Objectives and goals: The overall objective is to support the UTH pediatric care and treatment program to: perform PCR diagnosis of HIV infected infants; provide pre-assessment service before commencement of ART; perform HIV genotyping to monitor drug resistant viruses; train laboratory personnel and; to develop human resources. This is essential to supporting the scale up of the anti-retroviral program in Zambia.

These goals will be achieved by the following specific aims; several of which are ongoing and one that is new:

1) Continue to perform HIV PCR to diagnose HIV infection in infants born to HIV positive mothers;

2) Perform HIV genotyping analysis on ART treated failure cases for the drug resistant viruses;

3) Continue to train Zambian laboratory personnel on PCR HIV diagnosis and genotyping; and

4) Strengthen UNZA biomedical sciences curriculum through a hybrid training program with the University of Nebraska

Health systems strengthening: In line with WHO recommendations, the Zambian government has recommended ART for all infected infants and Protease Inhibitor based regimes for those exposed to Nevirapine. Infected infants will need to be identified, treated, and tested for the presence of ART resistant viruses at follow up to guide treatment options. Such monitoring will include not only CD4 count but viral load and genotyping for drug resistant viruses, which will guide treatment for FY 2010 and beyond.

Preliminary data, based on tests conducted at UTH and in Nebraska to gauge HIV drug resistance among treatment naïve Zambian adults, provides insight on the magnitude of the emerging resistance problem. Blood samples collected and tested during 2005 from 100 adults, found about 7% prevalence of NRTIs or NNRTIs resistant mutations. Moreover, the T74S polymorphism in the protease gene was about 23% for of treatment naïve individuals. A preliminary/baseline surveillance project carried out during 2000 in Zambia showed no NRTI or NNRTI resistance and only 12.5 percent protease gene polymorphism; this; this alarming increase highlights the urgent need to monitor treated patients.

Key Issues: Efforts in Zambia to diagnose and treat HIV/AIDS remain largely hampered by a lack of infrastructure, resources, and trained personnel. Not only is more physical infrastructure needed (e.g. clinic and lab space, equipment), there are also two key areas that need to be addressed. The first is that additional in-country expertise is necessary, including biomedical scientists with B.Sc. degrees that can enhance the health system workforce. Additionally, the second issue relates to development, adaptation and transfer of technology, so that they can be used in the setting where resource is limited,

Over the past year several key areas have been addressed including: providing laboratory support for pediatric care, transfer and development of infant PCR diagnosis, training of laboratory personnel, and the provision of equipment and supplies necessary to perform PCR diagnosis of HIV-exposed infants, viral load and HIV genotyping for monitoring of drug resistance. Currently, laboratory trained staff are performing all the needed laboratory assays, but at the same time they are providing technical assistance to personnel from other laboratories. They will be trained by personnel sent from Nebraska or be sent to Nebraska for further training as needed. The NIH Fogarty AIDS International Training and Research Program (AITRP) has provided ongoing support for the training of senior leadership and expertise for this activity.

Target Populations: The targeted populations for the program are infants and children at the UTH PCOE where they will be diagnosed, treated and follow-up. While the potential candidates for training and human resource strengthening will be in-country laboratory staff.

Strategy to enhance efficiency: We are anticipating a higher demand of the genotyping tests as more patients are being treated and more drug failure cases will be observed. Cheaper in-house viral load and genotyping tests will need to be developed and adapted to reduce future cost, since these tests are essential for the guidance of clinical care. Technical expertise from this center will support laboratory infrastructure development of other sites in Zambia if needed. Lessons learned from this activity in setting up the various tests will be applied to expanding activities to other sites if needed.

Monitoring and evaluation: There will be established standard operating procedures, documentation, database and instrument calibration procedures and preventive maintenance. Our plan has been daily monitoring by our project director and laboratory manager. There will be internal QC checks and data validation. In addition, there will be a semi-annual evaluation of performance and system audits by US personnel.

Early diagnosis and treatment of HIV infected infants and children are keys to successful pediatric care and support. Infected infants need to be identified, treated, and tested for ART resistant viruses at follow-up to guide treatment for FY 2010 and beyond. In FY 2010, funds will continue to be used to support PCR diagnosis, viral load and genotype for Pediatric Centre of Excellence. Currently five laboratory technicians are trained in PCR technology and engaged in these activities; three of these are also trained in viral load testing and genotyping. Supervision and oversight are provided from the laboratory Manager and Director to ensure daily monitoring and quality assurance. Nebraska budget will continue to support the salaries of three laboratory technicians and the Director of Genotyping is now available for monitoring of treated individuals with clinical and immunological failures. Over 150 cases have been successfully genotyped; results from an additional 100 cases from sentinel surveillance of drug naïve cases throughout the country were obtained, and 7% of these cases are already carrying potential drug resistance viruses. Therefore, we are anticipating a higher demand of the tests as more patients are being treated and more drug failure observed. The laboratory is expected to perform about 500 PCR diagnosis, 80 viral load tests and 20 genotyping per month. It will start seeking accreditation through a recognized international institution.

Much of the limitations on viral load and genotyping are due to reagent costs. Therefore, an additional activity is to adapt in-house viral load and genotyping tests to reduce the costs, increasing the number of tests conducted, especially when there is a continued scale-up of the treatment program and more demand on viral load and genotyping. In addition, technical expertise from this activity will be used to train laboratory personnel from UTH and other facilities (at least 20), and support laboratory infrastructure development of other sites in Zambia. Under this activity Zambians trained in FY 2010 will work with facilities in other provincial hospitals to transfer their knowledge and skills on viral load and resistance monitoring activities so more children can access treatment as well as build sustainable pediatric treatment at the provincial levels such as the Arthur Davison Children's Hospital in Ndola.

The following proposed activity is new for FY 2010, as there is critical shortage of trained human resources, even at the BSc level, such as those with a degree in Biomedical Science to support the HLAB technical area. UNL, UNZA, and UTH have a history of successful training and research collaboration, and through several projects have established considerable in-country research, training projects and infrastructure (these projects and facilities are staffed by former Nebraska Fogarty Program trainees). A total of 35 Zambians have been trained through the Nebraska training program since 2000 (including one trained in Nebraska and at CDC-Atlanta). However, the project team's experience with HIV/AIDS-related work in Zambia indicates there is still a pressing need to increase the number of well-trained healthcare personnel and to build additional infrastructure to support Zambia's response to the HIV/AIDS epidemic. The proposed human resource development program is modeled after the successful Nebraska Fogarty training program. A memorandum of agreement has been established between UNL and the University of Zambia to facilitate Nebraska-Zambia collaboration training and technical assistance projects and can be expanded to include training towards a BSc degree due to the need for a more vigorous curriculum for the degree. The proposal is to provide short-term training of UNZA lecturers at UNL, develop a more vigorous B.Sc. curriculum at UNZA, as well as to select several students from UNZA who have been accepted into the Biomedical Sciences degree program to take the required courses in Nebraska and through distance learning when appropriate, where the students will be awarded the B.Sc. degree by UNZA. This has been endorsed by UNZA and University of Nebraska administrations, and will first select a minimum of 4 students to enroll into such a program in FY 2010. In addition, educational materials, books, and audiovisual items will be purchased as needs arise.