HIV Testing Where Ice Melts Fast: EID Fellow Reports from Botswana

By R. Suzanne Beard, PhD, Emerging Infectious Disease Research Fellow

Dried blood spots (DBS), drops of blood collected to screen newborns for congenital disorders, are the wave of the future for HIV testing of all sorts; at least that is what I am trying to prove during my Emerging Infectious Disease Research Fellowship. How am I doing this, you ask? Great question! I am helping design studies to evaluate filter papers from different manufacturers for viral load testing and drug resistance genotyping in resource-limited settings.

As antiretroviral treatment expands in resource-limited areas, so does the need to complete testing quickly. The problem is that plasma – to date the gold standard in HIV testing — requires separation from whole blood, and then it needs to be frozen and kept that way until testing. This leads to the need for cold chain transport in places that may not have stable electricity or the infrastructure to maintain freezers. And all this in a place that makes summer in the south look refreshing. Trust me, if you order an ice water in Botswana in November, the ice doesn’t last very long, and the same thing goes for ice in a cooler with specimens.

HIV Testing Where Ice Melts Fast: EID Fellow Reports from Botswana | www.aphlblog.org

In the year since I started working with HIV, I have discovered that much of the research with DBS does not consider conditions in resource-limited settings, as a result, when protocols are implemented in these areas, the impact on patient care may not be as profound as it could or should be. My team is working to produce quality research that takes this into account and actually conducts the work in areas where cold chain transport isn’t an easy, inexpensive option.

I spent a month in Botswana initiating a protocol to investigate the usefulness of three DBS filter paper cards to evaluate viral loads, and in those failing treatment, the prevalence of HIV drug resistance in pediatric patients on anti-retroviral therapies (ART). As with every protocol, what you dream up sitting in your cubicle, doesn’t always account for the issues you find on the ground during implementation. It took almost two weeks before specimen collection could begin. In the meantime, we amended the protocol to speed up specimen collection and added a collaborator (Baylor Pediatric Clinic). The key to a successful trip to a new country is to be flexible and focus on the unique assets in front of you!

I also assisted in troubleshooting several assays in use at the Ministry of Health and CDC-Botswana labs. The opportunity to do technology transfer and troubleshooting is one of the things I like best about traveling to labs in other countries. Each new lab represents a completely different set of obstacles and challenges, even if those labs are right across the street from each other. On this trip, I was working to transfer a new, more cost-effective in-house HIV drug resistance genotyping test.  I had a great time working together with all of the technicians. We modified the protocols to fit what they had available to them and worked on sequencing analysis. After a couple of days, they felt more confident in their own abilities.

My final job was to visit clinics around Gaborone (the capital) and Francistown (the second largest city) to collect information on ART enrollment for an upcoming protocol with the Ministry of Health. After database issues delayed efforts to collect numbers needed to determine how many clinics should be established in the region, we decided to tackle the problem in a low tech fashion.  With the approval of the Ministry of Health, we spent several days visiting clinics. This gave me a chance to get to know the country a bit better and to interact with nurses, doctors and other community health support staff who work on the front lines of the HIV pandemic.

If we are to have a chance at achieving an AIDS free generation, we must collaborate to build capacity in labs and clinics through training and access to inexpensive specimen collection and testing. This capacity isn’t just useful in far-off, exotic places; everything we do is applicable here at home. During emergencies when power is down for long periods of time — think Katrina or Super Storm Sandy — DBS technology can keep key public health initiatives on track.

I look forward to returning to Botswana to continue working with my colleagues to transfer technology and expand use of DBS.

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