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Acceptability of Routine Point-of-Care Early Infant Diagnosis in Eight African Countries: Findings From a Qualitative Assessment of Clinical and Laboratory Personnel

Bianchi, Flavia MSca; Clemens, Sara MDb; Arif, Zainab MPHc; Sacks, Emma PhDc; Cohn, Jennifer MD MPHd, on behalf of the EGPAF POC EID Study Team

Author Information
JAIDS Journal of Acquired Immune Deficiency Syndromes: July 1, 2020 - Volume 84 - Issue - p S41-S48
doi: 10.1097/QAI.0000000000002372
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Abstract

INTRODUCTION

The World Health Organization recommends that HIV-exposed infants (HEIs) receive an HIV virologic test within 4–6 weeks of birth (and potentially also at birth) and at 9 months of age. They recommend result return within 4 weeks to allow immediate antiretroviral therapy (ART) initiation should the infant be found to be infected, while waiting for a second, confirmatory test.1 However, in 2018, only 59% of HEIs received a virologic test.2 In sub-Saharan Africa, where early infant diagnosis (EID) is predominantly central laboratory-based, studies have shown that results can take between 30 and 90 days to be returned to the infant's caregiver, and only about 50% of caregivers ever receive a test result.3–6 The long turnaround time (TAT) between sample collection and return of results contributes to delays in ART initiation.7 Although global ART coverage for children younger than 15 years has increased from 430,000 in 2010 to 940,000 in 2019, this still represents only 54% of eligible children.8 Perinatally infected infants have a peak mortality rate between 8 and 10 weeks of age, increasing to 35% by 12 months of age, and increasing to 50% by 2 years of age, without timely diagnosis and treatment.9–12 Early diagnosis and treatment can reduce the early infant mortality rate by 76% and the progression of HIV by 75%.13

Point-of-care (POC) testing for EID has been identified as 1 measure to address the long TAT, facilitating rapid initiation on ART, thereby reducing patient loss along the HIV testing and care cascade.7,14–16 This technology allows HEIs to be tested on-site rather than at centralized laboratories and does not require specialized laboratory technicians to operate, allowing task shifting to lower cadres of health care workers (HCWs) at decentralized facilities, who work directly with the patient.17 In 2016, Unitaid funded the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) to support the introduction of POC EID testing in 8 sub-Saharan African countries as part of routine service delivery. The POC EID project used a hub-and-spoke model to increase access, where a POC EID platform was placed at a health facility with a higher demand (the hub) and smaller nearby facilities (the spokes) would send samples to the hub for testing. Results from a preintervention and postintervention evaluation of key service delivery outcomes showed a significant decrease in TAT from sample collection to result return to the caregiver and a significant increase in HIV-infected infants initiated on ART within 60 days of sample collection when using POC for EID as compared to laboratory-based testing.7

In addition to clinical outcomes, stakeholder perspectives are critically important in evaluating the new methods of service delivery. Previous studies have shown that health care providers and infant caregivers have favorable opinions of POC EID technology when introduced as a pilot scale or a small scale.18–20 However, it is important to consider a range of settings and acceptability of POC EID when introduced at a scale. The stakeholders to consider in the use of laboratory-based and POC EID are the individuals performing the test in the clinical setting (HCWs) and program managers who oversee the overall laboratory system and/or EID system (laboratory managers). To inform future implementation of POC EID, we conducted a qualitative study of HCWs and laboratory managers across 8 African countries to elicit their perceptions, concerns, and acceptability regarding their experiences with EID systems, both before and after the introduction of POC EID. We believe that their on-the-ground experience and feedback could be useful in implementation, scale-up, and integration of POC EID within the overall EID network including central laboratories.

METHODS

The study, embedded within a preintervention and postintervention evaluation of key service delivery indicators comparing POC with central laboratory-based EID, was conducted in 8 sub-Saharan African countries, namely, Cameroon, Côte d'Ivoire, Eswatini, Kenya, Lesotho, Mozambique, Rwanda, and Zimbabwe. The protocol describing the intervention, country, and site selection for POC EID implementation and evaluation outcomes has been described elsewhere.7

Interviews with HCWs were conducted at selected sites scheduled to implement POC EID in each of the 8 countries. Facilities scheduled to receive a POC EID platform were chosen, so that HCWs interviewed at the sites would have experience both before and after the introduction of POC EID. However, the same HCWs were not always interviewed during the preintervention and postintervention time points. Sites were purposively selected to represent a range of locations (urban and rural), volume (high and low throughput), and type of facility (the testing site where the POC platform is located and “spoke” sites that send samples to testing sites), as well as the number, type, and, availability of staff.

For HCWs, 2 structured interview questionnaires were developed: a preintervention version used before the introduction of POC EID at the site and a postintervention version used at least 6 months after the introduction of POC EID at the site. We chose to conduct postintervention interviews at least 6 months after the introduction of POC for EID platforms because we believed that HCWs would have sufficient exposure and experience with the platforms to compare with laboratory-based EID. The questionnaires focused on HCWs' perceptions of complexity of preparing samples for and using laboratory-based and POC EID, trust in results, timing and reliability of result return, perceived impact on patient care, availability and acceptability of the given technology, and recommendations on which technology to use in the future for EID testing. Interviews with HCWs were conducted at the same sites before intervention and after intervention. Up to 5 sites could be sampled per country, and up to 8 health HCWs could be interviewed at each time point (preintervention and postintervention) for a maximum of 40 interviews. This sample size was deemed adequate to achieve a sufficient number and range of responses such that a larger sample size would not add new information. HCWs met the inclusion criteria if they worked at a site which has been offering standard EID for at least 3 months, worked directly with EID services as a staff member (ie, antenatal nurse or clinician), were present on the day of data collection, were older than 18 years, and consented to be interviewed.

EGPAF study staff trained in research ethics and qualitative methods conducted the recruitment of HCWs for interviews. The study staff scheduled interviews on days where a large number of HCWs likely to meet the inclusion criteria were on duty (as determined by the facility manager). On the day of data collection, the study staff approached all HCWs who met the inclusion criteria until the sample size (up to 8 HCWs from each site) was reached. The study staff obtained written informed consent. Once a potential participant consented, the interview was held in a private area at a location within the facility. Interviews took approximately 30–45 minutes and were conducted in English, French, Portuguese, or other national and local languages as determined appropriate by country staff. Questionnaires and interview guides were translated and back-translated to ensure fidelity to the intent of the original questions.

Interviews with laboratory and program managers were also conducted before and after the introduction of POC platforms using a preintervention and postintervention in-depth interview questionnaire, with open-ended questions and suggestions for probes. The interviews explored the participant's perception of the current quality of the EID system, challenges and opportunities with both laboratory-based and POC EID testing, and recommendations for the role of POC EID in the country's EID system. Up to 5 laboratory managers or program managers per country were recruited for each round of interviews. Where possible, laboratory managers were recruited from a laboratory located within an EID network directly impacted by POC EID (ie, central laboratories that received samples from sites that were scheduled to be enrolled in POC EID testing). Where this was not possible, any laboratory manager from the national laboratory system was recruited. Managers met the inclusion criteria if they were currently working in one of the provincial, regional, or national laboratories; were older than 18 years; and consented to be interviewed.

Laboratory managers were identified, recruited, and interviewed by trained EGPAF study staff. Laboratory managers selected for interviews were usually well known to EGPAF POC EID staff because the introduction and implementation of POC by the EGPAF was conducted in consultation with the Ministry of Health (MOH) and EID technical working groups. Once identified, a time was scheduled with laboratory managers to conduct the interviews, usually at the laboratory manager's office, to support confidentiality. Consent was requested for participation in the interview, which was to be audio-recorded. In the event the participant refused to be audio-recorded, the interview could proceed with informed consent to participate. Interviews with laboratory managers were conducted in English, French, or Portuguese, as appropriate.

Data from yes/no, multiple choice, or Likert scale questions were coded and entered into a database. Frequencies were calculated for each response. Data from open-ended questions were entered into Microsoft Word as data files. Up to 10% of interviews from each population were randomly selected by the project M&E focal point in each country for review for accuracy and completeness, comparing the paper document with the data entered into the database. Three different research staff members analyzed the qualitative data by hand. Thematic analysis was conducted with a line-by-line analysis of each interview, identifying codes, building categories, and finally common themes within and across countries around the perceived challenges and facilitators to POC EID. Results were analyzed by population, types of sites, and country and summarized into overall findings. In addition, results from HCW interviews were compared with those from laboratory manager interviews to highlight similarities and differences between different populations, each with their unique role in the implementation of POC.

Ethical approval was granted by Advarra (Pro00018323) and by the appropriate ethical review board(s) in each of the 8 countries (Cameroon National Ethics Committee, Comite National d'Ethique des Sciences de la Vie et de la Sante [Cote d'Ivoire], Kenyatta National Hospital-University of Nairobi ERC [Kenya], Lesotho MOH Research and Ethics Committee, Ministerio da Saud Comite Nacional de Bioetica para a Saud [Mozambique], MOH Rwanda National Ethics Committee, MOH of Eswatini Health Research Review Board, and Medical Research Council of Zimbabwe).

RESULTS

In total, 234 and 175 structured interviews with HCWs and 28 and 14 in-depth interviews with laboratory managers or program managers were conducted before and at least 6 months after the introduction of POC EID, respectively (Table 1). Preintervention interviews began in November 2016 and were completed by July 2017. Postintervention interviews began in October 2017 and were completed by May 2019. Most respondents for the preintervention and postintervention interviews were nurses (32.5% and 35.9%, respectively) (Table 2). Because of lack of research staff, in 2 countries (Kenya and Lesotho), we were unable to obtain postintervention laboratory manager interviews, and in 1 country (Lesotho), we were unable to obtain postintervention HCW interviews.

T1
TABLE 1.:
Number of Preintervention and Postintervention Interviews With HCWs and Laboratory Managers in 8 Project Countries
T2
TABLE 2.:
Participant Demographics of HCWs

Results of multiple choice and Likert ratings for select questions for HCWs are shown in Table 3. Overall, preintervention data indicate that although HCWs believed central laboratory-based EID to be accurate, they felt that the TAT was long and the system experienced frequent interruptions in functioning, leading to disruptions in care. There was near-universal interest in POC technology. Postintervention data indicate that HCWs found POC technology easy to use and reduced perceived TAT, and HCWs believed the technology improved care of HEIs. Several laboratory managers across multiple countries spoke about EID as being a part of the larger prevention of mother-to-child transmission (PMTCT) system, where barriers and facilitators for successful PMTCT and EID started in the community but were carried over into the facility and laboratory setting. In fact, during preintervention interviews, when asked about EID before the introduction of POC for EID, laboratory managers mostly discussed perceived challenges, which many claimed as occurring before the client even reaches the community. They also discussed that successful EID, as part of the larger PMTCT system, was heavily influenced by the involvement and support of the MOH and implementing partners.

T3
TABLE 3.:
Results of Multiple Choice and Likert Ratings for Select Questions for HCWs
table3-a
TABLE 3-A.:
Results of Multiple Choice and Likert Ratings for Select Questions for HCWs

Results from the interviews with both HCWs and laboratory managers are presented below, according to the main themes identified during analysis, as they pertain to the community, facility, and laboratory settings.

Results From Preintervention Interviews

Benefits of Central Laboratory-Based EID

For HCWs, a major benefit of central laboratory-based EID was that it was perceived as being accurate and reliable in results, and the process of drawing, assembling, and labeling the blood sample for processing was mostly considered to be very simple. Laboratory managers and HCWs had a high level of trust in the accuracy of central laboratory-based EID results, with 94.3% of HCWs feeling that central laboratory-based EID results were always or usually accurate (N = 230). However, some HCWs spoke about their experience with discordant results. A peer educator from Kenya remarked, “There are times we get positive PCR at week 6 and the confirmation is negative. So we have to stop a child who has already been initiated” (HCW, Kenya).

In Lesotho, a counselor who had a different experience remarked, “Confirmatory tests always came back positive, I have never experienced any discordant results” (HCW, Lesotho).

HCWs were questioned about the ease of drawing blood and making dried blood spot samples for EID, and 59.7% felt that it was “somewhat simple” or “very simple,” and 15.1% reported that it was “neither easy nor hard” (N = 139).

For laboratory managers, almost all discussed the multilevel challenges associated with central laboratory-based EID when asked to describe their experience with EID during preintervention interviews. As 1 laboratory manager from Zimbabwe commented, “So it might be 90 days because if I were the tell you that probably the sample took 2 weeks to get here, then in the lab we have our own 2 or 3 weeks, already we have 30 days before dispatching the result. Then we have 30 days after dispatching and then another 30 days for them to locate the mother of the child. So there is a problem in the system” (laboratory manager, Zimbabwe).

Challenges Associated With Central Laboratory-Based EID

Community-Level Challenges

At the community level, both laboratory managers and HCWs saw stigma as playing a large role in poor testing uptake and delay of caregivers picking up test results in a timely manner. Laboratory managers observed that women were reluctant to be tested for HIV, which they attributed to a lack of community-level sensitization and education around stigma as a potential culprit. As 1 laboratory manager stated, “So at the level of the community there is still room for improvement as concerns sensitisation, because some people still think that HIV is a taboo. They are not viewing it like a disease, a common disease… in our community, people do not easily assume that they are HIV positive because they are afraid of being stigmatised” (laboratory manager, Cameroon).

HCWs noted other reasons for delay in obtaining results by the caregiver, including distance from the facility, cost of transportation, availability of timely results, and lack of patient ability to communicate with the health facility.

Facility-Level Challenges

The most prominent and consistent challenge noted across countries at the facility level was the TAT from sample collection to receipt of result by the caregiver. HCWs estimated the average TAT from the day the sample was drawn to delivery of the result to the caregiver was 50 days, including a mean of 9.7 days of delay between receipt of results by the health care facility to delivery of results to the infant's caregiver. A laboratory manager noted, “I think EID is actually working very well in this country and even in our county. It's one of the things that is assisting us in actually as far as assisting the children with HIV. The only issue is actually the TAT. It takes a lot of time getting the results from the time they are collected and referred because we don't have any molecular laboratory in our county and so we usually send our samples to other counties and it usually takes time” (laboratory manager, Kenya).

An additional barrier noted by both HCWs and laboratory managers was disruption in the availability/functioning of EID services, which 19.5% of HCWs (N = 226) reported occurring in the previous 12 months. When services were disrupted, the mean length of disruption was estimated at 40 days and most interruptions were believed to be due to lack of test supplies [Dried Blood Spot (DBS) cards and lancets] at the facility (34.1%), followed by transportation system breakdown (12.9%). Almost all of these interruptions were estimated to cause a week or longer delay in 1 or more patients receiving their results.

Laboratory managers reported a lack of qualified, trained HCW staff (especially in rural areas), high staff turnover, staff burnout, and poor staff attitudes toward patients, as challenges associated with the facility.

Laboratory-Level Challenges

Laboratory managers reported that prominent barriers were laboratory supply stockouts, unreliable sample transportation, and lack of an electronic medical record system. Laboratory managers noted that hand-written request forms and results, duplication of forms, and poor data on test request forms (missing or incorrect information) were significant challenges. Communication barriers emerged as another major theme noted by laboratory managers. For example, some laboratory managers stated that they were unable to call health facilities for clarification when erroneous forms were received (due to financial or technical reasons). In addition, some were unable to follow-up whether results had successfully reached the health facility or the caregiver. As a laboratory manager summarized, “…there is just too few of the personnel in the system that has proven to be too much work at each stage. We also have poor sample tracking system as well as communications lines. EID look like it does not get enough attention as we relax on the knowledge that a DBS sample takes too long to expire” (laboratory manager, Lesotho).

Knowledge and Opinions of POC EID

HCWs and laboratory managers were asked about their knowledge of POC EID before its implementation. Among HCW respondents across all countries, 45.0% had heard of POC EID (N = 229). During interviews, POC was described to HCWs by the interviewer, after which almost all HCWs surveyed recommended that it be used in their country; 98.7% stated that they would want a platform located at their facility (N = 229). Two reasons were most common for these recommendations: the perception that POC EID would reduce the TAT and decrease the patient's travel expenses. HCWs from Mozambique and Lesotho supported POC, “I would recommend the use of POC EID because we would have immediate access to results” (HCW, Mozambique).

For the first time in the history of DNA PCR, early diagnosis is going to yield early initiation and most important the caregiver's trust is going to come back again. Lives will be saved” (HCW, Lesotho).

Laboratory managers were equally enthusiastic about the reduction in TAT with POC EID. One participant summarized, “More importantly, what we are fighting for in EID is the reduction of the turnaround time, this can be possible if assistance comes in from POC EID. So, POC would bring about reduced TAT. Since POC is done at the spot and within two hours the results are ready, positive cases would quickly be initiated to care unlike waiting for a month or two for conventional [central laboratory-based] EID result before treatment. That is my greatest argument for the need of POC” (laboratory manager, Cameroon).

However, laboratory managers hesitated to fully support POC EID due to concerns about result reliability and many requested pilot data before committing to endorsing scale-up of POC EID. In addition, they raised concerns regarding the ability to meet demand with a platform that can only perform 1 test at a time (and that demand might increase with the use of this method) and the ability to properly train HCWs to run the platform. Despite concerns, laboratory managers were generally supportive of scaling-up POC EID as a way to increase access and reduce loss along the treatment cascade.

Results From Postintervention Interviews

Benefits of POC EID

HCWs found POC EID easy to use and were very satisfied with the fast TAT, allowing fewer client visits, and noting that POC EID allowed for more rapid care and treatment initiation. At the clinical level, HCWs felt that POC EID was faster and simpler than central laboratory-based EID. They reported drawing blood into the specimen container for POC to be “less complicated” (71.3%) and sample labeling to be “less complicated” or “no difference” (81.4%) compared with preparation of DBS for central laboratory-based testing (N = 106). In operating the POC machine, 73.7% reported it to be “very simple” (N = 57). Of those that performed machine maintenance, 91.9% responded that it took “not much time” (N = 37) and 68.6% reported it was “very simple” (N = 35).

At the health facility level, 93.0% of HCWs reported that POC improved their ability to care for HEIs (N = 143). HCWs also believed that patient flow was largely unchanged or improved with POC, with 48.7% reporting no difference in patient flow between POC EID and central laboratory-based EID and 44.2% reporting that POC EID made patient flow easier/simpler (N = 156). A majority (55.9%) felt that POC EID increased the number of patients presenting for EID, whereas only 1.3% perceived a decrease (N = 152). POC EID results were viewed as accurate by 89.6% of HCWs (N = 154).

All HCWs from every country in the study felt POC EID was an effective and reliable intervention that improved care and treatment for HIV-positive patients, allowing earlier diagnosis and immediate treatment if infection was identified. HCWs felt that POC EID improved their decision-making capacity, which would have a positive impact on patient satisfaction. A laboratory technician from Cameroon commented, “Results arrive immediately after collection or the next day. This ensures quick initiation of positive cases and also communication of results to caregivers. For conventional [central laboratory-based], results return after 2 months and mother cannot be contacted to communicate results” (HCW, Cameroon).

Critically, HCWs felt that the TAT was greatly reduced with POC; as 1 laboratory technician in Kenya remarked, “There are no missed opportunities and lost to follow ups have been eliminated” (HCW, Kenya).

Laboratory managers similarly perceived a decrease in TAT, which they pointed out leads to quicker initiation of therapy and decreased loss to follow-up. A participant from Eswatini commented, “What I have seen is basically the reduced TAT because that is the most important thing. POC is [equivalent to] TAT because there is no need to wait for the results” (HCW, Eswatini).

They found the platform to be user-friendly and did not require highly trained HCWs to operate. The location of the machines in the community was also viewed positively, facilitating increased access for rural populations in hard to reach areas. One laboratory manager from Rwanda commented, “We recorded unprecedented figures since we started using the machine: this is the result for this new method [POC] that allows us to test early, find and communicate results and initiate on treatment on time, which led to an increased number of parents who requested POC EID services” (laboratory manager, Rwanda).

Challenges Associated With POC EID

HCWs did report challenges after the introduction of POC EID. In the postintervention interviews, 36.5% of HCWs reported a gap in POC EID functionality, with the mean gap lasting 7.5 days (N = 156). The most cited reasons were the platform breakdown at the testing site (74.5%) followed by lack of test kits at the facility (14.5%) (N = 44).

HCWs identified some interruptions in patient flow attributable to POC. For example, HCWs found that with POC testing, families had to be emotionally prepared to receive results the same or next day, and an HCW had to be available for counseling.

Some HCWs discussed the fact that once they were trained to use the platform, they found it was simple, but high HCW turnover would necessitate frequent retraining. Some HCWs spoke about a system to have permanent staff responsible for POC EID to avoid any gaps in service delivery. Although most found POC testing to be accurate, a few HCWs reported discordant test results; a nurse from Cameroon remarked, “There were two cases of false positive with POC EID testing… The issue was attributed to the reagents supplied for testing but it was rectified on time so the right result was communicated to caregiver” (HCW, Cameroon).

Laboratory managers noted that POC created the need for reliable electricity sources to power the platforms, and where electricity was not stable, batteries are needed. Concerns expressed preintervention remained, including concerns about stockouts of reagents and materials needed to run the tests. In addition, there were concerns about the volume of EID tests needed compared with the low throughput of the POC machines.

Considerations for Implementation and Scale

After intervention, 100% of HCWs in the sample recommended that their country increase the use of POC EID and that it would be a useful intervention. A vast majority (87.2%) wanted a platform at their facility. A nurse from Zimbabwe remarked, “[POC EID is] reducing turn-around time of results giving peace of mind to caregivers, anxiety is reduced. Collection of blood samples is less complicated, this eases the pressure of work on the health care worker who is already overloaded with work” (HCW, Zimbabwe).

HCWs spoke about a need to train more staff working with POC kits and to provide laboratory supervision to maintain quality of results. Strengthening transportation resources was also a priority for sites that were “spokes” that required specimen transport to a local “hub.” A laboratory technician from Kenya commented, “There is a need to optimize the logistics for sample transportation from the spokes to the hubs and vice versa (HCW, Kenya).

In addition, HCWs mentioned improving supply chains to avoid gaps in service and to recruit and train more staff to deliver care optimally and efficiently. Specifically, obtaining a consistent source of cartridges and microvettes was viewed as critical, as the short half-life of reagents requires frequent resupplying.

Laboratory managers were also supportive of POC because of the decrease in TAT, and the facilitation of timely follow-up leading to the rapid management of patients. They stressed the need for quality assurance before scale-up, monitoring for machine and human error, and the need for well-trained and sufficient staff. One participant remarked, “Emphasis should be placed on provider training. If we do not have enough people able to use the POC, we will not have any interesting results” (laboratory manager, Côte d'Ivoire).

Some felt that the duration of training was not enough and that all staff should be trained due to high staff turnover, whereas others felt that only some staff with relevant degrees should be trained. They agreed that sample transportation between “hubs and spokes” needed to be supported, especially in light of the potential increased demand for EID with the introduction of POC testing. Strengthening infrastructure for consistent power supplies, and supply chains, as well as internet connectivity was raised as a priority.

The recommendation by both HCWs and laboratory managers was that POC testing be integrated within the existing central laboratory-based system as a complement to central laboratory-based EID. Many felt that central laboratories would be preferable in central areas with dense population and a higher volume, whereas POC would be more ideal for hard to reach areas. Some suggested expanding the hub-and-spoke model to include more spokes. As 1 laboratory manager from Cote d'Ivoire commented, “POC should be placed in the most remote and hard-to-reach areas with power problems” (laboratory manager, Cote d'Ivoire).

Participants also stressed that should POC testing be scaled-up, there would need to be a standardized reporting procedure so that cases could be tracked in the same way they are currently reported through central laboratory-based EID (ie, integration of the 2 systems rather than parallel systems).

DISCUSSION

HCWs and laboratory managers or program managers from 8 countries strongly supported the introduction of POC testing for EID in this study. The key perceived benefit was a decrease in TAT for results, which facilitated earlier initiation of ART in HIV-positive infants. Respondents also felt that POC EID was simple to operate and allowed task shifting to run the sample on the POC EID platform to non–laboratory-trained health workers with only a small amount of training required. Stakeholders recommended that POC EID be scaled-up and integrated into the existing laboratory systems. Of note, however, is that laboratory managers especially considered POC EID as an important addition to the existing EID network. They recognized that POC EID alone would not resolve all challenges associated with EID, yet it could be an especially helpful solution hard to reach. Thus, POC EID was seen has a compliment to laboratory-based testing as opposed to a replacement.

Interviews with HCWs and laboratory managers also revealed important challenges and considerations for implementation and scale-up of POC. In particular, there was an emphasis on the need to strengthen the overall EID system. Many participants pointed out that EID is not just a laboratory function; rather, they pointed out that EID starts in the community. Awareness of EID among mothers and pregnant women is crucial to successful implementation of any sort of EID intervention. These results suggest that POC EID testing, while favorable to the participants, was just 1 part of a multifactorial solution targeting awareness, stigma, and health information systems and infrastructure. Several laboratory managers also commented that POC EID should be preferentially placed in more remote areas, which may experience a longer TAT. However, other data suggest that even health facilities in urban areas and close to central laboratory testing experience long TAT and this analysis should be taken into consideration by program managers when planning POC EID roll out.21

The strengths of this study include the multicountry nature, large sample size, and diversity of level and geographic location of health facilities included for sampling HCWs. Despite the broad range of countries and HCWs interviewed, we were able to identify very strong and consistent themes outlined here, which suggests these are consistent and commonly held views across various health and laboratory system contexts. Interviews were conducted both before and after the introduction of POC testing, allowing the evaluation of changes in opinions and viewpoints over time. This study also had several limitations. We only surveyed a limited range of key stakeholders. Most notably, caregivers of HEIs were not included, but are a vital part of EID; data for this population are included in another article in this supplement (add reference).22 In addition, because of lack of research staff, in 2 countries (Kenya and Lesotho), we were unable to obtain postintervention laboratory manager interviews, and in 1 country (Lesotho), we were unable to obtain postintervention HCW interviews. The decrease in interviews also affected the variety of respondents, which could introduce bias in postintervention data.

This study, along with the quantitative patient-level data and costing and cost-effectiveness data presented in other parts of this supplement, makes a compelling case for POC testing as the future of EID. Ultimately, buy-in and support from donors, implementing partners, and governments will be important to the sustainability of POC EID programs. Critical decisions will need to be made about the extent of POC EID coverage and how to most efficiently integrate this new technology into the existing EID system, maximizing beneficial impact while recognizing funding constraints. The viewpoints of HCWs and laboratory personnel should continue to be evaluated in future studies as POC EID is established and integrated. It will be necessary to ensure that stakeholders continue to support the use of POC and that the systems are sustainable and mitigate challenges associated with the introduction of a new technology.

CONCLUSIONS

POC for EID of HIV is a welcome addition to the existing EID network and is both accepted and appreciated by key health system stakeholders. In particular, participants in this study noted that POC EID's ability to improve TAT leads to quicker treatment initiation for HIV-positive children. POC EID is nearly universally supported for scale-up in this large multicountry qualitative evaluation of HCWs and laboratory managers. However, improving EID requires strengthening of the larger health system, and POC EID is 1 component of a multipronged solution.

ACKNOWLEDGMENTS

EGPAF POC EID Study Team:

Valery Nzima Nzima (EGPAF Cameroon), Patricia Fassinou (EGPAF Côte D'Ivoire), Mafusi Mokone (EGPAF Lesotho), Collins Odhiambo (EGPAF Kenya), Addmore Chadambuka (EGPAF Zimbabwe), Thembie Masuku (EGPAF eSwatini), Manuel Carlos Sabonete (EGPAF Mozambique), and Angelique Fundi (EGPAF Rwanda).

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Keywords:

POC EID; interviews; acceptability; health care workers; laboratory managers; multicountry; pediatric HIV; HIV testing

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