Decentralization of Laboratory Services for HIV Patients` Care in Rural Clinics in Shiselweni, Swaziland 1 Lassovski ,
1 Kyembe ,
2 Maphalala ,
Authors: Maryvonne Laban Gugu 3 1 1 Guillaume Jouquet , Lucy Anne Parker , Bernhard Kerschberger
Roberto de La
3 Tour ,
Francesca
1 Faraglia ,
Affiliation: 1 Médecins Sans Frontières, OCG, Swaziland; 2 Ministry of Health, Swaziland; 3 Médecins Sans Frontières, OCG, Switzerland Corresponding author: Bernhard Kerschberger; msfch-swaziland-dmedco@geneva.msf.org
BACKGROUND Swaziland is hardest hit by the dual HIV/TB epidemic with the highest HIV prevalence worldwide. Access to HIV laboratory baseline and follow up diagnostics is often limited in primary health clinics in rural areas. But decentralized care models with a task shifting component have shown to be feasible to improve access to HIV care in high HIV/TB prevalence settings. Photo 1: Rural Shiselweni region in Swaziland.
We describe the successful scale-up and integration strategy of laboratory HIV services for baseline and follow up diagnostics of HIV infected patients at primary health clinics in the rural context of Swaziland from 2010 to 2012.
Decentralization/ Integration & Scale up of Laboratory Services From 2010 onwards, primary health clinics were, in addition to already existent basic diagnostics (HIV testing, pregnancy-, syphilis tests, urinalysis), equipped with: CD4 Point of Care (POC) (PIMA), Biochemistry POC (Reflotron plus; creatinine, glucose, potassium, ALAT) and Hematology POC. This was possible through task shifting (ANNEX 1) where the phlebotomist cadre was strengthened nationally to support rapid scale up of HIV services1. Phlebotomists were laypersons with high school (level 5) education undertaking 5 days theoretical training and 4 weeks practical attachment enabling them performing all diagnostic tests offered in primary health clinics. Thus local capacity was strengthened and sustainability ensured. The phlebotomist cadre has also been successfully integrated to the government human resource (HR) plan.
PROJECT
Photo 2: CD4 (PIMA) [right] and biochemistry POC (Reflotron) [left] operated by phlebotomist in primary clinic.
The rural Shiselweni region in Swaziland with more than 200,000 inhabitants is served by three secondary health centers and 22 decentralized primary health clinics. Figure 1: MoH and MSF supported health centers and primary clinics scattered over Shiselweni region in Swaziland.
Since 2008, Médecins Sans Frontières (MSF) and the Ministry of Health (MoH) integrated and scaled up HIV and TB services in nurse lead primary health clinics. During the first years, patients and/or blood samples were sent to 3 distant secondary health centers to ensure baseline HIV diagnostics and routine laboratory ART (antiretroviral therapy) follow up.
OUTCOMES
CONCLUSION
Laboratory services, its costs (2012 data) and quality control (for 6 clinics in 2012) were retrospectively analyzed at primary and secondary health clinics from January 2010 to December 2012, using routine programmatic data recorded in paper and electronic registers.
Improving access to quality laboratory follow up in HIV care was feasible in a rural context through integration of laboratory services into nurse lead primary health clinics. Task shifting and low complexity PoC technology were key factors for successful scale up of laboratory services.
A total of 19 decentralized laboratories were integrated in primary health clinics: 5 in 2010, 10 in 2011 and 4 in 2012. 19 phlebotomists were trained who processed 12,043 PIMA CD4 (0 [year 2010], 3176 [2011], 8867 [2012]), 10,699 creatinine (248, 3266, 7185) and 10,484 ALAT (244, 3138, 7102) tests. Average time to results decreased from 2 days to 30 minutes. In 2012, out of 3110 quality control tests for CD4 POC, 0.2% (n=6) were out of range. Out of 144 quality control samples for biochemistry POC, 0.7% creatinine, 12.5% glucose, 8.3% potassium and 2.8% ALAT tests were out or range. The costs* for CD4 POC diagnostic per ART patient year were $12 lower in primary health clinics ($25 vs. $37 in secondary health clinics) (Figure 2). 40 35 30 25 20 15
Quality assurance was ensured by internal (using daily test specific control samples and supported by two-monthly supervision visits) and external (using external control samples provided by MoH) controls. Low complexity POC maintenance at clinic level.
technologies
enabled
Only minor support was provided by mobile laboratory technologists who provided trainings, remote technical supervision and investigation in case of quality concerns.
10 5 0
TOTAL COSTS:
$7 $11
$ 37 Staff - CD4
TOTAL COSTS:
$ 25
$5
Reag.+cons. CD4 QC
$1 $6
$16
$10
$1 $6
Implications Although lack of laboratory monitoring in resource constrained settings should never hamper increasing access to HIV care and ART roll out, decentralized point of care laboratory services for HIV/ ART baseline and treatment follow up diagnostic should be considered for resource constraint contexts where health policies demand close laboratory follow up.
ETHICAL APPROVAL MSF ethical approval was not required for retrospective analysis of routinely collected data not containing patient identifiers. REFERENCES (1) 2011; Swaziland task shifting implementation framework; Ministry of Health, Kingdom of Swaziland. ACKNOWLDGMENTS We thank the clinic staff and patients of Shiselweni region and the support of MoH provided to MSF since 2008.
Maintenance Equipment
Secondary Clinic Primary Clinic Figure 2: Costs* for CD4 POC diagnostic per ART patient year.
The combined costs* of CD4, ALAT, HB and creatinine diagnostic per ART patient year were $3 higher in primary health clinics ($65 vs. $62 in secondary health clinics). At the end of 2012, a total of 8,737 patients were followed in decentralized laboratory services. * Costs considered were laboratory staff, reagents and consumables, quality control (QC), maintenance, equipment.
ANNEX 1 Clinical activities shifted to phlebotomists1: Receives/ collects and records specimens; Numbers and keeps record of slides and cultures; Dispatches lab results; Sterilizes lab items; Performs laboratory tests: HB, Pregnancy Test, Sputum microscopy, Lactic acid test, point of care testing (CD4, biochemistry), Urine dipstick, HIV testing, DBS, malaria, etc.; Participates in quality assurance.