TRACE INITIATIVE: Specimen Collection, Handling, & Transport

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SPECIMEN COLLECTION

For whom should you collect additional venous or DBS specimens? NOTE FOR ADAPTING SLIDES: change this slide depending on country context For whom should you collect additional venous or DBS specimens? NOTE FOR ADAPTING SLIDES: change this slide depending on country context Only those that test recent on the POC test and do not have VL testing data available.

Collecting Blood Specimens: Dried Blood Spots (DBS)

DBS Kit: Supplies BD, blue lancet (1), Alcohol swab (1), 2 3 BD, blue lancet (1), Alcohol swab (1), Gauze square (1), Capillary tubes (2), Whatman 903 DBS card (1), Plaster (1), Desiccant packets (3), Plastic bag (1), Disposable gloves (2) 4 5 6 7 9 8

Other Supplies Needed: DBS Collection Sharps container (1) Drying rack (1) Specimen label (1) A pre-printed barcode label to affix to the DBS card OR An ultra-fine permanent marker to document the participant’s unique ID on the DBS card 1 2 3a 3b

DBS Collection – Prepare Supplies and Label Cards 1. Organize your supplies for DBS collection. 2. Label your DBS card per protocol. 3. Wash your hands thoroughly and put on a new pair of gloves.

DBS Collection – Preparing for the Finger-Prick 4. Position hand palm-side up. Choose whichever finger is least calloused. 5. Massage and apply intermittent pressure to the finger to help the blood to flow. 6. Clean the fingertip with alcohol. Start in the middle and work outward to prevent contaminating the area. Allow the area to dry. 7. Hold the finger and firmly place a new sterile lancet off-center on the fingertip.

DBS Collection – Finger-Prick Blood Collection 8. Firmly press the lancet to puncture the fingertip. 9. Wipe away the first drop of blood with a sterile gauze pad or cotton ball. Question: Do we have these capillary collection tubes? 11. Apply a gauze pad or cotton ball to the puncture site until the bleeding stops. 10. Collect drops of blood with capillary collection tubes.

DBS Collection – Preparing the DBS Card, & Clean Up 12. Lightly touch DBS card to end of capillary collection tubes and allow blood to flow. Repeat until all five circles are filled. 13. Place card on drying rack. 14. Remove gauze pad and apply plaster to puncture site. 15. Properly dispose of all hazardous materials.

Tips to Ensure High-Quality DBS Specimens Warm participant’s hand to encourage blood flow. Milk finger at a downward angle to prevent clotting If you see a blood clot, try firmly wiping the puncture with sterile gauze to disrupt clot formation If blood pools on the filter paper, gently tap the card to encourage saturation of the spot. The participant’s finger should never touch the filter paper. Do not layer blood spots on top of each other. Only package specimens once they are completely dry.

COMPLETION OF THE LAB REQUISITION FORM

Purpose To link the client ID number (HTS/ART/ANC number) and his/her laboratory results, namely the viral load test results To document the quality of the specimen during transport from the facility to the laboratory NOTE FOR ADAPTING SLIDES: change this slide depending on country context; in some countries, laboratory testing will include POC-Recency testing

Complete the Laboratory Requisition Form SECTION 1 Facility Name HTS/ART/ANC Facility Code Date of participant’s HIV diagnosis SECTION 2 Client ID Number Specimen Type: Check one: Venous or DBS Affix Participant ID label or write Participant ID number Name of staff collecting specimen Date and time of specimen collection Leave SECTIONS 3-6 blank To be completed later To be completed for venous AND DBS specimens

PACKAGING SPECIMENS FOR TRANSPORT

Purpose Proper packaging and storage of specimens before transport to the laboratory for viral load testing is essential to ensure the specimen quality Improper packaging or storage may result in the inability to perform viral load testing Packaging procedure varies by specimen type (DBS vs. venous blood) NOTE FOR ADAPTING SLIDES: change this slide depending on country context; in some countries, laboratory testing will include POC-Recency testing NOTE FOR ADAPTING SLIDES: change this slide depending on country context; in some countries, laboratory testing will include POC-Recency testing

Packaging DBS Specimens for Transport

Package DBS Specimens: Supply List Plastic sealable bag (1), Desiccant packs (3), Humidity indicator card (1), Filled DBS card (1), Brown paper envelope (1) Paperclip (1) Laboratory requisition form (1) 3 1 2 4 5 6 7 Generic labeling system – be sure you use the one for your country

Packaging DBS Before / After Drying 1. Allow DBS to air-dry for a minimum of four hours at ambient temperature before removing them from drying rack. Only remove the cards when completely dry. The color of the blood spots should change from bright red to dark red once dry. 2. Place each DBS card in plastic sealable bag with 3 desiccant packs and a humidity indicator card. Remove excess air, seal bag. Need to review these procedures with other investigators to confirm Optional: If using pre-printed barcode labels, attach sheet with remaining labels to your partially completed Laboratory Requisition Form.

Packaging DBS Need to review these procedures with other investigators to confirm 3. Using the same paper clip, append plastic bag that contains DBS card and desiccant packs to Laboratory Requisition Form. 4. Fold Laboratory Requisition Form so DBS card and unused Participant ID Labels are contained. Paperclip to seal.

Packaging DBS HIV Recency [Health Facility] [Laboratory] [Pick-up Date] HIV Recency [Health Facility] [Laboratory] [Pick-up Date] 6. Place folded forms (with DBS cards and unused labels, where appropriate) into brown paper envelope until pick-up. If risk factor questionnaires are conducted as part of recent infection surveillance in your country, and data entry will occur at the laboratory, completed questionnaires may be in this folder as well. 5. Label a brown paper envelope with HIV Recency, the name of your health facility, the name of the laboratory you are sending the sample(s) to, and the date the samples were picked up.

Packaging DBS – Tips Don’t allow DBS exposure to direct sunlight Don’t allow exposure to humidity Three desiccant packets per DBS card essential! Don’t package DBS before they are dry DBS samples must be dried for > 4 hours

Packaging Venous Blood Specimens for Transport

Packaging Venous Blood Specimens: Supply List Filled and sealed 6mL EDTA vacutainer (1), Sample tube storage box (1), Ice pack (1), Cooler (1), Laboratory requisition form (1) 1 2 3 4 5

Packaging Venous Blood Specimens 1. Place the sealed EDTA vacutainer tube in the sample tube storage box. 2. Place sample tube storage box in designated cooler with reusable ice pack(s) until pick-up (same day).

Packaging Venous Blood Specimens Envelope containing risk questionnaires (if conducting risk interviews) Laboratory Requisition Forms + Participant ID Labels (if using pre-printed barcode labels) Place packets comprised of Laboratory Requisition Form, Participant Risk Factor Questionnaire, and all remaining Participant ID Labels in waterproof folder(s). Place folder(s) in large plastic bag and place in cooler. All packets should be kept with their specimens at all times. Place the sealed 6.0 mL EDTA vacutainer tube in the appropriate cardboard storage box for EDTA tubes. Place cardboard boxes in designated 6L cooler with ice packs until time to transport to the central laboratory for recency testing. All samples should be sent to the central laboratory every day (even if the cardboard box is not full). 3. Place forms in brown paper folder. If risk factor questionnaires are conducted as part of recent infection surveillance in your country, and data entry will occur at the laboratory, completed questionnaires may be in this folder as well. The brown paper folder should be left unsealed and kept near cooler with specimens at all times. Optional: If using pre-printed barcode labels, attach sheet with remaining labels to your partially completed Laboratory Requisition Form.

Specimen Transport to Laboratory

Purpose All specimens must be sent to the lab in timely manner so that quality of viral load test results can be ensured. Venous blood specimens should be sent to the lab every day (vein to freezer in < 24 hours) DBS specimens must be sent to the lab at least once a week Leverage existing infrastructure for specimen transport – how are routine samples taken to the laboratory? For example, Malawi used a courier service (motorcycle riders) to transport specimens to the lab and return results to the facilities NOTE FOR ADAPTING SLIDES: change this slide depending on country context; in some countries, laboratory testing will include POC-Recency testing NOTE FOR ADAPTING SLIDES: change this slide depending on country context; in some countries, laboratory testing will include POC-Recency testing

Specimen Transport: Step 1 Prior to specimen pick-up, a designated person at the health facility will open the brown paper envelope and/or cooler to: Confirm there is a specimen that corresponds to each Laboratory Requisition Form; If using pre-printed barcode labels: Confirm that remaining Participant ID Labels are attached to each Laboratory Requisition Form; Check the quality of specimens and packaging and document on the Lab Requisition Form and Specimen Tracking Log; If conducting risk factor questionnaires: Count number of risk factor questionnaires and confirm number matches number of Laboratory Requisition Forms; and Seal brown paper envelope.

Specimen Transport: Step 2 Prior to specimen pick-up, a designated person at the health facility will: Document the quality of each specimen in Section 3 of the Laboratory Requisition Form. Use an acceptance/rejection code to indicate the quality of the specimen. Complete the column that says Health Facility in the Dried Blood Spot Card or Venous Blood Tube cell (depending on the type of specimen collected)

Acceptance/Rejection Codes 8) Over-saturation; 9) Clotted blood; 10) Scratched spots; 11) Scattered spots; 12) Serum rings; 13) Double-layer spots; 14) Improper drying; 15) Spots that cannot elute 1) Acceptable – No rejection; 2) Broken or cracked container; 3) Hemolysis; 4) Leaking container; 5) Insufficient blood; 6) Not labeled correctly 7) Specimen data missing;

Specimen Transport: Step 3 After completing Step 3, the designated person will complete Section 4 of the Laboratory Requisition Form, including: Sample Prepared for Transport at Health Facility by: (Name) Date/time transported to lab

Specimen Transport: Step 4 Important to have a schedule for specimen pick-ups Should also have an on-call system in place, in the event that a venous specimen is collected at a facility on a day when a pick-up is not scheduled The person responsible for picking up the specimen(s) will complete Section 5a of the Laboratory Requisition Form, including: Transported from Health Facility to Laboratory by: (Name) Date/time transported to lab

Specimen Transport: Step 5 At each pick-up, a designated health facility staff will complete Section 1 of the Specimen Tracking Log, including: Date and time that specimens were picked up from the facility Number of specimens picked up from the facility and list of Participant ID numbers Accepted/rejected codes (same as what is listed on each requisition form) His/her initials

Specimen Transport: Step 6 The person responsible for picking up the samples and taking them to the lab will complete Section 2 of the Specimen Tracking Log, including Number of specimens received; Confirmation that the specimens were correctly packaged and his/her initials

ALTERNATE: Keep 37+38 and this slide Specimen quality should be documented using one of these codes: Acceptance/Rejection code definitions: 1) Acceptable – No rejection; 2) Broken or cracked container; 3) Hemolysis; 4) Leaking container; 5) Insufficient blood; 6) not labeled correctly 7) Specimen data missing; 8) Over-saturation; 9) Clotted blood; 10) Scratched spots; 11) Scattered spots; 12) Serum rings; 13) Double-layer spots; 14) Improper drying; 15) Spots that cannot elute A log should be kept at the health facility to track outgoing specimen shipments. NOTE FOR ADAPTING SLIDES: change this slide depending on country context; in some countries, laboratory testing will include POC-Recency testing

RETURN OF RESULTS

Return of Results Results from the POC test will be available within 30-45 minutes after testing. A long-term result on the POC test for recent infection will be the final result Persons who test recent on the assay will be told that the test result is preliminary and may need to be confirmed through additional testing The viral load results will be printed at the laboratory and labeled with the participant’s unique Participant ID number These print-outs will be transmitted back to each HTS facility HTS staff will enter these data into the electronic data capture system. Participants will be contacted when their VL results are available. NOTE FOR ADAPTING SLIDES: change this slide depending on country context NOTE FOR ADAPTING SLIDES: change this slide depending on country context

RTRI Flow HTS Service Delivery Point Laboratory Persons POC TRI Recent Blood collected and sent for VL testing Issued laboratory specimen ID number; Undergo VL testing POC test for recent infection New HIV Diagnosis Persons POC TRI Long-term Recent Long-Term Electronic Data Capture System Over 1,000 copies/mL Laboratory Log Book to record Recent Infection Results (at facility) Client ID Number (HTS/ ART/ ANC number) Any other relevant data from HTS register Participant ID number Sex Viral load count (for recent on POC tests) Age Residence HIV testing history POC TRI Results Under 1,000 copies/mL NOTE FOR ADAPTING SLIDES: change this slide depending on country context HTS staff enter lab data into system Data entry staff print out VL results and send them to health facilities. NOTE FOR ADAPTING SLIDES: change this slide depending on country context

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