Implementing at-birth, point-of-care HIV testing in Kenya: a qualitative study using the Consolidated Framework for Implementation Research

Catherine Wexler, Yvonne Kamau, Elizabeth Muchoki, Shadrack Babu, Nicodemus Maosa, May Maloba, Melinda Brown, Kathy Goggin, Natabhona Mabachi, Brad Gautney, Sarah Finocchario-Kessler, Catherine Wexler, Yvonne Kamau, Elizabeth Muchoki, Shadrack Babu, Nicodemus Maosa, May Maloba, Melinda Brown, Kathy Goggin, Natabhona Mabachi, Brad Gautney, Sarah Finocchario-Kessler

Abstract

Background: At-birth and point-of-care (POC) testing can expedite early infant diagnosis of HIV and improve infant outcomes. Guided by the Consolidated Framework for Implementation Research (CFIR), this study describes the implementation of an at-birth POC testing pilot from the perspective of implementing providers and identifies the factors that might support and hinder the scale up of these promising interventions.

Methods: We conducted 28 focus group discussions (FGDs) with 48 providers across 4 study sites throughout the course of a pilot study assessing the feasibility and impact of at-birth POC testing. FGDs were audio-recorded, transcribed, and analyzed for a priori themes related to CFIR constructs. This qualitative study was nested within a larger study to pilot and evaluate at-birth and POC HIV testing.

Results: Out of the 39 CFIR constructs, 30 were addressed in the FGDs. While all five domains were represented, major themes revolved around constructs related to intervention characteristics, inner setting, and outer setting. Regarding intervention characteristics, the advantages of at-birth POC (rapid turnaround time resulting in improved patient management and enhanced patient motivation) were significant enough to encourage provider uptake and enthusiasm. Challenges at the intervention level (machine breakdown, processing errors), inner settings (workload, limited leadership engagement, challenges with access to information), and outer setting (patient-level challenges, limited engagement with outer setting stakeholders) hindered implementation, frustrated providers, and resulted in missed opportunities for testing. Providers discussed how throughout the course of the study adaptations to implementation (improved channels of communication, modified implementation logistics) were made to overcome some of these challenges. To improve implementation, providers cited the need for enhanced training and for greater involvement among stakeholders outside of the implementing team (i.e., other clinicians, hospital administrators and implementing partners, county and national health officials). Despite provider enthusiasm for the intervention, providers felt that the lack of engagement from leadership within the hospital and in the outer setting would preclude sustained implementation outside of a research setting.

Conclusion: Despite demonstrated feasibility and enthusiasm among implementing providers, the lack of outer setting support makes sustained implementation of at-birth POC testing unlikely at this time. The findings highlight the multi-dimensional aspect of implementation and the need to consider facilitators and barriers within each of the five CFIR domains.

Trial registration: ClinicalTrials.gov, NCT03435887 . Retrospectively registered on 19 February 2020.

Keywords: Birth testing; Consolidated Framework for Implementation Science (CFIR); Early infant diagnosis; HIV; Kenya; Pediatric HIV; Point-of-care; Qualitative.

Conflict of interest statement

The authors declare that they have no competing interests.

© 2021. The Author(s).

References

    1. Violari A, Cotton MF, Gibb DM, Babiker AG, Steyn J, Madhi SA, Jean-Philippe P, McIntyre J, CHER Study Team Early antiretroviral therapy and mortality among HIV-infected infants. New Engl J Med. 2008;359(21):2233–2244. doi: 10.1056/NEJMoa0800971.
    1. PEPFAR. Country Operational Plan (COP/ROP) 2020: Strategic Direction Summary 2020. 2020. Available from: .
    1. Wexler C, Cheng A-L, Okoth V, Gautney B, Finocchario-Kessler S, Goggin K, et al. Evaluating turn around times for early infant diagnosis samples in Kenya from 2011-2014: A retrospective analysis of HIT System program data. PloS one. 2017;12(8):e0181005.
    1. Hassan AS, Sakwa EM, Nabwera HM, Taegtmeyer MM, Kimutai RM, Sanders EJ, Awuondo KK, Mutinda MN, Molyneux CS, Berkley JA. Dynamics and constraints of early infant diagnosis of HIV infection in rural Kenya. AIDS Behav. 2012;16(1):5–12. doi: 10.1007/s10461-010-9877-7.
    1. Finocchario-Kessler S, Gautney B, Cheng A, Wexler C, Maloba M, Nazir N, Khamadi S, Lwembe R, Brown M, Odeny TA, Dariotis JK, Sandbulte M, Mabachi N, Goggin K. Evaluation of the HIV Infant Tracking System (HITSystem) to optimise quality and efficiency of early infant diagnosis: a cluster-randomised trial in Kenya. Lancet HIV. 2018;5(12):e696–e705. doi: 10.1016/S2352-3018(18)30245-5.
    1. UNAIDS . Country Factsheet: Kenya 2019. 2019.
    1. Wexler C, Nazir N, Gautney B, Maloba M, Brown M, Goggin K, Lwembe R, Finocchario-Kessler S. Predictors of early ART initiation among HIV + infants in Kenya: a retrospective review of HITSystem data from 2013 to 2017. Maternal Child Health J. 2020;24(6):739–747. doi: 10.1007/s10995-020-02909-3.
    1. Teasdale CA, Tsiouris F, Mafukidze A, Shongwe S, Choy M, Nhlengetfwa H, Simelane S, Mthethwa S, Ao T, Ryan C, Dale H, Rivadeneira E, Abrams EJ. Birth testing for infant HIV diagnosis in Eswatini: implementation experience and uptake among women living with HIV in Manzini region. Pediatric Infect Dis J. 2020;39(9):e235–ee41. doi: 10.1097/INF.0000000000002734.
    1. Technau K-G, Strehlau R, Patel F, Shiau S, Burke M, Conradie M, Sorour G, Sherman GG, Coovadia A, Murnane PM, Abrams EJ, Kuhn L. 12-month outcomes of HIV-infected infants identified at birth at one maternity site in Johannesburg, South Africa: an observational cohort study. Lancet HIV. 2018;5(12):e706–ee14. doi: 10.1016/S2352-3018(18)30251-0.
    1. Wexler C, Nazir N, Maloba M, Brown M, Goggin K, Gautney B, Maosa N, Babu S, Muchoki E, Mabachi N, Lwembe R, Finocchario-Kessler S. Programmatic evaluation of feasibility and efficiency of at birth and 6-week, point of care HIV testing in Kenyan infant. PloS one. 2020;15(10):e0240621. doi: 10.1371/journal.pone.0240621.
    1. Khumalo PN, Sacks E, Chouraya C, Tsabedze B, Masuku T, Nyoni G, Zikalala T, Nhlabatsi B, Mthethwa N, Cohn J. The cascade of care from routine point-of-care HIV testing at birth: results from an 18-months pilot program in Eswatini. J Acquir Immune Defic Syndr. 2020;84(1):S22–SS7. doi: 10.1097/QAI.0000000000002380.
    1. Spooner E, Govender K, Reddy T, Ramjee G, Mbadi N, Singh S, Coutsoudis A. Point-of-care HIV testing best practice for early infant diagnosis: an implementation study. BMC Public Health. 2019;19(1):731. doi: 10.1186/s12889-019-6990-z.
    1. Bianchi F, Cohn J, Sacks E, Bailey R, Lemaire JF, Machekano R. Evaluation of a routine point-of-care intervention for early infant diagnosis of HIV: an observational study in eight African countries. Lancet HIV. 2019;6(6):e373–ee81. doi: 10.1016/S2352-3018(19)30033-5.
    1. Sacks E, Cohn J, Ochuka B, Mafaune H, Chadambuka A, Odhiambo C, et al. Impact of routine point-of-care versus laboratory testing for early infant diagnosis of HIV: results from a multicountry stepped-wedge cluster-randomized controlled trial. J Acquir Immune Defic Syndromes (1999) 2020;84 Suppl 1(1):S5–S11. doi: 10.1097/QAI.0000000000002383.
    1. Ministry of Health, National AIDS and STI Control Programme. Guidelines on use of antiretroviral drugs for treating and preventing HIV infection in Kenya: 2016 edition. 2016. Available from: . Accessed 20 Nov 2020.
    1. Ministry of Health, National AIDS and STI Control Program. Guidelines on use of antiretroviral drugs for treating and preventing HIV infection in Kenya 2018 edition. 2018. Available from: . Accessed 20 Nov 2020.
    1. Sandbulte MR, Gautney BJ, Maloba M, Wexler C, Brown M, Mabachi N, Goggin K, Lwembe R, Nazir N, Odeny TA, Finocchario-Kessler S. Infant HIV testing at birth using point-of-care and conventional HIV DNA PCR: an implementation feasibility pilot study in Kenya. Pilot Feasibility Stud. 2019;5(1):18. doi: 10.1186/s40814-019-0402-0.
    1. Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. FostWexler C, Maloba M, Goggin K, Kale SB, Maosa N, Muchoki E, et al. ART initiation for infants diagnosed withering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci. 2009;4(1):50. 10.1186/1748-5908-4-50.
    1. Wexler C, Maloba M, Goggin K, Kale SB, Maosa N, Muchoki E, et al. ART initiation for infants diagnosed with HIV through point of care and conventional polymerase chain reaction testing in Kenya: a case series. Pediatric Infect Dis J. 2021;40(4):e151–3.
    1. Wexler C, Maloba M, Brown M, Mabachi N, Goggin K, Gautney B, Odeny B, Finocchario-Kessler S. Factors affecting acceptance of at-birth point of care HIV testing among providers and parents in Kenya: a qualitative study. PloS one. 2019;14(11):e0225642. doi: 10.1371/journal.pone.0225642.
    1. Wexler C, Kamau Y, Halder R, Brown M, Maloba M, Mabachi N, et al. “Closing the gap”: provider recommendations for implementing birth point of care HIV testing. AIDS Behav. 2018;23(4):1073–83.
    1. CFIR Research Team. CFIR: Consolidated Framework for Implementation Research. 2021. Available from: . Accessed 20 Nov 2020.
    1. Dedoose. 2020. Available from: . Accessed 20 Nov 2020.
    1. Boeke CE, Joseph J, Wang M, Abate ZM, Atem C, Coulibaly KD, Kebede A, Kiernan B, Kingwara L, Mangwendeza P, Maparo T, Mbaye RN, Mukungunugwa S, Ngugi C, Nzuobontane D, Okomo Assoumou MC, Reta Y, Wambugu B, Rioja MR, Peter T, Doi N, Vojnov L, Khan S, Sacks JA. Point-of-care testing can achieve same-day diagnosis for infants and rapid ART initiation: results from government programmes across six African countries. J Int AIDS Soc. 2021;24(3):e25677. doi: 10.1002/jia2.25677.
    1. Bardosh KL, Murray M, Khaemba AM, Smillie K, Lester R. Operationalizing mHealth to improve patient care: a qualitative implementation science evaluation of the WelTel texting intervention in Canada and Kenya. Globalization Health. 2017;13(1):87. doi: 10.1186/s12992-017-0311-z.
    1. Mc Sween-Cadieux E, Dagenais C, Somé DT, Ridde V. A health knowledge brokering intervention in a district of Burkina Faso: a qualitative retrospective implementation analysis. PloS one. 2019;14(7):e0220105. doi: 10.1371/journal.pone.0220105.
    1. Stokes T, Tumilty E, Doolan-Noble F, Gauld R. HealthPathways implementation in a New Zealand health region: a qualitative study using the Consolidated Framework for Implementation Research. BMJ Open. 2018;8(12):e025094. doi: 10.1136/bmjopen-2018-025094.
    1. King DK, Shoup JA, Raebel MA, Anderson CB, Wagner NM, Ritzwoller DP, et al. Planning for implementation success using RE-AIM and CFIR frameworks: a qualitative study. Front Public Health. 2020;8(59):1–14.
    1. Bianchi F, Clemens S, Arif Z, Sacks E, Cohn J. Acceptability of routine point-of-care early infant diagnosis in eight African countries: findings from a qualitative assessment of clinical and laboratory personnel. J Acquir Immune Defic Syndromes. 2020;84(1):S41–SS8. doi: 10.1097/QAI.0000000000002372.
    1. Iwelunmor J, Blackstone S, Veira D, Nwaozuru U, Airhihenbuwa C, Munodawafa D, et al. Toward the sustainability of health interventions implemented in sub-Saharan Africa: a systematic review and conceptual framework. Implement Sci. 2016;11:43. doi: 10.1186/s13012-016-0392-8.
    1. Kirk MA, Kelley C, Yankey N, Birken SA, Abadie B, Damschroder L. A systematic review of the use of the Consolidated Framework for Implementation Research. Implement Sci. 2016;11(1):72. doi: 10.1186/s13012-016-0437-z.

Source: PubMed

Patrocinadores e Colaboradores

Condições médicas

Intervenções de drogas

3
Se inscrever