A pilot program of a dry blood spot HIV1 RNA method for early infant diagnosis and viral load monito

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A pilot program of a dry blood spot HIV-1 RNA
method for early infant diagnosis and viral load
monitoring in rural Tanzania

• Sarah M. Lofgren, BA
• Research Fellow
• KCMC-Duke University Collaboration
• Moshi
• TANZANIA

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Overview

• Challenges for early infant diagnosis and viral
  load monitoring in sub-Saharan Africa
• Potential solutions
• HIV RNA capacity in northern Tanzania
• Pilot program of a dry blood spot method
• Performance against liquid plasma
• Program performance
• Impressions of clinicians and patients
• Challenges
• Next steps

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Challenges for early infant diagnosis

• Antibody-based methods
• Useful for adults
• Not reliable for infants lt18 months
• Early infant diagnosis
• Initiation of ART and other management
• Nucleic acid amplification tests (NAT)
• Challenges of NAT for rural areas
• Test locally using expensive, complex equipment
• Freeze and transport on dry ice to central
  laboratory

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Challenges for viral load monitoring

• Expansion of HIV treatment and care programs
• Monitoring by clinical and immunology assessments
• Virologic failure occurs earlier
• Viral load monitoring useful
• Technologic and logistic concerns
• Similar to early infant diagnosis

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Solutions to challenges

• Alternative NAT assays
• Simpler, cheaper systems that could be deployed
  to district hospital level
• Groups working on technologic advances
• Alternative sample type
• Easy to prepare, store, transport
• Tested in a central laboratory
• Dry blood spots (DBS)
• DBS DNA PCR for early infant diagnosis well
  validated and widely used
• DBS RNA PCR for early infant diagnosis less
  studied
• Single DBS RNA PCR platform for early infant
  diagnosis and viral load monitoring

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HIV RNA capabilities in northern Tanzania

• KCMC Biotechnology Laboratory, Moshi
• February 2006 Abbott m2000rt with manual sample
  preparation
• February 2008 Abbott m2000system with automated
  sample preparation
• Patient care and research
• Expand the reach of the service

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HIV RNA capabilities at Moshi Tanzania
Automated sample preparation and
amplification/detection using m2000 system
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Sites
Moshi
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Pilot program design

• A two-part program
• Part A HIV-1 exposed or suspected infants lt18
  months of age
• Part B HIV-infected patients 18 months

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Methods

• Brief standardized questionnaire
• EDTA blood collected
• Prepare DBS, sent by EMS to KCMC
• Plasma separated, frozen, shipped weekly to KCMC
• Dry blood spot
• HIV-1 RNA by Abbott m2000system
• HIV DNA PCR in South Africa (infant diagnosis)
• HIV RNA levels assessed at baseline and 10 weeks
• Liquid plasma sample
• HIV-1 RNA by Abbott m2000system
• Results returned to collection site for patient
  care

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Sample and result flow
Part A samples to CLS in South Africa for DNA DBS
testing
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Results

• See poster P_28 for technical performance of DBS
  vs. liquid plasma HIV RNA
• DBS HIV RNA performed well for early infant
  diagnosis against both liquid plasma HIV RNA and
  DBS DNA PCR
• Strong agreement between DBS and plasma HIV RNA
  for above 4 logs and reasonable agreement down to
  400 cp/mL
• DBS HIV RNA levels were stable over 80 days of
  storage

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Performance of the TanzaniaExpedited Mail
Service (EMS)

• Transit times
• Median 1.5 days (range 1-2 business days)
• Specimens or results lost
• 28 packages with DBS were sent from the rural
  sites and all were received at the KCMC
  Biotechnology Laboratory
• 27 packages with results, case report form and
  consent clarifications, and supplies were sent to
  rural sites and all were received

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Dry blood spot training at the KCMC Biotechnology
Laboratory

• Laboratory staff had gt2 years experience using
  m2000 instrument for HIV-1 RNA measurement on
  liquid plasma samples
• Staff needed lt1 day of training from an Abbott
  Field Application and Service Specialist for DBS
  testing

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Training for sites

• 2 day training at KCMC Biotechnology Laboratory
• 1 clinician and 1 lab worker from each site
• Trainees returned to sites to
• Train other program workers
• Training and trouble-shooting support was
  available from the Moshi-based Study Coordinator

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Total turnaround times

• Turnaround times from collection to result at
  site
• Collection to shipping 0-7 days
• Transit site to laboratory 1-2 days
• Sample receipt to testing 1-51 days
• Excluding Christmas 1-21 days
• Testing to shipping 1-7 days
• Transit laboratory to site 1-2 days
• Total turnaround time 4-69 days
• Excluding Christmas Period 4-39 days
• Most delays results from testing issues at the
  KCMC Biotechnology Laboratory

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Reasons for delays in the KCMC Biotechnology
Laboratory

• Run failures of liquid plasma
• At liquid handler- 2 run failures
• At amplification and detection- 1 run failures
• National grid power problems in December 2008
  combined with generator malfunction
• Interruption of study activities during
  Christmas period

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Rejections and lost samples

• 35 samples lost in run failures
• 3 lost because of successive machine errors
• 6 samples were hemolyzed
• 7 were of insufficient volume
• 4 rejected because collected outside study period
• 7 patients were 18 months at time of enrollment
• No samples were lost in transport

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Impressions of physicians

• The program has helped in capacity building for
  staff
• Participants thought DBS were helpful in
  deciding management (of exposed infants and
  infected adults)
• We advice if results are promising to hurry in
  next phase of (program) so that we can prolong
  life of infected infants and save lives of
  non-infected as mothers can stop breastfeeding
  and be very carefully in raising their babies to
  avoid other ways of transmission

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Impressions of patients

• Majority of patients were highly impressed by
  the study especially mothers of infants (part A)
  as they were very ambitious in knowing results of
  their babies and that was seen clearly when we
  gave results

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Would you use this service if it was available
via DBS? If not what barriers would there be to
using it?

• I think in future these diagnostic tools viral
  load/infant diagnosis via DBS very helpful, but
  usage it depends on guidelines from Ministry of
  Health.
• Malabeja Anangisye
• physician at Magunga Hospital

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Would you use this service if it was available
via DBS? If not what barriers would there be to
using it?
YES, YES, YES, PLEASE. Having early diagnosis
is great and the mothers really like it. The main
barrier is in the difficulties of getting the
results back effectively which would have to be
improved loads. Sally Edmonds physician at
Teule Hospital
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Challenges

• Issues in the KCMC Biotechnology Laboratory
• Time to get results back to sites

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Next steps

• Results can be used by policy makers to inform
  decisions about use of DBS to provide HIV-1 RNA
  services to rural and remote areas

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Acknowledgements
Korogwe Malabeja Ananagisye Omary Abdul Samwel
Gesase Gerald Kulwa Alvan Butichi Sr. Upendo
Mvungi Muheza Sally Edmonds Ben Amos Hawa
Chubwa Naftali Vadwiga Monica Mhilu
Moshi John Crump Caroline Chevallier Anne
Morrissey David Sifuna Emma Msuya Werner
Schimana John Shao
Abbott Daan Potgieter Sven Thamm Rob Dintruff
CLS Wendy Stevens
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Any Questions?