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Pilot Implementation of Point-Of-Care, CD4 Counting in Mozambique’s National Health System
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Pilot Implementation of Point-Of-Care, CD4 Counting in Mozambique’s National Health System

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Presentation at the IAS 2011 conference on 18 July 2011 by Ilesh V. Jani, Instituto Nacional de Saúde, Mozambique.

Presentation at the IAS 2011 conference on 18 July 2011 by Ilesh V. Jani, Instituto Nacional de Saúde, Mozambique.

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  • 1. Pilot Implementation of Point-Of-Care CD4 Counting in Mozambique’s National Health System
    Ilesh V. Jani
    Instituto Nacional de Saúde
    Maputo, Mozambique
  • 2. Acknowledgements
    • MISAU
    • 3. INS
    • 4. CHAI
    • 5. Provincial Health Authorities in Maputo City, Maputo Province, Gaza, Sofala and Niassa
    • 6. Implementing Health Centres
    • 7. Anglican Church, Niassa Province
    • 8. MSF-Belgium
    • 9. MSF-Switzerland
    • 10. ARK
    • 11. UNITAID
  • The Use of Rapid Tests Allowed Dramatic Scale Up of HIV Counselling and Testing
    Source: Ministério da Saúde, Moçambique
  • 12. HIV Rapid Testing – Leaps and Hiccups?Proficiency Testing Programs Show That Error Rates Are High in Some Settings
    % of Participating Institutions
    Number of Participations in the EQA
    Source: Instituto Nacional de Saúde, Moçambique
  • 13. Mozambique’s National Health System Adopted a Multi-Step Evaluation Process for Point-Of-Care Technologies
    Technology Selection
    Technical Evaluation
    (Laboratory, Field)
    Pilot Implementation
    (Site, Province)
  • 14. How to Select Technologies to Evaluate?
    • Description of technology and parameters
    • 15. Type of technology (disposable, handheld, tabletop)
    • 16. Technical Sophistication
    • 17. Mobility & Size
    • 18. Routine Maintenance Requirements
    • 19. Instrument Throughput
    • 20. Power Source
    • 21. Alternate Power Source Availability
    • 22. Capital Cost of Equipment
    30 criteria across 4 categories
    Technology
    Attributes
    30%
    • Heat and Humidity
    • 23. Type of Sample Tubes
    • 24. Need for Centrifuge
    • 25. Reagent & Control Preparation
    • 26. Expiration Period
    • 27. Reagent and Consumable Cost
    Testing Method & Procedures
    40%
    Reagents,
    Consumables &
    Supplies
    20%
    • Internal Quality Control
    • 28. External Quality Control
    • 29. Daily Calibration Requirements
    • 30. Number of Steps in Procedure
    • 31. Type of Sample Required
    • 32. Precise Sample Measurement Requirements
    • 33. Batching
    • 34. Result Delivery
    • 35. Result Storage
    • 36. Instrument Connectivity
    • 37. Waste Generation
    Other Company Information
    10%
    • Service and Maintenance
    • 38. Supply Chain and Distribution
    • 39. Timing & Regulatory Status
    • 40. Installation
  • Primary Health Care Nurses Can Accurately Perform CD4 Counts and Toxicity Monitoring Using Point-Of-Care Devices
    Alere PIMA (Lab Techs) vs. BD FACSCalibur
    Alere PIMA (Nurses) vs. BD FACSCalibur
    Limits of Agreement -249 to +148
    Limits of Agreement -314 to +257
    But training on capillary blood collection is critical!
    Jani et al. AIDS (2011)
  • 41. Pilot Implementation Was Initially Done in Six Clinics and One Mobile Team
    • Six primary health care clinics in urban and rural settings
    • 42. One mobile team in a remote rural area in the north of Mozambique
    • 43. Chart review for data collection performed at baseline and post-implementation
  • Point-Of-Care CD4 Counting Reduces Pre-Treatment Loss-To-Follow-Up
    Percent Of Patients Receiving
    CD4 Test Results
    Percent Of Patients Returning
    After Initial CD4
  • 44. A Mobile Team Successfully Operates in Northern Lake Niassa, Mozambique
    Setting: population ~20,000, area 1,600 km2.
    Strategy: Every 2 months, 2 community health workers, with no formal health qualifications, make a round trip of 220 km on foot or kayak, stopping at 8 health posts.
    Cumberland et al. Poster TULBPE060; IAS 2011
  • 45. Sites with POC CD4 Perform Well in the National Proficiency Testing Program
    Sites with
    POC CD4
    Sample QC49,
    average absolute CD4 count=400 cells/mm3
    Source: Instituto Nacional de Saúde, Moçambique
  • 46. A Pilot Implementation in Currently Ongoing in Mozambique’s Gaza Province
    Main Objectives:
    - Test an approach for the implementation of point-of-care CD4 counting from a health system perspective.
    - Develop and validate tools to assist provincial authorities in scaling-up the implementation of point-of-care assays.
  • 47. Site Matrix
    Preliminary site list generated from a site
    selection matrix.
    Nov
    2010
    Provincial Coordination
    Provincial stakeholder meetings. Site list validated.
    POC ToT
    Central level team trains provincial trainers.
    Dec
    2010
    Provincial trainers train and certify local POC
    CD4 operators.
    Train Sites
    Site Introduction
    Sites mentored. New patient flow diagrams
    implemented. Sites begin to implement POC CD4.
    Jan
    2011
    Joint Stakeholder evaluation meetings. Discussion
    of lessons learnt. Road map for continuous
    improvement. Validation of tools.
    Periodic Evaluation
    May
    2011
  • 48. Expected Outputs of the
    Provincial Pilot:
    • Site selection tool
    • 49. Implementation process manual
    • 50. Laboratory
    • 51. Clinic
    • 52. Logistics and supply chain
    • 53. Quality assurance
    • 54. Training curriculum
    • 55. Recommendations for division of responsibilities (national, provincial, local)
  • The Improvement of Access to CD4 Counting is Not Uniform Across All Clinics
    NEW TECHNOLOGY IS NOT
    THE SOLE SOLUTION
    Limiting Factors:
    • Limited human resources - Change of culture
    • 56. Patient overflow - Patient education
    • 57. Clinic workflow
  • Ultimately, sucessful implementation of point-of-care diagnostics will be about changing health systems, creating a new health care culture and shifting responsibilities to primary health care level.
    In the coming years we will need to learn fast through implementation research.
    OBRIGADO!

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