Partnership to Reduce Turnaround-time (TAT) for

Early Infant HIV Diagnosis (EID) in Nigeria - The

Strengthening of Process for Effective Early Infant Diagnosis in

Nigeria (SPEEiD Model)

By

Mr. Araoye Segilola Director, PDA,

Dr. Chukwuma Anyaike, CSG II/Head Prevention,

National AIDS/STIs Control Programme ( NASCP)

Federal Ministry of Health Nigeria

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Outline of Presentation

• Background

• Objectives of the intervention

• Strategies and Structure

• Links to policy

• Service Delivery

• Successes and Challenges

• Sustainability and Replication

• Awards and Recognition

• Lessons Learned

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Background information

Located in West African region.

Estimated population 177millions

Annual

Most populous country in Africa and

10th globally

# Annual pregnancy - 6 Millions

# Health facilities – 22, 726

Total Fertility rate - 5.7%

Comprised 36 states and Federal Capital Territory (Abuja)

# of Local Government Areas - 774

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Background Information 2

• Nigeria has the second highest burden of HIV in the world with a

National prevalence of 3.4% and approximately 3.3 million people

living with HIV.

• Nigeria accounted for 30% of 240,000 new paediatrics infection in

2013.

• The National mode of transmission study indicates that MTCT

accounts for 22% of new infections.

• The PMTCT coverage in Nigeria is 27% while paediatric ART is 5%.

• Weak Early Infant Diagnosis (EID) Programme is a major factor:

- Low coverage of EID services

- Long Turn Around Time ( TAT) with attendant loss to follow up.

- Loss of confidence in PMTCT programme by the preg. women

- Poor evaluation of PMTCT interventions.

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Background Information 3

• Nigeria scaled up PCR laboratories to 23 in 2013

• Assessment of EID programme revealed TAT of 90 – 120 days

even though the national protocol is 28-30 days.

• Existing models of DBS sample and result transportation are

expensive and unsustainable (using private mailing carriers eg DHL

• National AIDS/STIs Control Programme (NASCP)&Management

Sciences for Health( MSH) designed an innovative logistic system –

Strengthening of Process for Effective Early Infant Diagnosis in

Nigeria (SPEEiD Model)

• The platform of the NIPOST presents a cost-effective and

sustainable solution for EID logistics management in Nigeria based

on its simple and existing wide distribution of over 955 post offices

and over 3,000 postal agencies spread across the country, with high

coverage particularly in hard-to-reach areas.

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Objectives of the Intervention

• To reduce the EID turn-around time (TAT) by harnessing

the strengths of the government owned National Postal

Service (NIPOST) network.

• To improve the early evaluation of the PMTCT

interventions.

• To improve the early initiation of ART in HIV infected.

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Strategies and Structure

• Stakeholders meeting coordinated by NASCP involving MSH,

NIPOST for buying-in.

• Training of NIPOST staff on confidentiality and safety ie handling of

biological samples

• Mapping of the distribution of NIPOST offices and proximity to

PMTCT sites.

• Hub and Spoke models used for sample transfer among the PMTCT

sites.

• Samples are processed at the laboratory within a range of 7-10

days. EID results are retrieved directly from the laboratory by

NIPOST in sealed pre-labelled envelopes for direct dispatch to the

hub where it is sorted for further dispatch to each spoke by NIPOST

• within 2days.

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Strategies and Structure 2

• Critical enablers :

- Full commitment of the NIPOST staff

- They became advocates to the

programme by convincing other states.

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Links and Policy

• It encouraged the early diagnosis and

initiation of antiretroviral therapy to HIV

infected children.

• The SPEEiD Model has also encouraged

the policy on ownership and sustainability

of national programmes

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Service Delivery

• The SPEEiD model pools samples from low volume health facilities (HFs) or

“spokes” into a large volume health facility or “hub” from where they are

picked weekly by NIPOST staff and shipped to the nearest regional PCR

laboratory. Samples are processed at the laboratory within a range of 7-10

days. EID results are retrieved directly from the laboratory by NIPOST in

sealed pre-labelled envelopes for direct dispatch to the hub and spoke by

NIPOST.

• Training/orientation was conducted for all staff in the NIPOST/Expedited

Mail Services in targeted States. Training focused on safety and

confidentiality procedures in handling of biological sample.

• NIPOST offices and postal agencies were mapped to identify their location

and proximity to PMTCT sites. NIPOST’s mail and hard-to-reach routes

operated by NIPOST’s postal agents within the state were also identified.

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Service Delivery II

• During implementation, spokes log samples to the hubs on a weekly

basis. On designated day (once a week or as needed), the hub

pools samples received from all spokes together as a single batch

and are picked up promptly by NIPOST dispatch rider. The package

is shipped to the PCR laboratory from NIPOST office which could be

within the same state or in the adjoining state – usually once a

week.

• NIPOST rider returns to the laboratory to pick up the results, and

ensures they are shipped back to the hub. At the hub, the results are

sorted into pre-prepared envelopes (with addresses and postage

stamps) for each of the spokes.

• The results in the labeled envelopes are then delivered directly to

the spokes by NIPOST – within 2 days of pick up from the hub. A

rigorous quality control system was integrated to ensure

completeness of efficiency of the system.

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Successes and Challenges

• This model was piloted in 6 PMTCT sites in Adamawa between 2011 and

2012. Thereafter, it was rolled out in 4 states: Kwara and Niger in 2013,

Kebbi in 2014, and Zamfara in 2015.

• An evaluation in two states (Adamawa and Kwara) showed a 75% - 85%

reduction in turnaround time (TAT) from 90 -120 days to 14-30 days from

sample collection to delivery of results.

• The cost of round shipment of BDS samples dropped from $69 to $14

• In Adamawa State quantity of DBS samples received at the regional PCR

laboratories increased from 51% to 78% between 2011 and 2012; TAT for

EID results dropped from an average of 105 days to 30 days; and the cost

of round shipment of DBS sample and result dropped from $69 to $14.

• An evaluation carried out in Kwara state showed an increase in quantity of

DBS sample received at the PCR Laboratory to 97% (compared to 51%

from baseline )

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Challenges

• Stock out of DBS Kits caused by UNTAID

discontinuation of supply.

• Migration of PCR machines from manual to Automated

Platform.

• Occasional rejection and non processing of the DBS

samples due to poor sample collection by the health

worker.

• Paucity of laboratory technicians at the PCR labs.

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Sustainability and Replication

• The uniqueness of SPEEiD model lies on its use of

existing and well established nationwide mailing

infrastructure, reaching remote and hard-to-reach

Primary Health Centres (PHCs).

• The simplicity of its operation makes it more cost

effective and easier to replicate when compared with

other models.

• Because it is integrated with the government owned

postal system, the SPEEiD model is likely to be more

sustainable compared to models involving privately

owned courier firms.

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Awards and Recognition

• The success of SPEEiD Model has been recognized by

the National Programme to improve EID programme by

reducing the TAT in DBS sample logistics.

• The reduction of the TAT to within the national protocol

of 28-30 days for health facility visit appointment has

increased the confidence in the PMTCT programme

among HIV positive breastfeeding mothers.

• The strategy has been adopted for replication in other

states of the federation

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Lessons learned

• The model drastically reduce turn around time and improved the

initiation of ART on HIV infected infants.

• It encouraged ownership and sustainability because it uses existing

structures.

• It could be used to cover the PHC at hard to reach areas.

• It could be replicated to other states of the federation.

• The tracking mechanism using registers and delivery notes provided

assurances of sample delivery and evaluation of the process

• It removed red-tape associated with payments

• The use of prepaid stamped envelopes made quick dispatch to

different spokes from the hub irrespective of distance.

• It was available at a reasonable cost as it did not attract additional or

hidden cost associated with new initiatives ie extensive training and

licensures or administration cost.

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Conclusion

• Implementation of the SPEEiD model has achieved its

intended purposed, reducing turnaround time for EID by

75% - 85% and enabling health providers to fast-track

identification and early initiation of HIV positive infants on

ART.

• It has also helped alleviate anxiety among mothers and

families especially those whose infants are negative and

instilled greater confidence in the PMTCT program

among families and communities.

• The wide network of NIPOST and the reasonable price

makes the SPEEiD model easily scalable in Nigeria and

replicable in settings with similar platform of a National

Postal Service.

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Acknowledgements

• UNICEF

• NPHCDA

• USG/PEPFAR

• NEPWHAN

• ASWHAN

• NACA

• SASCP

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Thank you for listening!