Using m-health strategies to improve laboratory
data management in PMTCT programs
m-health satellite
Washington, July 23, 2012
Financing
overview:
Malawi is expecting
a funding
gap in the
term, but significant
Large
numbers
of HIV-infected
children
continue
to near
get infected
despite
worsening after 2013, unless additional funding is secured
increasing access
to PMTCT
• Access to PMTCT services has expanded markedly in recent
years
• UNAIDS estimates that ~350,000 pediatric HIV infections have
been prevented since 1995
• But…at best, we are preventing only 20-25% of new infections
annually
• In 2010, there were an estimated 390,000 new pediatric
infections
• More than 1,000 infants are newly infected each day
• In the absence of treatment, mortality in these infants is very
high – approaching 50% by age 2
Source: UA report 2011, Newell et al. Lancet 2005
overview:
Malawi
is expectingand
a funding
the near term,
significant
WeFinancing
need to
improve
performance
strivegap
forin “eMTCT”,
butbutwe
also
worsening after 2013, unless additional funding is secured
must do a better
job of treating the children already living with HIV
51%
Adults Receiving ART
Children Receiving ART
42%
Coverage % - Children
Coverage % - Adults
1.3M
0.1M
2005
1.9M
0.1M
2006
2.8M
0.2M
2007
3.8M
0.3M
2008
21%
23%
4.9M
0.4M
6.2M
2009
2010
0.5M
Adapted from: UA report 2011
overview: Malawi
expecting
a fundingmothers
gap in the and
near term,
but significant
OnFinancing
the continuum
of careisfor
HIV positive
children,
infant
worsening after 2013, unless additional funding is secured
diagnosis is essential
for infant treatment and program monitoring
HIV Ab
test
CD4 for
ART
eligibility
Infant
Diagnosis
ART monitoring
in mothers and
children
Infant diagnosis is essential to
monitor progress towards eMTCT
and identify infected infants
Financing
Malawi
is expecting
a funding
gapusing
in the near
term, but significant
But,
infantoverview:
diagnosis
requires
virologic
testing
DNA-PCR
worsening after 2013, unless additional funding is secured
• All HIV exposed infants have maternal HIV antibodies so infant
diagnosis requires virologic testing
• DNA PCR identifies the DNA of the virus in cells but requires many
steps including extraction, amplification and detection of HIV DNA
• Use of innovative blood collection methods such as Dried Blood Spots
(DBS) has enabled many national programs to offer this test by using
sample transport to link peripheral sites to central labs
Financing
Malawi
is expecting
funding
gap in the near
buthas
significant
Using
DBS overview:
and sample
transport,
inamany
countries,
EID term,
testing
worsening after 2013, unless additional funding is secured
scaled up rapidly
in recent years
Uganda example
Number of DNA PCR tests performed, by year
40,000
35,000+
35,000
30,000
25,000
20,000
17,520
15,000
10,000
5,000
6,437
0
2007
2008
2009
Number of sites
providing PMTCT
507
646
947
Number of Sites
providing EID
145 (29%)
285 (44%)
550 (58%)
Financing
overview:
is expecting
a funding
gapup
in the
term,
but significant
But
scale up
of EID Malawi
has not
translated
to scale
of near
infant
treatment
worsening after 2013, unless additional funding is secured
due to high rates
of LTFU – especially between testing and results return
Infant Retention Cascade at 3 Regional Referral Hospitals in Uganda
Sept 2007 – Feb 2009
350
300
39% of positive
250
infants never
received results
35% of positive
infants receiving
results were never
enrolled into care
200
42% of positive
infants in care &
treatment were lost
150
244
100
150
98
50
57
0
Given PCR Test
(Pos only)
Received PCR
Results (Pos
only)
Enrolled into
Care/ Treatment
Currently Active
in Care/
Treatment
Source: CHAI/MOH Uganda 2011
Postnatal PMTCT visits are linked to EPI at 6 and 10 weeks. If the turn
around time is too long, EID results are not there when mothers return
Caregiver
returns for
results
DBS drawn
for PCR
Birth
6 wks
10 wks
Batch
sent Sample Results
to lab Tested Dispatched
14 days
5
days
6
days
18 days
Kangemi Health Center – Nairobi
Total5 TAT 639 days
days
days
GSM Printers were used to reduce turnaround time from availability of
result to delivery to clinic
Caregiver
returns for
results
DBS drawn
for PCR
Birth
 10 wks
6 wks
Batch
sent Sample
to lab Tested
14 days
5
days
6
days
5
days
6
days
What’s next after the SMS printers?? An “EID-ecosystem” to leverage
the SMS network and build a real time national database of test results
A Public-Private partnership between HP, NASCOP and Safaricom resulted in the
creation of a real time, online database to track EID nationally
Sample
information
entered into
data terminal
EID sample
received at
lab
HP provided &
supports
servers
Information
instantly
enters
NASCOP’s
data “cloud”
Auto SMS to
clinic
confirming
receipt and
providing
batch number
Sample
processed and
result entered
into data
terminal
Paper result
dispatched to
clinic
Auto SMS
sent to clinic
with result
Safaricom
supports
the auto
SMS
function
This wireless
“ecosystem” enables
>2,000 facilities to have
access to all data & test
results over SMS and
web in real time AND
allows program staff to
review national,
regional and site level
performance
EID data can be accessed through a web interface
http://www.nascop.org/eid
EID data can be accessed through a web interface
http://www.nascop.org/eid
What lessons have we learned, what challenges remain?
• PPPs work! The support of CHAI, HP and Safaricom has created a highly
effective system
• Building trust with partners was critical. Although it took a while to bring
partners on board and overcome concerns of data sharing, the benefits of
being able to access and view real time information is apparent to all
• With transparency comes accountability. Lab performance is closely
tracked and problems can be addressed very quickly
• Clinics and providers are empowered by seeing their performance and
having access to this technology
• The national EID data system helps us track progress better than ever
before, but EID is a clinical service not only a programme monitoring tool.
When a test is positive it is essential to link that child to treatment and this
remains a challenge in many settings