Operational experiences associated with the implementation of near point-of-care early infant diagnosis of HIV in Myanmar: a qualitative study

Win Lei Yee,Win Win Yee,Claire E Nightingale,Yasmin Mohamed,Htay Htay Tin,Win Thein,Latt Latt Kyaw,Angela Kelly-Hanku,Steven G Badman,Stanley Luchters,Andrew J Vallely,Moe Myat Aye,David Anderson,Hla Htay

doi:10.1186/s12913-021-06797-3

Abstract

BackgroundTimely diagnosis and early initiation of life-saving antiretroviral therapy are critical factors in preventing mortality among HIV-infected infants. However, resource-limited settings experience numerous challenges associated with centralised laboratory-based testing, including low rates of testing, complex sample referral pathways and unacceptably long turnaround times for results. Point-of-care (POC) HIV testing for HIV-exposed infants can enable same-day communication of results and early treatment initiation for HIV-infected infants. However, complex operational issues and service integration can limit utility and must be well understood prior to implementation.We explored and documented the challenges and enabling factors in implementing the POC Xpert® HIV-1 Qual test (Cepheid, Sunnyvale, CA, USA) for early infant diagnosis (EID) as part of routine services in four public hospitals in Myanmar.MethodsThis sub-study was part of a randomised controlled stepped-wedge trial (Australian and New Zealand Clinical Trials Registry, number 12616000734460) designed to investigate the impact of POC testing for EID in Myanmar and Papua New Guinea. Infants recruited during the intervention phase underwent POC testing at the participating hospitals as part of routine care. Semi-structured interviews with 23 caregivers, 12 healthcare providers and 10 key informants were used to explore experiences of POC-EID testing. The research team and hospital staff documented and discussed implementation challenges throughout the study.ResultsOverall, caregivers and healthcare workers were satisfied with the short turnaround time of the POC test. Occasional delays in POC testing were mostly attributable to late receipt of samples by laboratory technicians and communication constraints among healthcare staff. Hospital staff valued technical assistance from the research group and the National Health Laboratory. Despite staff shortages and infrastructure challenges such as unreliable electricity supply and cramped space, healthcare workers and caregivers found the implementation of the POC test to be feasible at pilot sites.ConclusionsAs plans for national scale-up evolve, there needs to be a continual focus on staff training, communication pathways and infrastructure. Other models of care, such as allowing non-laboratory-trained personnel to perform POC testing, and cost effectiveness should also be evaluated.

Highlights

Diagnosis and early initiation of life-saving antiretroviral therapy are critical factors in preventing mortality among HIV-infected infants
POC implementation studies to date have occurred in high-burden countries with high caseloads of HIV-exposed infants; Myanmar’s facilities have low caseloads so staff are less experienced in testing and referral procedures, presenting new challenges
Hospitals were eligible for participation if they: i) offered antenatal HIV screening to pregnant women, (ii) provided services for laboratorybased polymerase chain reaction tests for early infant diagnosis (EID), (iii) had an estimated caseload of at least three HIV-exposed infants attending each month; (iv) had the capacity, or potential capacity, to follow infants for at least 6 months after delivery, and (v) had access to long-term HIV care services, including antiretroviral treatment (ART), so that HIV-infected children who met national criteria for treatment during the study would have immediate and accelerated access to treatment

Summary

Introduction

Diagnosis and early initiation of life-saving antiretroviral therapy are critical factors in preventing mortality among HIV-infected infants. According to UNICEF, only about half of the new-born (47%) received nevirapine syrup for prevention of mother-to-child transmission [13], resulting in a vertical transmission rate of about 17% [11] These figures highlight the critical importance of a functional and effective early infant diagnosis (EID) testing and treatment program in reducing infant deaths. Long test result turnaround times (> 7 weeks) were documented for 36% of babies, with a further 33% never receiving their result, and this was worse for those living further from a centralised laboratory [14] Another evaluation indicated that only 47% of babies received timely EID (before 8 weeks of age), with 27% experiencing a delay in sample collection, and 26% never getting tested [15]

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Discussion

Conclusion