ART Laboratory Monitoring

The proceedings at the 18th International Conference on AIDS in Vienna on Wednesday and Thursday had particularly resounding relevance to some of the work the clinical department at the JSI – NUMAT project has hitherto been engaged in. On Wednesday, we were given an opportunity to showcase our largely successful effort to provide CD4 lymphocyte and full blood count tests to HIV patients in hard to reach communities. NUMAT presented the oral poster “Innovative CD4 lymphocyte testing for rural communities in Northern Uganda.” The following day, I sat in on another session discussing the monitoring of ART.

The NUMAT Oral Poster: Cost analysis of the project.
As we prepared for the Wednesday oral poster presentation; we had anticipated that questions would be raised about the cost effectiveness of drawing blood from patients, transporting samples by motorbike to the centralized laboratories based in Lira and Gulu, and later disseminating results to the sites. We actually had an answer to this query: NUMAT was just completing a draft cost evaluation report on the CD4 project. But alas! The money quotes in the draft were still in Uganda shillings! In his characteristically witty manner, Dr Luigi Cicciò, the NUMAT Director of Strategic Information asked why we did not at least quote costs in Italian Lira for the benefit of the international audience at Q and A session. “… And after all,” he quipped, “NUMAT has always had something to do with Lira!” (Lira is coincidentally a name of one of the major towns in Northern Uganda).

Let it be known in “USD” this time! We did ascertain that the cost of a single test, transportation and testing, inclusive, in our outreach program was US$13.78. Compared to US$9.64 in the static model, a single CD4 count test in the outreach programme cost more than a single test in the static program by 43%. The higher cost of the outreach model is very much expected given the extensive organizational network and geographical coverage. However, the cost-effectiveness measure shows that the outreach program was actually more cost-effective than the static model. It would cost only US$33.96 to offer a CD4 test to 1% of clients, compared to US$89.81 incurred in the static model to achieve the same level of coverage. In other words, the static model cost 2.5 times more than the outreach model to achieve the same level of coverage.

The measure took into account the sub-optimal performance of the static laboratories. Yet, even if the static laboratories were performing optimally, as a best case scenario, the outreach model would still be more cost-effective. The cost of achieving 1% coverage by the static model in this case would have been US$44.26 (the static model would have cost 30% more to achieve the same level of coverage).

Again in terms of cost savings, the outreach program provided additional economic benefits to its beneficiaries. By taking services closer to the clients, the outreach model saved the beneficiaries an estimated US$21.88 per client per test. This represented 80% of the cost patients would have incurred had they endeavored to travel out to the static sites to access a CD4 lymphocyte test.

Of course, not all of the achievements can be described in numerical terms. During the first part of the year, one of the laboratories we use had run aground. At no extra cost, our contractor rerouted the samples to the second laboratory; the beneficiaries were only vaguely aware of the switch. There has actually never been a break in our service. There were infrequent occasions when the patients were not prepared for bleeding by the team at the health facility. NUMAT would quickly work with the health workers to address the gap. The monthly reports provided by the contractor helped us quickly identify these trouble spots and address the bottlenecks. It was recognized that patients recently testing positive for HIV were more accepting of the optimal course of disease management if they had a CD4 test done. Previously, many patients offered chronic care management on the basis of a simple clinical assessment remained unconvinced and “shopped” for better care in elsewhere. A CD4 test better supported the psychological aspects of care, and both the patient and the clinician were more confident in the disease management plan selected.

Viral load testing, CD4 testing and collaborating to make laboratory monitoring more available

The presentations in the Thursday morning session by Gilks, et al were rich with information and needed a longer peek for appropriate assimilation. However the take home message for me was that the CD4 test still remains relevant as a routine monitoring test whose access at all points of care needs to be scaled up. The viral load count is extremely vital, though it is expensive and is best recommended as backup arsenal confirming ART treatment failure. As people remain longer on ART, the need for a viral load count will generally become more and more essential as more patients start taking second-line drugs.

The PMTCT dry blood spot (DBS) being used as a surrogate for the DNA RNA assay made me jump in my seat. Viral load testing can actually be done as we speak using the DBS cards at a smaller cost. The study carried out by Vazquez and others evaluating the use of DBS to measure HIV-1 viral load had interesting findings in terms of high specificity and sensitivity patterns compared with the gold standard viral load test. What I did not hear the presenter state in her recommendations was that the DBS test probably less useful as an on-the-spot test. In my opinion, DBS might only be of use if the test per individual is done on temporal and sequential basis.

I then engaged some Nigerian colleagues—Dr. Anne & Dr. Mercy—in an interesting discussion. By the time I found them at their poster stand; it was getting to two o’clock, almost the end of the poster exhibition period, and their exhaustion was visibly setting in: the ladies were seated on the carpeted floor by their poster. The poster had a lengthy title alluding to integrating continuous quality improvement into ensuring six monthly CD4 counts for all patients. They convinced me that Nigeria—or at least their State—had prevailed on the various funding agencies and implementers supporting HIV management to work together so that CD4 lymphocyte testing was more universally available. It is just like what happens in Uganda with ARV drugs. They are routinely “borrowed” (and never returned) from clinic X when there are shortages in clinic Y. In fact some indolent clinicians who will not make their consumption reports in time continually borrow drugs —simply depending on the good will of others.

The Nigerians have found ways of ferrying blood samples in bulk from one hospital, where CD4 lymphocyte testing equipment has broken down, to another hospital, so that the bulk samples are tested free of charge. The implementers had found novel ways of collaborating and sharing their activity data as well. As to Uganda —I thought that as we seek ways of making tests more available for the populations we serve, just like we are considering central procurement or storage for ARVs, we should consider a strategy of pooling resources for laboratory monitoring. Of course this might also include synchronizing equipment procurements so that procurement of consumables is better coordinated and centrally done.

The findings from NUMAT have helped further the discussion of how to take lab testing closer to the people in greatest need. The examples and approaches presented by my colleagues in other settings have great promise as we continue our work in Northern Uganda.

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