Silver Spring, MD, September 26, 2023—The Association of Public Health Laboratories (APHL) received an award through the US Centers for Disease Control and Prevention (CDC) and the President’s Emergency Plan for AIDS Relief (PEPFAR) to strengthen laboratory systems and services for timely, quality testing for HIV, tuberculosis and HIV-related diseases.
The cooperative agreement, which begins September 30, will strengthen the laboratory workforce and sustainable lab systems and services over five years. It will focus on lab informatics and data systems and help accelerate improvements in integrated diagnostic networks, the clinical-lab interface and public health preparedness and response.
“We are excited to begin this work that will close gaps in the global laboratory response to HIV,” said Scott J. Becker, MS, chief executive officer of APHL. “The award will help us leverage currently effective programs and assure access to quality laboratory systems and services. Through greater collaboration with leading partners in the field, we can better meet PEPFAR goals and control the global HIV/AIDS epidemic.”
APHL organized the Laboratory Improvement Partnership (LIP) to facilitate collaboration and maximize partners’ capabilities to effectively scale efforts toward PEPFAR goals. LIP unites highly proficient laboratory and clinical organizations with extensive experience in implementing PEPFAR laboratory initiatives. The partnership includes APHL, the American Society for Clinical Pathology, CRDF Global, US Pharmacopeia and the University of California San Francisco.
“This partnership marks a significant step forward in the collective laboratory efforts to combat HIV/AIDS and related diseases worldwide,” said Becker. “By consolidating the expertise and resources of these prominent organizations, LIP is set to play a pivotal role in advancing PEPFAR’s vital mission.”
APHL will coordinate LIP activities to achieve maximum effectiveness and avoid duplication of efforts and will build competency of local organizations to eventually assume direct management of PEPFAR-supported activities.
The Association of Public Health Laboratories (APHL) works to strengthen laboratory systems serving the public’s health in the US and globally. APHL’s member laboratories protect the public’s health by monitoring and detecting infectious and foodborne diseases, environmental contaminants, terrorist agents, genetic disorders in newborns and other diverse health threats. Learn more at www.aphl.org.
By Robyn Sagal, specialist, Global Health, APHL; Samantha Dittrich, manager, Global Health Security, APHL
When HIV first struck Ghana in 1986, it didn’t adhere to global trends. There was a high prevalence of HIV in females, not males. The spread began in rural areas, not urban centers. Regions with more polygamy had lower rates of HIV, not higher. Over 30 years later, Ghana has made significant headway in slowing new infections, but there continues to be an upward trend that’s deeply concerning.
The top HIV/AIDS experts around the world see substantial evidence that antiretroviral therapy (ART) can be highly successful in suppressing the virus in infected people and decreasing the likelihood of transmission. In fact, evidence shows that when the virus is suppressed to the point of being undetectable, the infected individual has low or no risk of transmitting the virus to others. Given these facts, one key to slowing and eventually halting the transmission of HIV is close monitoring of every infected person’s viral load (testing for the amount of HIV in the blood). Regular and consistent viral load testing can determine whether ART is a success or failure. If ART is successful, viral load testing will indicate viral suppression; if not, as when treatment is inconsistent or the virus has become drug resistant, it will show either no change or an increase in viral load. Viral load testing is critical to determining next steps for individual treatment as well as determining whether the epidemic is progressing or regressing.
In keeping with global HIV response efforts, Ghana is shifting their attention to scaling-up viral load testing per the World Health Organization’s (WHO) “treat all” recommendation. That is, not only should infected and high-risk individuals receive ART, they should also have access to regular viral load testing. Additionally, the country has adopted the UNAIDS 90/90/90 global targets aimed at ensuring that 90% of the people receiving treatment are virally suppressed, with the goal of ending HIV/AIDS by 2030. Scaling-up viral load testing requires increasing laboratory capacity, an undertaking to which Ghana and APHL are committed.
In order to develop the Ghana Laboratory Viral Load Testing Extension plan, APHL has worked closely with CDC-Ghana, the Ghanaian Ministry of Health (MOH), Ghana Health Service (GHS), the National AIDS Control Programme (NACP) and many other partners and stakeholders. This plan outlines a strategy to increase and monitor laboratory capacity for viral load testing. It includes an ambitious, targeted approach that balances achieving global goals of ART treatment monitoring with the limited resources available in the country. The plan accelerates the scale-up of viral load testing by defining national testing targets and a timeframe for achieving them, improving stakeholder collaboration and pooling available resources for better distribution.
In addition, APHL has collaborated with the Centre for Remote Sensing and Geographic Information Services (CERSGIS) to map all 245 ART centers in Ghana. This huge undertaking generated geo-referenced maps for each site, including the latitude and longitude of the ART centers along with other related attributes such as differentiated models of care sites, regional viral load centers, sector viral load centers, functional viral load centers, testing staff capacity, ART equipment at the centers and much more. Visualizing these data at various administrative levels provides national decision makers with a more nuanced understanding of program coverage and priorities for scale-up. By mapping rather than graphing or charting the data, users are better able to recognize important patterns.
As the global health community works to end AIDS by 2030, laboratory testing will continue to be essential for diagnosis, treatment and prevention. APHL’s viral load scale-up activities in Ghana will help those already afflicted by HIV/AIDS to receive effective treatment and will ultimately decrease the number of new infections in the country.
From Zimbabwe’s first diagnosed case of HIV/AIDS in 1985 until 1997, the country’s health situation became increasingly dire: At the disease’s peak, 29% of the population was infected. Since then, Zimbabwe has made significant strides in the fight against HIV/AIDS. HIV prevalence has been reduced to 16% (2015 estimate) – 1.6 million people.
Now the nation is striving to achieve the UN’s 90/90/90 goals: 90% of people living with HIV know their status, 90% of people diagnosed HIV positive are on sustained antiretroviral treatment (ART), and 90% of those on ART have an undetectable viral load.
By 2012, the percentage of Zimbabweans living with HIV who knew their status was estimated to be 66%, and of those, ART coverage was at 55%. Viral load test availability was extremely low in 2015, but the 2016 figures are expected to increase dramatically thanks to the newly established viral load testing program. Developed with APHL’s support, six provincial super-laboratories now have the infrastructure, equipment, personnel and supply chain support to perform routine viral load testing.
Working in collaboration with Zimbabwe’s Ministry of Health and National Microbiology Reference Laboratory, APHL – the only PEPFAR laboratory partner in the country – has adopted a comprehensive approach to improving testing quality, one that leads to better diagnosis and treatment. The association is developing external quality assurance systems to verify test results. Already half of Zimbabwe’s 1,848 testing sites are using this method successfully to ensure the quality of laboratory services.
APHL has proved critical in the establishment of quality point-of-care testing, which has meant quicker and more reliable test results. This work has been implemented primarily by Shanette Nixon, APHL consultant, and Goodridge Mguni, APHL’s external quality assurance manager for Zimbabwe.
Together, they have built capacity at the National Microbiology Reference Laboratory to produce dried tube specimen panels – which can be preserved for up to a year without refrigeration – for health testing sites to ensure quality assurance and control. Given the country’s warm climate, these panels could be key to achieving universal access to quality HIV testing in Zimbabwe. However, they require new training for rapid diagnostic HIV testers who already shoulder many tasks. That is why Shanette and Goodridge work so hard to train as many people as possible.
Below Shanette and Goodridge talk about their work.
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What challenges do you face in your work?
GOODRIDGE:
Insufficient human and financial resources are huge challenges. There is a massive brain-drain here in Zimbabwe, so it can be difficult to find staff.
SHANETTE:
Yes, it can make the work very hard. Many folks say that point-of-care testing eliminates the barriers to HIV treatment in one step. The quick results are a huge advantage and the tests can be highly accurate—but only if properly trained people perform the tests.
GOODRIDGE:
I agree, but at least the use of lay counsellors in point-of-care testing has helped to mitigate the training issue a bit.
Financially, the Global Fund, PEPFAR and other donor organizations continue to assist, but the country will need resources beyond those external ones.
Another challenge is poor sample transportation networks. The country is working on an integrated network which will improve movement of test samples.
There has also been a lack of effective coordination between stakeholders, which has led to a lot of overlapping projects. Partners such as APHL, though, have supported Ministry of Health efforts to keep all implementing partners engaged to avoid duplicated efforts. For example, the technical working group, which APHL has actively participated in, allows key stakeholders to communicate regularly.
What does your work mean to you?
GOODRIDGE:
In the past, I witnessed patients receiving wrong HIV results and it’s a terrible sight—families can break apart. I want to keep those scenarios in the past.
That’s why I feel so blessed to go to each site, talk to scientists as my brothers and show them how we can succeed together. That one-on-one time makes all the difference.
To be clear, all of our teammates see the importance of accurate results, but it can take some doing to get people comfortable with the new steps to take and the changes they involve.
SHANETTE:
I’ve seen that, too. That’s why when I’m training a scientist, I keep in mind that I’m affecting one person who can affect millions. That’s why I do what I do. Every time I see that lightbulb go off in someone’s head, I’m thrilled.
GOODRIDGE:
Yes, it feels like a triumph when someone truly understands, and it’s extra special when I get comments from people doing the hard work in the field. In Masvingo, nurses told me that the program satisfies clients and motivates testers. “Keep it up!” they said. And in Manicaland, a nurse said, “Every health center should participate to enhance competence among testers.” That felt so good to hear, and I’m trying to make that happen. I’m excited that dried tube specimen is in 925 sites, halfway to our goal!
SHANETTE:
And once the Ministry gives us the go-ahead to train scientists in the remaining provinces, everyone will have full access no matter where they are!
What are your thoughts when you look to the future?
GOODRIDGE:
I sometimes worry that access to testing, no matter how high quality, isn’t enough. Since antiretroviral medication is for life, there has to be real follow-through for decades. I know you’ve preached sustainability, Shanette, so I’m always looking for ways to sustain the dried tube specimen approach if the current funding disappears.
SHANETTE:
Well we hope that never happens, but I’m glad you’re trying to be sustainable! Creating institutional memory and standardizing testing practices at the labs is so important. Plus, your easy way with people helps motivate them to keep up the techniques you’re teaching them. And I’ve seen how eager they are to ensure that you succeed.
GOODRIDGE:
Thank you, I hope so! I’m just glad to have an impact. When we reach the UN’s 90/90/90 goal, oh, will I celebrate!
For decades, APHL has worked in more than 30 nations to train and support lab professionals fighting HIV/AIDS, often under agreements with CDC and the US President’s Emergency Plan for AIDS Relief (PEPFAR). One of those nations is Zimbabwe.
In 2004, when PEPFAR was established, the HIV rate in Zimbabwe was 25% and the treatment rate for people with HIV was 13%. Today, Zimbabwe’s HIV rate is under 15%, and there’s a 60% treatment rate among people with HIV.
APHL is working closely with the Zimbabwe Ministry of health to provide leadership, mentorship and support in an effort to increase patient access to quality tests for monitoring HIV treatment. In addition to increasing testing capacity at six provincial laboratories of public health (aka, super laboratories), APHL and the Ministry of Health established a state-of-the-art transport system for blood samples so that patients in remote areas would gain access to testing. Levi Vere, an APHL consultant, supervises the in-country team to meet these objectives.
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By Levi Vere, Quality Monitoring Supervisor, APHL Global Health Consultant
Not long ago, some of my relatives were among the people who had to travel long distances to a city hospital for a test to learn if they had HIV. Sometimes they would line up at 4 a.m. and wait four hours for the clinic to open, only to be sent away because there were too many people seeking HIV services that day.
Today, they can access testing and treatment in clinics that are a stone’s throw from their homes. Those clinics connect to our six Ministry of Health super laboratories, with samples transported by a motorbike delivery network.
This is just one of the changes supported by our work in Zimbabwe. It seems simple, but these improvements have made an enormous difference in people’s health. Seeing these changes in their lives really touches my heart, and keeps me excited about the difference we are making every day.
High stakes and pervasive challenges
Handling logistics and samples is only one challenge. Zimbabwe faces a huge staff deficit in lab services.
Zimbabwe has historically had a strong university program, resulting in valuable laboratory expertise. We have 10 Zimbabweans on the APHL-Zimbabwe staff team: eight highly qualified medical technologists, a highly experienced database administrator and an office administrator.
But much of this country’s expertise has emigrated. The government typically can’t afford competitive salaries for laboratorians. University training capacity has also suffered under economic hardships. Current microscopy training isn’t sufficient for the complex tests required for monitoring HIV treatment.
The national budget for fighting the HIV/AIDS pandemic is tiny, and the total gross domestic product spent on health is small. The Ministry of Health’s allocation often must go to purchasing drugs, not to laboratories and testing. Hospitals struggle because so many patients can’t afford to pay.
And the challenge of sample transport needs further consistency and improvement. Better access for patients in remote areas would not only improve testing and treatment for HIV/AIDS, but would extend to surveillance for other diseases, such as tuberculosis and malaria.
Other challenges are cultural. HIV is a chronic issue, so people have become used to it and don’t have the same level of response as when it was seen as a crisis. Also, it’s culturally acceptable for men to have several wives which means several sexual partners. And because men face stigma in visiting a hospital, many don’t seek help until they’re quite sick.
People make the difference
Technical know-how alone will not change systems—it takes a change in the laboratory culture. I have seen a huge leap in commitment to quality.
When I began as a mentor, I experienced resistance to change. But when the laboratory personnel began to see the impact of their efforts and the improvements we were making together, they placed more value on the importance of their work.
The change in morale was remarkable: Staff don’t just come in and quietly head for their bench. Everyone’s ideas are welcome. We saw reductions in sick leave applications and absenteeism, and more punctuality. People are willing to go the extra mile.
The three letters at the heart of change: QMS
Mistrust of test results can lead to resistance to treatment. Strengthening of Quality Management Systems (QMS) leads to more accurate testing and better compliance.
I supervise our mentors who coach and train the laboratory staff in organization, management of testing processes and quality assurance protocols. In order to pass proficiency testing and gain lab accreditation by international standards, they must learn and adhere to World Health Organization (WHO) and International Organization for Standardization techniques.
Lab monitoring of patients on treatment is another critical factor. APHL laboratory mentors at the six super laboratories help ensure quality of services from data to supplies to equipment maintenance.
In the past, we had to handle so many samples that lab equipment would often break down. I remember one mother in the infant HIV testing lab who was in tears because she couldn’t breastfeed her baby until lab results were in—and the machine had broken.
With technical assistance from APHL, including attention to routine maintenance, equipment downtime has been greatly reduced.
Increased and improved testing
With the new transport system bringing more tests from far-flung areas, our changes have opened the floodgates to testing. In the past year, we performed 25% more CD4 tests, a standard measure for HIV. We have more tests to do each day, and we’re improving them by every measure: completing them faster, with less spoilage, fewer rejection of samples and more accurate results.
Improvement in turnaround time of tests—the time from sample collection to release of the results to the patient—is particularly important. For instance, infant HIV test results used to take six weeks and now take five days—or even three. As I mentioned above, this time difference is critical for breastfeeding mothers—they need to know if their HIV status or medication will affect their children.
Our work has truly helped make the difference: fewer equipment breakdowns, more efficient use of supplies, improved understanding of quality and the use of standardized, streamlined processes.
What’s next? Expanded viral load testing
Until now, our focus was on building the capacity of the labs that we support. This year, we will focus on expanding viral load testing, which we have already launched in two of our super laboratories so far.
Viral load testing is a more sensitive test for monitoring efficacy of HIV treatment. It measures the rate of suppression of the virus itself, as opposed to CD4 testing which slowly monitors the impact of such suppression on the body’s defenses. With viral load testing, we can see resistance to treatment in a patient sooner and switch treatment quickly to one that works.
With the WHO promotion of a test-and-treat strategy, our focus is on ensuring quality of HIV tests, both in early infant diagnosis and in HIV rapid diagnostic testing.
The sooner patients start treatment, the better the outcome, so we are ramping up our efforts to get accurate results. We will then monitor treatment progress through viral load testing as quickly as possible. This entails adding more instruments and reagent supplies in all of our labs to keep pace with both the viral load testing demand and the increased numbers of people being tested.
90/90/90
For Zimbabwe, for Africa and for the world, the next goal is to reach the United Nations’ 90/90/90 goal: 90% of people are tested; 90% of these are on treatment; 90% of these have an undetectable viral load.
The fact that we can even discuss reaching this goal is amazing; it reflects the progress that we and other partners are making in Africa. As the Zimbabwean proverb says, “If you can envision it, you can accomplish it. If you can imagine it, you can reach the heavens.” In Zimbabwe, we are reaching for the heavens.
Interested in becoming an APHL global health volunteer? We offer consultancies for two weeks to 12 months in Africa, the Caribbean, Eastern Europe or Southeast Asia. Learn more about making a difference with APHL.
Twenty-five years ago I was huddled by a radio listening to the BBC broadcaster tell of the fall of the Berlin Wall. As I listened, I became more and more aware of how much Americans take our freedom for granted.
Earlier that same week I moved to Geneva, Switzerland to begin an assignment with the World Health Organization (WHO); not only was it a big move, it was also my first ever trip overseas. I was in a temporary apartment, didn’t speak the language (French), didn’t know anyone and, although very excited, was generally overwhelmed. Meanwhile, only a few hundred miles away, history was being made. I didn’t realize it at the time, but those first few weeks in Geneva helped shape my career and, really, the person I became from that point forward.
My assignment at WHO was to coordinate a global conference on integrating HIV/ AIDS into the curriculum of health professional schools across the globe. While healthcare professionals weren’t scared like they were when the disease was first discovered, they really didn’t have much experience with HIV/ AIDS. So my project was to integrate this disease into curricula to teach a new generation of healthcare workers. It was an exciting and difficult challenge not only because of the heavy subject matter at hand or the language which was still unfamiliar to me, but also because I had to navigate the complex bureaucracy of WHO.
When I began this project, the public was just beginning to understand that HIV wasn’t a gay disease or an African disease, but it was a disease that could impact anyone. In fact, we were seeing heterosexual transmission explode in Africa. There was a huge stigma attached to AIDS causing those who were infected to be shunned in public and in the workplace.
As the international conference commenced in Istanbul, Turkey, I felt enormous pride that we were doing something, but it was short lived. One day a man who was HIV positive showed up at the meeting looking for care. Despite being unable to publicize the meeting because of the stigma, this man heard that all these health professionals were coming together in his city to discuss his disease. He was desperate and really had nowhere to turn in his community. He was an outcast and felt like he lost his freedom. The man cried when we told him that it wasn’t really a medical meeting and that we weren’t able to help him directly. My heart broke. I remember going back into the meeting and sharing his story with a colleague from the Turkish health ministry who took down his information and promised to reach out. (I’m fairly certain he did that to placate me, not for real follow up. I’ll never know for sure.)
By that point the Berlin Wall was fully down, people were passing back and forth between East and West Germany, and we were getting glimpses of hope for the future. Back in Geneva, I began to explore the connections between global public health and basic human freedoms. The fall of the wall and my experiences in Istanbul really solidified my desire to be part of improving health for all. It was abundantly clear that good health provided freedom in so many ways. I had found my niche.
I’ve thought a lot about the man in Istanbul recently as I’ve listened to stories about Ebola. Here, too, we have a new and very scary disease. Except that it’s not really new, but new to many in America. The stigma now being associated with Ebola is much like that of AIDS 25 or more years ago. The treatment of returning healthcare workers – heroes, in my mind – is shameful and disappointing. The lack of respect for information shared by scientific and medical experts, people who have studied Ebola for their entire career, is frustrating. And the worst of all, watching public fear escalate and place demands on decision makers is deeply troubling.
Healthcare workers in any region – whether those testing samples in New York City or those treating patients in Sierra Leone – deserve their freedom to move freely until medical experts determine they present a risk to the public. Patients who have recovered from Ebola deserve their freedom as they return to life in good health. And we all deserve freedom from fear, something that is given to me every time I speak with colleagues who understand the intricacies of how Ebola operates and how it can be contained.
My hope for the future is that we as public health professionals, healthcare workers, neighbors and as Americans can move beyond stigma to a better place, one where health is recognized as both a right and a freedom.
*Photo: World Health Organization’s headquarters in Geneva, Switzerland
This is yet another David-versus-Goliath “news” report on a maverick humanitarian who just happens to have stumbled upon a cure for a debilitating or fatal disease that just so happens to be dirt cheap, and so Big Pharma does not even return his calls because it can’t make trillions of dollars selling his cure. Let the people die from their sickness! It’s not like pharmaceutical company employees have families and friends of their own who may also be sick; rather every pharma employee in the world is a soulless, corporate drone addicted to money.
This particular article tells the story of a Robert Vachy, a hardcore mountain-climber (which has no bearing on the story except to anchor your mind on this idea of a lone man who conquers the odds) who tinkered in his kitchen and created, get this, his very own sunscreen! The story specifies that he was the head of R&D for Sandoz, now part of Novartis, so there is some reason to believe that he had a sufficient background, if the story is to be trusted, to engage in a bit of combinatorial chemistry in his spare time. The article does not explain why he felt the need to create his own sunscreen.
However, it turns out that his homemade sunscreen was not just great at repelling dastardly UV light; it was a universal virus killer. That’s right: from herpes to the common cold to HIV, the active ingredient in his homemade sunscreen could kill any virus. He even expects it to work against the Ebola virus!
The problem, of course, is that his miracle molecule costs only a few Euros: no pharmaceutical company in their right mind would want to sell it, since they would stop raking in the dough from their much more lucrative triple therapy. So the poor 81-year-old sap has sold his apartment “in Montmartre” (cue “La Bohème), invested all of his life savings into his small lab, and is now a pauper begging, just begging for the money he needs to cure AIDS.
Do you know why I know for a fact that this is quackery at its most typical? The article claims that none other than Françoise Barré-Sinoussi, the co-discoverer of the HIV, tested this miracle molecule in her lab in 1995, found that minimal amounts of it would kill 99.99% of HIV… and didn’t publish this revolutionary finding in any peer-reviewed journal.
I checked Medline.
There are no articles with “Amovir” (the name of the molecule) and either her name or Robert Vachy’s name. If you can find this article, please send it to me. As it stands, it looks as if the co-discoverer of the HIV had the miracle cure in her lab and decided against publishing these findings. It must be a conspiracy by Big Pharma.
The mistake Vachy made was in going to the wrong co-discoverer of the HIV. If he’d gone to Luc Montagnier instead, the two of them would be in China right now, investigating homeopathic Amovir to cure the Ebola virus.
Many prominent people involved in HIV/AIDS research lost their lives when Malaysian plane MH17 was shot down over Eastern Ukraine. HIV/AIDS researchers exemplify how scientists serve the public good. A key to HIV/AIDS research has involved embracing a certain type …
Stephen O' Brien talked at UC Davis a few days ago. I met with him in the afternoon before his talk. It was one of the more interesting discussions I have had in a long time. He has done some very interesting and important work (e.g., comparative genomics, HIV, feline evolution) though most of what we talked about was not work per se (e.g., we talked a lot about baseball and big cats since my kids are obsessed with big cats).
To be clear, all of our teammates see the importance of accurate results, but it can take some doing to get people comfortable with the new steps to take and the changes they involve.
book with a dedication to my kids.