Author(s):
Peter Preko, Londiwe Nkambule, Joris Vandelanotte, Harrison Kamiru, Françoise Louis, Hosea Sukati, Velephi Okello
Region and Country: Swaziland Organization:
Columbia University
ICAP SWAZILAND - Mailman School of Public Health
The Report
Problem:
With an HIV prevalence on 26% (DHS, 2008), Swaziland remains the hardest hit country. Over 77% of its population is rural, however, ART services were concentrated in hospitals and health centers in the urban areas. ICAP has since 2009 supported the Ministry of Health to rapidly decentralize ART services to primary health care facilities in the rural areas. The quality of this decentralization process was hindered by lack of laboratory services at the rural clinics. Patients were therefore given appointments to come back on specific days for blood samples to be collected for CD4, CBC, LFTs etc. Most clinics only collected blood samples once a week. This delayed initiation of patients eligible for ART, resulted in high loss to follow up since there was no system in place to follow up patients who were given lab appointments. Turn around time for lab results was also very long and patients had to visit the clinics several times before receiving their results. Many samples were getting missing as well because of poor lab sample tracking system .
Intervention:
ICAP and MOH piloted a daily lab sample transportation system using local public mini-buses (kombis) over a 6-week period. Clinics and lab staff from six facilities were trained prior to starting the pilot. Samples were documented using a lab sample transportation log designed for the pilot. Samples were triple-bagged and transported daily to the lab in a sealed cooler box by a phlebotomist or orderly riding in the kombi. Any available test results were collected by the phlebotomist or orderly and brought back to the clinic via the kombi on the same day.
Results:
Results were measured using the sample transportation logs. We observed a 13-fold increase (from 22 to 293) in the monthly average numbers of clients who had blood drawn, a significant reduction in sample turn-around time from 13 to 3 days leading to more rapid preparation of clients for ART initiation. The system also made feasible on-site sputum collection which helped fast-track TB diagnosis and treatment. No samples were reported missing or spoilt in the process. The increase in numbers of samples collected was very impressive because the pilot was conducted in November and December, a period noted for low clinic attendance. Some facilities could not transport the samples on a daily basis because of poor human resources and distance to the laboratory. The irregular schedule of public transport sometimes resulted in samples arriving at the labs very late to the displeasure of the lab staff. It also took the staff transporting the samples too long to return to their facilities.
Lessons:
The providers thought the new system was convenient for them as well as the clients, improved treatment monitoring, and ensured quicker processing of clients for ART initiation. The system was also found to be inexpensive, reliable and therefore a good option to consider for resource-constrained settings. However, availability of a dedicated staff for sample collection and transportation, such as a phlebotomist helps to minimize the time constraint on clinic staff with regard to time spent transporting the samples. The use of the sample transportation log ensured that people were more responsible for the samples they collected or received and it ensured better sample tracking.
