Strengthening Laboratory Capabilities in Improving HIV/AIDS and Other Diseases Support in Zimbabwe

The laboratory information system functionality assessment tool: Ensuring optimal software support for your laboratory

A key limiting factor in the scale up and sustainability of HIV care and treatment programmes is the global shortage of trained health care workers. This paper discusses why it is important to move beyond conceptualising health care workers simply as 'inputs' in the delivery of HIV treatment and care, and to also consider their roles as partners and agents in the process of health care. It suggests a framework for thinking about their roles and responses in HIV care, considers the current evidence base, and concludes by identifying key areas for future research on health care workers' responses in HIV treatment and care in low and middle income settings.

BackgroundNon-communicable diseases (NCDs) contribute significantly to the global disease burden, with low-and middle-income (LMICs) countries disproportionately affected. A significant knowledge gap in NCDs exacerbates the high burden, worsened by perennial health system challenges, including human and financial resources constraints. Primary health care workers play a crucial role in offering health care to most people in LMICs, and their views on the barriers to the provision of quality care for NCDs are critical. This study explored perceived barriers to providing NCDs care in primary health care facilities in Zimbabwe.MethodsIn-depth, individual semi-structured interviews were conducted with general nurses in primary care facilities until data saturation was reached. We focused on diabetes, hypertension, and depression, the three most common conditions in primary care in Zimbabwe. We used thematic content analysis based on an interview guide developed following a situational analysis of NCDs care in Zimbabwe and views from patients with lived experiences.ResultsSaturation was reached after interviewing 10 participants from five busy urban clinics. For all three NCDs, we identified four cross-cutting barriers, a) poor access to medication and functional equipment such as blood pressure machines, urinalysis strips; b) high cost of private care; c)poor working conditions; and d) poor awareness from both patients and the community which often resulted in the use of alternative potentially harmful remedies. Participants indicated that empowering communities could be an effective and low-cost approach to positive lifestyle changes and health-seeking behaviours. Participants indicated that the Friendship bench, a task-shifting programme working with trained community grandmothers, could provide a platform to introduce NCDs care at the community level. Also, creating community awareness and initiating screening at a community level through community health workers (CHWs) could reduce the workload on the clinic nursing staff.ConclusionOur findings reflect those from other LMICs, with poor work conditions and resources shortages being salient barriers to optimal NCDs care at the facility level. Zimbabwe's primary health care system faces several challenges that call for exploring ways to alleviate worker fatigue through strengthened community-led care for NCDs. Empowering communities could improve awareness and positive lifestyle changes, thus optimising NCD care. Further, there is a need to optimise NCD care in urban Zimbabwe through a holistic and multisectoral approach to improve working conditions, basic clinical supplies and essential drugs, which are the significant challenges facing the country's health care sector. The Friendship Bench could be an ideal entry point for providing an integrated NCD care package for diabetes, hypertension and depression.

Extended laboratory information system downtime: Implementing a backup laboratory information system in the cytology laboratory.

Recently, laboratory information systems (LIS) have become necessary for every laboratory to improve the decision-making process and achieve better treatment and diagnostic results. By standardizing laboratory's tests, procedures, and workflows, the software enables laboratories to improve patient care, reduce human error, and constructively lower operating costs. Implementing LIS has a multidimensional impact on improving the delivery of laboratory services. This paper aims to investigate how patient services can be improved by laboratory information system. This paper is based on a review conducted by searching PubMed, Google Scholar, Saudi Digital Library and Research Gate for English language articles published from 2015 to 2021 and focused primarily on laboratory information systems. The literature searches yielded a total of 30 articles that were then initially screened based on the titles and abstracts. Seven articles were excluded because they did not primarily address LIMS for biosafety, automated verification of test results in the core clinical laboratory, clinical biochemistry, or the impact of health information technology on patient safety, or were not written in English. The remaining 23 articles were then screened in full text. Advanced laboratory information systems may eliminate diagnostic errors in the preanalytical, analytical, and postanalytical phases. In addition, they can incorporate genomic data at the analytical stage to generate useful reports for providers and patients.

Although sub-Saharan Africa contains approximately 12% of the world’s population, it hosts an estimated 68% of all living HIV-infected people (22.5 million persons) and 30% of annual cases of TB (4.4 million persons). In countries with an extended epidemic of both HIV and TB, both infections commonly affect the same individuals. However, TB care services (WHO’s Directly Observed Therapy Short Course) and HIV care services essentially function as separate vertical programs. In 2004, in an effort to improve the management and control of TB and HIV, WHO produced an Interim Policy on collaborative TB/HIV Activities with a range of measures to improve the integration of TB care into HIV treatment programs (intensified TB case finding, isoniazid preventive therapy and TB infection control in healthcare settings) and the integration of HIV care into TB treatment programs (HIV testing and counseling, HIV prevention, co-trimoxazole preventive therapy, HIV/AIDS care and support, and antiretroviral therapy). In this review, we describe and critically discuss the evidence relating to the implementation of the proposed collaborative activities in sub-Saharan Africa.

The transition to PEPFAR 2.0 with its focus on country ownership was accompanied by substantial funding cuts. We describe the impact of this transition on HIV care in a large network of HIV clinics in Nigeria. We surveyed 30 comprehensive HIV treatment clinics to assess services supported before (October 2013-September 2014) and after (October 2014-September 2015) the PEPFAR funding policy change, the impact of these policy changes on service delivery areas, and response of clinics to the change. We compared differences in support for staffing, laboratory services, and clinical operations pre- and post-policy change using paired t-tests. We used framework analysis to assess answers to open ended questions describing responses to the policy change. Most sites (83%, n = 25) completed the survey. The majority were public (60%, n = 15) and secondary (68%, n = 17) facilities. Clinics had a median of 989 patients in care (IQR: 543–3326). All clinics continued to receive support for first and second line antiretrovirals and CD4 testing after the policy change, while no clinics received support for other routine drug monitoring labs. We found statistically significant reductions in support for viral load testing, staff employment, defaulter tracking, and prevention services (92% vs. 64%, p = 0.02; 80% vs. 20%, 100% vs. 44%, 84% vs. 16%, respectively, p<0.01 for all) after the policy change. Service delivery was hampered by interrupted laboratory services and reduced wages and staff positions leading to reduced provider morale, and compromised quality of care. Almost all sites (96%) introduced user fees to address funding shortages. Clinics in Nigeria are experiencing major challenges in providing routine HIV services as a result of PEPFAR’s policy changes. Funding cutbacks have been associated with compromised quality of care, staff shortages, and reliance on fee-based care for historically free services. Sustainable HIV services funding models are urgently needed.

Background Synnovis supplies core pathology services to six hospitals and 175 family doctor services to a population of 2 million people in southeast London, and reference services to more than 1000 healthcare providers across the UK. In 2021, we commenced a large-scale transformation from the legacy distributed model, where each hospital had its own laboratory services, to a new hub and spoke model. Methods This huge undertaking will complete in 2025 and to capture and share learning from the transformation process we have documented our five “Keys to Success”, as set out below. Results Clear Vision and Benefits Stakeholder buy-in is a necessary first step and to achieve this we described to our customers and staff a detailed description of the future model including the location and services that would be available in the hub laboratory. We communicated the benefits to our customers: improved service quality and better value for money, and to our staff: modern working environment and increased potential for innovation. Clinical Leadership Since doctors are renowned for having strong options, we appointed senior and respected doctors drawn from the six hospitals we serve to be Strategic Clinical Leads, one for each pathology discipline. Their role was to consult with their clinical colleagues and provide consensus opinions to our transformation team to ensure decisions were clinically appropriate and acceptable. All decisions were required to be evidence based and to provide value to the healthcare system. Test and Platform Harmonisation A single version of each test and test panel was agreed and a single platform was identified to supply each test. For example, we precisely defined what component assays a liver function test comprised and offered this standard panel, performed on the same type of chemistry analyser, to all requesters across in the six hospitals and family doctor practices. This allowed comparison and trending of test results across our network and provided economy of scale. LIMS Alignment We change from over sixty separate laboratory information systems (LIMS) to a single core LIMS. This was greatly simplified by having first completed the test and platform harmonisation step above. The benefits of the single modern LIMS included better security and support as well as significantly improved management information to help optimise our processes. Programme Management Underpinning the transformation was the use of established project management techniques led by a Project Management Office. Key techniques included mapping critical paths, risk, issue and dependency management, the use of Gantt charts and adopting an agile approach where required. Service migrations were done in phases and were governed by a robust readiness framework including readiness assessments and Early Life Support used to minimise impact during cutover and monitor the stabilization of services post transformation. Conclusion Adopting the “Keys to Success” outlined above has enabled us to complete the desired transformation and deliver the promised benefits to the National Health Service, our staff and the patients we serve.

Background The US PEPFAR program is one of the most successful global health initiatives ever undertaken. However, congressional reauthorization is unclear. We evaluate the clinical and economic impact of scaling back PEPFAR funding ($460 million) from South Africa’s HIV budget ($2.60 billion) in 2024. Methods Using the Cost-Effectiveness of Preventing AIDS Complications (CEPAC) microsimulation model, we examine 100% (PEPFAR_100%), 50% (PEPFAR_50%), and 0% (PEPFAR_0%) PEPFAR funding cutbacks among South African adults (HIV prevalence: 16.2%; incidence: 0.32/100PY [person-years]) using published HIV care continuum data (Table 1) and PEPFAR funding estimates. We model proportional decreases in HIV diagnosis (26.0, 24.3, 22.6/100PY), treatment (one-year engagement among people with HIV [PWH] on/initiating antiretroviral therapy: 92.2%/80.4%, 87.1%/76.0%, 82.0%/71.5%), and primary prevention (4.0%, 2.2%, 0.5% reduction in incidence with no programming [1.24/100PY]) (Table 2). We project new HIV infections and HIV-related deaths over 10 years, life expectancy and HIV-related lifetime costs in 2023 US dollars from a modified societal perspective. We vary key parameters and assumptions in sensitivity analyses. Results With current HIV programming (PEPFAR_100%), a projected 1,190,000 infections would occur over 10 years (Table 3); life expectancy would be 61.42 years for PWH with lifetime costs of $11,180/PWH. PEPFAR_50% and PEPFAR_0% would add 286,000 and 565,000 infections and worsen HIV care continuum outcomes (Figure 1). PWH would lose 2.02 and 3.71 life-years with nominal lifetime cost reductions of $620/PWH and $1,140/PWH that would be offset at the population level by more PWH requiring treatment for infection. In sensitivity analyses, clinical and epidemiologic impacts of scaling back PEPFAR would remain substantial. Conclusion Abruptly scaling back PEPFAR funding would have a striking, detrimental impact on the progress South Africa has made towards HIV epidemic control. Any total cost reductions would be short-lived and at the expense of up to an additional 565,000 new HIV infections and 601,000 HIV-related deaths in South Africa by 2034. The estimated 2024 HIV care cascade (black bars) is based on published data. The projected HIV care cascade in 2029 is shown for PEPFAR_100% (dark blue bars), PEPFAR_50% (blue bars), and PEPFAR_0% (light blue bars). Each set of bars represents PWH who are aware of their HIV status, receiving ART, and virally suppressed (HIV RNA &amp;lt;20 copies/mL), respectively. The percentages shown are in respect to the conditional UNAIDS’ 95-95-95 epidemic targets (i.e., proportion of all PWH who are aware of their status, proportion of PWH aware of their status who are receiving ART, and proportion of PWH receiving ART who are virally suppressed). The estimated number of PWH alive in South Africa in 2024 is 7,400,000; the projected number of PWH alive in 2029 would be 6,913,000 with PEPFAR_100%, 6,950,000 with PEPFAR_50%, and 6,997,000 with PEPFAR_0%. The number of PWH associated with each bar is labeled at the bottom of Panel B and rounded to the nearest 10,000. Disclosures Linda-Gail Bekker, Gilead Health Sciences: Honoraria|MSD (Pty) Ltd: Honoraria|ViiV Healthcare: Honoraria

BackgroundAccess to HIV testing and subsequent care among health care workers (HCWs) form a critical component of TB infection control measures for HCWs. Challenges to and gaps in access to HIV services among HCWs may thus compromise TB infection control. This study assessed HCWs HIV and TB screening uptake and explored their preferences for provision of HIV and TB care.MethodsA cross-sectional mixed-methods study involving 499 HCWs and 8 focus group discussions was conducted in Mukono and Wakiso districts in Uganda between October 2010 and February 2011.ResultsOverall, 5% of the HCWs reported a history of TB in the past five years. None reported routine screening for TB disease or infection, although 89% were willing to participate in a TB screening program, 77% at the workplace. By contrast, 95% had previously tested for HIV; 34% outside their workplace, and 27% self-tested. Nearly half (45%) would prefer to receive HIV care outside their workplace. Hypothetical willingness to disclose HIV positive status to supervisors was moderate (63%) compared to willingness to disclose to sexual partners (94%). Older workers were more willing to disclose to a supervisor (adjusted prevalence ratio [APR] = 1.51, CI = 1.16–1.95). Being female (APR = 0.78, CI = 0.68–0.91), and working in the private sector (APR = 0.81, CI = 0.65–1.00) were independent predictors of unwillingness to disclose a positive HIV status to a supervisor. HCWs preferred having integrated occupational services, versus stand-alone HIV care.ConclusionsDiscomfort with disclosure of HIV status to supervisors suggests that universal TB infection control measures that benefit all HCWs are more feasible than distinctions by HIVstatus, particularly for women, private sector, and younger HCWs. However, interventions to reduce stigma and ensuring confidentiality are also essential to ensure uptake of comprehensive HIV care including Isoniazid Preventive Therapy among HCWs.

Resource-limited settings have made slow progress in integrating TB and HIV care for co-infected patients. We examined the impact of integrated TB/HIV care on clinical and survival outcomes in rural western Guatemala. Prospective data from 254 newly diagnosed TB/HIV patients (99 enrolled in the pre-integrated program from August 2005 to July 2006, and 155 enrolled in the integrated program from February 2008 to January 2009) showed no significant baseline differences between clients in the two periods. They were principally male (65.5 %), Mayan (71 %), median age 33 years, and CD4 count averaged 111 cells/mm³. TB/HIV co-infected patients were more likely to receive antiretroviral therapy in the integrated program than in the pre-integrated program (72 vs. 22 %, respectively) and had lower mortality (HR 0.22, 95 % CI 0.14–0.33). This study shows how using a TB setting as the entry point for integrated TB/HIV care can improve health outcomes for HIV-positive patients in rural Guatemala.

The national health system: future possibilities for the clinical laboratory

ObjectiveTo assess the outcomes of linkage to TB and HIV care and identify risk factors for poor referral outcomes.DesignCohort study of TB patients diagnosed at an urban hospital.MethodsLinkage to care was determined by review of clinic files, national death register, and telephone contact, and classified as linked to care, delayed linkage to care (>7 days for TB treatment, >30 days for HIV care), or failed linkage to care. We performed log-binomial regression to identify patient and referral characteristics associated with poor referral outcomes.ResultsAmong 593 TB patients, 23% failed linkage to TB treatment and 30.3% of the 77.0% who linked to care arrived late. Among 486 (86.9%) HIV-infected TB patients, 38.3% failed linkage to HIV care, and 32% of the 61.7% who linked to care presented late. One in six HIV-infected patients failed linkage to both TB and HIV care. Only 20.2% of HIV-infected patients were referred to a single clinic for integrated care. A referral letter was present in 90.3%, but only 23.7% included HIV status and 18.8% CD4 cell count. Lack of education (RR 1.85) and low CD4 count (CD4≤50 vs. >250cells/mm3; RR 1.66) were associated with failed linkage to TB care. Risk factors for failed linkage to HIV care were antiretroviral-naïve status (RR 1.29), and absence of referral letter with HIV or CD4 cell count (RR1.23).ConclusionsLinkage to TB/HIV care should be strengthened by communication of HIV and CD4 results, ART initiation during hospitalization and TB/HIV integration at primary care.

The HIV epidemic in South Africa (SA) has had a substantial impact on laboratory services, at least partially owing to the well-described propensity to cytopenias in HIV-positive patients. (i) To formally gauge the impact of HIV infection on the state sector haematology services in SA by determining the HIV seropositivity rate among full blood counts (FBCs) performed at a large academic state sector laboratory; and (ii) to document the prevalence of cytopenias among HIV-positive patients in this setting. Randomly selected FBCs submitted to the National Health Laboratory Service laboratory at Chris Hani Baragwanath Academic Hospital, Johannesburg, were extracted from the laboratory information system (LIS) and retrospectively reviewed. HIV test results and other pertinent information in the LIS were documented, as was the presence of any cytopenias. HIV status was documented in 561 of 1 006 samples (55.8%), with 307 (54.7%) of these being HIV-positive. Of the HIV-positive patients, 63.2% had one or more cytopenia/s. Anaemia was present in 183/307 (59.6%) of the HIV-positive patients, and was severe (haemoglobin &lt;8 g/dL) in 32/307 (10.4%). Multivariate linear regression analysis showed significant independent associations between the presence of anaemia and both immunological AIDS (iAIDS) (p&lt;0.0001) and male sex (p&lt;0.025), but not HIV viral load (VL) (p=0.33) or antiretroviral therapy (ART) exposure (p=0.70). Thrombocytopenia and neutropenia were present in 37/307 (12.1%) and 11/51 (21.6%) of the HIV-positive patients, respectively, with no statistically significant association between either of these cytopenias and iAIDS, exposure to ART or VL. The findings reflect the substantial impact of the HIV epidemic on state sector laboratory resources, particularly the haematology service.

Background: Laboratory information systems (LIS) play a crucial role in managing laboratory data and supporting quality laboratory services. However, limited research has explored the relationship between LIS user satisfaction and the quality of laboratory services in Saudi Arabian hospitals. This study investigated this relationship and identified factors influencing LIS user satisfaction and service quality. Methods: A cross-sectional study was conducted among 400 laboratory professionals from 15 hospitals using stratified random sampling. Data were collected using a validated questionnaire assessing LIS user satisfaction and the quality of laboratory services. Descriptive statistics, Pearson's correlation, and multiple regression were used for analysis. Results: Participants reported moderate levels of LIS user satisfaction (M=3.5, SD=0.8) and perceived quality of laboratory services (M=3.8, SD=0.7). LIS user satisfaction was significantly correlated with service quality (r=0.65, p&lt;0.001). Regression analysis revealed that system reliability (β=0.35, p&lt;0.01), information quality (β=0.30, p&lt;0.01), and technical support (β=0.20, p&lt;0.05) were significant predictors of LIS user satisfaction, which in turn predicted service quality (β=0.60, p&lt;0.001). Conclusion: LIS user satisfaction is significantly associated with the quality of laboratory services in Saudi Arabian hospitals. Enhancing system reliability, information quality, and technical support can improve LIS user satisfaction and subsequently elevate service quality. Investing in robust LIS and providing adequate training and support to users are recommended to optimize laboratory performance and patient care.