BackgroundIn 2002, the Ministry of Health (MoH) of Botswana began its journey toward laboratory accreditation in an effort to enhance the quality of laboratory services. After a difficult start, the MoH recognised the need for a more practical and sustainable method for change that could be implemented nationally; they therefore adopted the Strengthening Laboratory Management Toward Accreditation (SLMTA) programme.ObjectiveThis study describes the process and lessons learned in implementing SLMTA and the role of supplemental training and mentoring so as to achieve Botswana’s national laboratory quality improvement goal.MethodsEight laboratories were enrolled into the SLMTA programme in 2010, which included a series of workshops and improvement projects conducted over nine months. Four of these laboratories received supplementary training and focused mentorship from the Botswana Bureau of Standards (BOBS). Laboratory performance was measured at baseline and exit using the World Health Organization Regional Office for Africa’s Stepwise Laboratory Quality Improvement Process Towards Accreditation (SLIPTA) checklist. One laboratory did not receive an exit audit and was thus excluded from the analysis.ResultsAn 18 percentage-point improvement was observed when comparing the median baseline score (53%) to the median exit score (71%) for the seven laboratories. Laboratories that received additional training and mentorship from BOBS improved 21 percentage points, whilst non-BOBS-mentored laboratories improved eight percentage points. Hospital management buy-in and strong laboratory staff camaraderie were found to be essential for the positive changes observed.ConclusionSLMTA facilitated improvements in laboratory quality management systems, yielding immediate and measurable results. This study suggests that pairing the SLMTA programme with additional training and mentorship activities may lead to further increases in laboratory performance; and that SLMTA is a practical approach to extending quality improvement to MOH laboratories.

c Dried blood spots (DBS) collected onto filter paper have eased the difficulty of blood collection in resource-limited settings. Currently, Whatman 903 (W-903) filter paper is the only filter paper that has been used for HIV load and HIV drug resistance (HIVDR) testing. We therefore evaluated two additional commercially available filter papers, Ahlstrom grade 226 (A-226) and Munktell TFN (M-TFN), for viral load (VL) testing and HIVDR genotyping using W-903 filter paper as a comparison group. DBS specimens were generated from 344 adult patients on antiretroviral therapy (ART) in Botswana. The VL was measured with NucliSENS EasyQ HIV-1 v2.0, and genotyping was performed for those specimens with a detectable VL (>2.90 log 10 copies/ml) using an in-house method. Bland-Altman analysis revealed a strong concordance in quantitative VL analysis between W-903 and A-226 (bias ‫؍‬ ؊0.034 ؎ 0.246 log 10 copies/ml [mean difference ؎ standard deviation]) and W-903 and M-TFN (bias ‫؍‬ ؊0.028 ؎ 0.186 log 10 copies/ml) filter papers, while qualitative VL analysis for virological failure determination, defined as a VL of >3.00 log 10 copies/ml, showed low sensitivities for A-266 (71.54%) and M-TFN (65.71%) filter papers compared to W-903 filter paper. DBS collected on M-TFN filter paper had the highest genotyping efficiency (100%) compared to W-903 and A-226 filter papers (91.7%) and appeared more sensitive in detecting major HIVDR mutations. DBS collected on A-226 and M-TFN filter papers performed similarly to DBS collected on W-903 filter paper for quantitative VL analysis and HIVDR detection. Together, the encouraging genotyping results and the variability observed in determining virological failure from this small pilot study warrant further investigation of A-226 and M-TFN filter papers as specimen collection devices for HIVDR monitoring surveys. In response to the increased coverage of antiretroviral therapy (ART) in resource-limited settings, the World Health Organization (WHO) has developed a strategy for HIV drug resistance (HIVDR) prevention and assessment (1). This strategy provides guidelines for monitoring the development and transmission of HIVDR variants at the population level by assessing the viral load (VL) and HIVDR genotype of HIV-1-infected patients commencing ART in a prospective cohort (2). Such surveys are essential for maintaining the efficacy of antiretroviral drug regimens within the population in areas where individualized patient monitoring is not available.Plasma is the gold-standard specimen type for HIVDR surveys and the only specimen type that is currently recommended by WHO for monitoring patients on ART (3). Due to the increased cost and logistical challenges of separating and maintaining frozen plasma specimens, several studies investigated alternative specimen types for VL analysis and HIVDR genotyping (reviewed in reference 4). Dried blood spots (DBS) require minimal technical skills to collect and do not require cold-chain transportation (3) and therefore have been the most widely studied a...

As more HIV-infected people gain access to antiretroviral therapy (ART), monitoring HIV drug resistance (HIVDR) becomes essential to combat both acquired and transmitted HIVDR. Studies have demonstrated dried blood spots (DBS) are a suitable alternative in HIVDR monitoring using DBS collected on Whatman 903 (W-903). In this study, we sought to evaluate two other commercially available filter papers, Ahlstrom 226 (A-226) and Munktell TFN (M-TFN), for HIVDR genotyping following ambient temperature storage. DBS were prepared from remnant blood specimens collected from 334 ART patients and stored at ambient temperature for a median time of 30 days. HIV-1 viral load was determined using NucliSENS EasyQ® HIV-1 v2.0 RUO test kits prior to genotyping of the protease and reverse transcriptase regions of the HIV-1 pol gene using an in-house assay. Among the DBS tested, 26 specimens had a viral load ≥1000 copies/mL in all three types of filter paper and were included in the genotyping analysis. Genotyping efficiencies were similar between DBS collected on W-903 (92.3%), A-226 (88.5%), and M-TFN (92.3%) filter papers (P = 1.00). We identified 50 DR-associated mutations in DBS collected on W-903, 33 in DBS collected on A-226, and 48 in DBS collected on M-TFN, resulting in mutation detection sensitivities of 66.0% for A-226 and 88.0% for M-TFN when compared to W-903. Our data indicate that differences among filter papers may exist at this storage condition and warrant further studies evaluating filter paper type for HIVDR monitoring.