procurement, redistribution, and quality assurance did not need improvement. All parameters are key in ensuring full functionality of SCM systems and equitable access to SARS-CoV-2 POC diagnostics in resource limited settings.

[Trends in the incidence of the human immunodeficiency (HIV) virus in Chile, by age and gender 2010-2017]

OBJETIVE

To determine the trends in the incidence of contagion by the HIV in Chile, according to age and gender, for the period 2010-2017.

METHODS

Analysis from the database of confirmed HIV positive diagnosis cases. HIV incidence rates were made from HIV-confirmed cases adjusted for year, age, and sex, with population denominators from the INE. A general and specific trend analysis was performed using regression equations.

RESULTS

There is a trend to increase in HIV incidence rates in the study period. 36.48% of the reported cases correspond to the male sex between 20-29 years, group with the highest incidence in the period. The estimated regression equations effectively increase more steadily in the male and young population.

CONCLUSIONS

There are deficit informative and educational factors in HIV prevention in the Chilean population. Despite the strong progression of new cases, the diagnostic gap of people living with HIV who are unaware of their health remains to be consolidated. Gaps were identified between recommendations, public policies and the Chilean results obtained.

Temporal discrepancies in "rapid" HIV testing: explaining misdiagnoses at the point-of-care in Zimbabwe

BACKGROUND

Rapid diagnostic tests have revolutionized the HIV response in low resource and high HIV prevalence settings. However, disconcerting levels of misdiagnosis at the point-of-care call for research into their root causes. As rapid HIV tests are technologies that cross borders and have inscribed within them assumptions about the context of implementation, we set out to explore the (mis)match between intended and actual HIV testing practices in Zimbabwe.

METHODS

We examined actual HIV testing practices through participant observations in four health facilities and interviews with 28 rapid HIV testers. As time was identified as a key sphere of influence in thematic analyses of the qualitative data, a further layer of analysis juxtaposed intended (as scripted in operating procedures) and actual HIV testing practices from a temporal perspective.

RESULTS

We uncover substantial discrepancies between the temporal flows assumed and inscribed into rapid HIV test kits (their intended use) and those presented by the high frequency testing and low resource and staffing realities of healthcare settings in Zimbabwe. Aside from pointing to temporal root causes of misdiagnosis, such as the premature reading of test results, our findings indicate that the rapidity of rapid diagnostic technologies is contingent on a slow, steady, and controlled environment. This not only adds a different dimension to the meaning of "rapid" HIV testing, but suggests that errors are embedded in the design of the diagnostic tests and testing strategies from the outset, by inscribing unrealistic assumptions about the context within which they used.

CONCLUSION

Temporal analyses can usefully uncover difficulties in attuning rapid diagnostic test technologies to local contexts. Such insight can help explain potential misdiagnosis 'crisis points' in point-of-care testing, and the need for public health initiatives to identify and challenge the underlying temporal root causes of misdiagnosis.

Rituals of care: Strategies adopted by HIV testers to avoid misdiagnosis in rapid HIV testing in Zimbabwe

A growing number of studies highlight high levels of misdiagnosis in the scale-up of HIV rapid testing programmes, which often remain invisible to individual testers. Drawing on interviews with HIV testers and observations in four health facilities in Zimbabwe, we show that testers navigated the translation of the standardised, dis-embodied norms of laboratory-based testing into the body work of point-of-care testing through ritualisation of laboratory-practices in their daily clinical work. Yet, this was interrupted through the challenging work conditions the testers face. They ritualised careful procedures, forcing themselves to focus even if queues were long, and making quality assurance procedures part of their daily routine. They actively tried to reduce their workloads and double-checked and discussed unexpected results, especially when a test result did not match their evaluation of clients' circumstances or clinical status. This helped not only to increase confidence in the authenticity of their diagnosis, but also to share responsibility for potential errors. Existing approaches to tackle the problem of misdiagnosis through quality assurance (QA) procedures mainly focus on adjusting individual testers' performance and ensuring that basic testing resources were present, thus falling short of creating a work environment that is conducive to high quality testing.

Laser-enabled delivery of antiretroviral drugs into HIV-1 infected TZM-bl cells

The use of femtosecond laser to create sub-microscopic transient pores on the cell membrane allowing exogenous material into mammalian cells has become a very efficient optical delivery method over the past decade. This study focuses on laser-enabled delivery of antiretroviral (ARV) drugs into HIV-1 infected TZM-bl cells in vitro. A 1 kHz femtosecond laser emitting at a wavelength of 800 nm was used to photoporate cells at 6.5 μW. Trypan blue was used for characterisation and its uptake was quantified using Matlab software. Cell membrane damage was assessed using the lactate dehydrogenase (LDH) assay while HIV-1 infection was assessed using luciferase assay. Our results showed successful delivery of ARVs into HIV-1 infected cells without compromising their cell membranes, subsequently reducing the level of infection. The LDH assay showed no significant cell membrane damage of laser-treated cells, and the luciferase assay demonstrated significant reduction in the level of HIV-1 infection.

The (in)visibility of misdiagnosis in point-of-care HIV testing in Zimbabwe

There is a global trend to introduce point-of-care diagnostic tests, enabling healthcare workers at any level to test, provide results, and initiate immediate treatment if necessary. This article explores how healthcare workers conducting rapid HIV tests - in contexts of limited external quality assurance mechanisms - ascertain the accuracy of their test results. Drawing on interview data and participant observations from health facilities in Zimbabwe, we open the black box of misdiagnosis (in)visibility and reveal a range of proxies and markers that HIV testers draw on to develop certainty, or question, the reliability of their diagnostic classifications.

A Scoping Review of Supply Chain Management Systems for Point of Care Diagnostic Services: Optimising COVID-19 Testing Capacity in Resource-Limited Settings

Background: Point of care (POC) testing has enabled rapid coronavirus disease 2019 (COVID-19) diagnosis in resource-limited settings with limited laboratory infrastructure and high disease burden. However, the accessibility of the tests is not optimal in these settings. This scoping review mapped evidence on supply chain management (SCM) systems for POC diagnostic services to reveal evidence that can help guide future research and inform the improved implementation of SARS-CoV-2 POC diagnostics in resource-limited settings. Methodology: This scoping review was guided by an adapted version of the Arksey and O’Malley methodological framework. We searched the following electronic databases: Medline Ovid, Medline EBSCO, Scopus, PubMed, PsychInfo, Web of Science and EBSCOHost. We also searched grey literature in the form of dissertations/theses, conference proceedings, websites of international organisations such as the World Health Organisation and government reports. A search summary table was used to test the efficacy of the search strategy. The quality of the included studies was appraised using the mixed method appraisal tool (MMAT) version 2018. Results: We retrieved 1206 articles (databases n = 1192, grey literature n = 14). Of these, 31 articles were included following abstract and full-text screening. Fifteen were primary studies conducted in LMICs, and 16 were reviews. The following themes emerged from the included articles: availability and accessibility of POC diagnostic services; reasons for stockouts of POC diagnostic tests (procurement, storage, distribution, inventory management and quality assurance) and human resources capacity in POC diagnostic services. Of the 31 eligible articles, 15 underwent methodological quality appraisal with scores between 90% and 100%. Conclusions: Our findings revealed limited published research on SCM systems for POC diagnostic services globally. We recommend primary studies aimed at investigating the barriers and enablers of SCM systems for POC diagnostic services for highly infectious pathogens such SARS-CoV-2 in high disease-burdened settings with limited laboratory infrastructures.

An integrated self-powered 3D printed sample concentrator for highly sensitive molecular detection of HIV in whole blood at the point of care

Rapid and efficient biological sample preparation and pretreatment are crucial for highly sensitive, reliable and reproducible molecular detection of infectious diseases. Herein, we report a self-powered, integrated sample concentrator (SPISC) for rapid plasma separation, pathogen lysis, nucleic acid trapping and enrichment at the point of care. The proposed sample concentrator uses a combination of gravitational sedimentation of blood cells and capillary force for rapid, self-powered plasma separation. The pathogens (e.g., HIV virus) in separated plasma were directly lysed and pathogen nucleic acid was enriched by an integrated, flow-through FTA® membrane in the concentrator, enabling highly efficient nucleic acid preparation. The FTA® membrane of the SPISC is easy to store and transport at room temperature without need for uninterrupted cold chain, which is crucial for point of care sampling in resource-limited settings. The platform has been successfully applied to detect HIV virus in blood samples. Our experiments show that the sample concentrator can achieve a plasma separation efficiency as high as 95% and a detection sensitivity as low as 10 copies per 200 μL blood (∼100 copies per mL plasma) with variability less than 7%. The sample concentrator described is fully compatible with downstream nucleic acid detection and has great potential for early diagnostics, monitoring and management of infectious diseases at the point of care.

HIV supply chains in low- and middle-income countries: overview and research opportunities

Purpose

Despite HIV being reported as one of the major global health issues, availability and accessibility of HIV services and supplies remain limited, especially in low- and middle-income countries. The effective and efficient operation of HIV supply chains is critical to tackle this problem. The purpose of this paper is to give an introduction to HIV supply chains in low- and middle-income countries and identify research opportunities for the operations research/operations management (OR/OM) community.

Design/methodology/approach

First, the authors review a combination of the scientific and grey literature, including both qualitative and quantitative papers, to give an overview of HIV supply chain operations in low- and middle-income countries and the challenges that are faced by organizing such supply chains. The authors then classify and discuss the relevant OR/OM literature based on seven classification criteria: decision level, methodology, type of HIV service modeled, challenges, performance measures, real-life applicability and countries covered. Because research on HIV supply chains in low- and middle-income countries is limited in the OR/OM field, this part also includes papers focusing on HIV supply chain modeling in high-income countries.

Findings

The authors conclude this study by identifying several tendencies and gaps and by proposing future research directions for OR/OM research.

Originality/value

To the best of the authors’ knowledge, this paper is the first literature review addressing this specific topic from an OR/OM perspective.

Quantum Dots: An Emerging Tool for Point-of-Care Testing

Quantum dots (QDs) are semiconductor crystals in the nanodimension having unique optical and electronic properties that differ from bulk material due to quantum mechanics. The QDs have a narrow emission peak, size-dependent emission wavelength, and broad excitation range which can be utilized for diverse biomedical applications such as molecular imaging, biosensing, and diagnostic systems. This article reviews the current developments of biomedical applications of QDs with special reference to point-of-care testing.

"I just believe there is a risk" understanding of undetectable equals untransmissible (U = U) among health providers and HIV-negative partners in serodiscordant relationships in Kenya

Introduction

Sustained HIV viral suppression resulting from antiretroviral therapy (ART) eliminates the risk of HIV transmission, a concept popularly framed as Undetectable = Untransmittable (U = U). We explored knowledge and acceptance of information around the elimination of HIV transmission risk with ART (U = U) in Kenya.

Methods

Our qualitative study was conducted within a project evaluating the use of pre‐exposure prophylaxis (PrEP) integrated into ART care for HIV serodiscordant couples in public clinics in Kenya (the Partners Scale Up Project). From February 2017 to April 2019, we conducted semi‐structured key informant interviews with 83 health providers and in‐depth interviews with 61 HIV‐negative people in serodiscordant relationships receiving PrEP services. Transcripts were coded using thematic analysis.

Results

Health providers reported being aware of reduced risk of HIV transmission as a result of consistent ART use and used words such as “very low,” “minimal” and “like zero” to describe HIV transmission risk after viral suppression. Providers reported finding viral load results helpful when counselling clients about the risk of HIV transmission. Many lacked confidence in U = U and counselled on consistent condom use even after viral suppression while some expressed concerns that communicating this message to people living with HIV (PLHIV) would lead them to engage in multiple sexual relationships. Other providers reported that they did not counsel about the reduced risk of HIV transmission after viral suppression for fear of being blamed if HIV transmission occurred. HIV‐negative partners reported being informed about U = U by providers but they did not believe nor trust the message. Even after their partners achieved viral suppression, some HIV‐negative partners were unwilling to stop PrEP, while others indicated that they would use condoms if they stopped PrEP to be sure that they were protected from HIV.

Conclusions

Despite awareness that effective ART use eliminates HIV transmission risk, there is both a lack of in‐depth knowledge and conviction about the strategy among health providers and HIV‐negative partners in serodiscordant relationships. New strategies that go beyond communicating the science of U = U to consider the local social and clinical environments could maximize the effectiveness of U = U.

Uncertainties, work conditions and testing biases: Potential pathways to misdiagnosis in point-of-care rapid HIV testing in Zimbabwe

Disconcerting levels of misdiagnosis are common in point-of-care rapid HIV testing programmes in sub-Saharan Africa. To investigate potential pathways to misdiagnosis, we interviewed 28 HIV testers in Zimbabwe and conducted weeklong observations at four testing facilities. Approaching adherence to national HIV testing algorithms as a social and scripted practice, dependent on the integration of certain competences, materials and meanings, our thematic analysis revealed three underlying causes of misdiagnosis: One, a lack of confidence in using certain test-kits, coupled with changes in testing algorithms and inadequate training, fed uncertainties with some testing practices. Two, difficult work conditions, including high workloads and resource-depleted facilities, compounded these uncertainties, and meant testers got distracted or resorted to testing short-cuts. Three, power struggles between HIV testers, and specific client-tester encounters created social interactions that challenged the testing process. We conclude that these contexts contribute to deviances from official and recommended testing procedures, as well as testing and interpretation biases, which may explain cases of misdiagnoses. We caution against user-error explanations to misdiagnosis in the absence of a broader recognition of how broader structural determinants affect HIV testing practices.

Pooled testing: A tool to increase efficiency of infant HIV diagnosis and virological monitoring

Background

Pooled testing, or pooling, has been used for decades to efficiently diagnose relatively rare conditions, such as infection in blood donors. Programmes for the prevention of mother-to-child transmission of HIV and for antiretroviral therapy (ART) are being rolled out in much of Africa and are largely successful. This increases the need for early infant diagnosis (EID) of HIV using qualitative nucleic acid testing and for virological monitoring of patients on ART using viral load testing. While numbers of patients needing testing are increasing, infant HIV infections and ART failures are becoming rarer, opening an opportunity for pooled testing approaches.

Aim

This review highlights the need for universal EID and viral load coverage as well as the challenges faced. We introduce the concept of pooled testing and highlight some important considerations before giving an overview of studies exploring pooled testing for EID and virological monitoring.

Results

For ART monitoring, pooling has been shown to be accurate and efficient; for EID it has not been tried although modelling shows it to be promising. The final part attempts to place pooling into the context of current mother-to-child transmission of HIV and ART programmes and their expected trajectories over the next years.

Conclusion

Several points warrant consideration: pre-selection to exclude samples with an elevated pre-test probability of positivity from pooled testing, the use of dried blood or plasma spots, and choosing a pooling strategy that is both practically feasible and economical. Finally, novel ideas are suggested to make pooling even more attractive.

Expanding access to HIV testing through Canadian community pharmacies: findings from the APPROACH study

Background

There is a need for acceptable and feasible HIV testing options to ensure people living with HIV know their status so they can access care. Pharmacist-provided HIV point-of-care testing (POCT) may overcome testing barriers, including privacy concerns, testing wait times, and improve accessibility. In the APPROACH study, we aimed to develop and assess an HIV POCT program in community pharmacies for future scale up and evaluation. This paper describes the program uptake, participant and pharmacist experiences, and implementation factors.

Methods

A pharmacist-provided HIV POCT program was offered in 4 pharmacies in two Canadian provinces. A mixed methods design incorporated self-report questionnaire data, participant telephone interviews, pharmacist focus groups, workload analysis, and situational analysis to assess the uptake, acceptability and feasibility of the HIV POCT program.

Results

Over the 6-month pilot, 123 HIV tests were performed. One new case of HIV was identified; this participant was linked with confirmatory testing and HIV care. Participants were predominantly male (76%), with a mean age of 35 years. This was the first HIV test for 27% participants, and 75% were at moderate to very high risk of undiagnosed HIV infection, by Denver HIV Risk Score. Questionnaires and telephone interviews showed participants were very satisfied with the program; 99% agreed HIV POCT should be routinely offered in pharmacies and 78% were willing to pay for the service. Participants felt the pharmacy was convenient, discreet, and that the pharmacist was supportive and provided education about how to reduce their future risk. Pharmacists felt prepared, confident, and expressed professional satisfaction with offering HIV POCT. Community and public health supports, clear linkage to care plans to refer participants with positive HIV POCT results, and provision of counselling tools were important enabling factors for the program. Pharmacist remuneration, integration with existing healthcare systems, and support for ongoing promotion of HIV POCT availability in pharmacies were identified as needs for future scale-up and sustainability.

Conclusions

A successful model of pharmacy-based POCT, including linkage to care, was developed. Further research is needed to determine the effectiveness and cost-effectiveness of this approach in finding new diagnoses and linking them with care.

Trial registration

Retrospectively registered with clinicaltrials.gov (NCT03210701) on July 6, 2017.

Point-of-care viral load monitoring: outcomes from a decentralized HIV programme in Malawi

Introduction

Routinely monitoring the HIV viral load (VL) of people living with HIV (PLHIV) on anti‐retroviral therapy (ART) facilitates intensive adherence counselling and faster ART regimen switch when treatment failure is indicated. Yet standard VL‐testing in centralized laboratories can be time‐intensive and logistically difficult in low‐resource settings. This paper evaluates the outcomes of the first four years of routine VL‐monitoring using Point‐of‐Care technology, implemented by Médecins Sans Frontières (MSF) in rural clinics in Malawi.

Methods

We conducted a retrospective cohort analysis of patients eligible for routine VL‐ testing between 2013 and 2017 in four decentralized ART‐clinics and the district hospital in Chiradzulu, Malawi. We assessed VL‐testing coverage and the treatment failure cascade (from suspected failure (first VL>1000 copies/mL) to VL suppression post regimen switch). We used descriptive statistics and multivariate logistic regression to assess factors associated with suspected failure.

Results and Discussion

Among 21,400 eligible patients, VL‐testing coverage was 85% and VL suppression was found in 89% of those tested. In the decentralized clinics, 88% of test results were reviewed on the same day as blood collection, whereas in the district hospital the median turnaround‐time for results was 85 days. Among first‐line ART patients with suspected failure (N = 1544), 30% suppressed (VL<1000 copies/mL), 35% were treatment failures (confirmed by subsequent VL‐testing) and 35% had incomplete VL follow‐up. Among treatment failures, 80% (N = 540) were switched to a second‐line regimen, with a higher switching rate in the decentralized clinics than in the district hospital (86% vs. 67%, p < 0.01) and a shorter median time‐to‐switch (6.8 months vs. 9.7 months, p < 0.01). Similarly, the post‐switch VL‐testing rate was markedly higher in the decentralized clinics (61% vs. 26%, p < 0.01). Overall, 79% of patients with a post‐switch VL‐test were suppressed.

Conclusions

Viral load testing at the point‐of‐care in Chiradzulu, Malawi achieved high coverage and good drug regimen switch rates among those identified as treatment failures. In decentralized clinics, same‐day test results and shorter time‐to‐switch illustrated the game‐changing potential of POC‐based VL‐testing. Nevertheless, gaps were identified along all steps of the failure cascade. Regular staff training, continuous monitoring and creating demand are essential to the success of routine VL‐testing.

HIV Point of Care Testing (PoCT) at Late-Night Sex on Premises Venues (SOPV) for Gay and Bisexual Men and Other Men Who Have Sex with Men (GBMSM): A Mixed Methods Analysis

The aim of this study was to establish 'proof of concept' for a novel approach to HIV and STI testing at a sex on premises venue (SOPV) for gay and bisexual and other men who have sex with men (GBMSM) during late night group sex theme parties. A mixed-methods approach was used, and the study aimed to: (1) Build upon existing SOPV funded service delivery and establish 'proof of concept' for this unique setting within an SOPV; (2) evaluate the uptake and feasibility/acceptability of routine HIV/STI testing for GBMSM during theme parties in SOPV; and (3) identify beliefs/perceptions regarding this health promotion activity and venue suitability. The characteristics of patrons utilising PoCT (Point of Care Testing) were established to help further reach potentially stigmatised, highly sexually adventurous GBMSM. The findings support further PoCT endeavours within MSM communities to target harder to reach communities to reduce the rate of new transmissions of HIV. Findings can inform future health promotion, screening and interventions, as well as to identify a successful method to engage harder to reach GBMSM that need further focused targeting for HIV and STI testing to reduce transmission.

Optimal control analysis of vector-host model with saturated treatment

Vector-host infectious diseases remain a challenging issue and cause millions of deaths each year globally. In such outbreaks, many countries especially developing or underdevelopment faces a situation where the number of infected individuals is getting larger and the medical facilities are limited. In this paper, we construct an epidemic model to explore the transmission dynamics of vector-borne diseases with nonlinear saturated incidence rate and saturated treatment function. This type of incidence rate, as well as the saturated treatment function, is also known as the Holling type II form and describes the effect of delayed treatment. Initially, we formulate a mathematical model and then present the basic analysis of the model including the positivity and boundedness of the solution. The threshold quantity R 0 is presented and the stability analysis of the system is carried out for the model equilibria. The global stability results are shown using the Lyapunov function of Goh-Voltera type. The existence of backward bifurcation is discussed using the central manifold theory. Further, the global sensitivity analysis of the model is carried out using the Latin Hypercube sampling and the partial rank correlation coefficient techniques. Moreover, an optimal control problem is formulated and the necessary optimality conditions are investigated in order to eradicate the disease in a community. Four strategies are presented by choosing different set of controls combination for the disease minimization. Finally, the numerical simulations of each strategy are depicted to demonstrate the importance of suggesting control interventions on the disease dynamics and eradication.

Onsite healthcare worker acceptability and performance of the point-of-care Pima CD4 assay in Dar es Salaam, Tanzania

Background: Healthcare workers’ acceptance of and ability to perform point-of-care testing is important for reliable and accurate results. The Alere Pima™ CD4 assay (Pima CD4) is the CD4 point-of-care test for HIV management in Tanzania.Objectives: To evaluate healthcare workers’ acceptance and performance of Pima CD4 testing.Methods: The study was implemented in five high volume sites in Dar es Salaam, Tanzania, in 2011. Trained healthcare workers performed Pima testing using three whole-blood specimens collected from each patient: venous blood, fingerstick blood directly applied to a Pima cartridge (capillary-direct), and fingerstick blood collected in a microtube (capillary-microtube). Using a semi-structured interview guide, we interviewed 11 healthcare workers about specimen collection methods and Pima CD4 acceptability. Quantitative responses were analysed using descriptive statistics. Open-ended responses were summarised by thematic areas. Pima CD4 results were analysed to determine variation between cadres.Results: Healthcare workers found Pima CD4 user-friendly and recommended its use in low volume, peripheral facilities. Both venous and capillary-direct blood were considered easy to collect, with venous preferred. Advantages noted with venous and capillary-microtube methods were the ability to retest, perform multiple tests, or delay testing. Pima CD4 results were trusted by the healthcare workers and were in agreement with laboratory Pima testing.Conclusion: In this point-of-care testing setting, the Pima CD4 assay was accepted by healthcare workers. Both venous and fingerstick capillary blood specimens can be used with Pima CD4, but fingerstick methods may require more intensive training on technique to minimise variation in results and increase acceptability.

Tuberculosis, HIV, and viral hepatitis diagnostics in eastern Europe and central Asia: high time for integrated and people-centred services

Globally, high rates (and in the WHO European region an increasing prevalence) of co-infection with tuberculosis and HIV and HIV and hepatitis C virus exist. In eastern European and central Asian countries, the tuberculosis, HIV, and viral hepatitis programmes, including diagnostic services, are separate vertical structures. In this Personal View, we consider underlying reasons for the poor integration for these diseases, particularly in the WHO European region, and how to address this with an initial focus on diagnostic services. In part, this low integration has reflected different diagnostic development histories, global funding sources, and sample types used for diagnosis (eg, typically sputum for tuberculosis and blood for HIV and hepatitis C). Cooperation between services improved as patients with tuberculosis needed routine testing for HIV and vice versa, but financial, infection control, and logistical barriers remain. Multidisease diagnostic platforms exist, but to be used optimally, appropriate staff training and sensible understanding of different laboratory and infection control risks needs rapid implementation. Technically these ideas are all feasible. Poor coordination between these vertical systems remains unhelpful. There is a need to increase political and operational integration of diagnostic and treatment services and bring them closer to patients.

Wireless colorimetric readout to enable resource-limited point-of-care

A scalable, generic wireless colour detector for point-of-care diagnostics in resource-limited settings is presented. The challenges faced in these settings have limited the effectiveness of point-of-care diagnostics. By combining the growing fields of paper-based diagnostics and printed electronics with Southern African clinic perspectives, a mass-producible, low-cost, paper-based solution for result readout and communication was developed. Printed radio frequency identification devices with sensing capabilities were manufactured, targeting colour detection from lateral flow test strip devices and other typical paper-based rapid test formats. The results were compared to those obtained from a commercial lateral flow test strip reader and image analysis using ImageJ, and demonstrate suitability for delivering automated readout and communication of results. The wireless colour detector is compatible with different test strip form factors, providing a modular solution and reducing the need for training. The solution is low cost and maintenance free, and thus fitting for resource-limited settings. A scalable version of the solution has been developed, making use of standard manufacturing processes for printing and packaging industries, initially using sheet-to-sheet formats, but with the goal of being scalable to roll-to-roll processes. This would enable the possibility of local manufacture, and mass distribution of the devices to those resource-limited areas where they are most needed, and where they will have the greatest impact on point-of-care testing.

Supply chain management and accessibility to point-of-care testing in resource-limited settings: a systematic scoping review

BACKGROUND

World Health Organization (WHO) has created an essential list of in-vitro diagnostics. Supply chain management (SCM) is said to be the vehicle that ensures that developed point-of-care (POC) tests reach their targeted settings for use. We therefore, mapped evidence on SCM of and accessibility to POC testing (availability and use of POC tests) in low- and middle-income countries (LMICs).

METHODS

We conducted a systematic scoping review using Arksey and O'Malley's framework as a guide. We searched PubMed; CINAHL; MEDLINE; WEB of Science; Science Direct; and Google Scholar databases for studies that focused on POC diagnostic tests and SCM. The review included studies that were undertaken in 140 countries defined by the World Bank as LMICs published up to August 2017. Two reviewers independently screened the abstracts and full articles against the eligibility criteria. The study used the mixed methods appraisal tool version 2011 to assess the risk of bias for the included studies. NVivo version 11 was employed to extract themes from all included studies and results presented using a narrative approach.

RESULTS

Of 292 studies identified in this review, only 15 published between 2009 and 2017 included evidence on POC diagnostics and SCM. Of the 15 studies, three were conducted in Zambia, one each in Mozambique, Uganda, Guatemala; South Africa, one in Burkina Faso, Zimbabwe, and one multi-country study (Tanzania, Uganda, China, Peru and Zambia and Brazil). Six studies were not country specific since they were not primary studies. Majority of the studies reported stock-outs of HIV, syphilis, and malaria POC tests. There was a moderate to substantial level of agreement between the reviewers' responses at full article screening stage (Kappa statistic = 0.80, p < 0.01). Nine studies underwent methodological quality appraisal and all, scored between 90 and 100%.

CONCLUSIONS

The results demonstrated limited published research on SCM of and accessibility to POC testing in LMICs. Further studies aimed at investigating SCM of POC tests in resource-limited settings to identify the barriers/challenges and provide a context-specific evidence-based solutions for policy/decision makers, implementers, and POC developers, funders, and development partners would be essential.

PROSPERO REGISTRATION NUMBER

CRD42016043711.

Systematic review of the performance and clinical utility of point of care HIV-1 RNA testing for diagnosis and care

BACKGROUND

Point of-care (POC) HIV-1 RNA tests which are accurate and easy to use with limited infrastructure are needed in resource-limited settings (RLS). We systematically reviewed evidence of POC test performance compared to laboratory-based HIV-1 RNA assays and the potential utility of these tests for diagnosis and care in RLS.

METHODS

Studies published up to July 2018 were identified by a search of PUBMED, EMBASE, Web of Science, CINAHL and Cochrane Central Register of Controlled Trials. Studies evaluating the use of POC HIV-1 RNA testing for early infant diagnosis (EID), acute HIV infection (AHI) diagnosis, or viral load monitoring (VL), compared to centralized testing, were included. Separate search strategies were used for each testing objective.

RESULTS

197 abstracts were screened and 34 full-text articles were assessed, of which 32 met inclusion criteria. Thirty studies evaluated performance and diagnostic accuracy of POC tests compared to standard reference tests. Two of the thirty and two additional studies with no comparative testing reported on clinical utility of POC results. Five different POC tests (Cepheid GeneXpert HIV-1 Quantitative and Qualitative assays, Alere q HIV-1/2 Detect, SAMBA, Liat HIV Quant and Aptima HIV-1 Quant) were used in 21 studies of VL, 11 of EID and 2 of AHI. POC tests were easy to use, had rapid turnaround times, and comparable accuracy and precision to reference technologies. Sensitivity and specificity were high for EID and AHI but lower for VL. For VL, lower sensitivity was reported for whole blood and dried blood spots compared to plasma samples. Reported error rates for Cepheid GeneXpert Qual (2.0%-5.0%), GeneXpert Quant (2.5%-17.0%) and Alere q HIV-1/2 Detect (3.1%-11.0%) were higher than in WHO prequalification reports. Most errors resolved with retesting; however, inadequate sample volumes often precluded repeat testing. Only two studies used POC results for clinical management, one for EID and another for VL. POC EID resulted in shorter time-to-result, rapid ART initiation, and better retention in care compared to centralised testing.

CONCLUSIONS

Performance of POC HIV-1 RNA tests is comparable to reference assays, and have potential to improve patient outcomes. Additional studies on implementation in limited-resources settings are needed.

Accessibility of pregnancy-related point-of-care diagnostic tests for maternal healthcare in rural primary healthcare facilities in Northern Ghana: A cross-sectional survey

Background

Improving access to maternal healthcare in resource-limited settings plays a critical role in improving maternal health outcomes and reducing maternal deaths. However, barriers and challenges may exist in rural clinics and could affect successful implementation. This study assessed the current accessibility of pregnancy-related point-of-care (POC) diagnostic tests for maternal healthcare in rural primary healthcare (PHC) clinics in northern Ghana.

Method

We randomly selected 100 PHC clinics providing maternal healthcare from a total list of 356 PHC clinicss obtained from the Regional Health Directorate. Selected clinics were surveyed from February to March 2018, using an adopted survey tool. We obtained data for clinic-level staffing, availability, usage, and desired POC diagnostic tests. Stata 14 was used for data analysis.

Findings

Majority (64%) of the respondents were midwives. The mean ± standard deviation (SD) years of work experience and working hours per week were estimated at 5.6 years ± 0.4 and 122 hours ± 5.2 respectively. Average antenatal clinic attendance (clinic census) per month was 65 ± 67 pregnant women (Range: 3–360). The mean ± SD POC tests available and use was 4.9 tests ± 2.2. POC tests for malaria, HIV, urine pregnancy, and blood pressure monitoring devices were available in most clinics. POC tests requested by the clinics to assist them care for pregnant women included: Glucose-6-phosphate dehydrogenase (95%); hepatitis C (94%); sickling (91%); tuberculosis, blood glucose and blood type (89%) each; urinary tract infection (87%); urine protein (81%); hepatitis B (78%); haemoglobin (76%); and syphilis (76%).

Interpretation

There is poor accessibility to pregnancy-related POC diagnostic tests for maternal healthcare due to low availability (≤5 tests per PHC clinic) of POC tests in rural PHC clinics in northern Ghana.

Electrophoresis Titration Model of a Moving Redox Boundary Chip for a Point-of-Care Test of an Enzyme-Linked Immunosorbent Assay

Enzyme-linked immunosorbent assays (ELISAs) have been widely used in clinical examination, food safety, and environmental analyses. However, they still face a great challenge in designing a device for a point-of-care test (POCT) due to its bulk optical detector and complexity. Herein an electrophoresis titration (ET) model of a moving redox boundary (MRB) was proposed for constructing an ET-ELISA chip of a POCT just with sextuplet electrode pairs and laminated cells. The chip had an anodic well, middle well, and cathode well which were connected by microchannels. The ELISA process was conducted in the bottom of the middle well, where horseradish peroxidase (HRP) catalyzed 3,3',5,5'-tetra-methyl benzidine (TMB) as a blue TMB dimer with two positive charges. Under an electrical field of 29 V, the TMB dimer migrated into the titration channel and reacted with the ascorbic acid, creating an MRB. The MRB motion was a function of antigen content, indicating a visual distance-based assay. As a proof of concept, a C-reactive protein was chosen as a model antigen. The experiments systemically validated the ET-ELISA model and method. Particularly, the chip was smartphone-detected, traditional power supply free, and did not use sulfuric acid used in typical ELISA, making the ET-ELISA method extremely simple, portable, and safe. The ET-ELISA has great potential to visual and portable ELISA in clinical medicine, the environment, and food safety immunoassay.

Performance and usability evaluation of the INSTI HIV self-test in Kenya for qualitative detection of antibodies to HIV

BACKGROUND

HIV testing is often undermined by lack of confidentiality, stigma, shortage of counselors and long distances to testing centers. Self-testing has the potential to circumvent these constraints.

OBJECTIVE

To determine the performance and usability characteristics of the INSTI® HIV-1/HIV-2 Self-Test.

METHODS

The performance evaluation was a cross sectional study and the usability a mixed methods study. For method comparison, Bioelisa HIV-1+2 Ag/Ab test was used as the reference test. When the test results were discrepant, results from Alere Determine™ HIV-1/2 and First Response HIV-1-2 Antibody tests were used for confirmation of status.

RESULTS

Sensitivity of the INSTI HIV Self-Test was 98.99% (95% CI 96.05-99.75%), and specificity 98.15% (95% CI 95.63-99.23%). The concordance was therefore 97.27%. A total of 354 participants took part in the usability study. Of those, 343 (98.00%) found instructions for use easy to follow, 330 (94.29%) found the finger prick device easy to use, 303 (86.57%) were confident while performing the test, 342 (97.71%) felt result interpretation was easy, while 304 (86.86%) declared results within the recommended five minutes. Three hundred and forty two (342, 97.71%) were willing to use the test again while 344 (98.29%) would recommend the kit to a sexual partner. None of the 350 participants quit the process at any stage. Three hundred and eighteen (318, 91.12%) participants felt the test needed no further improvement. All 91 lay users correctly identified cartridges that showed positive, negative and invalid results. Only 31 (34.07%) participants correctly identified weak positive dummy test results.

CONCLUSION

The excellent performance and usability characteristics of INSTI HIV-1/HIV-2 self-test make the kit a viable option for HIV self-testing. To improve the identification of weak positive results, the manufacturer should indicate on the IFU that even a faint test spot should be interpreted as positive.

The cascade of HIV care among key populations in Indonesia: a prospective cohort study

BACKGROUND

Indonesia has had low uptake of HIV testing and treatment. We did a study to estimate the cascade of HIV care in key populations and identify predictors of outcomes at key cascade steps.

METHODS

We used an observational cohort study design to recruit and follow up men who have sex with men (MSM), female sex workers, transgender women (known as waria in Indonesia), and people who inject drugs (PWID) diagnosed with HIV in four locations in Indonesia: Bali, Bandung, Jakarta, and Yogyakarta. Recruitment, baseline, and follow-up visits were done at collaborating clinical services, including both primary care sites and hospitals. Inclusion criteria for participants included identifying as a member of a key population, age 16 years or older, not previously tested positive for HIV, and HIV positivity at baseline. All participants were offered treatment as per national guidelines, with the addition of viral load testing and completion of study-specific forms. Estimates were calculated of proportions of participants linked to care, commencing treatment, adherent to treatment, and who achieved virological suppression. We used logistic regression to investigate characteristics associated with antiretroviral therapy (ART) initiation and viral suppression and Cox regression to identify factors associated with loss to follow-up. This study is registered with ClinicalTrials.gov, NCT03429842.

FINDINGS

Between Sept 15, 2015, and Sept 30, 2016, 831 individuals were enrolled in the study, comprising 637 (77%) MSM, 116 (14%) female sex workers, 27 (3%) waria, and 51 (6%) PWID. Of those enrolled, 703 (84·6%, 95% CI 82·1-87·1) were linked to HIV care and 606 (86·2%, 83·7-88·8) who were linked with care started ART. Among participants who started treatment, 457 (75·4%, 71·8-78·9) were retained in care, of whom 325 (71·1%, 66·7-75·2) had a viral load test about 6 months after enrolment, with 294 (90·5%, 86·7-93·4) of those tested (294 [35%, 32·1-38·7] of the original cohort) virally suppressed. 146 (24%) of 606 who started treatment were lost to follow-up. People who enrolled at sites that offered both testing and treatment had a higher likelihood of treatment initiation than those who enrolled at sites offering testing only (p<0·0001 by multivariate analysis), and participants who had been linked to care and had a high school or university education were significantly more likely to achieve viral suppression than those with a primary school or lower level of education (p≤0·029 by mulivariate analysis).

INTERPRETATION

HIV cascade data among key populations in Indonesia show very poor rates of retention in treatment and viral suppression. Site and individual characteristics associated with initiating and continuing treatment suggest an urgent need to develop and implement effective interventions to support patients in achieving viral suppression among all people with HIV.

FUNDING

Australian Government Department of Foreign Affairs and Trade, WHO, and Indonesian Government.

Racing for results: lessons learnt in improving the efficiency of HIV viral load and early infant diagnosis result delivery from laboratory to clinic

INTRODUCTION

In pursuit of the 90-90-90 goals, emphasis has been placed on accelerating centralized-laboratory HIV viral load testing of a population that is largely rural and decentralized. Successful outcome requires effective specimen transport, laboratory testing, and results delivery. This paper focuses on the methods currently employed for results delivery. New innovations in this area are yielding mixed results; we analyze different approaches and estimate the impact of each on achieving the third '90.' Areas covered: Strategies employing electronic or mobile health platforms, such as online portals, SMS, and SMS printers are showing potential to deliver results in significantly improved turnaround times but are not without challenges. Also, merely delivering a result to the clinic is not sufficient; results need to be actioned to ensure improved patient linkage and retention. Innovative solutions that not only support real-time reporting but monitor receipt of results and address infrastructure constraints faced by limited-resource settings are discussed. Expert commentary: There is tremendous opportunity to inform better patient care and directly contribute to '90-90-90' progress by developing digital systems for result delivery. Besides infrastructure and technical challenges, systems should address the entire cascade of care from initial diagnosis to monitoring treatment response.

Point of Care Diagnostics for HIV in Resource Limited Settings: An Overview

Human immunodeficiency virus (HIV) is a global health problem. Early diagnosis, rapid antiretroviral therapy (ART) initiation and monitoring of viral load are the key strategies for effective HIV management. Many people in resource limited settings where timely access to medical care is a challenge and healthcare infrastructure is poor have no access to laboratory facilities and diagnosis is dependent on the presence of point of care (POC) devices. POC instruments have shown to be easy to operate, maintain and transport and can easily be operated by less skilled health workers. Additionally, POC tests do not require laboratory technicians to operate. POC devices have resulted in a growing number of people testing for HIV and thereby receiving treatment early. In recent years, there has been great improvement in the development of POC technologies for early HIV diagnosis, HIV viral load and cluster of differentiation 4 (CD4) measurement. This review discusses POC technologies that are currently available and in the pipeline for diagnosing and monitoring HIV. We also give an overview of the technical and commercialization challenges in POC diagnostics for HIV.

Multidisease testing for HIV and TB using the GeneXpert platform: A feasibility study in rural Zimbabwe

BACKGROUND

HIV Viral Load and Early Infant Diagnosis technologies in many high burden settings are restricted to centralized laboratory testing, leading to long result turnaround times and patient attrition. GeneXpert (Cepheid, CA, USA) is a polyvalent near point-of-care platform and is widely implemented for Xpert MTB/RIF diagnosis. This study sought to evaluate the operational feasibility of integrated HIV VL, EID and MTB/RIF testing in new GeneXpert platforms.

METHODS

Whole blood samples were collected from consenting patients due for routine HIV VL testing and DBS samples from infants due for EID testing, at three rural health facilities in Zimbabwe. Sputum samples were collected from all individuals suspected of TB. GeneXpert testing was reserved for all EID, all TB suspects and priority HIV VL at each site. Blood samples were further sent to centralized laboratories for confirmatory testing. GeneXpert polyvalent testing results and patient outcomes, including infrastructural and logistical requirements are reported. The study was conducted over a 10-month period.

RESULTS

The fully automated GeneXpert testing device, required minimal training and biosafety considerations. A total of 1,302 HIV VL, 277 EID and 1,581 MTB/RIF samples were tested on a four module GeneXpert platform in each study site. Xpert HIV-1 VL testing was prioritized for patients who presented with advanced HIV disease, pregnant women, adolescents and suspected ART failures patients. On average, the study sites had a GeneXpert utilization rate of 50.4% (Gutu Mission Hospital), 63.5% (Murambinda Mission Hospital) and 17.5% (Chimombe Rural Health Centre) per month. GeneXpert polyvalent testing error rates remained lower than 4% in all sites. Decentralized EID and VL testing on Xpert had shorter overall median TAT (1 day [IQR: 0-4] and 1 day [IQR: 0-1] respectively) compared to centralized testing (17 days [IQR: 13-21] and 26 days [IQR: 23-32] respectively). Among patients with VL >1000 copies/ml (73/640; 11.4%) at GMH health facility, median time to enhanced adherence counselling was 8 days and majority of those with documented outcomes had re-suppressed VL (20/32; 62.5%). Median time to ART initiation among Xpert EID positive infants at GMH was 1 day [IQR: 0-1].

CONCLUSION

Implementation of near point-of-care GeneXpert platform for integrated multi-disease testing within district and sub-district healthcare settings is feasible and will increase access to VL, and EID testing to priority populations. Quality management systems including monitoring of performance indicators, together with regular on-site supervision are crucial, and near-POC test results must be promptly actioned-on by clinicians for patient management.

Adaptation of POCT for pharmacies to reduce risk and optimize access to care in HIV, the APPROACH study protocol: examining acceptability and feasibility

Background

Approximately 1 in 5 Canadians with HIV are unaware of their status. In many provinces and especially rural communities, barriers to HIV testing include lack of access, privacy concerns, and stigma. The availability of HIV point-of-care testing (POCT) is limited across Canada. Pharmacists are well positioned to address barriers by offering rapid HIV POCT and facilitating linkage to care.

Methods

We will use a type-2 hybrid implementation-effectiveness design to assess a pilot HIV POCT model in one urban and one rural pharmacy in each of two Canadian provinces over 6 months. In this feasibility trial the research aims include developing and assisting pharmacies in implementing the model, evaluating processes/determinants of program implementation, evaluating the model’s effects on client outcomes, preferences, and testing satisfaction. Using a community-based research approach, the research team will engage community stakeholders in each province including individuals with lived experience to inform the development of the pharmacy-based HIV testing model and support the research team throughout the study. A multipronged promotion campaign will be used to promote the study and facilitate recruitment. The pharmacy-based testing model will include pre/post-test counseling and linkage to care plans in addition to pharmacist-administered HIV POCT. Pharmacists will complete a comprehensive training program prior to implementing the testing model. Client demographics and satisfaction will be assessed by surveys and interviews. Pharmacists will document time required for testing and participate in a post-study focus group to discuss barriers/enablers. Implementation will be assessed qualitatively and quantitatively. The process of developing and implementing the model will be described using qualitative data and a logic model. Acceptability and barriers/enablers will be examined qualitatively based on survey responses. A preliminary costing assessment will consider the client, pharmacy, and government perspectives.

Discussion

The results of this pilot will inform modifications to the HIV POCT model to optimize effectiveness and increase scalability. The study has national importance, providing valuable information on improving access to HIV testing. Future applications of this research may expand the role of pharmacists in offering POCT for other sexually transmitted/bloodborne infections as tests become available in Canada.

Trial registration

Clinicaltrials.gov, NCT03210701

Promoting Local Ownership: Lessons Learned from Process of Transitioning Clinical Mentoring of HIV Care and Treatment in Ethiopia

Introduction

Focus on improving access and quality of HIV care and treatment gained acceptance in Ethiopia through the work of the International Training and Education Center for Health. The initiative deployed mobile field-based teams and capacity building teams to mentor health care providers on clinical services and program delivery in three regions, namely Tigray, Amhara, and Afar. Transitioning of the clinical mentoring program (CMP) began in 2012 through capacity building and transfer of skills and knowledge to local health care providers and management.

Objective

The initiative explored the process of transitioning a CMP on HIV care and treatment to local ownership and documented key lessons learned.

Methods

A mixed qualitative design was used employing focus group discussions, individual in-depth interviews, and review of secondary data. The participants included regional focal persons, mentors, mentees, multidisciplinary team members, and International Training and Education Center for Health (I-TECH) staff. Three facilities were selected in each region. Data were collected by trained research assistants using customized guides for interviews and with data extraction format. The interviews were recorded and fully transcribed. Open Code software was used for coding and categorizing the data.

Results

A total of 16 focus group discussions and 20 individual in-depth interviews were conducted. The critical processes for transitioning a project were: establishment of a mentoring transition task force, development of a roadmap to define steps and directions for implementing the transition, and signing of a memorandum of understanding (MOU) between the respective regional health bureaus and I-TECH Ethiopia to formalize the transition. The elements of implementation included mentorship and capacity building, joint mentoring, supportive supervision, review meetings, and independent mentoring supported by facility-based mechanisms: multidisciplinary team meetings, case-based discussions, and catchment area meetings.

Conclusion

The process of transitioning the CMP to local ownership involved signing an MOU, training of mentors, and building capacity of mentoring in each region. The experience shed light on how to transition donor-supported work to local country ownership, with key lessons related to strengthening the structures of regional health bureaus, and other facilities addressing critical issues and ensuring continuity of the facility-based activities.

Improving the Accessibility and Efficiency of Point-of-Care Diagnostics Services in Low- and Middle-Income Countries: Lean and Agile Supply Chain Management

Access to point-of-care (POC) diagnostics services is essential for ensuring rapid disease diagnosis, management, control, and surveillance. POC testing services can improve access to healthcare especially where healthcare infrastructure is weak and access to quality and timely medical care is a challenge. Improving the accessibility and efficiency of POC diagnostics services, particularly in resource-limited settings, may be a promising route to improving healthcare outcomes. In this review, the accessibility of POC testing is defined as the distance/proximity to the nearest healthcare facility for POC diagnostics service. This review provides an overview of the impact of POC diagnostics on healthcare outcomes in low- and middle-income countries (LMICs) and factors contributing to the accessibility of POC testing services in LMICs, focusing on characteristics of the supply chain management and quality systems management, characteristics of the geographical location, health infrastructure, and an enabling policy framework for POC diagnostics services. Barriers and challenges related to the accessibility of POC diagnostics in LMICs were also discussed. Bearing in mind the reported barriers and challenges as well as the disease epidemiology in LMICs, we propose a lean and agile supply chain management framework for improving the accessibility and efficiency of POC diagnostics services in these settings.

Multidisciplinary Point-of-Care Testing in South African Primary Health Care Clinics Accelerates HIV ART Initiation but Does Not Alter Retention in Care

BACKGROUND

Lack of accessible laboratory infrastructure limits HIV antiretroviral therapy (ART) initiation, monitoring, and retention in many resource-limited settings. Point-of-care testing (POCT) is advocated as a mechanism to overcome these limitations. We executed a pragmatic, prospective, randomized, controlled trial comparing the impact of POCT vs. standard of care (SOC) on treatment initiation and retention in care.

METHODS

Selected POC technologies were embedded at 3 primary health clinics in South Africa. Confirmed HIV-positive participants were randomized to either SOC or POC: SOC participants were venesected and specimens referred to the laboratory with patient follow-up as per algorithm (∼3 visits); POC participants had phlebotomy and POCT immediately on-site using Pima CD4 to assess ART eligibility followed by hematology, chemistry, and tuberculosis screening with the goal of receiving same-day adherence counseling and treatment initiation. Participant outcomes measured at recruitment 6 and 12 months after initiation.

RESULTS

Four hundred thirty-two of 717 treatment eligible participants enrolled between May 2012 and September 2013: 198 (56.7%) SOC; 234 (63.6%) POC. Mean age was 37.4 years; 60.5% were female. Significantly more participants were initiated using POC [adjusted prevalence ratio (aPR) 0.83; 95% confidence interval (CI): 0.74 to 0.93; P < 0.0001], the median time to initiation was 1 day for POC and 26.5 days for SOC. The proportion of patients in care and on ART was similar for both arms at 6 months (47 vs. 50%) (aPR 0.96; 95% CI: 0.79 to 1.16) and 12 months (32 vs. 32%) (aPR 1.05; 95% CI: 0.80 to 1.38), with similar mortality rates. Loss to follow-up at 12 months was higher for POC (36% vs. 51%) (aPR 0.82; 95% CI: 0.65 to 1.04).

CONCLUSIONS

Adoption of POCT accelerated ART initiation but once on treatment, there was unexpectedly higher loss to follow-up on POC and no improvement in outcomes at 12 months over SOC.

Improved HIV-1 Viral Load Monitoring Capacity Using Pooled Testing With Marker-Assisted Deconvolution

OBJECTIVE

Improve pooled viral load (VL) testing to increase HIV treatment monitoring capacity, particularly relevant for resource-limited settings.

DESIGN

We developed marker-assisted mini-pooling with algorithm (mMPA), a new VL pooling deconvolution strategy that uses information from low-cost, routinely collected clinical markers to determine an efficient order of sequential individual VL testing and dictates when the sequential testing can be stopped.

METHODS

We simulated the use of pooled testing to ascertain virological failure status on 918 participants from 3 studies conducted at the Academic Model Providing Access to Healthcare in Eldoret, Kenya, and estimated the number of assays needed when using mMPA and other pooling methods. We also evaluated the impact of practical factors, such as specific markers used, prevalence of virological failure, pool size, VL measurement error, and assay detection cutoffs on mMPA, other pooling methods, and single testing.

RESULTS

Using CD4 count as a marker to assist deconvolution, mMPA significantly reduces the number of VL assays by 52% [confidence interval (CI): 48% to 57%], 40% (CI: 38% to 42%), and 19% (CI: 15% to 22%) compared with individual testing, simple mini-pooling, and mini-pooling with algorithm, respectively. mMPA has higher sensitivity and negative/positive predictive values than mini-pooling with algorithm, and comparable high specificity. Further improvement is achieved with additional clinical markers, such as age and time on therapy, with or without CD4 values. mMPA performance depends on prevalence of virological failure and pool size but is insensitive to VL measurement error and VL assay detection cutoffs.

CONCLUSIONS

mMPA can substantially increase the capacity of VL monitoring.

Brief Report: High Sensitivity and Specificity of the Cepheid Xpert HIV-1 Qualitative Point-of-Care Test Among Newborns in Botswana

BACKGROUND

HIV point-of-care (POC) testing allows for early infant HIV diagnosis and treatment, but POC accuracy at birth and in the setting of antiretroviral prophylaxis for the prevention of mother-to-child HIV transmission is unknown.

METHODS

We evaluated the Cepheid Xpert HIV-1 Qual POC test against the Roche Taqman HIV-1 DNA polymerase chain reaction (PCR) platform using dried blood spots from 15 HIV-infected and 75 HIV-exposed uninfected newborns. These infants were screened for HIV at <96 hours of life at 5 hospital maternity wards in Botswana; all infants received postexposure antiretroviral prophylaxis with single-dose nevirapine and zidovudine, and most mothers received 3-drug antiretroviral therapy in pregnancy and at delivery.

RESULTS

Fourteen of the 15 PCR positive samples tested positive by Cepheid POC, yielding a sensitivity of 93.3% (95% confidence interval: 68.1 to 99.8). Baseline viral load among positive infants ranged from <40 to >10,000,000 copies/mL, with a median of 2403 copies/mL. The HIV RNA for the infant with false-negative POC testing was 1661 copies/mL. Of note, 2 infants with low HIV RNA (<40 and 272 copies/mL) were correctly identified as HIV positive by Cepheid POC. All the 75 PCR-negative samples tested negative by Cepheid POC, yielding a specificity of 100% (95% confidence interval: 96.1 to 100).

DISCUSSION

Our study demonstrates high sensitivity and specificity for the Cepheid POC assay in the first week of life despite early infection and antiretroviral prophylaxis. This platform may be a useful approach for adding early infant HIV diagnosis to current testing programs.

Point-of-care diagnostics to improve maternal and neonatal health in low-resource settings

Each day, approximately 830 women and 7400 newborns die from complications during pregnancy and childbirth. Improving maternal and neonatal health will require bringing rapid diagnosis and treatment to the point of care in low-resource settings. However, to date there are few diagnostic tools available that can be used at the point of care to detect the leading causes of maternal and neonatal mortality in low-resource settings. Here we review both commercially available diagnostics and technologies that are currently in development to detect the leading causes of maternal and neonatal mortality, highlighting key gaps in development where innovative design could increase access to technology and enable rapid diagnosis at the bedside.

Protocol for a randomised controlled implementation trial of point-of-care viral load testing and task shifting: the Simplifying HIV TREAtment and Monitoring (STREAM) study

INTRODUCTION

Achieving the Joint United Nations Programme on HIV and AIDS 90-90-90 targets requires models of HIV care that expand antiretroviral therapy (ART) coverage without overburdening health systems. Point-of-care (POC) viral load (VL) testing has the potential to efficiently monitor ART treatment, while enrolled nurses may be able to provide safe and cost-effective chronic care for stable patients with HIV. This study aims to demonstrate whether POC VL testing combined with task shifting to enrolled nurses is non-inferior and cost-effective compared with laboratory-based VL monitoring and standard HIV care.

METHODS AND ANALYSIS

The STREAM (Simplifying HIV TREAtment and Monitoring) study is an open-label, non-inferiority, randomised controlled implementation trial. HIV-positive adults, clinically stable at 6 months after ART initiation, will be recruited in a large urban clinic in South Africa. Approximately 396 participants will be randomised 1:1 to receive POC HIV VL monitoring and potential task shifting to enrolled nurses, versus laboratory VL monitoring and standard South African HIV care. Initial clinic follow-up will be 2-monthly in both arms, with VL testing at enrolment, 6 months and 12 months. At 6 months (1 year after ART initiation), stable participants in both arms will qualify for a differentiated care model involving decentralised ART pickup at community-based pharmacies. The primary outcome is retention in care and virological suppression at 12 months from enrolment. Secondary outcomes include time to appropriate entry into the decentralised ART delivery programme, costs per virologically suppressed patient and cost-effectiveness of the intervention compared with standard care. Findings will inform the scale up of VL testing and differentiated care in HIV-endemic resource-limited settings.

ETHICS AND DISSEMINATION

Ethical approval has been granted by the University of KwaZulu-Natal Biomedical Research Ethics Committee (BFC296/16) and University of Washington Institutional Review Board (STUDY00001466). Results will be presented at international conferences and published in academic peer-reviewed journals.

TRIAL REGISTRATION

NCT03066128; Pre-results.

A historical review of HIV prevention and care initiatives in British Columbia, Canada: 1996-2015

INTRODUCTION

British Columbia has made significant progress in the treatment and prevention of HIV since 1996, when Highly Active Antiretroviral Therapy (HAART) became available. However, we currently lack a historical summary of HIV prevention and care interventions implemented in the province since the introduction of HAART and how they have shaped the HIV epidemic. Guided by a socio-ecological framework, we present a historical review of biomedical and health services, community and structural interventions implemented in British Columbia from 1996-2015 to prevent HIV transmission or otherwise enhance the cascade of HIV care.

METHODS

We constructed a historical timeline of HIV interventions implemented in BC between 1996 and 2015 by reviewing publicly available reports, guidelines and other documents from provincial health agencies, community organizations and AIDS service organizations, and by conducting searches of peer-reviewed literature through PubMed and Ovid MEDLINE. We collected further programmatic information by administering a data collection form to representatives from BC's regional health authorities and an umbrella agency representing 45 AIDS Service organizations. Using linked population-level health administrative data, we identified key phases of the HIV epidemic in British Columbia, as characterized by distinct changes in HIV incidence, HAART uptake and the provincial HIV response.

RESULTS AND DISCUSSION

In total, we identified 175 HIV prevention and care interventions implemented in BC from 1996 to 2015. We identify and describe four phases in BC's response to HIV/AIDS: the early HAART phase (1996-1999); the harm reduction and health service scale-up phase (2000-2005); the early Treatment as Prevention phase (2006-2009); and the STOP HIV/AIDS phase (2010-present). In doing so, we provide an overview of British Columbia's universal and centralized HIV treatment system and detail the role of community-based and provincial stakeholders in advancing innovative prevention and harm reduction approaches, as well as "seek, test, treat and retain" strategies.

CONCLUSIONS

The review provides valuable insight into British Columbia's HIV response, highlights emerging priorities, and may inform future efforts to evaluate the causal impact of interventions.

Health care workers' perceptions of point-of-care testing in a low-income country-A qualitative study in Southwestern Uganda

Background

Point-of-care (POC) tests have become increasingly available and more widely used in recent years. They have been of particular importance to low-income settings, enabling them with clinical capacities that had previously been limited. POC testing programs hold a great potential for significant improvement in low-income health systems. However, as most POC tests are developed in high-income countries, disengagement between developers and end-users inhibit their full potential. This study explores perceptions of POC test end-users in a low-income setting, aiming to support the development of novel POC tests for low-income countries.

Methods

A qualitative study was conducted in Mbarara District, Southwestern Uganda, in October 2014. Fifty health care workers were included in seven focus groups, comprising midwives, laboratory technicians, clinical and medical officers, junior and senior nurses, and medical doctors. Discussions were audio-recorded and transcribed verbatim. Transcripts were coded through a data-driven approach for qualitative content analysis.

Results

Nineteen different POC tests were identified as currently being in use. While participants displayed being widely accustomed to and appreciative of the use of POC tests, they also assessed the use and characteristics of current tests as imperfect. An ideal POC test was characterized as being adapted to local conditions, thoughtfully implemented in the specific health system, and capable of improving the care of patients. Tests for specific medical conditions were requested. Opinions differed with regard to the ideal distribution of POC tests in the local health system.

Conclusion

POC tests are commonly used and greatly appreciated in this study setting. However, there are dissatisfactions with current POC tests and their use. To maximize benefit, stakeholders need to include end-user perspectives in the development and implementation of POC tests. Insights from this study will influence our ongoing efforts to develop POC tests that will be particularly usable in low-income settings.

Challenges with targeted viral load testing for medical inpatients at Queen Elizabeth Central Hospital in Blantyre, Malawi

BACKGROUND

Approximately 75% of medical inpatients at Queen Elizabeth Central Hospital (QECH) in Blantyre, Malawi are HIV seropositive, and a third of these patients are on antiretroviral therapy (ART). Malawi guidelines recommend targeted viral load (VL) testing for patients on ART for at least one year who report excellent adherence and present with a WHO clinical stage 3 or 4 HIV disease. A switch to second-line ART is only indicated if a VL result >5000 copies/mL confirms treatment failure.

METHODS

During an audit of targeted VL testing at QECH, all adult medical admissions were screened to identify those in need of VL testing. Daily review of inpatient notes ascertained whether VL testing was ordered and carried out. At 8 weeks post-discharge the laboratory database was checked for results and was triangulated with the HIV outpatient database to ascertain whether patients had attended clinic, received results, and if these results had been acted upon.

RESULTS

Out of 81 patients recruited, 63 (77%) had a VL requested. At 8 weeks post-discharge, nine patients (14%) had VL results available. The median (IQR) waiting time for those with results was 29 days (20-47). Five patients had a VL >5000 copies/mL. Of these patients, three attended clinic and one was switched to second-line ART. Of the remaining 55 patients awaiting results, the median (IQR) waiting time at the 8-week follow-up point was 72 days (67-80). At 8 weeks post-discharge, 8 patients (33%) had died.

CONCLUSIONS

Our findings demonstrate challenges with targeted VL testing at QECH. Only two-thirds of patients with clinical ART failure were identified as eligible for targeted VL testing, and of these less than one-sixth had VL results available after 8 weeks. Interventions such as point-of-care targeted VL testing could result in faster turnaround times. In the interim, we suggest further evaluation of the possibility of switching patients with clinical ART failure and a low CD4 count to second-line ART while awaiting VL results.

HIV Point-of-Care Testing in Canadian Settings: A Scoping Review

Background

HIV point-of-care testing (POCT) was approved for use in Canada in 2005 and provides important public health benefits by providing rapid screening results rather than sending a blood sample to a laboratory and waiting on test results. Access to test results soon after testing (or during the same visit) is believed to increase the likelihood that individuals will receive their results and improve access to confirmatory testing and linkages to care. This paper reviews the literature on the utilization of HIV POCT across Canadian provinces.

Methods

We searched OVID Medline, Embase, EBM Reviews, PsycINFO, CINAHL, and 20 electronic grey literature databases. All empirical studies investigating HIV POCT programs in Canada published in French or English were included.

Results

Searches of academic databases identified a total of 6,091 records. After removing duplicates and screening for eligibility, 27 records were included. Ten studies are peer-reviewed articles, and 17 are grey literature reports. HIV POCT in Canada is both feasible and accepted by Canadians. It is preferred to conventional HIV testing (ranging from 81.1 to 97%), and users are highly satisfied with the testing process (ranging between 96 and 100%).

Conclusion

The majority of studies demonstrate that HIV POCT is feasible, preferred, and accepted by diverse populations in Canada. Losses to follow-up and linkage rates are also good. However, more research is needed to understand how best to scale up HIV POCT in contexts that currently have very limited or no access to testing.

Exploring the Case for a Global Alliance for Medical Diagnostics Initiative

In recent years, the private and public sectors have increased investments in medical diagnostics for low- and middle-income countries (LMICs). Despite these investments, numerous barriers prevent the adoption of existing diagnostics and discourage the development and introduction of new diagnostics in LMICs. In the late 1990s, the global vaccine community had similar challenges, as vaccine coverage rates stagnated and the introduction of new vaccines was viewed as a distraction to delivering existing vaccines. To address these challenges, the international community came together and formed the Global Alliance for Vaccines Initiative (GAVI). Sixteen years after the formation of GAVI, we see evidence of a healthier global vaccine landscape. We discuss how GAVI's four guiding principles (product, health systems strengthening, financing and market shaping) might apply to the advancement of medical diagnostics in LMICs. We present arguments for the international community and existing organizations to establish a Global Alliance for Medical Diagnostics Initiative (GAMDI).

Strategies for overcoming challenges for decentralised diagnostics in resource-limited and catastrophe settings

INTRODUCTION

Globally, both communicable and non-communicable diseases pose a serious threat to populations in developed as well as developing countries. Access to reliable diagnostic testing along with qualified health practitioners is severely limited in low resource and very remote areas and following natural catastrophes. Areas covered: This paper provides an overview of the challenges involved and suggests strategies to address them. The emergence of more robust, user-friendly, cost-effective and 'sample-to-result' point-of-care (POC) tools, along with the proliferation of mobile technologies, may provide a practical approach in addressing some of the challenges. Expert commentary: The successful implementation of POC testing requires the availability of versatile diagnostic technologies, improved platforms and back-up infrastructure, successful leveraging of human resources through training and, finally, engagement/coordination of associated stakeholders, including public health agencies, diagnostics companies, healthcare practitioners and local rural authorities.

Experience from a pilot point-of-care CD4 enumeration programme in Kenya

No abtract available.

Point-of-Care Viral Load Testing for Sub-Saharan Africa: Informing a Target Product Profile

Point-of-care viral load tests are being developed to monitor patients on antiretroviral therapy (ART) in sub-Saharan Africa. Test design involves trade-offs between test attributes, including accuracy, complexity, robustness, and cost. We used a model of the human immunodeficiency virus epidemic and ART program in Zimbabwe and found that the attributes of a viral load testing approach that are most influential for cost effectiveness are avoidance of a high proportion of failed tests or results not received, use of an approach that best facilitates retention on ART, and the ability to facilitate greater use of differentiated care, including through expanding coverage of testing availability.

Delayed entry into HIV care after diagnosis in two specialized care and treatment centres in Cameroon: the influence of CD4 count and WHO staging

BACKGROUND

Delayed entry into HIV care has complicated the challenges faced in sub-Saharan Africa due to the high HIV burden. A clear knowledge of the factors affecting delayed entry will be essential in directing interventions towards reducing delayed entry into HIV care. There exist very limited data on delayed entry in Cameroon despite its relevance; hence this study was conducted to determine the rate of delayed entry and its associated factors in HIV programmes in Cameroon.

METHODS

Data used for this study was routine data obtained from the files of HIV patients who were diagnosed between January 1, 2015 and June 30, 2015 at Limbe and Buea regional hospital HIV centers in the South West region of Cameroon. Data analysis was done using SPSS version 20.

RESULTS

Of the 223 patients included in the study, nearly one-quarter of patients (22.4 %) delayed to enter HIV care within 3 months. Those who delayed to enter care were less likely to present at first diagnosis (using HIV rapid test) with symptoms such as fever > 1 month (5 % versus 30 %, p = 0.01) and weight loss > 10 % (13 % versus 48 %, p < 0.001). Alcohol consumption, WHO stage and CD4 count levels were also associated with delayed entry in bivariate analysis. In multivariate analysis only CD4 count greater than 500cells/μl and WHO stages I and II were independently associated with delayed entry into HIV care within 3 months.

CONCLUSION

In the South West region of Cameroon, approximately 1 out of 4 patients delay to enter HIV care. This high proportion of patients who delay to enter care correlates to the findings recorded by other studies in sub Saharan Africa. Interventions tackling delayed entry into HIV care might need to be favorably directed towards patients that have high CD4 counts and are at very early WHO clinical stages.