title: Specimen Referral Network to Rapidly Scale-Up CD4 Testing: The Hub and Spoke Model for Haiti.
abstract: OBJECTIVE
  Regular and quality CD4 testing is essential to monitor disease progression in people living with HIV. In Haiti, most laboratories have limited infrastructure and financial resources and have relied on manual laboratory techniques. We report the successful implementation of a national specimen referral network to rapidly increase patient coverage with quality CD4 testing while at the same time building infrastructure for referral of additional sample types over time.
  
  
  METHODS
  Following a thorough baseline analysis of facilities, expected workload, patient volumes, cost of technology and infrastructure constraints at health institutions providing care to HIV patients, the Haitian National Public Health Laboratory designed and implemented a national specimen referral network. The specimen referral network was scaled up in a step-wise manner from July 2011 to July 2014.
  
  
  RESULTS
  Fourteen hubs serving a total of 67 healthcare facilities have been launched; in addition, 10 healthcare facilities operate FACSCount machines, 21 laboratories operate PIMA machines, and 11 healthcare facilities are still using manual CD4 tests. The number of health institutions able to access automated CD4 testing has increased from 27 to 113 (315%). Testing volume increased 76% on average. The number of patients enrolled on ART at the first healthcare facilities to join the network increased 182% within 6 months following linkage to the network. Performance on external quality assessment was acceptable at all 14 hubs.
  
  
  CONCLUSIONS
  A specimen referral network has enabled rapid uptake of quality CD4 testing, and served as a backbone to allow for other future tests to be scaled-up in a similar way.
authors.affiliation: Centers for Diseases Control and Prevention, Port-au-Prince, Haiti.
authors.forename: Frantz Jean
authors.initials: FJ
authors.lastname: Louis
authors.affiliation: Clinton Health Access Initiative, Port-au-Prince, Haiti.
authors.forename: Anna Janick
authors.initials: AJ
authors.lastname: Osborne
authors.affiliation: Laboratoire National de Santé Publique, Ministry of Health, Government of Haiti, Port-au-Prince, Haiti.
authors.forename: Viala Jean
authors.initials: VJ
authors.lastname: Elias
authors.affiliation: Laboratoire National de Santé Publique, Ministry of Health, Government of Haiti, Port-au-Prince, Haiti.
authors.forename: Josiane
authors.initials: J
authors.lastname: Buteau
authors.affiliation: Laboratoire National de Santé Publique, Ministry of Health, Government of Haiti, Port-au-Prince, Haiti.
authors.forename: Jacques
authors.initials: J
authors.lastname: Boncy
authors.affiliation: Partnership for Supply Chain Management, Port-au-Prince, Haiti.
authors.forename: Angela
authors.initials: A
authors.lastname: Elong
authors.affiliation: Centers for Diseases Control and Prevention, Atlanta, Georgia, USA.
authors.forename: Amber
authors.initials: A
authors.lastname: Dismer
authors.affiliation: Laboratoire National de Santé Publique, Ministry of Health, Government of Haiti, Port-au-Prince, Haiti.
authors.forename: Vikram
authors.initials: V
authors.lastname: Sasi
authors.affiliation: Centers for Diseases Control and Prevention, Port-au-Prince, Haiti.
authors.forename: Jean Wysler
authors.initials: JW
authors.lastname: Domercant
authors.affiliation: Unite de Gestion des Programmes, Ministry of Health, Government of Haiti, Port-au-Prince, Haiti.
authors.forename: Daniel
authors.initials: D
authors.lastname: Lauture
authors.affiliation: Centers for Diseases Control and Prevention, Atlanta, Georgia, USA.
authors.forename: S Arunmozhi
authors.initials: SA
authors.lastname: Balajee
authors.affiliation: Centers for Diseases Control and Prevention, Atlanta, Georgia, USA.
authors.forename: Barbara J
authors.initials: BJ
authors.lastname: Marston
keywords: CD4 testing; External quality assessment; Hubs; Specimen referral network; Spokes