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Bull World Health Organ 2015;93:42–46 | doi: http://dx.doi.org/10.2471/BLT.14.138909Lessons from the field42Ensuring accurate testing for human immunodeficiency virus in MyanmarLatt Latt Kyaw, a Ikuma Nozaki, b Koji Wada, b Khin Yi Oo, a Htay Htay Tin a & Namiko Yoshihara cIntroductionEarly diagnosis of human immunodeficiency virus (HIV) infection is needed to ensure timely access to care and prevent disease transmission. 1 The emergence of rapid tests that detect HIV antibodies in body fluids has enabled the expansion of HIV diagnosis in resource-poor settings. However, many laboratory services remain inefficient because of a lack of equipment and technicians. 2,3 There are concerns regarding testing accuracy, quality and interpretation of algorithms. 4 Ac-curate HIV tests are essential for patient care and outcomes. 5,6Others have described some of the challenges of estab-lishing national quality assessment schemes for HIV testing services. 7–11 We report lessons learnt during eight years of establishing such a scheme in Myanmar.ApproachThe Myanmar Ministry of Health provides laboratory ser-vices through the national reference laboratory which began to implement quality assessment in 2005 with technical and financial support from the Japan International Cooperation Agency. The scheme included four parts: (i) training work-shops for laboratory personnel; (ii) an external proficiency panel testing programme for participating laboratories; (iii) on-site assessment by national reference laboratory staff; and (iv) development of national guidelines.From 2005, the national reference laboratory conducted two cycles of training each year. The training was held at the reference laboratory and supported technically by the Japan International Cooperation Agency.Biannually, the national reference laboratory sent five serum panels to all participating laboratories. The laborato-ries were expected to return test results within one month of receipt. The panels included strong-positive, weak-positive and negative HIV antibody samples. The number of positive and negative samples differed by panel. To maintain a satisfac-tory response rate, the national reference laboratory contacted every laboratory twice by phone, before sending the samples and afterwards to confirm receipt of samples. After assessing results from the participating laboratories, the national ref-erence laboratory provided feedback by mail, including the proportion of the laboratories that kept the deadline.In 2010, the Myanmar Ministry of Health legislated na-tional guidelines for the scheme based on guidelines produced by the Joint United Nations Programme on HIV/AIDS. 12 This was done to standardize the procedures and facilitate the expansion of the scheme. 13 The guidelines describe each step in the scheme and the HIV testing procedures, includ-ing the serial testing algorithm for rapid tests. The guidelines propose that Alere Determine (Alere, Waltham, United States of America) be used for screening, Uni-Gold Recombigen® HIV-1/2 (Trinity Biotech, Wicklow, Ireland) for confirma-tion and HIV 1/2 STAT-PAK® (Chembio, Medord, USA) for second confirmation. 14Problem Until 2005, the quality of rapid diagnostic human immunodeficiency virus (HIV) testing was not monitored and no regular technical support was provided to hospital laboratories in Myanmar.Approach The national reference laboratory introduced a national external quality assessment scheme. The scheme involved (i) training laboratory technicians in HIV testing and in the requirements of the quality assessment system; (ii) implementing a biannual proficiency panel testing programme; (iii) on-site assessments of poorly-performing laboratories to improve testing procedures; and (iv) development of national guidelines.Local setting In 2011, a total of 422 public hospitals in Myanmar had laboratories providing HIV tests. In addition, private laboratories supported by nongovernmental organizations (NGOs) conducted HIV testing.Relevant changes The scheme was started in 65 public laboratories in 2005. In 2012, it had expanded nationwide to 347 laboratories, including 33 NGO laboratories. During the expansion of the scheme, laboratory response rates were greater than 90% and the proportion of laboratories reporting at least one aberrant result improved from 9.2% (6/65) in 2005 to 5.4% (17/316) in 2012.Lessons learnt National testing guidelines and a reference laboratory are needed to successfully implement quality assurance of HIV testing services. On-site assessments are crucial for all participating laboratories and the only source for insight on the causes of aberrant results; lessons that the reference laboratory can share nationally. Proficiency testing helps laboratory technicians to maintain HIV testing skills by ensuring that they regularly encountered HIV-positive samples.a National Health Laboratory, Ministry of Health, Yangon, Myanmar.b Bureau of International Medical Cooperation, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, Japan.c JICA Major Infectious Disease Control Project II, Yangon, Myanmar.Correspondence to Ikuma Nozaki (email: i-nozaki@it.ncgm.go.jp).(Submitted: 18 March 2014 – Revised version received: 8 September 2014 – Accepted: 1 October 2014 – Published online: 24 October 2014 )Lessons from the field