Baylor College of Medicine
Children’s Foundation - Uganda
Children’s Foundation - Uganda
Overview
Testing for viral load is a globally accepted mechanism for monitoring HIV treatment success and virologic failure among people living with the virus. In 2018, Uganda transitioned from the dry blood spot mechanism to plasma as a measure of the effectiveness of ART. Both the CD4 and viral load processes allow clinicians to determine which client is eligible for initiation on antiretroviral therapy (ART), the disease progression, and treatment response.
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Viral load testing for children and adolescents is conducted every six months; pregnant women every three months and adults once every year. Before 2022 revised consolidated guidelines for the prevention and treatment of HIV, viral load blood tests for stable clients were repeated when they have more than 1,000 copies of the virus per ml of blood. In 2022, viral load suppression was reduced to 200 copies of the virus per ml of blood.
Problem
The viral load testing coverage target for the United Nations Joint Program on HIV/AIDS (UNAIDS) is 95 percent of all HIV clients active on ART. However, by October 2021, viral load testing coverage for the Bukedi region, one of the regions for USAID Local Partner Health Services- Eastern (LPHS-E) By Oct 2021 stood at 84 %.
USAID LPHS-E is the main HIV and TB implementing partner in the Bukedi and Bugisu regions. The Activity must facilitate the transportation of samples from the lower health facilities to the hub before they reach the Ministry of Health’s Central Public Health Laboratories (CPHL), says Ronald Mangeni, Laboratory Services Officer for Cluster II, USAID LPHS-E.
By Oct 2021, hub riders delivered only half (50%) of the viral load samples within two days at the hub laboratories for processing using point-of-care testing for Pregnant and breastfeeding women, and transportation of other patients’ samples for processing at the National referral laboratory CPHL in Kampala. Delays were due to sample packaging at the spoke facility, online CPHL hub tracker data was not utilized. The facilities lacked the centrifuges necessary for extracting plasma from the blood sample.
Packaging dry blood spot samples were challenging because they were collected and stored at different points of care at facilities. Sometimes health workers forwarded the samples without request forms. “We often engaged in packaging samples. If we didn’t, we would delay more,” says David Okiria,Hub Rider for Pallisa, Kibuku, and Butebo Districts.
Human resources shortages in laboratories exacerbated the turnaround challenge. Kibuku District Health facilities could have over 100 samples on the clients
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clinic day with only one active lab technician to bleed the clients and fill forms. A form filled in by a Clinician is supposed to accompany each sample for testing in the laboratory. Delivering the dry blood spot samples from the facility to CPHL would take on average 10 days, only to be rejected because the samples had been packed without a form.
The facilities lacked refrigerators for keeping the Plasma Viral load samples which can only be stored at room temperature for six hours. In addition, the hubs were not utilizing the online turnaround time (TAT) tracker data to guide them about which facilities required support.
“The viral load situation was not good. We would send approximately 80% of the dry blood samples to CPHL for processing,” says Samuel Erepu, Lab Technician and Viral Load Focal Person at Pallisa General Hospital.
With the dry blood spot, the procedure was to massage the finger, but the health workers rarely cleaned the finger. Patients were happy because little blood was required of them, says Anyodo.
“After pricking the patient, sometimes we would not get sufficient blood in the circle on the DBS card. The lab was overwhelmed. We rarely took notice of these anomalies because we had a human resource challenge. This made Pallisa Hospital’s performance drop,” says Anyodo.
Results of the dry blood spot test would sometimes take close to three months before they were returned because they were taken to Kampala. Every time Grace Aloyet, Community Health Worker at Pallisa General Hospital, Pallisa District got a month’s drug refill, she would ask health workers if her results were back. Sometimes she never got the results. “Whenever I didn’t receive my results, I felt bad. I needed to know how I was progressing,” says Aloyet.
Aloyet got to know that she was HIV positive in 2004. At the time she received an operation because of intestinal TB. A year later, Aloyet received her CD4 results a month after CPHL in Kampala got her blood sample. She was not suppressing at the time. She enrolled in treatment with The AIDS Support Organization (TASO), Mbale City to receive Co-trimoxazole (Septrin®). The same year, she started volunteering at Pallisa General Hospital.
Since CPHL was processing results of all hubs nationally, the turnaround time would sometimes last up to 49 days, depending on the type of sample tested (Plasma or Dry blood spot). The overall turnaround time for viral load results in the region was 25 days in April 2022 against the national target of 14 days.
“The delay process of 11 days was between sample transportation from the spoke facility to hubs at Busolwe and Pallisa hospitals,” says Mangeni.
Strategies
In 2019, CPHL partially decentralized viral load testing services, placing Point of Care (POC) machines on site in 100 hubs countrywide and selected high volume health facilities. Bugisu and Bukedi regions have 18 POC machines that CPHL regularly services.
With support from USAID LPHS-E, the hubs mapped 20 high-volume facilities in Pallisa, Kibuku, Butaleja, Budaka, and Butebo districts, Bukedi sub-region.
Due to the backlog on viral load testing, the facilities followed up with the clients to re-bleed them. However, some patients would have relocated without their contact details or lacked transport to return to the health facility.
“Whenever we reached a client and started counseling afresh, his facial expression communicated enough. It was as though he was saying the health worker doesn’t know what she is doing,” said Anyodo.
The hubs assigned riders to facilities within a 10 km radius to be revisited twice a day or visited on a non-scheduled day in case emergency samples were collected. A hub rider visits a high-volume facility thrice a week. The five study districts of the Bukedi region have two general hospitals, six HC IV and 38 HC III. The CPHL driver visits a hub on the second and fifth day of the week. The hub makes reminder calls to the facility to prepare samples ahead of visit time. USAID LPHS-E facilitated hub riders to work on Saturdays during services improvement campaigns to timely transport samples from Health facilities and Community
“We established a schedule for the riders which LPHS-E and us review weekly using the online CPHL hub rider’s tracker. The riders go because they are being tracked,” says Erepu.
USAID LPHS-E trained the lab team in different quality, and service provision systems and continues to provide technical support on lab quality management. It supports the districts to hold quarterly performance review meetings to identify challenges and share learnings.
The Activity continues to support hubs like Pallisa General Hospital, Busolwe General Hospital with airtime, stationery, and cartridges for printing the results and pays the salaries of hub riders and some other human resource personnel at the hospital. One such staff is a Lab Assistant who helps with human resources issues. It facilitates the lab staff to run the samples. It provides fuel and maintains the hub riders’ motorcycles. LPHS-E collaborates with USAID Regional Health Integration to Enhance Services- Eastern (RHITES-E) to service the hub motorcycle.
USAID LPHS-E mentored us for two weeks about bleeding and extracting plasma for viral load testing. We would follow up with CPHL about the turnaround time. We would mention the amount of blood to be taken to facilitate the extraction of the plasma. says Erepu.
Results
The proportion of plasma samples collected for Viral load in four districts (Kibuku, Pallisa, Butaleja, and Butebo) improved from 29% (511 DBS VL and 209 plasma VL) in April 2022 to 85% (184 DBS and 1,022 
plasma VL) in March 2023 against a national target of 60.0% plasma VL. All health facilities in Budaka District still rely on DBS VL due to a lack of centrifuges. The USAID LPHS-E activity is procuring centrifuges for health facilities.
Hubs like Pallisa General Hospital now do 100 percent plasma. “It is very easy to handle plasma, rather than dry blood spot. The timely response in case there is a need promotes teamwork” says Erepu. “Using plasma has eased my work. It is better than the dry blood spot. The turnaround time has improved client satisfaction. They can now access results in time,” says Anyodo.
The percentage of viral load samples delivered at a hub in two days from 20 facilities increased from 50 percent in April 2022 to 100 percent by mid-May 2022. The partners have maintained the achievements.
“Patients i.e. EID clients and Pregnant and breastfeeding mothers for Viral load testing are enjoying the services. The testing sites are nearby. It is not like it used to be when the samples were taken to Kampala,” says Okiria.
“I am now suppressed. I am very happy about this system [plasma]. It is the best,” says Aloyet.
The overall turnaround time from sample collection to results printing was reduced from 25 days to 18 days close to the national target of 14 days. Further, within three months of improvement activities, on average, hub riders delivered 699/792 (88 percent) viral load samples at hubs in two days. Currently, in May 2023, the overall Viral load result turnaround time from sample collection to results printing is 14 days as per the National target of 14 days.
“When I see things move, it motivates me. We have very many resourceful people who are cooperative. This makes the process shorter,” says Mangeni.
Conclusion
The turnaround time for results improved through cohesive coordination between the health workers and hub riders.
Recommendations
USAID LPHS-E’s adequate logistical support, roll out of CPHL Results Delivery System using SMS/USD, and timely motorcycle maintenance motivate the hub riders and health workers to reduce the TAT for results. Results are sent in batch numbers and no longer get lost.
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