The Caribbean: Riding the dark horse of HIV/AIDS towards a brighter future

On behalf of the Caribbean Cytometry and Analytical Society (CCAS) and its members, I would like to thank Dr. Chuck Goolsby, Editor of “Cytometry, Part B: Clinical Cytometry,” for giving us the honor of contributing the first “Regional Spotlight” contribution to the Journal. I applaud the vision of the CCS and its president, Dr. Phil McCoy, in taking the lead towards creating an international network of flow cytometry societies. This can only strengthen and enrich the discipline within our respective countries and for developing countries provides an invaluable bridge to the international community. Since 1989, when the first flow cytometer was installed in Trinidad & Tobago, the Caribbean has followed a stuttering course towards flow cytometry development. This course is littered with the corpses of machines sitting idle, idiosyncratic procurement and initiatives rising and falling with the fortunes of a single individual. However, the logistical challenges facing the Caribbean can hardly be over-stated: The Caribbean is composed of a tapestry of 28 countries separated over >2,000 miles, covering a range of sizes from tiny Montserrat to vast Guyana, some celebrating their 202nd anniversary of independence (Haiti) and others retaining sovereign links to their colonial ancestry, four different official languages being spoken (English, French, Spanish, and Dutch), with nations at widely differing stages of development, occupying all parts of the political spectrum and, finally, not averse to political upheaval or even the odd coup! A special challenge faced by Caribbean nations is a human resource problem: 20 of the Caribbean countries have populations <300,000 and once you have taken away the core of teachers, nurses, doctors, civil servants, etc. needed for the running of the country, there may not be many people left to be trained as flow cytometrists! Achieving a consistent level of competence in flow cytometry is always going to remain a challenge in the Caribbean. Nevertheless, a unity of purpose has been brought to the discipline by the awesome threat of HIV/AIDS, which is menacing Caribbean society with potential economic ruin and is already the leading cause of death in the 19–49 year age group. A region with just 24 million people has 330,000 people living with HIV/AIDS (compared to 1 million infected persons in the US out of a population of 300 million). The fragile development of the region is literally at stake and the Caribbean nations have responded with commendable political will. Riding on the back of this political will, flow cytometry has expanded dramatically in the past 5 years. Effective delivery of antiretroviral therapy (ART) requires, at a bare minimum, continuous monitoring of patient CD4 levels. Delivery of ART across the region is poor, with just 23% of patients receiving treatment. A major logistical obstacle remains CD4 monitoring by flow cytometry. However, significant gains have been made in flow cytometry capacity building over the past 5 years, with ∼80% of all cytometers procured during this period. There are now >50 flow cytometers in the region, the majority being BD FACS Counts, a highly accurate but somewhat limited CD4 counter that generates absolute CD4 counts from a single platform. Newer and more versatile volumetric cytometers from Guava and Pointcare Technologies, capable of generating absolute and % CD4 counts, are beginning to enter the Caribbean market, while at the upper end the more developed countries have purchased three- and four- parameter flow cytometers from BD and Beckman Coulter. Procurement, however, is only part of the challenge in expanding diagnostic capacity for CD4 monitoring: the other is human resource development and sustainability of laboratory HIV/AIDS programs. The price per CD4 test has been reduced dramatically following abandonment of isotype controls, multitube protocols, and the spread of single platform technologies for calculating absolute and % CD4s. However, one can still question why the CD4/CD3/CD45 panel, needing a three color cytometer, is recommended by CDC as the gold standard single platform test for developing countries trying to build a sustainable HIV laboratory program? Volumetric flow cytometers allied to novel gating strategies can manage with two- or even one-parameter, thus lowering unit costs per tests significantly. Are we being too cautious in embracing these cheaper alternatives? The sustainability of CD4 testing is also threatened by erratic service contracts and loss of the supply cold-chain experienced in the Caribbean. We would appeal to cytometry manufacturers to consider all possible options, such as reagent rental or no-cost replacement, as alternatives to costly service contracts. We also appeal to the reagent manufacturers to develop more thermostable fluorochromes, or shipping formulations, for their antibody conjugates - is liquid PE really the best we can do? The greatest roadblock to expansion of flow cytometry in the region, however, remains human resource development. To tackle this issue, Dr. Akin Abayomi, Director of the Barbados Government HIV Reference Laboratory, conceptualized the Caribbean International HIV Workshop in 2004. This remains the only workshop in the region to provide regional delegates with the technical background and spread of diagnostic vendors necessary to make informed equipment choices and implement effective HIV laboratory programs. The workshop therefore fills an important gap between single vendor CD4 workshops and regional programs aimed at raising laboratory standards in general. In typical Caribbean style, the workshop proved an instant success but was almost immediately threatened with total collapse upon Dr. Abayomi's departure to South Africa in 2005. There are huge logistical and financial challenges in hosting such a meeting, with an onus to provide financial support for Caribbean delegates to attend the workshop. By the end of 2005, the Caribbean HIV Workshop initiative looked set to fail. The CCAS was therefore conceived in April 2006 to bring some coherence to the Caribbean flow cytometry community, with emphasis on expanding CD4 enumeration in HIV/AIDS (and hence raise the number of patients receiving ART treatment) across the region. The motto of the CCAS is: “Fighting HIV/AIDS in the Caribbean through the spread of technology.” The remit of the CCAS is: (1) to organize the annual HIV training workshop, (2) provide a voice for the Caribbean within the flow cytometry community, and (3) to expand the discipline beyond CD4 monitoring. A concerted fund-raising drive is underway to consolidate the financial base of the CCAS, a prerequisite to ensure the immediate survival of the CCAS and enable the workshop to rotate between islands, the only way to achieve true regional relevance (to date, all workshops have been hosted in Barbados). The CCAS will continue to work with institutional bodies, including the Centers for Disease Control (CDC), the Caribbean Regional Epidemiology Centre (CAREC), the Caribbean HIV/AIDS Regional Training Network (CHART), the Canadian Investment Development Agency (CIDA), The Wallace H. Coulter Foundation, The Destiny Group of Companies, and the University of the West Indies (UWI), to deliver training for flow cytometrists and molecular biologists in the Caribbean involved in the laboratory management of HIV/AIDS. From the outset, the CCAS has been fortunate to be partnered with the CCS and European Society for Clinical Cell Analysis (ESCCA), with links between our website (www.caribcas.com) and the corresponding CCS and ESCCA websites. Those international links have been critical in our development, as we have benefited from distinguished speakers and trainers at our workshops, learnt of external quality assurance programs and established personal networks to international centers of excellence. The recently concluded 3rd CCAS Caribbean International HIV Workshop in September 2006 was another success and was much appreciated by delegates in assisting their professional career development. While Caribbean flow cytometry is geared almost exclusively towards CD4 enumeration at present, some of the more developed countries, especially those with University campuses, have sporadically engaged in research using flow cytometry and are looking to expand clinically towards routine leukemia/lymphoma phenotyping. In developing our region's cytometry capability, the CCAS is particularly indebted to our partner societies for granting three advanced training scholarships annually (2 from CCS, 1 from ESCCA) for Caribbean cytometrists to receive training at US and European workshops. We are most grateful for these training opportunities, which will help the Caribbean reach the brighter horizons in flow cytometry, towards which we are riding, at present, on the dark horse of HIV/AIDS. The 3rd CCAS Caribbean International HIV/AIDS Workshop, Barbados, Sept. 3–8, 2006. Some images from the sessions and the social night. [Color figure can be viewed in the online issue, which is available at www.interscience.wiley.com.] R. Clive Landis President CCAS*, * Chronic Disease Research Centre University of the West Indies Barbados.

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