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Keywords:

  • human immunodeficiency virus;
  • CD4 lymphocyte count;
  • resource-poor countries;
  • flow cytometry;
  • immunological monitoring;
  • antiretroviral therapy;
  • consumables

Abstract

  1. Top of page
  2. Abstract
  3. HIV/AIDS IN THE CARIBBEAN
  4. POLITICAL AND HISTORICAL CONTEXT
  5. STRATEGIC LABORATORY PLAN
  6. THE WIDER ASPECTS OF HEALTH INTERVENTION PROGRAMS
  7. FUTURE VISION
  8. CONCLUSION
  9. Acknowledgements
  10. LITERATURE CITED

HIV is targeting the developing nations of the world, threatening their economic development, overwhelming public health systems, and depleting human capital. The Caribbean is no exception, with the second highest incidence of HIV/AIDS outside Sub-Saharan Africa, sharing similar mixed fortunes from a postcolonial heritage, limited resources, and an HIV population dispersed in small population centers. Here we share the experience of Barbados, an island state of 280,000 people, in mounting a holistic and sustainable program against HIV/AIDS. At the forefront of this response has been the growth in clinical flow cytometry used for CD4 monitoring, which has prompted a welcome expansion in diagnostic capacity even beyond HIV/AIDS. A pan-Caribbean extension to Barbados' program has been the founding of the Caribbean Cytometry & Analytical Society (CCAS), which acts as a regional forum to accelerate technology transfer and develop the human resources needed to mount an effective response against HIV/AIDS. The 4th CCAS workshop in 2007 produced a consensus statement on the desirable characteristics for a “diagnostic dream machine”: a simple-to-use, rugged flow cytometer capable of carrying out multiple diagnostic functions at the point of patient care in rural or island settings of the developing world, including CD4 count, blood count, and opportunistic infections, without the need for a supply cold-chain or dependable power source. It is our ambitious vision that the spread of flow cytometry, primarily to monitor CD4 in HIV/AIDS, can act as a Trojan horse to deliver better general and specialized diagnostic services to the developing world. © 2008 Clinical Cytometry Society


HIV/AIDS IN THE CARIBBEAN

  1. Top of page
  2. Abstract
  3. HIV/AIDS IN THE CARIBBEAN
  4. POLITICAL AND HISTORICAL CONTEXT
  5. STRATEGIC LABORATORY PLAN
  6. THE WIDER ASPECTS OF HEALTH INTERVENTION PROGRAMS
  7. FUTURE VISION
  8. CONCLUSION
  9. Acknowledgements
  10. LITERATURE CITED

Figures published in the UNAIDS December 2007 AIDS Epidemic Update confirm that the Caribbean is the region hardest hit by the HIV epidemic outside of Sub-Saharan Africa (1). As the HIV/AIDS pandemic enters its 3rd decade it is clear that no country has been left untouched, with the most devastating effects felt in the nations of the third world and particularly Africa where the epidemic is known to have started and has had a longer period to diversify and mature (2). The chilling latest tally published by UNAIDS of 2.1 million deaths globally in 2007 and 33.2 million presently affected is a stark reminder of the task at hand. The average HIV prevalence rate in the Caribbean is 1.0% with a reported range of 0.1% in Cuba to 3.0% in Haiti. The updated UNAIDS data from December 2007 show that there were an estimated 230,000 Persons living with HIV/AIDS (PLWHA) in this region. Of this number by far the largest burden of 153,000 live in Haiti and the Dominican Republic. There are an estimated 3,000 PLWHA in Barbados (3). Based on this data, it is clear that the Caribbean region has a large range of prevalence rates, but significantly some of these rates are rivaling those seen in some African countries.

POLITICAL AND HISTORICAL CONTEXT

  1. Top of page
  2. Abstract
  3. HIV/AIDS IN THE CARIBBEAN
  4. POLITICAL AND HISTORICAL CONTEXT
  5. STRATEGIC LABORATORY PLAN
  6. THE WIDER ASPECTS OF HEALTH INTERVENTION PROGRAMS
  7. FUTURE VISION
  8. CONCLUSION
  9. Acknowledgements
  10. LITERATURE CITED

Health Economics in the Caribbean

The Caribbean on the whole and in keeping with the United Nation General Assembly special session (UNGASS 2001) on HIV/AIDS (4–6), adopted a sense of urgency toward the HIV/AIDS crisis, galvanized primarily by work done at the University of the West Indies Health Economics Unit (HEU) and the experience emanating out of Africa. The mounting evidence showed significant predictable direct economic losses of the order of 5% of the Caribbean territories gross domestic product (GDP) by the year 2005 (4). This works out to a figure of approximately US$ 2 billion per year, which ironically represents the total health expenditure budget of the region using 1997 income versus health expenditure figures. The HEU further estimated that if nothing was done to contain the spread, escalation was inevitable with exponentially increasing economic losses to the region over time. The HEU emphasized that care, support, and treatment of persons living with HIV/AIDS was an indispensable component of prevention. To mount a comprehensive response, UN technical and regional experts conservatively estimated an annual cost of US$ 3.4 billion, but the HEU were concerned that even if this amount was realized, most if not all the country members of the Caribbean did not have the infrastructural and human resource capacity to make use of these allocations at this time. The simplicity of the matter is that caring for persons living with HIV (PLWH) involves much more than simply supplying drugs or building facilities to deliver HAART optimally (5, 6). The Caribbean Country heads of government in July 2001 developed clear objectives for the region as outlined in the Caribbean Cooperation on Health Initiative document two (CCH-II) (7). These declarations called for a fully integrated HIV/AIDS prevention, care and treatment plan into the mainstream development by the year 2003, with the introduction of HAART in a careful and monitored manner to improve adherence and effectiveness with the aim of reducing risk of developing resistance.

The Importance of Political Will

The Government of Barbados (GOB), adopted the CCH-II mandate with vigor and embarked upon an aggressive 5-year expanded program to meet these objectives vested in the National HIV/AIDS Commission. Within this framework the Ministry of Health sought to fulfil its role through a combined prevention and treatment approach based on the Pan American Health Organization (PAHO) building blocks model. The key component to date has been the restructuring and scaling up of the treatment services, building capacity to ensure sustainable systems for the delivery of HAART to all those in need in Barbados free of charge and providing a platform for support to other Caribbean regional countries. Central to this approach is the rational provision of antiretroviral drugs and the close monitoring of the response of patients to treatment, to guide clinical management and ensure successful outcomes. The latter required a major upgrade in laboratory facilities and staff expertise aimed at acquiring the technology to measure parameters of the HIV induced decline of the immune system and response to therapy (8–10). Until recently these measurements had remained in the domain of sophisticated immunophenotyping, molecular biology, and gene sequencing laboratories. This focused activity culminated in the evolution of a National HIV/AIDS referral and treatment center, also known as the Ladymeade HIV/AIDS Reference Unit (LRU), which was commissioned beginning full operations in June 2002 in Barbados. The facility is comprised of a multidisciplinary clinic (for consulting, treatment, and counseling) and a laboratory facility comprised of immunophenotyping and molecular biology suites capable of monitoring CD4 counts, viral load, and HAART resistance profiling of PLWHA after the commencement of treatment. In addition it is designed to conduct basic and applied research, and offer support to the regional Islands in keeping with the principles of Caribbean Cooperation on Health initiatives (7).

STRATEGIC LABORATORY PLAN

  1. Top of page
  2. Abstract
  3. HIV/AIDS IN THE CARIBBEAN
  4. POLITICAL AND HISTORICAL CONTEXT
  5. STRATEGIC LABORATORY PLAN
  6. THE WIDER ASPECTS OF HEALTH INTERVENTION PROGRAMS
  7. FUTURE VISION
  8. CONCLUSION
  9. Acknowledgements
  10. LITERATURE CITED

The Laboratory Task Force

The first step in commissioning the new LRU laboratory was to create a task force with the mandate of formulating the plan and policy of development and implementation of the National HIV laboratory monitoring service. The laboratory's primary goal was to guide the use of HAART as outlined in the guidelines published by the United States DHHS (11). This indicates that initiation of HAART should be guided by carefully monitored laboratory parameters of CD4 T cells and plasma viral load, as well as the clinical condition of the patient. The laboratory parameters are crucial in the decision process on when to treat with HAART in asymptomatic PLWH, and, having commenced HAART, to monitor the ongoing efficacy of the selected regime. With this goal in mind, the responsibility of the Task Force was to formulate the overall HIV national laboratory policy and strategy, design and oversee the infrastructure construction for laboratory physical plant. Other responsibilities were to review current and new laboratory technology options, decide on procurement choices and mechanisms, advise on laboratory training mechanisms and curricula, validate technology on site, establish quality systems, and integrate the laboratory into the project data management system.

Facility Design and Layout

The laboratory facility is a stand alone unit within walking distance of the main national referral center teaching hospital. It is in the vicinity of other medical ancillary facilities, thereby as much as possible ensuring it is an inconspicuous health care provider facility. However and unfortunately this does not remove the possibility of client identification and stigma association. The laboratory is directly adjacent to the clinic and patients are seen at the reception bay with their requests and information immediately recorded in the Laboratory information data system. Venesection is performed in a separate enclosure and samples are then channeled either to the immunophenotyping laboratory or the molecular nucleic acid extraction secure enclosure. Nucleic extraction is carried out in a negative pressure hood with appropriate precaution to avoid contamination and carriage of contamination outside of this enclosure. Real time PCR for HIV viral load is done in the amplification room and assays for HIV genotype resistance profiling are performed in the sequencing suite. As Barbados is located geographically in an equatorial weather pattern system with temperatures known to exceed 30 degrees centigrade on occasion and also potentially in the hurricane belt, the entire laboratory facility is air-conditioned and all major electronic equipment is protected with heavy duty current stabilizers and surge protectors. The entire facility has a stand-by generator.

Equipment Choices and Relationship with Manufacturers

The selection of equipment is crucial to the commissioning of a successful laboratory particularly in a developing world environment. Certain considerations were at the forefront of our decision making process in selecting vendors and manufacturers of equipment. These included favorable reputation gained in the country or region, availability of in-country or regional maintenance facilities with technical personnel, ease of access to a continuous supply of reagents, and open access assay options to incorporate future plans for open source home brew assays. Extensive research was done in these areas to arrive at the choices of equipment suppliers and vendors with lesser considerations given to immediate capital outlay, but rather to the long term sustainability. There are two modalities for entering contract arrangements with equipment suppliers. Conventionally outright equipment purchase with a negotiated maintenance contract over at least 5 years after a 1 year warranty period has been the standard. Advantages of the outright purchase option are cheaper reagent costs and flexibility to use nonproprietary reagents. The disadvantages are initial large capital outlay, eventual obsolescence of equipment, and cost of maintenance after the warranty period has expired. More recently the concept of reagent rental has been gaining rapid popularity. This effectively is a total package equipment placement by the supplier with a negotiated cost per test performed. The reagent rental is convenient but comes with a price. The supplier is responsible for installation and ensuring the smooth running of all the equipment and supplies, but the cost per test will naturally compensate for this convenience in monetary terms, and with this arrangement there is no leverage in reagent choices or technique modification. However, over the long term, the reagent rental agreement although binding in many ways is generally more cost effective (12). A training contract for the staff is included in both packages and should be negotiated to include start up as well as ongoing technology transfer in a spirit of partnership. It is our experience that to ensure smooth operational output of the facility, all major equipment purchased or rented should be ordered in duplicate to provide backup support if there are anticipated time delays in maintenance and service response. An example of this was the decision to purchase two identical flow cytometers. This enabled us to negotiate a substantial discount on the initial purchase price and to negotiate a rebated service contract based on semiurgent call out (since one machine would cover for the other in the event of a malfunction). This has allowed the seamless delivery of CD4 counts for the LRU over the 5 years of its operation to date. Projected assay loads based on country prevalence rates and possibility of processing regionally referred work is essential to help in deciding which technology will be most suitable for the facility in question. Automation is a major consideration when throughput issues are determined, as this will save in the long term on consumables and staff time. A major consideration at the outset should be the adaptability of the platform to perform other diagnostic tests in the future for other specialties in the healthcare service.

Reagent Procurement and Stock Management

Reagent purchase and transportation is a key logistical consideration and clear lines of communication need to be established to ensure there is a smooth transfer of these reagents, which are usually temperature sensitive and will rapidly disintegrate if the cold chain is broken. Stock management in this regard to avoid expiration or lack of reagents is crucial for smooth running of operations. Unfortunately, the cold chain is not infrequently broken and we would reiterate our appeal to manufacturers and suppliers of HIV/AIDS monitoring reagents to develop fluorochromes and shipping formulations that are not cold-chain sensitive.

Human Capital and Resource Training

In the Caribbean as it is in most of the developing world, there is a shortage of laboratory staff with training and skills in the field of flow cytometry and molecular biology, with a great tendency for brain drain to developed countries once they have gained experience. In this regard staff should be selected that have the appropriate background training on which capacity development can take place. Ongoing human resource training and appreciation will create an atmosphere to minimize brain drain. Because of the poverty of expertise in the region allowances should be made for consultants to visit the facility to assist with protocol and strategic development. The program must have built in a definite structure for human resource development both in-country and internationally through training, workshop, and conference participation. To minimize cost of training, several web based training programs and resource sites are available and have been useful to our development.

Validation, Standardization, Proficiency, and Accreditation

Verification, validation, and standardization of assays were commenced at the LRU while the installation and technical team was still on site. It is advisable that in the initial phase of development reagents are supplied by the manufacturer. Verification exercises were performed to establish accuracy, precision, and concurrence with manufacturer's reference ranges. Validation involves comparison of two assay techniques on the same equipment and comparing this to results from other equipment utilizing a different or related technology. This is followed by operational research to determine stability of samples and the ideal anticoagulation medium. From this data, standard operating protocols (SOPs) were developed. Deviation from these SOP is not permitted without evaluating any new techniques. The normal reference range for CD4 counts and diurnal variation patterns were established for our own population in Barbados (13, 14). It is only at this point that the facility should be commissioned to put out results that will guide clinical decisions. Quality assurance is the planned set of activities to ensure confidence in results. This involves quality control (QC), instrument maintenance, proficiency testing, ongoing training of staff, and developing strict SOP. Multiple or new staff, different suppliers of reagents, and multiple instrumentation will introduce imprecision. This was minimized in our setting by ensuring that all staff dedicated rather than rotating from a pool of laboratory scientists. Human error was minimized by bypassing as many manual steps as possible and through vigorous batch standardization exercises. With increasing workload, the laboratory gradually progressed to fully automated systems. QC is the system used to ensure that all operational techniques meet the predetermined requirements. This involves instrument and analyte QC, using supplied control ranges and instrument verification standardization. External QC is the process of ensuring accuracy across multiple laboratories. Our lab is actively involved in the QASI external QC exercise for flow cytometry. Efforts are currently evolving through an European Union funded initiative to strengthen routine medical laboratory services in the Caribbean through various modalities. Of significance is the development of the Caribbean Laboratories Accreditation Services or CLAS, which has a major focus on Quality assurance now, implementing its first phase of QA for routine services (15). However flow cytometry is still considered a specialized service and therefore will be addressed in the next phase of development. To meet this void both Caribbean Regional Epidemiology Centre (CAREC) in Trinidad and the LRU in Barbados have been exploring the possibility of fast tracking this process by establishing regional coordination for either QASI or NEQAS pending the evolution of an indigenous EQA service. Continuous quality improvement should be the aspiration of all labs and this should be adopted as an organizational philosophy, covering preanalytic, analytic, and postanalytic phases of laboratory process. Active feedback from the consumers should be sought through regular management meetings. All of these steps are necessary in the process of approaching the ultimate goal of international accreditation. The choice of single versus dual platform cell counting assays was rationally evaluated by our group and subjected to operational research, logistical, and cost analysis. A study was performed on the three routine hematology analyzers available to us in the main laboratory to select the most appropriate instrument for providing total lymphocyte counts (TLC) should we opt for dual platform analysis. We therefore compared TLCs on 263 treatment naive HIV patients using the three hematology analyzers versus the lymphosum derived by flow cytometry. The lymphosum being the sum of the CD3, CD19, and CD56, representing T lymphocytes, B lymphocytes, and Natural Killer cells enumerated on single platform bead methodology. Our results showed unacceptable discrepancies in TLCs between the three routine hematology analyzers (16). These findings suggested that a dual platform approach would introduce significant margins of error and in conjunction with logistics and cost, a decision was made to adopt the single platform approach, especially with the knowledge that we would be upgrading to automation.

Administration and Red Tape

Most Caribbean civil services still have a laborious system of bureaucratic hurdles that are sufficient to frustrate many well-meaning efforts. The high profile status that the GOB gave the national HIV laboratory project has been of tremendous benefit to the organizing team in facilitating and fast-tracking most circuits, allowing the commissioning of the project in record time. However these potential benefits gained are in danger of being neutralized by new rules and regulations imposed by Funding Agencies. While the need for accountability is paramount, external Funding Agencies should be cognizant of the urgency of the HIV/AIDS crisis and assist the process by implementing administrative procedures that eliminate as much red tape as possible.

Laboratory operations

The laboratory is an integral part of the dedicated HIV reference unit comprising other facets such as the clinical facility, the pharmacy, outreach activity, and voluntary counseling and testing (VCT). The hierarchy of authority is entrenched in the Directors of the Clinical and Laboratory facilities who are answerable to the Senior Medical Officer for infectious diseases within the Ministry of Health and onwards through the Minister of Health directly the Prime Ministers office. There is a dedicated laboratory staff compliment of five supervised by the laboratory director, four of which are laboratory science graduates and one a community nurse/phlebotomist. There are about 1,100 registered HIV patients in the facility seen regularly and 635 of these are on HAART. This patient load generates on average about 4,000 CD4 and 3,000 viral load tests per year. A small additional workload of samples is sent from community physicians in public and private sectors. There is a steady but growing number of cases requiring resistance testing as some patients are now on their 3rd or 4th HAART regimes, and the attending physicians are increasingly requesting laboratory guidance for protocol decisions (Unpublished data). Patients are referred to the laboratory reception area from the clinic where their request forms are entered into the laboratory information system and then phlebotomized accordingly. Sample flow is into one of four channels. The first channel being the immunophenotyping lab for lymphocyte subsets and specifically CD4 counts. This lab has a compliment of two Coulter 4 color EPICS XL with the TQ-Prep and Prep Plus for automated sample preparation (17). The second channel is to the viral load extraction lab and onwards into the real time PCR enclosure where analysis is performed on ROCHE COBAS Amplicor platform recently upgraded to incorporate the automated sample preparation and nucleic acid extraction unit Taqman 48 Ampliprep (18). This channel also caters for qualitative PCR for human papilloma virus (HPV) analysis done on spot urine specimens (19). The third channel is into the gene sequencing molecular laboratory suite where HIV genotyping is currently being developed on the General Electrics Healthcare MegaBace 1000 sequencer (20). The fourth channel is for samples that need to be dispatched to the hospital main laboratory for general hematology, chemistry, or HIV serology testing from walk in VCTs. All samples except immunophenotyping can be prepped and stored at −70°C pending batched analysis. The flow cytometers and the gene sequencers were acquired on an outright purchase basis, while the real time PCR platform is currently on a reagent rental arrangement.

Sustainability

While this initial endeavor by the GOB is to be highly applauded, it should not be taken for granted that the GOB will be able to sustain such a continuous expenditure. Furthermore, not many countries in the region or in the world for that matter have the capacity to rise to a challenge of this magnitude. In this regard urgent research to find alternative and cheaper methods of monitoring without compromising quality, need to be actively embarked upon. Using the gold standard technology now available in Barbados and in the regional referral centers such as CAREC, comparative technological research can be embarked upon with urgency. Operational research looking at cheaper assays for the parameters outlined above have been embarked upon with potential for significant cost reductions. In house research confirmed the accuracy, reliability, and precision of the Panleucogating (PLG) assay (Fig. 1), which allowed us to make an informed decision to move from the standard recommended TetraChrome 4 antibody assay to the 2 antibody PLG platform with significant cost reduction from $25.86 USD per CD4 test to $8.00 USD per test, this cost inclusive of ancillary control reagents (Sippy-Chatrani et al., this issue). The overall operating budget of the laboratory for performing 3400 CD4 enumerations annually was reduced from $119,000 p.a. to $52,500 p.a. following the switch to PLG. The laboratory has gained considerable experience and expertise evaluating smaller platforms, such as the Guava 2 color portable flow cytometer (21, 22) and we have also being instrumental in field evaluation for the PointCARE Now flow cytometer during its instrumental and component design (23). Flow cytometry based surrogate markers for viral load in HIV infection have been on our priority list and we are currently involved in FISH flow study for intracellular CD4 HIV viral analysis on an assay developed by Invirion diagnostics (24), and at the preliminary stages of evaluating a semiquantitative flow cytometry assay for CD38 as a clinically useful marker of activation in HIV infection (Glencross et al., this issue).

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Figure 1. The PanLeucogating (PLG) protocol. (a) A panleucogate was drawn using CD45 fluorescence (FL1) and side scatter to identify leukocytes in HIV infected blood. CD4 staining (FL2) of cells in the PanLeucogate (b) and the lymphocyte gate (c) shows clear separation of CD4 positive T lymphocytes. CD4 counts for this HIV/AIDS patient were 195 cells/μl absolute and 8.7 percent.

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Reagent Home Brews and Generic Analytes

Sustainability is a major concept to grapple with in resource constrained environments. It is without a doubt that the initial set up costs are a barrier to many countries initiating expensive immunophenotyping and molecular facilities, but this is further compounded by expensive reagent kits which run on closed systems. A major component of the kit pricing embraces the costs of Research & Development, resulting in price ranges out of reach of most economies of scale. This is an almost identical scenario with the cost of branded antiretroviral drugs and the recent trend to reduce prices via a plethora of generic manufacturing in the light of global emergencies inclusive of all the legal issues surrounding patenting (25). The opportunities and advocacy for open platform cheaper home brew diagnostic assays coupled with local generic manufacturing of reagents are gaining ground and expanding rapidly. This concept does however require a significant degree of collaboration, transfer of technology and capacity coupled with rigorous QC, and mandatory accreditation. To achieve further sustainability by cost savings the laboratory recently acquired an open real time thermocycler by Applied Biosystems for validation of a home brew viral load assay against the COBAS Amplicor standard, the incentive here being the sustained high cost of viral load assays in the range of $60 to $70 USD for the quantity that we consume per year on a reagent rental contract. Using established open protocols for real time PCR viral load assays, we are collaborating with the AIDS Research Program in Puerto Rico (26) to develop a home brew with significant cost savings aiming for a range of less than $20 USD per test.

Impact of Laboratory on Local and Regional Laboratory Services

Operational research done in this reference unit has been useful in guiding instrument choices made by regional HIV programs in selecting equipment based on our validation and cost analysis. On a more local note, the immense capacity of the laboratory to carry out sophisticated immunophenotyping and molecular laboratory tests has been capitalized on by the other disciplines within the medical routine and research fraternity of Barbados. The laboratory now conducts leukemia/lymphoma immunophenotyping for selected hematology patients and is embarking on other research pilot projects to provide other markers of prognostic importance and response to therapy for clinicians managing serious malignant disease and other infectious disorders. There are plans to establish a stem cell therapy facility in the country which will draw on the depth of infrastructure and capacity acquired over the years. Up to now such patients and their samples were sent at great expense and logistics to facilities in America or Europe.

THE WIDER ASPECTS OF HEALTH INTERVENTION PROGRAMS

  1. Top of page
  2. Abstract
  3. HIV/AIDS IN THE CARIBBEAN
  4. POLITICAL AND HISTORICAL CONTEXT
  5. STRATEGIC LABORATORY PLAN
  6. THE WIDER ASPECTS OF HEALTH INTERVENTION PROGRAMS
  7. FUTURE VISION
  8. CONCLUSION
  9. Acknowledgements
  10. LITERATURE CITED

Effect on Local HIV Demographics and Cost Analysis

Since the commissioning of the dedicated HIV/AIDS laboratory and treatment center, the Ladymeade Reference Unit, in 2002, monitoring and evaluation of the HIV/AIDS epidemic in Barbados has shown a steady decline in AIDS related deaths and conditions requiring hospital admissions (3). There has also been comparable decline of new cases presenting on a yearly basis indicating that there has been a reversal in the upward trend seen in the 1990s. Overall expenditure per year also shows a significant cost saving mainly due to the decline in inpatient management of severe complications of AIDS, which has been directly attributable to the roll-out or HAART therapy. Within 2 years of starting the unit and the roll-out program, there was a 56% decline in AIDS related mortality and a 42% reduction in hospital admissions; thus, already achieving the 5-year target set by the National HIV/AIDS commission at a net and highly gratifying cost of $46 USD per patient per year (3, 27). Other social and legislative framework interventions have been activated in parallel mainly dealing with prevention and stigma discrimination through a multisector approach. The objective is to identify as many cases as possible, reduce the disease burden by active holistic case management and prevent new infections through both counseling of patient groups and public awareness campaigns. The GOB continues to seek ways to reduce this cost and hopefully this will occur when the overall disease burden continues to decline and the investment in infrastructure and human capital is engrafted into mainstream diagnostics.

Building Capacity and Technology Transfer in the Caribbean

HIV is now a recognized international emergency and whatever transcends one continent is invariably going to affect the global community. It is therefore vital that all regions reach the levels of at least minimal capacity that are currently available in the developed world. The scenario of providing these levels of appropriate monitored treatment, which is aimed at complete virological suppression with minimal risk of resistance mutant strain emergence, requires the rapid and comprehensive transfer of technology and personnel development. Such technology can dramatically enhance the standard of quality and delivery of biomedical capacity of developing nations. To accelerate the empowerment of the region, rapid realization of the Caribbean HIV/AIDS regional training initiative (CHART) and other collaborative efforts should gain momentum. Incentives should be developed to retard the tendency for brain drain, as a matter of high priority. Sustained negotiations by the World Health Organization (WHO) and the Clinton HIV AIDS initiative (CHAI) for cost reductions in both pharmaceuticals and lab equipment and reagents should be actively sought and encouraged. The most basic form of equipment training is provided by the manufacturers which must be built into the contract from the outset. Some of this training will take place in house and some will be at training facilities abroad, this training should be completed before the installation of the equipment. Start up training by the vendor is however basically rudimentary and confers the most simplistic of competencies. Training and technology transfer must be an active and a continuous process aimed at developing country and regional capacity comparable to any international reference center. Unlike more developed countries where there are multiple avenues for training, development, and exchange of ideas, a facility of this nature in the developing world is essentially an oasis in the midst of a desert. This was the motivation for setting up the Caribbean Cytometry & Analytical Society (CCAS), of which the authors are founding officers. The CCAS was established with a mandate to accelerate technology transfer and human resource development in the Caribbean, leading to improved diagnostic and clinical care of HIV/AIDS.

The Caribbean Cytometry and Analytical Society

The fore-runner of the CCAS workshops was the Caribbean International HIV/AIDS Workshops, held in 2004 and 2005 in Barbados under the auspices of the Ministry of Health and University of the West Indies. The workshops were convened to meet the urgent need in the Caribbean to expand the technical expertise needed for the fight against HIV/AIDS. The workshops were a great success and provided a unique forum in the Caribbean for regional scientists involved in HIV/AIDS laboratory diagnostics to be trained by international experts in the field in specialist techniques such as flow cytometry and molecular biology. There was tremendous benefit from intense theory and laboratory practical sessions in basic and advanced flow cytometry. An important principle that distinguished these workshops from other laboratory training workshops was that they were vendor neutral. The workshops thus attracted a cross section of smaller pioneering firms in addition to the major diagnostic companies as exhibitors, allowing Caribbean delegates to chose the type of equipment best suited to their setting. The popularity of these workshops led to the birth of “The Caribbean Cytometry & Analytical Society (CCAS)” in 2006, a nonprofit charity founded as a joint venture between Ministry of Health staff at the LRU and staff from the University of the West Indies, Barbados, creating essentially a Caribbean neutral entity that would take on the mantle of workshop logistics and organizing (28). The purpose of forming CCAS was to regionalize the training effort, so that workshops could rotate between Caribbean countries, and to act as a vehicle for fundraising. CCAS also formed critical international links with the Clinical Cytometry Society (CCS) and the European Society for Clinical Cell Analysis (ESCCA). These sister societies have contributed enormously to the workshop syllabus, with leaders in the field acting as the scientific steering committee and delivering expert tuition on the principles of flow cytometry and a range of related topics. The CCS has also offered our members discounted electronic access to the journal “Clinical Cytometry: Part B” and provided two advanced training places annually for Caribbean members to extend their flow cytometry training beyond HIV/AIDS monitoring to other advanced (and costly if outsourced) disciplines, such as leukemia typing; ESSCA provides a similar scheme with one place annually on their training course. The Clinical Cytometry Foundation is also a sponsor of the CCAS workshops. Our international links with the CCS, CCF, and ESSCA have provided the Caribbean with a voice on the international stage and we hope our input will be beneficial not only for developing—but also developed—countries, since much of flow cytometry innovation is being driven by the needs and limited resources of settings like the Caribbean. The 3rd Caribbean International HIV/AIDS workshop was duly held under the CCAS banner in September 2006, again in Barbados; however, nine regional council members were invited onto a CCAS Regional Council during that workshop as a first step toward spreading the organization regionally. Detailed evaluations that year showed that 93% of delegates would recommend the CCAS workshop to their professional colleagues.

The 4th CCAS Caribbean International HIV/AIDS Workshop, Barbados, August 2007

2007 was a year of financial consolidation and refinement of the training model. The workshop now offers a one-stop, vendor-neutral shop for the whole HIV/AIDS healthcare team, from program managers, doctors, nurses, laboratory technicians, and counselors, to learn the full spectrum of HIV disease and treatment: from immunopathology, to emerging technologies, laboratory best practice, principles of antiretroviral therapy, and the corrosive effect of stigma and discrimination on national treatment programs. Attendance was a record 115 delegates from 19 Caribbean countries, including an outstanding speaker faculty of 14 international and 13 regional experts delivering an intense 5 day training syllabus. The Regional CCAS Council was expanded during the 4th CCAS Workshop to 15 Caribbean states and a new host country selected, Suriname, as the inaugural venue for the pan-Caribbean rotation of the workshop beginning in 2008.

FUTURE VISION

  1. Top of page
  2. Abstract
  3. HIV/AIDS IN THE CARIBBEAN
  4. POLITICAL AND HISTORICAL CONTEXT
  5. STRATEGIC LABORATORY PLAN
  6. THE WIDER ASPECTS OF HEALTH INTERVENTION PROGRAMS
  7. FUTURE VISION
  8. CONCLUSION
  9. Acknowledgements
  10. LITERATURE CITED

Brainstorming a “Diagnostic Dream Machine” for the Developing World

One of the highlights of the 4th CCAS workshop was the coming together of a distinguished panel of flow cytometry gurus to brainstorm a futuristic “diagnostic dream machine”: a simple-to-use cytometer that would combine a number of clinically meaningful diagnostic tests onto one platform at the point of patient care in rural or isolated clinics of the developing world. Notable inputs were received from Howard Shapiro, Frank Mandy, George Janossy, Peter Hansen, Mo O'Gorman, Christoph Larsen, Maria Arroz, Ank Gowans, Julia Lizondo, and Roy Overton—all guided through the enthusiastic input and practical experiences of the Caribbean delegates in attendance. Recognizing that two-thirds of all HIV/AIDS patients live in rural or other dispersed population centers, the discussion was based on the need to decentralize CD4 monitoring to enable same-visit HAART therapy in rural settings. A second assumption was that this moment in time represented a unique opportunity to combine the explosive growth in flow cytometry across the globe, driven by the political will to tackle HIV/AIDS, with an amalgamation of multiple diagnostic tests onto one platform to enhance the diagnostic arsenal available in remote parts of the world. Tables 1 and 2 show the result of this brainstorming session, with an itemised wish list of physical, logistical, and diagnostic capacities of such a futuristic flow cytometer. Table 3 itemizes other desirable serologic and biochemical tests that might be incorporated as a separate module of the “dream machine” or available on a separate platform, nonetheless adhering to the same physical and logistical requirements as established in Table 1.

Table 1. Physical and Logistical Requirements of a “Diagnostic Dream Machine”
Simple to use
 • Requiring no training, no pipetting
 • Simply insert blood sample (blood spot/dip stick/vacutainer) and “walk away”
 • Wireless reporting
Rugged
 • Not sensitive to cold/heat/dust/humidity
 • Not requiring a dependable power source
Inexpensive to build and maintain
 • Assembled at sites within the developing world
 • Serviced by local staff
 • Remote systems checks and troubleshooting via VPN
 • “Lego-style” modular construction for easy replacement of defective parts
Not dependent on reagents needing a supply cold-chain
Portable (to fit in the back of a van)
Table 2. A Flow Cytometric “Dream Machine”Relevant to the Developing World
CD4/CD4%
Full blood count and differential
TB, other HIV coinfections
Malaria
Flow cytometric in situ hybridiztion (FISH) for viral infections
 • HIV
 • Hepatitis C
 • CMV
 • HPV
Leukemia/lymphoma typing
Table 3. A Biochemical Module for the “Diagnostic Dream Machine”
Blood biochemistry
 • Na/K/Cl/Bicarb
 • Glucose
 • Lactate
 • Liver enzymes: AST, ALT, GGT
 • Kidney function: creatinine, BUN, urea, electrolytes
Serologic tests for HIV/TB/PCP/Chagas/Kala-Azar/HPV/syphilis/pregnancy
Hematology profile
Lipid profile

The point of the brainstorming session was to provide a strategic vision for the future, unencumbered by practical constraints of what might/might not be considered possible by today's standards. Although some of the hypothetical qualities of the “dream machine” may seem far-fetched, several milestones have already been accomplished. The feasibility of using inexpensive red and green laser-pointers in flow cytometry has been demonstrated (29, 30) and smaller diode or diode-pumped solid state lasers have been incorporated into cytometers by Guava, Partec, and Apogee, making them lighter and more portable (31–33). PointCare has eliminated the laser altogether (it uses a light emitting diode) in a portable hematology/CD4 counter that is fully automated and requires no manual handling or pipetting (34). Partec is using its distribution chain to offer tests for HIV coinfections, TB, and malaria, although these tests are noncytometric (35); however, the principle of cell based testing for TB and malaria has been demonstrated (Shapiro and Perlmutter, this issue). Combined with the power of bead-based suspension array technology (36, 37), flow cytometers in the near future should be capable of delivering a comprehensive diagnostic picture for HIV/AIDS management at the point of patient care, including HIV serology, viral load, CD4 counts, and coinfections.

With the manufacturing base gradually moving out of the US and Europe, flow cytometers in the future are likely to be manufactured in the developing world, making them more affordable and accessible to the bulk of the HIV infected population residing there. Wireless networks are established or growing in most parts of the developing world and the use of such technologies for remote QC, troubleshooting, and inventory control in flow cytometry is likely in the near future (Larsen, this issue).

Despite these remarkable innovations in diagnostic flow cytometry already achieved, with more in the pipeline, it will be important to validate any novel methods against established gold-standards. Such validation studies should be performed within the developing world at established laboratories to ensure that clinical complications and coinfections of patients are reflective of the local environment, as these may differ widely from Western countries. In this way the investigative arsenal available for detecting HIV-related hematological, virological, and bacteriological complications can be gradually extended to peripheral areas via ever-more versatile flow cytometers without any compromise in proper quality assessment.

CONCLUSION

  1. Top of page
  2. Abstract
  3. HIV/AIDS IN THE CARIBBEAN
  4. POLITICAL AND HISTORICAL CONTEXT
  5. STRATEGIC LABORATORY PLAN
  6. THE WIDER ASPECTS OF HEALTH INTERVENTION PROGRAMS
  7. FUTURE VISION
  8. CONCLUSION
  9. Acknowledgements
  10. LITERATURE CITED

The most radical innovations in flow cytometry during the past decade have arguably been prompted by the need to tackle the HIV/AIDS epidemic in the developing world. Our vision is that the expanded capacity and capability of flow cytometers to conduct CD4 tests in the developing world will prove to be the silver lining in the cloud of AIDS and that flow cytometers may become the Trojan horse to deliver improved diagnostic services universally.

Acknowledgements

  1. Top of page
  2. Abstract
  3. HIV/AIDS IN THE CARIBBEAN
  4. POLITICAL AND HISTORICAL CONTEXT
  5. STRATEGIC LABORATORY PLAN
  6. THE WIDER ASPECTS OF HEALTH INTERVENTION PROGRAMS
  7. FUTURE VISION
  8. CONCLUSION
  9. Acknowledgements
  10. LITERATURE CITED

We acknowledge Dr. Frank Rosenbloom for his insight into useful diagnostic tests needed in the developing world. We gratefully acknowledge the support received in running the CCAS Caribbean International HIV/AIDS Workshops from: The Government of Barbados, University of the West Indies, National HIV/AIDS Commission of Barbados, The Clinical Cytometry Foundation, philanthropic donations from David Singh (Destiny Group of Companies), The Centers for Disease Control, Caribbean Regional Epidemiology Centre, Caribbean MedLabs Strengthening Program, Canada Fund for Local Initiatives, Caribbean HIV/AIDS Regional Training network, and the Barbados Tourism Authority.

LITERATURE CITED

  1. Top of page
  2. Abstract
  3. HIV/AIDS IN THE CARIBBEAN
  4. POLITICAL AND HISTORICAL CONTEXT
  5. STRATEGIC LABORATORY PLAN
  6. THE WIDER ASPECTS OF HEALTH INTERVENTION PROGRAMS
  7. FUTURE VISION
  8. CONCLUSION
  9. Acknowledgements
  10. LITERATURE CITED