# Presentation: 217422

## NIGERIA: HIV TESTING ISSUES FOR SURVEILLANCE

**Professor G.O. Okafor**
- College of Medicine, University of Nigeria
- Mr. S.A. Egbewunmi
- Federal Ministry of Health

- Atlanta, Georgia,   October 19, 2004

## Slide 2

## HISTORY OF HIV SURVEILLANCE IN NIGERIA:

- - HIV was first reported in Nigeria in 1986.
- - Between 1986 and 1990 there was no organized 	surveillance of the growing epidemic.
- - Prevalence values were based on reports by individual 	investigators.
- -  Up to 1995/96 there was no central training for 	survey participants.
- -  First HIV sero-prevalence survey was carried out in 	1991 in selected towns covering 9 out of 30 		States of Federation.

## 						continuation...

- - Individuals were given responsibility to organize and supervise survey in their states. Survey employed Wellcozyme and Genelavia kits.
- - There was no formal training, no centralized supervision and no Q.C.
- - - Second national survey took place in 17 States in 1993/94, employing Genelavia and Test – Pack reagents.
- -  As in 1991 this survey was neither properly planned nor  supervised.
- - In 1995/96 21 States out of the 30 then in existence were 	covered in the survey.

## 						continuation...

- - The FMOH planned the survey with State  AIDS 	Programme Co-ordinators (SACP’S) without any input from the laboratory .
- 	- Genelavia and Test Pack Kits were used in the survey.
- - 1999 survey was planned with consultants from WHO, 	DFID, UNICEF and UNAIDS.
- - Laboratory quality assurance, centralized TOT and state level  training and minimal data entry quality control were introduced. Supervision was carried out at federal and state levels.
- All above newly introduced activities were expected to raise the standard of the 1999 survey. Unfortunately the survey suffered a set-back by late arrival of 	consumables and other materials.

## 						continuation...

- -Furthermore, as a result of non-involvement of  Laboratory personnel at planning stage wrong tubes,  pipette tips and some other materials were procured.
- - Late release of funds and late disbursement at various stages of survey were additional problems.
- - Overall, 1999 survey was a great improvement on previous ones.
- -  The approaches introduced in 1999 were further developed for use in 2001 and 2003 surveys.

## 						continuation...

- - The 1999 survey raised awareness on the sensitivity of 	the conduct of a national sentinel sero-prevalance survey.
- These are - need for careful planning
-                       -  adequate training
-                       - strict adherence to survey protocol.
- - Effort was made to build on the gains of the 1999 survey in the planning, training and execution of the next two surveys– 2001 and 2003.
- - Problems encountered overtime are grouped under:  	Planning, logistics, funding, training and supervision.

## CENTRAL TRAINING

- STATE LEVEL TRAINING

- SAMPLE COLLECTION

- SAMPLE RETRIEVAL

- QUALITY CONTROL

- DATA MANAGEMENT &
- REPORT PRODUCTION

- ON SITE SUPERVISION
- STATE COORDINATION
- ZONAL SUPERVISION
- CENTRAL SUPERVIISION

## Survey Flowchart

**1****ANC Clinic****Screen Client for Eligibility Criteria for Syphilis Test**

**1.2****ANC Site****Collect Blood**

**2****Syphilis Test at Site****RPR Screening for Syphilis ****Screen Client for Eligibility Criteria for HIV**

**3**
**State Lab****Perform Rapid HIV Test (Capillus & Genie II) **
** ****Confirm Syphilis Test (TPHA)**

**4**
**Federal Level**
**Quality Control ****Confirm HIV Serorstatus (Capillus, & Genie II & Determine)**

**2.2****ANC Site****Create Dried Blood Spot****Collects blood, label, store, **
**transport cards to ****federal Lab**

## State Lab Testing 

**Capillus**

**Negative Result**

**Genie II**

**Capillus**

**State Lab Testing**

**Genie**** ****II**

**Determine (tie breaker)**

**QC Testing**

**Negative**

**Negative**

**Negative**

**Positive**

**Positive**

**Positive**

**Positive**

**100%**

**100%**

**10%**

**Negative**

**Positive Result**

**90%**

## Quality Control Retesting

- Supervision of QC retesting was done by the National Technical Working Group with technical support from CDC.
- All samples transported to QC Center by laboratory personnel.
- From every site retesting was run on:
- 100% positives
- 10% negatives
- >5% discordance all negatives tested from the state)
- All laboratory results were entered into database by laboratorians.

## Planning

- Inadequate and late start for planning.
- _Solution_:
- 	- Planning starts early, stakeholders to show early 	     	commitment to avoid short falls and funding gaps.

## Logistics 

- - Procurement of wrong consumables.
- - Insufficient supply of consumables and reagents.
- - Inadequate cold storage facilities.
-  Inadequate provision of power back-up.
- - Cold chain maintenance.

## Solution:

- 	- All consumables, reagents and other materials to be on 	ground before commencement of survey .
- - Laboratory personnel should always be involved in planning.
- - Samples of consumables and other materials should be kept and used to make purchases.
- -Problems of inadequate storage facilities  have yet to be 	completely resolved.
- - Appropriate training has improved cold chain maintenance

## Funding 

- Funding issues have remained recurrent decimal
- Inadequate funding for survey and late release of funds

## SOLUTION:- 

- All funds for survey should be on ground before  commencement of survey.

## Training: 

- This is one of the most important components preparatory to any survey:
- Inadequate Training often arises from engaging too many people at a time and insufficient time for practical training
- Wrong personnel trained for laboratory work.
- e. g  - Laboratory scientists unable to use vacutainers.
- Poor adherence to SOP resulting in poor concordance.

## Solution:

- Training should be decentralized but this will 	mean extra funding to cover additional facilitators and logistics.
- ToT should be stregthened, with emphasis on  information disemination.
- Only laboratory personnel performing HIV testing should be trained.
- SOP’s should be boldly written and prominently pasted for easy reference.
- Right consumables and materials for survey should be used in training the participants.

## Problems Observed  During Supervisory Visits

- Poor record keeping (Inconsistent reporting between sites)
- Inconsistent labeling and coding of specimen bottles
- Improper sample handling at sites
- Maintenance of confidentiality
- Bad arrangement of stored samples
- Lack of surveillance understanding at site level
- loss of information during transfer
- Inadequate means of transportation for supervisors

## Solution:- 

- Two levels of supervision were introduced:
- Central and Zonal
- Included individuals from various organizations (national and international, eg CDC, APIN, WHO)
- Continuous supervision ensured through out the survey period.
- Several feed back meetings with all supervisors
- Adequate supervision has minimized most of the  problems listed above.

## National Technical Working Group

- Made up of 6 experts in HIV/AIDS testing from different organizations and diverse parts of the country.
- Participated in following:
- Protocol development
- Compiled lab supply list
- Development of training modules
- Supervision of training
- Supervisory visits
- QC retesting

## National HIV Prevelance Trend

**National HIV Prevelance Trend**
** ****1991-2003**

## Prevalence Distribution

**Prevalence Distribution**