Opportunities and challenges in public health clinical diagnostic laboratories in Uganda: a cross sectional study

Abstract Background Optimum laboratory performance remains cardinal to definitive clinical disease diagnosis, prognosis and surveillance. In low and middle-income countries (LMICs) most public health clinical diagnostic laboratory capacity and their sustainability are at various levels of development. The objective of this study was to asses available opportunities and challenges faced by public health clinical diagnostic laboratories in Uganda so as to provide data to inform capacity building in such and similar settings. Methods A descriptive cross-sectional study was conducted between 10th Dec 2018 and 31 Jan 2019. All the 14 public health clinical diagnostic laboratories in Ministry of Health Regional Referral Hospital establishments in Uganda were purposively sampled. A standardized data abstraction tool was developed from the elements of ISO 15189 and 17025 laboratory standards and check list. Data were analysed using PRISM data analysis program and excel. Proportions were computed and some correlations deduced. Ethical approval was obtained before data collection commenced. Results Thirteen (13) of the laboratories participated in the study and their data included in the analysis. All the laboratories had: qualified laboratory staff, conducted quality improment meetings and kept laboratory records and documents. Of these, 12 (92.3%) had organizational structures endorsed by the respective hospital administration, functional basic laboratory equipment in the departments of haematology, microbiology, parasitology, clinical chemistry, Immunology and molecular biology. All the laboratories were government supported and offered free diagnostic services while 11 (84.6%) offerd surrveilance services. Eight (61.5%) laboratories were licenced by Allied Health Professionals, twelve (92.3%) were involved in internal quality control programs, eleven (84.6%) were enrolled on External Quality assurance testing programs while one (7.7%) was fully accredited by South African National Accreditation System (SANAS). The challenges identified included; under-staffing 10 (76.9% ), insufficient infrastructure 1 (7.7%), supplies stock-outs 3 (23.1%), inadequate equipment 2 (15.4%) and hard copy laboratory results. Additionally, they lacked independent budgets, finance management and autonomous financing. Conclusion Various challenges identified hindered public health diagnostic laboratories in Uganda to operate at full diagnostic capacity, overcoming them will standardise quality and attain equity of services across the country.</jats:p

Evaluation of a point-of-care immunoassay test kit ‘StrongStep’ for cryptococcal antigen detection

BackgroundHIV-associated cryptococcal meningitis is the leading cause of adult meningitis in Sub-Saharan Africa, accounting for 15%-20% of AIDS-attributable mortality. The development of point-of-care assays has greatly improved the screening and diagnosis of cryptococcal disease. We evaluated a point-of-care immunoassay, StrongStep (Liming Bio, Nanjing, Jiangsu, China) lateral flow assay (LFA), for cryptococcal antigen (CrAg) detection in cerebrospinal fluid (CSF) and plasma.MethodsWe retrospectively tested 143 CSF and 77 plasma samples collected from HIV-seropositive individuals with suspected meningitis from 2012-2016 in Uganda. We prospectively tested 90 plasma samples collected from HIV-seropositive individuals with CD4 cell count ResultsStrongStep CrAg had a 98% (54/55) sensitivity and 90% (101/112) specificity in plasma (P = 0.009, versus reference standard). In CSF, the StrongStep CrAg had 100% (101/101) sensitivity and 98% (41/42) specificity (P = 0.99). Adjusting for the cryptococcal antigenemia prevalence of 9% in Uganda and average cryptococcal meningitis prevalence of 37% in Sub-Saharan Africa, the positive predictive value of the StrongStep CrAg was 50% in plasma and 96% in CSF.ConclusionsWe found the StrongStep CrAg LFA to be a sensitive assay, which unfortunately lacked specificity in plasma. In lower prevalence settings, a majority of positive results from blood would be expected to be false positives

Safety, uptake, and use of a dapivirine vaginal ring for HIV-1 prevention in African women (HOPE): an open-label, extension study

BackgroundTwo phase 3 clinical trials showed that use of a monthly vaginal ring containing 25 mg dapivirine was well tolerated and reduced HIV-1 incidence in women by approximately 30% compared with placebo. We aimed to evaluate use and safety of the dapivirine vaginal ring (DVR) in open-label settings with high background rates of HIV-1 infection, an important step for future implementation.MethodsWe did a phase 3B open-label extension trial of the DVR (MTN-025/HIV Open-label Prevention Extension [HOPE]). Women who were HIV-1-negative and had participated in the MTN-020/ASPIRE phase 3 trial were offered 12 months of access to the DVR at 14 clinical research centres in Malawi, South Africa, Uganda, and Zimbabwe. At each visit (monthly for 3 months, then once every 3 months), women chose whether or not to accept the offer of the ring. Used, returned rings were tested for residual amounts of dapivirine as a surrogate marker for adherence. HIV-1 serological testing was done at each visit. Dapivirine amounts in returned rings and HIV-1 incidence were compared with data from the ASPIRE trial, and safety was assessed. This study is registered with ClinicalTrials.gov, NCT02858037.FindingsBetween July 16, 2016, and Oct 10, 2018, of 1756 women assessed for eligibility, 1456 were enrolled and participated in the study. Median age was 31 years (IQR 27-37). At baseline, 1342 (92·2%) women chose to take the DVR; ring acceptance was more than 79% at each visit up until 12 months and 936 (73·2%) of 1279 chose to take the ring at all visits. 12 530 (89·3%) of 14 034 returned rings had residual dapivirine amounts consistent with some use during the previous month (&gt;0·9 mg released) and the mean dapivirine amount released was greater than in the ASPIRE trial (by 0·21 mg; p&lt;0·0001). HIV-1 incidence was 2·7 per 100 person-years (95% CI 1·9-3·8, 35 infections), compared with an expected incidence of 4·4 per 100 person-years (3·2-5·8) among a population matched on age, site, and presence of a sexually transmitted infection from the placebo group of ASPIRE. No serious adverse events or grade 3 or higher adverse events observed were assessed as related to the DVR.InterpretationHigh uptake and persistent use in this open-label extension study support the DVR as an HIV-1 prevention option for women. With an increasing number of HIV-1 prophylaxis choices on the horizon, these results suggest that the DVR will be an acceptable and practical option for women in Africa.FundingThe Microbicide Trials Network and the National Institute of Allergy and Infectious Diseases, The Eunice Kennedy Shriver National Institute of Child Health and Human Development, and the National Institute of Mental Health, all components of the US National Institutes of Health