Role of public-private partnerships in achieving UNAIDS HIV treatment targets

Abstract

Background
Despite progress towards achieving UNAIDS 90–90-90 goals, barriers persist in laboratory systems in sub-Saharan Africa (SSA) restricting scale up of early infant diagnosis (EID) and viral load (VL) test monitoring of patients on antiretroviral therapy. If these facilities and system challenges persist, they may undermine recorded gains and appropriate management of patients. The aim of this review is to identify Public Private Partnerships (PPP) in SSA that have resolved systemic barriers within the VL and EID treatment cascade and demonstrated impact in the scale up of VL and EID.

Methods
We queried five HIV and TB laboratory databases from 2007 to 2017 for studies related to laboratory system strengthening and PPP. We identified, screened and included PPPs that demonstrated evidence in alleviating known system level barriers to scale up national VL and EID testing programs. PPPs that improved associated systems from the point of viral load test request to the use of the test result for patient management were deemed eligible.

Results
We identified six PPPs collaborations with multiple activities in select countries that are contributing to address challenges to scale up national viral load programs. One of the six PPPs reached 14.5 million patients in remote communities and transported up to 400,000 specimens in a year. Another PPP enabled an unprecedented 94% of specimens to reach national laboratory through improved sample referral network and enabled a cost savings of 62%. Also PPPs reduced cost of reagents and enabled 300,000 tested infants to be enrolled in care as well as reduced turnaround time of reporting results by 50%.

Conclusions
Our review identified the benefits, enabling factors, and associated challenges for public and private sectors to engage in PPPs. PPP contributions to laboratory systems strengthening are a model and present opportunities that can be leveraged to strengthen systems to achieve the UNAIDS 90–90-90 treatment targets for HIV/AIDS. Despite growing emphasis on engaging the private sector as a critical partner to address global disease burden, PPPs that specifically strengthen laboratories, the cornerstone of public health programs, remain largely untapped.

Full text

R E S E A R C H A R T I C L E Open Access
Role of public-private partnerships in
achieving UNAIDS HIV treatment targets
Ritu Shrivastava
1
, Peter N. Fonjungo
1*
, Yenew Kebede
2
, Rajendra Bhimaraj
3
, Shabnam Zavahir
3
, Christina Mwangi
4
,
Renuka Gadde
5
, Heather Alexander
1
, Patricia L. Riley
1
, Andrea Kim
1
and John N. Nkengasong
6
Abstract
Background: Despite progress towards achieving UNAIDS 90–90-90 goals, barriers persist in laboratory systems in
sub-Saharan Africa (SSA) restricting scale up of early infant diagnosis (EID) and viral load (VL) test monitoring of
patients on antiretroviral therapy. If these facilities and system challenges persist, they may undermine recorded
gains and appropriate management of patients. The aim of this review is to identify Public Private Partnerships
(PPP) in SSA that have resolved systemic barriers within the VL and EID treatment cascade and demonstrated
impact in the scale up of VL and EID.
Methods: We queried five HIV and TB laboratory databases from 2007 to 2017 for studies related to laboratory
system strengthening and PPP. We identified, screened and included PPPs that demonstrated evidence in
alleviating known system level barriers to scale up national VL and EID testing programs. PPPs that improved
associated systems from the point of viral load test request to the use of the test result for patient management
were deemed eligible.
Results: We identified six PPPs collaborations with multiple activities in select countries that are contributing to
address challenges to scale up national viral load programs. One of the six PPPs reached 14.5 million patients in
remote communities and transported up to 400,000 specimens in a year. Another PPP enabled an unprecedented
94% of specimens to reach national laboratory through improved sample referral network and enabled a cost
savings of 62%. Also PPPs reduced cost of reagents and enabled 300,000 tested infants to be enrolled in care as
well as reduced turnaround time of reporting results by 50%.
Conclusions: Our review identified the benefits, enabling factors, and associated challenges for public and private
sectors to engage in PPPs. PPP contributions to laboratory systems strengthening are a model and present
opportunities that can be leveraged to strengthen systems to achieve the UNAIDS 90–90-90 treatment targets for
HIV/AIDS. Despite growing emphasis on engaging the private sector as a critical partner to address global disease
burden, PPPs that specifically strengthen laboratories, the cornerstone of public health programs, remain largely
untapped.
Keywords: Public-private partnership, Viral load, Early infant diagnosis, Laboratory systems strengthening, Cascade
* Correspondence: pdf4@cdc.gov
1
International Laboratory Branch, Division of Global HIV/AIDS, Center for
Global Health, Centers for Disease Control and Prevention, 1600 Clifton Road
NE, Atlanta, GA 30333, USA
Full list of author information is available at the end of the article
© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Shrivastava et al. BMC Health Services Research (2019) 19:46
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Background
The Joint United Nations Programme on HIV/AIDS
(UNAIDS) fast track treatment targets call for 90% of
people living with HIV infection to know their status;
90% of those who know their status to receive antiretro-
viral therapy (ART); and 90% of those on ART to
achieve viral suppression by 2020 [1]. Despite significant
progress towards controlling the HIV/AIDS pandemic
[2], these new targets have overwhelmed many public
health laboratory systems in sub-Saharan Africa (SSA)
due to increased demand for early Infant diagnostic
(EID) testing of HIV-exposed infants (HEI) and viral
load (VL) test monitoring of patients on ART [3]. The
VL and EID cascade is characterized by phases from the
point of test request to the use of the test results for pa-
tient management. There are three phases and include
the pre-analytical phase defined as the period from col-
lection of specimens at the referral clinic to receipt of
specimens in the laboratory (includes demand creation
for testing from care providers and patients, specimen
collection and processing, specimen transport system),
the analytical phase defined as the period from testing of
specimens to obtaining results at the laboratory (in-
cludes quality laboratory testing and supply chain man-
agement for test reagents and supplies), and the
post-analytical phase which entails results transmission
from laboratory to receipt of results at the referral clinic
and use for patient management (comprised of result
reporting to clinics, interpretation and uptake for patient
management). Monitoring and evaluation (M&E) is
cross-cutting through the different phases and allows
monitoring of progress of these phases.
Multiple barriers within the VL and EID cascade pre-
vent optimal access and uptake of test results for better
patient management. In the pre-analytical phase, these
barriers include lack of patient awareness for available
HIV test; non-standardized specimen collection prac-
tices, and weak specimen referral networks [4]. In the
analytical phase, challenges include frequent equipment
breakdown, weak supply chain systems, and unsafe bio-
logical waste management. In the post analytical phase,
the challenges experienced comprise delayed and incon-
sistent delivery of test results, limited data systems for
reporting results, and poor clinician utilization of labora-
tory results for improved patient management. There is
also a dearth of adequate numbers of competent work-
force along all phases of the cascade [4–6].
In 2009 leaders of the US Government’s global AIDS
program stated that “The problems we face today will be
solved not by governments alone but in partnerships;
partnerships with philanthropy, global business and civil
societies”[2]. While global PPPs that have improved
public health programs such as Global Fund, Foundation
for Innovative New Diagnostics, and the Global Alliance
for Vaccines and Immunizations (GAVI), have been
around for decades [7], PPPs that specifically target the
advancement of laboratories, an indispensable compo-
nent of these programs, are rare. The gap persist despite
the increasing emphasis on engaging the private sector
as a critical partner to improve services and systems to
address diseases that are threats to public health [8–
11]. One of the reasons for engagement of fewer than
anticipated private entities could be the paucity of em-
pirical data and strategies for effective private sector
engagement [12].
Studies suggests that the influx of donor funding has
led to decreased private contributions for HIV/AIDS.
The reduction in private sector investment and engage-
ment raises concerns about the sustainability of HIV/
AIDS programs, particularly in light of the current glo-
bal economic crisis and emerging competing priorities
[13]. There exist opportunities for partnerships to
strengthen systems in the VL and EID cascade and ad-
dress gaps to accelerate achieving the UNAIDS 90–
90-90 goals. SSA countries are at different stages of scal-
ing up VL and EID and have varying challenges [5].
Partnerships, especially PPP can play an important role
in resolving system barriers affecting VL and EID. In this
review, we identify and provide a description of PPPs in
SSA that have been used to resolve systemic barriers
within the cascade and demonstrated its impact in the
scale up of VL and EID.
Methods
Data sources and search strategy
We queried five HIV and TB laboratory databases
(Medline, Embase, CINAHL, Global Health, Scopus)
from 2007 to 2017, with an aim to identify
public-private partnerships focused on laboratory sys-
tem strengthening. We used search terms Public
-Private Sector Partnerships, private public partnership,
public private partnership, laboratory or specimen
handling, specimen transport, specimen referral, sample
transport, laboratory quality management, laboratory
worker or laboratory technician. Only articles published
in English were included.
Selection criteria
We used barriers to scale up VL and EID testing cascade
(Fig. 1) as criteria to guide the selection of PPPs in our
review. Records of PPPs that were operational in SSA
and had successfully implemented interventions to im-
prove systems for demand creation for tests, specimen
collection and transportation, laboratory testing, report-
ing laboratory results to clinics were deemed eligible.
A wide spectrum of private sector engagement options
exist for delivery of public health programs [14,15].
PEPFAR defines PPPs as a ‘collaborative endeavors that
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combines monetary and in-kind resources from the pub-
lic and private sector to accomplish PEPFAR’sHIV/
AIDS prevention, care, and treatment goals’[16]. All
forms of PPP engagements were included in the identifi-
cation step (Fig. 2).
Outcomes of interest and data abstraction strategy
Our search yielded 375 records in EndNoteX7 library,
and eight from non-peer reviewed sources bringing our
total to 383 records (Fig. 2). Using Endnote’s“find dupli-
cates”function we removed 128 duplicates. We system-
atically assessed each record by evaluating the following
broad questions: 1) Was there a clear study objective
that addressed barriers to scale up VL and EID testing in
record? 2) Did the study use the right methods to ad-
dress the study objective? 3) Are the results of the study
valid? 4) Are the results applicable to my population of
interest? Of the 255 remaining articles, 225 records were
removed because of their focus on non-healthcare PPPs.
We tabulated characteristics of the remaining 30 PPPs
by ability of the PPP to address barriers in the various
phases of VL and EID cascade, country of operation,
name of PPP, start year, intervention type, impact and
source using MS Office Excel spreadsheet. Eleven of the
30 abstracts unrelated to laboratory system strengthen-
ing were excluded and leaving 19 full text articles for
review. Thirteen of the 19 articles provided valuable in-
sights into various modes and interpretations of oper-
ationalizing PPPs, benefits and challenges, enabling
factors, reasons for dearth of PPPs in global health care.
We referenced these 13 articles in introduction and
other sections in the manuscript. Six PPP records that
met the eligibility criteria were reviewed and analyzed.
Results
Pioneering PPPs focused on laboratory system
strengthening
Five of the six eligible PPPs have an international scope
and the other one is an example of a local PPP. Three of
the six PPPs have partnerships with the President’s
Emergency Plan for AIDS Relief (PEPFAR) program and
the other two are independent of PEPFAR (Table 1).
Memoranda of Understanding (MOUs) were signed
between PEPFAR and three private companies to focus
on strengthening laboratory networks and systems to
support ART scale up. The MOUs were signed between
the US Centers for Disease Control and Prevention
(CDC), Office of Global AIDS Coordinator—PEPFAR
implementing office and three private companies: Bec-
ton Dickinson and Company (BD) [17]; Roche Diagnos-
tics [18] and Siemens Healthineers [19] for $18, $10 and
$15 million, respectively, in shared resources. In 2012,
Fig. 1 Schematic representation depicting different elements of the viral load and early infant diagnosis cascade (Square boxes within the arrow). The
3 major phases (pre-analytical, analytical, post-analytical) of the cascade are delineated within the arrow. Barriers within the different phases of the
cascade are identified above the arrow (dotted line boxes). Public-private partnerships (PPPs) addressing different barrier and at what phase of the
cascade have been identified below the arrow (solid line boxes). Pre-analytical phase defined as the period from collection of specimens at the referral
clinic to receipt of specimens in the laboratory; the analytical phase defined as the period from testing of specimens to obtaining results at the
laboratory and the post-analytical phase entails results transmission from laboratory to receipt of results at the referral clinic and use for patient
management. Siemens =PEPFAR is Stronger Together PPP; Turn Key laboratories =PPP between UNITAID, Roche Diagnostics and Clinton Foundation;
Labs for Life= PPP between Becton Dickinson and Company and PEPFAR; Roche = PEPFAR's PPP with Roche Diagnostics
Shrivastava et al. BMC Health Services Research (2019) 19:46 Page 3 of 10
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BD and PEPFAR renamed the partnership, Labs for Life,
and renewed it for $20 (2012–2017) and $12 (2018–
2020) million, respectively.
i). Labs for Life (L4L) strengthened access to ART by
building standardized in-country capacity for speci-
men collection, referral and result reporting sys-
tems. With operations in Uganda, Ethiopia,
Mozambique, South Africa, Kenya and India, BD
deployed experts to provide in-country training
(Fig. 1and Table 1).
ii). Roche has three PPPs designated for the VL and
EID programs. In 2008, only 15% of HEI in SSA
were accessing EID services during the first two
months of life [20]. Roche Diagnostics responded
to this critical service gap with a PPP agreement
with UNITAID and the Clinton HIV/AIDS
Initiative (CHAI). Roche provided molecular
diagnostics supplies and set up ‘Turn Key
Laboratories’, to provide timely HIV testing for
the pediatric population [20]. In 2012, Roche and
PEPFAR partnered to create capacity for a well-
trained laboratory cadre offering didactic courses
at the Roche Scientific Campus (RSC) in Johan-
nesburg, South Africa. In 2014, Roche signed an-
other landmark PPP, known as the Global Access
Program, which negotiated and lowered the price
of VL tests in low- and middle-income countries
(Fig. 1and Table 1).
iii). Stronger Together is a five-year PPP that was
signed in 2014 between PEPFAR and Siemens
Healthineers, the new brand name of Siemens
Healthcare company. The goal of ‘Stronger To-
gether’was to develop a competent laboratory
workforce globally through a virtual education
platform on social media [21].
iv). Abbott Fund, a global healthcare company,
demonstrated a unique example of a locally
operated PPP in Tanzania in response to the
growing HIV epidemic to rapidly scale up HIV care
and treatment activities. In 2001, Ministry of
Health and Social Welfare (MOHSW) signed a
PPP with Abbott Fund for expanded access to
health care and to strengthen laboratory
infrastructure [22] and system capacity (Fig. 1
and Table 1).
v). Riders for Health PPP was established 25 years ago
in the United Kingdom, and continues now to be
managed out of Africa [15] to address lack of access
to health care among residents in remote
communities in seven countries. Riders for Health
managed a fleet of 1300 motor cycles and a variety
of four wheeled vehicles in harsh conditions with
little infrastructure to connect vital health care with
Fig. 2 PRISMA flow diagram outlining the different stages of literature review search and selection of Public-Private Partnerships (PPP) in
laboratory systems strengthening
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Table 1 Summary of Public-Private Partnerships (PPPs) (2007–2017) that address barriers and strengthen laboratory systems in
resource-limited settings to improve access, coverage, quality and utilization of Viral Load and Early Infant Diagnosis testing
Cascade
phase
Barrier Country PPP PPP Intervention Impact Source
Pre-
analytical
Phase
Poor and non-
standardized
specimen
collection
procedures.
Kenya L4L •Trained 91 HCW
on safe phlebotomy
collection practices.
•Increased
knowledge of
phlebotomists
by 41%.
•Integration of
safe phlebotomy
practices into
pre-service training.
Kimani
et.al., [26]
Weak supply chain
and unreliable
specimen
transportation
system.
Gambia,
Kenya,
Lesotho,
Malawi,
Nigeria,
Zambia,
Zimbabwe.
Riders for
Health
•Accessed hard-to-
reach communities
for healthcare needs
by providing
motorcycles for
transportation.
•Trained healthcare
workers on
managing supply
chain distribution
of medicines,
transportation
of specimens
and return of
results and
managed emergency
referrals.
•Improved access
to 14.5 million people
to healthcare.
•Transported 400, 000
specimens/year
between laboratory and
healthcare facilities.
WHO [23,
28]
World Bank
[15]
Weak specimen
transportation system.
Uganda L4L •Use of GIS to map
efficient sample
referral network.
•Provided standardized
specimen transportation
materials.
•Training of transporters
to safely package
and transport
specimens.
•Ten-fold increase in
referrals of patients
sample with presum
ptive MDR-TB.
•94% specimens reached
the national laboratory
within the established
target time of 72 h.
Joloba et al., [27]
Analytical
Phase
Lack of skilled
workforce, modern
laboratory infrastructure
to provide timely and
accurate services to
patients.
SSA Global
Access
Program
•Engaged manufacturer and
negotiated lower prices for
HIV VL and EID reagents.
•300, 000 infants enrolled
into care and treatment.
•Provided 900,000 tests
for EID.
•–Projected anticipated
cost savings of $150
million in next 5 years.
Roche Diagnostics
[20]
SSA Turn Key
Laboratory
•Set up‘Turn Key Laboratory’
for access to pediatric testing.
•900,000 tests were
made available.
•100 laboratories in
SSA now routinely
offer PCR for EID.
Roche Diagnostics
[20]
Mozambique L4L •Establishment of national
laboratory quality assurance
program to facilitate stepwise
quality improvement of
laboratory services.
•Trained and mentorship
resulted in 18 MOH
qualified auditors and
28 manager/quality
officers capacitated to
manage improvements
of laboratories and
steer towards accreditation.
Skaggs et al., [29]
Tanzania Abbott
Fund
•Built and modernized 23
regional-level laboratories,
•Built outpatient center at
the national hospital serving
1000 patients/day.
•Provided mentorship.
•10 fold increase (from
110,000 to 1,158,000)
in test volumes in 5 years.
•Improved healthcare
services for people
living with HIV and other
chronic diseases across
the country.
Abbott Fund [25]
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rural areas hitherto unreachable except on foot
[23].
vi). Phones for Health PPP was initiated in 2007 with
operations in countries including Kenya, Tanzania,
and Rwanda, leveraging over $3 million annually
[24]. Utilizing mobile phone technologies or
mHealth as tools and platforms for health research
and healthcare delivery [25]. It is a PPP between the
health care software provider Voxiva, the phone
producer Motorola, the telecom company MTN,
the GSMA Development Fund, PEPFAR, CDC
Foundation and Accenture Development
Partnerships.
Impact of PPPs addressing barriers to scale up HIV viral
load and early infant diagnostic testing
Taken together, the collective contributions of the six
eligible PPPs have impacted a cost savings of 62%, in-
creased access to 14.5 million patients to healthcare,
transported 400,000 specimens/year, tested 300,000 add-
itional HEI, reduced turnaround time of reporting re-
sults by 50%. The specific contributions of the six PPPs
within the pre-analytical, analytical and post analytical
phases of the VL and EID cascade are highlighted below
(Fig. 1and Table 1).
A. Pre-analytical phase
i). Demand creation for testing: In 2014, when
Global Access Program lowered the price of VL
testing by 40% thereby increasing its affordability
and availability, it was projected that this PPP will
save more than $150 million in costs over the next
5 years [20].
ii). Specimen collection and processing: L4L PPP
made significant progress in improving blood draw
practices by developing and institutionalized a
curriculum for phlebotomists to standardize safe
blood-drawing procedures in Kenya. Following the
initial curriculum training, the average knowledge
increase was 41% for phlebotomists [26], which they
went on to apply in their practices.
Table 1 Summary of Public-Private Partnerships (PPPs) (2007–2017) that address barriers and strengthen laboratory systems in
resource-limited settings to improve access, coverage, quality and utilization of Viral Load and Early Infant Diagnosis testing
(Continued)
Cascade
phase
Barrier Country PPP PPP Intervention Impact Source
Post -
analytical
phase
Delayed and
inconsistent
delivery of VL
and EID test
results to
patients.
Ethiopia L4L •Used GIS to map and
network 554 clinic facilities
to laboratories testing for VL,
EID, CD4 and hematology.
•Procured 400 standard
specimen transportation
containers.
•Trained 586 and 81
laboratory and
postal workers,
respectively.
•50% reduction in
TAT (from
specimen collection
to reporting
results) for ART
patients (10 to 5
days).
•Standardized training
module used for
training in all
the regions
•62% in cost savings for
transporting EID
specimens.
•Reduced TAT from
1 to 2 months
to 5–10 days.
Kebede et al., [32]
Kiyaga et al. [6]
Kenya,
Tanzania
and Rwanda
Phones
for Health
•Allowed input
of health data
and transfer to
central database.
•Enabled ordering
medicines,
sending alerts and
download of guidelines.
•Enabled access to
training materials.
•Facilitated transmission
of results to SMS
printers.
•Improved access
to knowledge and
information of 50,000
community health workers.
•Reduced TAT
for results delivery
•Effective monitoring
of mother-to-child
transmission through
EID systems rolled
out to 63 sites
nationally.
UNAIDS [25],
Fogarty [24]
a = Labs fo r Life;
Abbreviations: L4L Labs for Life, HCW healthcare workers, GIS geographic information system, MDR-TB multidrug resistant tuberculosis, PC R polymerase chain
reaction, SSA sub Saharan Africa, VL viral load, EID early infant diagnosis, ART antiretroviral therapy, MOH ministry of health, TAT turnaround time, WHO World
Health Organization, CD4 cluster of differentiation 4, SMS short message service
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iii). Specimen transport system: In 2007, Uganda’s
effort to control the spread of the deadly
Multidrug-Resistant Tuberculosis (MDR-TB) was
severely limited by weak laboratory network
coupled with inadequate specimen referral and re-
sult reporting system. L4L PPP collaborated with
Ugandan Ministry of Health (MOH), CDC and
local partners to use geographic information system
(GIS) technology to map and strengthen a national
specimen referral system [27]. This resulted in 94%
of specimens reaching the national laboratory
within the established target time of 72 h. This
model later served as the cornerstone for the EID
specimen transportation and result reporting system
and generated a cost savings of 62% and reduced
average turnaround time from 1 to 2 months to 5–
10 days [6]. Riders for Health transported 400,000
blood and sputum samples between laboratories
and health centers every year and improved access
to healthcare for 14.5 million people in Gambia,
Kenya, Lesotho, Malawi, Nigeria, Zambia,
Zimbabwe [15,28].
B. Analytical phase
i). Laboratory testing: Roche’s PPP for “Turn Key
Laboratory”introduced a paradigm shift for
expanding laboratory services for pediatric HIV
patients resulting in 900,000 tests being made
available, an increase of 300,000 infants enrolled
into care and treatment, and Polymerase Chain
Reaction (PCR) testing being routinely provided in
more than 100 laboratories [20].
ii). L4L PPP has also played a significant role in
strengthening Continuous Quality Improvement
(CQI) of laboratories in several SSA countries
including Mozambique, Kenya, Ethiopia, India. In a
joint collaboration, L4L helped MOH Mozambique
program by providing training and mentorship that
resulted in 18 MOH qualified auditors and 28
manager/quality officers capacitated to establish a
national laboratory quality assurance program [29].
iii). In collaboration with CDC Tanzania and partners
such as Design 4 Others and the Association of
Public Health Laboratories, the Abbott Fund’s
PPP contributed $10 million to building and
strengthening a network of 23 regional-level la-
boratories in Tanzania [25]. These laboratories
provided support for 120 district hospital labora-
tories resulting in improved healthcare services.
Abbott Fund provided mentoring, technical sup-
port, and expertise in the areas of construction,
engineering, infection control, waste management,
information technology, and laboratory manage-
ment [30]. This PPP also built a modern out-
patientcenterattheMuhimbiliNationalHospital
serving over 1000 patients a day for HIV and
non-communicable ailments and the system
strengthening efforts increased by 10 fold labora-
tory tests volumes [31].
C. Post analytical phase
i). Result reporting and interpretation by
clinicians: From 2010 to 2012, L4L, MOH and
CDC partnership in Ethiopia reduced the
turnaround time of laboratory patient results by
50% from 10 to 5 days [32] in 554 (59%) of the 944
districts. The program has demonstrated sustainable
expansion covering 800 (85%) of the 944 districts as
of 2017 and transports specimens for CD4, EID,
chemistry, hematology and TB tests, independent of
the PPP.
ii). Phones for Health PPP enabled health workers to
input health data and transfer them to a central
database, order medicines, send alerts, download
guidelines, and access training materials. In
Rwanda, it empowered practitioners to monitor
antiretroviral drug stocks in real time, and
accelerated the return of CD4 and viral load test
results to remote facilities. In September 2012, 252
of the 457 health facilities were using the electronic
system (> 50% of coverage) [33]. Kenya and other
countries have used the mhealth technology to
transmit laboratory results to mobile phones which
are sent to SMS printers in referring clinics to
utilize for patient management [24,25,34–36].
Discussions
Opportunities for PPPs to scale up HIV viral load and
early infant diagnostic testing
Globally, as of 2016, 70% of people living with HIV
(PLHIV) were diagnosed, 77% of those were on ART,
and 82% of those were virally suppressed [37]. This find-
ing highlights the need for additional synergistic partner-
ships to close the gap in HIV testing, treatment, and
viral suppression. Since 2006, the U.S. has been engaged
in nearly 300 partnerships, which have yielded nearly
$400 million in private sector investment and $335 mil-
lion in funding from PEPFAR [38]. More PPP are needed
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with a focus to strengthen laboratory systems and net-
works. There are still challenges, for instance, access to
testing, return of laboratory test results to patients, en-
suring quality of testing, develop a cadre of trained
workforce, and present opportunities for collaborations
to increase efficiencies. PPPs can play a key role in ad-
dressing some of these challenges.
a). Uptake of VL and EID test results: To close the
knowledge gap of clinicians (e.g., nurses, midwives,
clinical officers, medical doctors) for the uptake of
viral load test results [39], members of African
Regional Collaborative for Laboratory Technologists
collaborated with Roche-PEPFAR PPP and provided
VL training to nurse leaders from 17 countries in
SSA. The training emphasized the role of nurses in
initiating request for VL testing and utilizing VL test
results for patient management in ART clinics [40].
b). Safe and standardized specimen collection
process: Phlebotomy-related errors account for >
60% of errors in the pre-analytical phase [41] and
can lead to delayed or incorrect results, with unjus-
tifiable costs to patient. Roche-PEPFAR PPP collab-
orated with the US CDC to develop an online
training tool to standardize specimen collection
procedures using an alternate specimen type - dried
blood spots (DBS), to improve access to viral load
testing. The training is accessible at the African So-
ciety for Laboratory Medicine (ASLM) portal in
English, French and Portuguese [42].
c). Quality assured test results to clients:
Strengthening the tiered laboratory network in a
country to expand and ensure access to reliable,
high-quality VL and EID testing services is critical
[39]. US CDC developed a CQI program and
Roche-PEPFAR PPP continue to offer the CQI pro-
gram in its campus in Johannesburg. Average pre-
test scores in five courses for 94 students from 22
countries rose from 12 to 88% (personal communi-
cation, facilitator Anna Murphy, affiliation ASLM).
To develop a sustainable, cost-effective solution for
wider dissemination, Stronger Together PPP repli-
cated the two week long didactic curriculum into
an e-library of 48 training videos, available free of
cost through an innovative e-platform [43]. This ap-
proach has caught the interest of MOH in several
African countries and can also be used to deploy
training materials in any area including VL and
EID.
d). Specimen transport and result reporting system:
Innovative strategies such as unmanned aerial
vehicles to pick up specimens and deliver results
within Switzerland (Matternet company) [44] and
in Rwanda and Tanzania (Zipline company) [45] are
examples of technology for use in improving
laboratory-clinic interface. These innovations could
be leveraged to improve delivery of VL and EID re-
sults in similar contexts.
Other unmet needs in the VL cascade represent op-
portunities for new partnerships. The needs are inad-
equate and competent workforce, unsafe disposal of
hazardous waste materials generated due to increased
volume of testing, equipment maintenance, limited data
management options to improve laboratory-clinic inter-
face (Fig. 1).
Benefits of PPP to private and public sector
PPPs provided an avenue for private entities to gain ac-
cess and improved understanding of government’s pol-
icies and strategies, which can increase market
knowledge and awareness of national priorities. By en-
gaging in PPPs, the private sector can also benefit the
local workforce by providing increased access to re-
sources; introducing new goods and services; sharing
product/service risks and investments [7], identifying
and increasing local expertise; institutionalizing inter-
ventions; and build sustainable laboratory networks with
regard to public-supported laboratories [32]. From the
public sector perspective, effective PPPs provide add-
itional capabilities, flexibility, skills, resources and fund-
ing, which enhance their ability to respond to the
demands for increased services or scale-up programs of
national importance. Furthermore, at the country-level,
PPP’s collaboration can empower countries to mobilize
funds and direct them towards highest priority activities;
facilitate research and development; and improve afford-
able healthcare interventions [12].
Strengths and limitations
This review successfully identified PPPs that have con-
tributed to achieving UNAIDS 90–90-90 treatment
goals. While most of the PPP were international, we ob-
served the important role played by local indigenous
PPP and further highlighting the important contribution
of PPPs. We are cognizant of the small number of pub-
lished studies highlighting PPP in laboratory system
strengthening. Nonetheless, their impact remains un-
questionable and underscore the need for more labora-
tory systems and service delivery focused PPP.
Conclusions
Clearly PPP plays a critical role towards achieving the
UNAIDS 90–90-90 targets. Despite the growing em-
phasis on engaging the private sector as a critical partner
to address health care systems, PPPs that strengthen la-
boratories, the cornerstone of public health programs re-
main largely untapped. Increased partnerships between
Shrivastava et al. BMC Health Services Research (2019) 19:46 Page 8 of 10
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

public sector and private companies are needed to syn-
ergistically address the challenges of achieving universal
HIV testing, VL and EID scale up. Opportunities for
new local and global PPPs should be harnessed for a
standardized and sustained scale up of VL and EID to
reach the 90–90-90 goals.
Acknowledgements
The authors would like to thank Joanna M. Taliano, librarian at Center for
Disease Control and Prevention, Atlanta, USA for helping in the literature
search. The authors are indebted to Chin-Yih Ou, retired senior officer China
CDC for critically reviewing the manuscript. Authors would also like to ac-
knowledge input of Ellen Sampson, Director, Global Marketing at Siemens
Healthineers and William Magagna, Vice President Virtual Education Solutions
at Siemens Healthineers.
Funding
The President’s Emergency Plan for AIDS Relief (PEPFAR) supported staff who
designed the study; collected, analyzed, and interpreted the findings; and
wrote and reviewed the manuscript.
Availability of data and materials
Data used for this systematic review are available through peer-reviewed ma-
terials cited in the manuscript and can be freely accessed online. The data is
also available upon request from the corresponding authors.
Declarations
The findings and conclusions in this report are those of the author(s) and do
not necessarily reflect the views of the Centers for Disease Control and
Prevention.
Authors’contributions
RS, PNF, AK, JNN conceived and designed the study; RS, PNF, AK analyzed
the data; RS, PNF, AK wrote the paper; RS, PNF, YK, RB, SZ, CM, RG, HA, PLR,
AK, JNN interpreted the results, critically reviewed and revised the
manuscript, and approved the final manuscript.
Ethics approval and consent to participate
Not applicable; literature review-based research and not involving human
subjects or human material.
Consent for publication
Not applicable
Competing interests
The authors declare that they have no competing interests.
Publisher’sNote
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Author details
1
International Laboratory Branch, Division of Global HIV/AIDS, Center for
Global Health, Centers for Disease Control and Prevention, 1600 Clifton Road
NE, Atlanta, GA 30333, USA.
2
Centers for Disease Control and Prevention,
Addis Ababa, Ethiopia.
3
Roche Diagnostics, Johannesburg, South Africa.
4
Centers for Disease Control and Prevention, Kigali, Rwanda.
5
Becton
Dickinson and Company, Trenton, NJ, USA.
6
Africa Centres for Disease
Control and Prevention, Addis Ababa, Ethiopia.
Received: 20 August 2018 Accepted: 20 November 2018
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