Akwa Ibom AIDS indicator survey: Key findings and lessons learnt.

BACKGROUND: The burden of HIV/AIDS epidemic is huge, but this varies widely by population in Nigeria. Data that could be used to guide the scale up of HIV prevention and control strategies has significant gaps. The study sought to estimate the prevalence of HIV and its associated determinants in Akwa Ibom state. METHODS: Akwa Ibom AIDS Indicator Survey (AKAIS) is a population based cross-sectional survey, with a two-stage probability sampling. The survey had both behavioural and biological components. Tablet-based questionnaire was used to collect data on participant's household information, demographics, socio-economic, and behavioral risk factors associated with HIV; while the biological component involved collection of venous blood samples for participants who were over 19months. For children aged 18months on less, capillary blood from finger prick sample was used. Participants were tested for HIV. Other biomarker tests for HIV positive participants included CD4, HIV-1 RNA viral load and incidence assays. RESULTS: In all 15,609 people (8,963 adults aged 15 years and older (55% females), 6,646 individuals less than 15 years (51% males), from 4,313 households, participated in AKAIS. Overall, 2.8% (423 persons; 422 HIV-1 and 1 HIV-2) were found to be HIV positive. HIV prevalence was 4.8% in adults (15 years and above) and 0.4% in pediatric (< = 14 years) participants. HIV prevalence was significantly higher in females (5.6%) than males (3.7%) aged 15 years and older (p <0.001). Overall HIV incidence was 0.41. CONCLUSIONS: HIV prevalence among adults was 4.8% with an overall incidence of 0.41%. These estimates are essential to inform strategic control and prevention of HIV epidemic in Akwa Ibom state targeting the affected populations.

Performance evaluation of BD FACSPresto™ point of care CD4 analyzer to enumerate CD4 counts for monitoring HIV infected individuals in Nigeria.

BACKGROUND: Despite the upsurge in support and intervention of donor agencies in HIV care and treatment programing in Sub-Sahara African, antiretroviral (ART) programs are still confronted with access and coverage challenges which influence enrolment of new patients. This study investigated the validity of point of care BD FACSPresto™ CD4 analyzer for CD4+ cell count, overall agreement, correlation, sensitivity, and specificity in comparison to a reference standard flow cytometry method. We also assessed the feasibility of use among non-laboratorians. METHODS: Blood samples from 300 HIV infected individuals were analyzed for CD4+ T cell and CD4%, using finger prick capillary sample from 150 PMTCT clients and 150 ART clients at Murtala Mohammed Specialist Hospital, Kano, Nigeria. Their venous samples were compared on a flow cytometry reference method using BD FACSCount CD4+ count system. The accuracy of the BD FACSPresto machine in comparison to BD FACSCount was evaluated. Statistical analysis was carried out using STATA (version 12). Bland-Altman method and correlation analysis were used to analyze agreement between both measurements. In addition, sensitivity and specificity of both measurements were determined. Statistical significance was set at p-value <0.05. RESULTS: The mean bias and limit of agreement for CD4+ count between BD FACSPresto and BD FACS count machine were 7.49 (95% CI: 2.44 to 12.54) and -8.14 to 96.39 respectively. Further analysis revealed close agreement between BD FACSPresto and BD FACSCount with no significant difference between the two methods (p = .0.95). Using a threshold of 500 cells/µL, sensitivity and specificity of BD FACSPresto were 95.1% and 97.1% respectively, compared to BD FACSCount. There was no statistically significant difference in the misclassification between BD FACSPresto and BD FACSCount results (p = 0.23). Furthermore, sensitivity and specificity were similar when BD FACSPresto machine was operated by a nurse or laboratory scientist, there was no substantial difference in testing variability observed between laboratory and non-laboratory operators using the BD FACSPresto analyzer. CONCLUSIONS: Overall, BD FACSPresto Point of Care CD4+ count finger stick capillary blood results is a reliable method in comparison to venous sample cytometry method and no significant difference variability observed between laboratory personnel and non-laboratory operators. The BD FACSPresto is simple, more robust and easy to use equipment without significant variability in reliability by non-laboratory health care workers hence will be a valuable instrument in increasing access and coverage of CD4 estimations in developing countries. The introduction of the BD FACSPresto POC analyzer has a high potential in reducing patients waiting time and improving the overall quality of ART service and clients' satisfaction especially in rural settings.

Piloting laboratory quality system management in six health facilities in Nigeria.

BACKGROUND: Achieving accreditation in laboratories is a challenge in Nigeria like in most African countries. Nigeria adopted the World Health Organization Regional Office for Africa Stepwise Laboratory (Quality) Improvement Process Towards Accreditation (WHO/AFRO- SLIPTA) in 2010. We report on FHI360 effort and progress in piloting WHO-AFRO recognition and accreditation preparedness in six health facility laboratories in five different states of Nigeria. METHOD: Laboratory assessments were conducted at baseline, follow up and exit using the WHO/AFRO- SLIPTA checklist. From the total percentage score obtained, the quality status of laboratories were classified using a zero to five star rating, based on the WHO/AFRO quality improvement stepwise approach. Major interventions include advocacy, capacity building, mentorship and quality improvement projects. RESULTS: At baseline audit, two of the laboratories attained 1- star while the remaining four were at 0- star. At follow up audit one lab was at 1- star, two at 3-star and three at 4-star. At exit audit, four labs were at 4- star, one at 3-star and one at 2-star rating. One laboratory dropped a 'star' at exit audit, while others consistently improved. The two weakest elements at baseline; internal audit (4%) and occurrence/incidence management (15%) improved significantly, with an exit score of 76% and 81% respectively. The elements facility and safety was the major strength across board throughout the audit exercise. CONCLUSION: This effort resulted in measurable and positive impact on the laboratories. We recommend further improvement towards a formal international accreditation status and scale up of WHO/AFRO- SLIPTA implementation in Nigeria.

Implementing and measuring the level of laboratory service integration in a program setting in Nigeria.

BACKGROUND: The surge of donor funds to fight HIV&AIDS epidemic inadvertently resulted in the setup of laboratories as parallel structures to rapidly respond to the identified need. However these parallel structures are a threat to the existing fragile laboratory systems. Laboratory service integration is critical to remedy this situation. This paper describes an approach to quantitatively measure and track integration of HIV-related laboratory services into the mainstream laboratory services and highlight some key intervention steps taken, to enhance service integration. METHOD: A quantitative before-and-after study conducted in 122 Family Health International (FHI360) supported health facilities across Nigeria. A minimum service package was identified including management structure; trainings; equipment utilization and maintenance; information, commodity and quality management for laboratory integration. A check list was used to assess facilities at baseline and 3 months follow-up. Level of integration was assessed on an ordinal scale (0 = no integration, 1 = partial integration, 2 = full integration) for each service package. A composite score grading expressed as a percentage of total obtainable score of 14 was defined and used to classify facilities (≤ 80% FULL, 25% to 79% PARTIAL and <25% NO integration). Weaknesses were noted and addressed. RESULTS: We analyzed 9 (7.4%) primary, 104 (85.2%) secondary and 9 (7.4%) tertiary level facilities. There were statistically significant differences in integration levels between baseline and 3 months follow-up period (p<0.01). Baseline median total integration score was 4 (IQR 3 to 5) compared to 7 (IQR 4 to 9) at 3 months follow-up (p = 0.000). Partial and fully integrated laboratory systems were 64 (52.5%) and 0 (0.0%) at baseline, compared to 100 (82.0%) and 3 (2.4%) respectively at 3 months follow-up (p = 0.000). DISCUSSION: This project showcases our novel approach to measure the status of each laboratory on the integration continuum.