CDC's Global AIDS Program GAP

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Building Laboratory Capacity in Support of
HIV/AIDS Care Programs in Resource-limited
Countries
Laboratory Support for the Global AIDS Program
Organization and Response Strategy Robert Martin,
DrPH Director, Division of Laboratory Systems
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CDC Global AIDS Program Mission

• GAP helps resource-constrained countries
• prevent HIV infection
• improve treatment, care, and support for people
  living with HIV
• build capacity/infrastructure to address the
  global HIV/AIDS pandemic
• GAP provides its assistance directly through CDC
  staff and through partnerships with governments,
  communities, and national and international
  institutions

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GAP Budget History
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HIV/AIDS Burden Year-End 2002

• Total estimated HIV-infected population
  worldwide 42 million, 95 in the developing
  world
• Total HIV burden in GAP countries 37?million
• gt90 of all HIV-infected persons live in
  countries that have a CDC Global AIDS Program
  presence

Source UNAIDS, December 2002
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GAP Countries 2003
China
India
Haiti
Vietnam
Nigeria
Senegal
Ethiopia
Guyana
Cambodia
Thailand
Côte dIvoire
Uganda
D.R. Congo
Kenya
Rwanda
Angola
Tanzania
Zambia
Zimbabwe
Brazil
Namibia
Malawi
Botswana
Mozambique
South Africa
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Presidents Emergency Plan for AIDS Relief

• Prevent 7 million new infections (60 percent of
  the projected new infections) Large-scale
  prevention efforts, including voluntary testing
  and counseling. The availability of treatment
  will enhance prevention efforts by providing an
  incentive for individuals to be tested.
• Treat 2 million HIV-infected people First global
  effort to provide advanced antiretroviral
  treatment on a large scale in the poorest, most
  afflicted countries.
• Care for 10 million HIV-infected individuals and
  AIDS orphans Range of care, including support
  for AIDS orphans.

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Designated Countries in the Presidents PMTCT
Initiative

• Africa
• Botswana
• Côte dIvoire
• Ethiopia
• Kenya
• Mozambique
• Namibia
• Nigeria
• Rwanda

• South Africa
• Tanzania
• Uganda
• Zambia
• Caribbean
• Guyana
• Haiti
• and Regional efforts through CAREC (Trinidad)
• Southeast Asia
• 15. Vietnam

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Major GAP Activities

• HIV Prevention Programs
• Including behavior change (abstinence, delay,
  risk reduction), voluntary counseling and
  testing, prevent/treat other sexually transmitted
  infections, prevent mother-to-child transmission,
  blood safety
• HIV/AIDS Treatment and Care Programs
• Including diagnosis, prophylaxis and treating
  opportunistic infections, tuberculosis and
  HIV/AIDS, and operational research related to
  developing program models, standards and
  guidelines
• Program Infrastructure
• Including surveillance, operational research,
  informatics, training, laboratory support and
  monitoring and evaluation

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CDC GAP Program Model

• Surveillance
• HIV surveillance
• Behavioral surveys

• Primary Prevention

• Care and Treatment
• - Palliative care
• - Treatment of OIs
• - TB treatment
• - Use of ARVs

Capacity and Infrastructure Strengthening

- Laboratory - Information systems
- Monitoring and evaluation - Training
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GAP Laboratory Support Structure
Steering Committee T. Mastro, S. Wiktor, A.Demby,
P. Crippen GAP R. Martin, T. Hearn, J.
Ridderhof PHPPO M. Rayfield, J. Kaplan, R.
Ballard, S. McDougal DASTLR Yvette Benjamin -
APHL
Laboratory Technical Advisory Group CDC/CIOs, Lab
Leaders in GAP countries, WHO
UTAP
UTAP
APHL
DASTLR
PHPPO
Technical Working Groups
Lab Sys
STI
Dx Surv
Dx Care
QA
TB
OI
GAP country-specific lab liaison team
GAP country
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Organizational Model for Response

• Partnership Matrix
• GAP US-based Coordination
• PHPPO Lab systems, QA, training (MOU)
• DASTLR Wet bench technology transfer (MOU)
• NCEH Dried Blood Spot Technology
• NRL National Reference Serology Laboratory
• APHL Public Health Laboratory
  Assessments, long term twinning
  partnerships, lab management training
  (CoAg)
• ASCP Training materials development -
  (CoAg/Contract)
• UTAP Technology transfer and long term
  partnership (CoAg)
• WHO Regional/international leadership and
  coordination - (CoAg)

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Operationalizing Laboratory Technical Support

• Strengthen National Reference laboratories
• - Quality Reference work national
  level
• (hub for GAP program activities)
• - Set national standards, guidelines and
  protocols
• - Perform QA/QC and national oversight
• Support District level laboratory
  capacity/capability
  
• Rapid Testing point-of-service for programs
• Training - national, regional and international

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Implementation of Laboratory Capacity
Strengthening in CambodiaApril 2003
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Mission/Scope of Work

• Assess resources, capabilities and needs of
  laboratories in Phnom Penh and eight provinces.
• Recommend improvements for public health
  laboratory infrastructure supporting HIV/AIDS and
  OIs.
• Prepare implementation plan to carry out
  recommendations.

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Recommendations - National Level (3)

• Quality Management / Quality Assurance
• Development and improve the quality of training
  and supervision
• Determine the Ministry of Healths responsibility
  in maintaining and assuring the integrity of
  laboratory equipment

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Implementation Steps

• Coordinate a National meeting to develop a
  national strategy for improving the quality of
  laboratory testing

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Developing the Agenda for the Establishment of a
National Network of Health Laboratories

• Phnom Penh, Cambodia
• September 3-4, 2003

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Quality Assurance Group

• MoH establish a single laboratory quality
  assurance body through Sub-committee action.

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Declaration of Commitment

• The Ministry of Health, Kingdom of Cambodia, the
  Health Directors of the Provinces, and the U.S.
  Global AIDS Program have participated in the
  first national meeting of the Cambodian National
  Laboratory Network. The purpose of the meeting
  was to develop an agenda for the establishment of
  the national network through participation of all
  appropriate levels of the Cambodian government
  and the U.S. Global AIDS Program.
• The undersigned are committed to
• Establishing the Cambodian National Laboratory
  Network (CNLN)
• Developing and participating in a national
  laboratory quality assurance program
• Continuation and assurance of the impact of the
  CNLN through organization of workshops and
  meetings on specific topics, such as
• Networking
• Management and Leadership Skills
• Quality Assurance, Quality Control and Quality
  Improvement
• Laboratory Procedures and Methods Updates
• Equipment Management/Maintenance
• Inventory Management
• The undersigned are committed to pursuing the
  recommendations of the workgroup deliberations at
  this meeting for the purpose of making quality
  laboratory testing a priority for addressing the
  HIV/AIDS epidemic and other significant public
  health needs in the Kingdom of Cambodia.

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Building Laboratory Quality Systems A
Route to Reliable Laboratory DataJuly 2004

• Workshop Goals

Information Management
Occurrence Management
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Building Laboratory Quality Systems Workshop
Participants

• Laboratory leadership from Cambodia (Laboratory
  Directors, Ministries of Health, Quality
  Assurance specialists)
• Participants from China, Vietnam, Thailand
• Association of Public Health Laboratories
• Australia National Reference Laboratory
• CDC Global AIDS Program

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Workshop Goals

• Describe the framework for a quality system
• Provide information on how to address essential
  elements of the Quality System including
  organizational responsibilities, specimen
  management, quality control, personnel
  management, documentation and record keeping,
  equipment management, external quality
  assessments, and information management

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Workshop Goals

• Develop common approaches for implementing
  national programs
• Provide a forum for exchange of experiences in
  efforts to promote, establish, and implement a
  quality laboratory system in GAP-supported
  countries
• Provide participants with materials for training
  others

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Workgroup Sessions

• Divide participants into six workgroups
• Each workgroup will have two facilitators
• Two tasks for workgroups
• How to develop a plan for a quality laboratory
  system and present (Thursday)
• Develop a national quality system plan and
  present (Friday)

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Scheme for Group Work
1
2
3
4
5
6
Group
Topic 1
Topic 2
Topic 3
Topics
Topic 4
Topic 5
Topic 6
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How To Develop a Plan

• Gathering information
• What is quality of laboratory testing in
  Cambodia?
• What problems might prevent implementing a
  quality system?
• What are the current strengths that can be built
  on (whats good, whats bad)?

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How to Develop a Plan

• Getting Support
• Is a national system important and how do you
  tell others?
• How do you get support from national and local
  leadership?

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How to Develop a Plan

• Communications
• How do you get people involved (national and
  local)?
• Laboratory staff
• Customers

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How to Develop a Plan

• Assessment of Laboratory
• Have assessments been conducted and what are
  results?
• How would you get more information if you need
  it?
• What quality system essentials are already being
  addressed?

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How to Develop a Plan

• Authorities and Responsibilities
• Who will have overall responsibility for planning
  and implementation?
• Who has authority for laboratory policy (national
  and local)?
• Are there laws or regulations that address
  laboratory practices?

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How to Develop a Plan

• Measuring Success
• Is the plan working?
• How would you know?

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Making the Plan

• Identify and include stakeholders (who are your
  customers)
• Establish goals and objectives
• Identify activities
• Determine resource needs
• Assign responsibility
• Develop a timeline
• Develop mechanism for evaluation, monitoring and
  continuous improvement.

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Ongoing Rating of the Sessions

• Session Date
• Rate 5 - 1 ( all I expected not what I
  expected)
• I am learning new information
• I am understanding the information
• I hear the information
• I can use the information in my work

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Collaboration and partnership are keyskillful
project management is essential
Thailand
Vietnam
Cambodia