Lab Culture Ep. 7: APHL’s International Team Meeting

Lab Culture Ep. 7: APHL’s International Team Meeting |

The APHL International Team Meeting allows for US-based APHL leadership and global health program staff and consultants working in-country to discuss organizational operations and key programmatic successes and challenges. In most cases, this is the only time during the year that these individuals have an opportunity to meet face-to-face. Participants from Zambia, Zimbabwe, Kenya, Tanzania, Mozambique, Guinea, Sierra Leone and APHL’s US headquarters were all in attendance.

In November, Scott Becker, APHL’s executive director, traveled to Johannesburg, South Africa for the second APHL International Team Meeting. While he was there, he sat down with five members of the APHL international team to discuss their work and what led them to pursue a career in laboratory science.

Interviews include:

  • Levi Vere, Laboratory Quality Monitoring Manager, APHL Zimbabwe
  • Shanette Nixon, Global Health Consultant, APHL
  • Esther Vitto, Laboratory Program Support, APHL Sierra Leone
  • Mohamed Fofanah, Associate Specialist, Administration and Finance, APHL Sierra Leone
  • Rufus Nyaga, LIS Technical Consultant and Project Manager, APHL Kenya
Scott Becker and Levi Vere Scott Becker and Shanette Nixon Scott Becker, Esther Vitto and Mohamed Fofanah Scott Becker and Rufus Nyaga


APHL’s Global Health Program

Mudslides in Sierra Leone

Zimbawe After Mugabe


The post Lab Culture Ep. 7: APHL’s International Team Meeting appeared first on APHL Lab Blog.

Zimbabwe makes significant strides in the fight against HIV/AIDS

Zimbabwe makes significant strides in the fight against HIV/AIDS |

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.


What challenges do you face in your work?


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.


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.


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?


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.

Zimbabwe makes significant strides in the fight against HIV/AIDS | www.APHLblog.orgTo 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.


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.


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!


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?


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.


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.


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!

The post Zimbabwe makes significant strides in the fight against HIV/AIDS appeared first on APHL Lab Blog.

Small but mighty Zimbabwe lab team meets challenges in reaching HIV testing goals

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.


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.


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.


A rainbow arches over Victoria Falls in Zimbabwe. Photograph by…

A rainbow arches over Victoria Falls in Zimbabwe. Photograph by Volkmar Wentzel, National Geographic Creative

Ndebele chief Mtonzima Gwebu wears traditional dress in his…

Ndebele chief Mtonzima Gwebu wears traditional dress in his modern home in Zimbabwe, 1975.Photograph by Thomas Nebbia, National Geographic Creative

Study linking antidepressants to diabetes retracted when authors publish it twice

A group of researchers from Texas and Zimbabwe has lost a paper after they tried publishing it twice — first in the European Journal of Clinical Pharmacology, and then in the International Journal of Clinical Pharmacy.

Here’s the notice:

The International Journal of Clinical Pharmacy has been alerted to a case of duplicate publication in the following papers.

Int J Clin Pharm. 2012 Jun;34(3):432-8. Epub 2012 Jan 18. Use of antidepressants and the risk of type 2 diabetes
mellitus: a nested case–control study. Khoza S, Barner JC, Bohman TM, Rascati K, Lawson K, Wilson JP.

Eur J Clin Pharmacol. 2011 Nov 26. [Epub ahead of print]. Use of antidepressant agents and the risk of type 2 diabetes. Khoza S, Barner JC, Bohman TM, Rascati K, Lawson K, Wilson JP.

The International Journal of Clinical Pharmacy is retracting the paper. We sincerely apologize to the scientific community.

The studies are indeed quite similar. The IJCP abstract:

Background Recent evidence from case reports, observational studies, and randomized trials suggests that long-term use of antidepressants increases the risk of developing diabetes. However, the nature of the relationship between antidepressants and diabetes remains unclear. Objective To determine whether there is an association between antidepressant use and the risk of developing type 2 diabetes mellitus. Methods A nested case–control study using the Texas Medicaid prescription claims database was conducted. Data were extracted for new users of either antidepressant agents (exposed) or benzodiazepines (unexposed) from January 1, 2002 through December 31, 2009. Patients aged 18–64 years without a history of diabetes were included in the cohort. The adjusted odds ratio (OR) and 95% confidence interval (CI) for the risk of diabetes associated with antidepressant exposure was computed using conditional logistic regression, controlling for demographic and clinical covariates. Main outcome measure Development of type 2 diabetes mellitus Results Among the total sample (N = 44,715), the majority were in the exposed (N = 35,552) vs. the unexposed (N = 9,163) group. A total of 2,943 cases of type 2 diabetes mellitus and 11,748 matched controls (1:4) were identified using risk-set sampling. Cases and controls were matched using age and gender. Antidepressant use was associated with an increase in the risk of (type-2) diabetes when compared to benzodiazepine use [Adjusted Odds Ratio (OR) = 1.512; 95% CI 1.345–1.700]. The association was observed with serotonin-norepinephrine reuptake inhibitors (OR = 1.742; 95% CI 1.472–2.060), tricyclic antidepressants (OR = 1.533; 95% CI 1.295–1.814), selective serotonin reuptake inhibitors (OR = 1.457; 95% CI 1.279–1.659), “Other” antidepressants (OR = 1.318; 95% CI 1.129–1.540). Conclusions Antidepressant use was associated with an increased risk of (type-2) diabetes. This association was observed for tricyclic antidepressants, serotonin-reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, and other antidepressants.

The EJCP abstract:


To determine whether there is an association between antidepressant use and the risk of developing type 2 diabetes.


This study was a retrospective cohort analysis using the Texas Medicaid prescription claims database. Data were extracted for new users of either antidepressant agents (exposed) or benzodiazepines (unexposed) from January 1, 2002 through December 31, 2009. Patients aged 18–64 years without a prior history of diabetes were included. Cox proportional hazards regression was used to examine the association between diabetes incidence among exposed and unexposed groups, while controlling for demographic and clinical covariates.


Among the total study population (N = 44,715), the majority were in the exposed (N = 35,552) versus the unexposed (N  = 9,163) group. A total of 2,943 patients (6.6%) developed type 2 diabetes during the follow-up period. Antidepressant use was associated with an increase in the risk of diabetes when compared to benzodiazepine use (adjusted hazard ratio [HR] 1.558, 95% confidence interval [CI] 1.401–1.734). The association was observed with tricyclic antidepressants (TCAs; HR 1.759, 95% CI 1.517–2.040), serotonin–norepinephrine reuptake inhibitors (SNRIs; HR 1.566. 95% CI 1.351–1.816), selective serotonin reuptake inhibitors (SSRIs; HR 1.481, 95% CI 1.318–1.665), and “other” antidepressants (HR 1.376; 95% CI 1.198–1.581).


The results of this study suggest that antidepressant use is associated with an increased risk of diabetes. This association was observed with use of TCAs, SNRIs, SSRIs, and “other” antidepressants.

Both journals, we should note, are Springer publications. We’ve contacted corresponding author Star Khoza — who seems to have done her PhD thesis on the subject of the papers at the University of Texas at Austin before moving to Zimbabwe — for comment, and will update with anything we learn.

Duplication retractions — sometimes referred to, somewhat inelegantly, as “self-plagiarism” — can spark heated debate here on Retraction Watch. There are copyright issues, which some scientists say make them do unnecessary rewrites of their own words. But a more important point, and of significance in this case, is that review articles and meta-analyses can end up counting the same study twice, inflating the results and skewing conclusions.