235 Quality ART Scale Up Through Regionalization of Laboratory Services In Nigeria:

Issues: Setting up of standard lab infrastructure and provision of free laboratory tests by PEPFAR has improved health care delivery system and services to PLWHAs in Nigeria. We here describe the challenges and successes of the tier laboratory infrastructure established by the Institute of Human Virology - University of Maryland PEPFAR funded AIDS Care and Treatment in Nigeria (ACTION) program to support the diagnosis, care and treatment of HIV infected Nigerians. Description: The ACTION program currently treats over 80,000 and cares for another 150,000 HIV-infected Nigerians; also, about 300,000 are screened. To support this, the laboratory infrastructure expanded from 12 to a regionalized tier system with 22 tertiary, 25 secondary and 12 primary laboratories all linked with appropriate oversight and referral system. Choice of laboratory equipment was based on ease of use, in country vendor/service provider, ease of purchase of reagents, and overall manufacturer's support. Implementation included: 1) Decentralization of laboratory field services into regions with central oversight 2) Detailed site assessments/renovations 3) Step wise site activation in HIV Rapid Testing, Pregnancy Testing, Manual CD4 Count, HbAg screening, CyFlow SL (tertiary) or Counter (secondary) for CD4, Sysmex KX 21N for Hematology, Vitros V250 (tertiary) DT 60 II (tert/sec) or Reflotron (sec/prim) for Chemistry assays. 4) Monitoring and mentoring of site personnel through an aggressive QA/QC program. 5) Hub and spoke linkage between comprehensive and satellite sites. Lessons learned: Tier lab network with adequate mentoring and referral led to a successful lab expansion to 59 (22 tertiary, 25 secondary and 12 primary) sites performing HIV Serology, CD4, Pregnancy, Hematology, Chemistry, Hepatitis B, Cryptococcus, and TB tests. Also, 57 HCT/PMTCT sites performing HIV Serology Tests. Improved proficiency at sites from 40-60% to 80-95%. Recommendations: Regionalization and tier lab system is critical for scale up. Defined roles for lab personnel creates a good network to support rapid scale up. QA/QC program involving site monitoring is critical for sustained high quality lab results.