Scale-up Efforts Research Articles

On the reliability of image analysis for bubble size distribution measurements in electrolyte solutions in stirred reactors

The translation of chemical processes from laboratory to industrial scale is crucial for the effective and sustainable implementation of new technologies. This transition presents significant challenges, particularly in multiphase systems where variations in physical chemistry can complicate scale-up efforts. A key aspect of this challenge is understanding bubble dynamics in gas-liquid systems, which are pivotal in processes such as hydrogen production and CO2 absorption. Bubble size significantly influences mass transfer rates and process efficiency, necessitating accurate measurement methods. A factorial design approach was employed to assess the sensitivity of results to key parameters. The findings provide quantitative guidelines for optimizing image analysis techniques and improving the accuracy of bubble size measurements in diverse operational conditions. This work advances the understanding of bubble dynamics in gas-liquid systems and offers practical insights for refining measurement techniques, ultimately supporting more effective scale-up of chemical processes.

A Multi-scale Framework for Advancing Battery Safety Through Early Calorimetric Analysis of Materials and Components

Batteries are the cornerstone of the global shift toward electrification, powering applications from passenger transportation, like electric vehicles (EVs), to load shifting of renewable energy generation at the grid level. The demand for batteries is accelerating, and is projected to nearly quadruple by 2030. In response to increasing battery demands, in particular demand for longer range EVs, higher energy density and specific energy alternatives to conventional Li-ion battery technologies are being researched. However, higher energy density directly correlates with an increased potential for higher peak temperatures on failure. In addition, safety evaluation of conventional and new battery technologies generally occurs late in development, often at the commercialization stage when mandated by stakeholders or industry standards. This approach can be costly and challenging as it may require a change to manufacturing processes, a re-design of the battery, and even a change in chemistry to meet safety requirements. This is critical; scale-up efforts alone can take tens to hundreds of millions of dollars and >5 years to achieve. Safety risks discovered after commercialization can significantly exacerbate those figures. Furthermore, safety is still a major risk with already commercialized Li-ion batteries. These risks hinder adoption, slow commercialization, and when they become issues, the outcome may result in recalls, fires, injuries, and even fatalities. Providing additional levers to proactively mitigate safety risk at the materials and components scale (e.g., composite cathode) will lead to considerable time and money savings in the long run.

Chlor-Iron Process for the Low-Temperature, Direct Reduction of Iron Oxide for Green Steel

The reduction of iron ores to metal for steelmaking produces comparable carbon emissions to all light-duty vehicles. We have identified a scalable electrochemical pathway for iron (Fe) production, which we term the chlor-iron process, that consumes only iron and salt water as reactants and could potentially be cost-competitive with iron produced in blast furnaces. Here, we report recent investigations on the mechanism of direct oxide reduction using naturally occurring and synthetic ores and identify key impurities that influence the current efficiency towards Fe. We present device-level data for continuous production of Fe and Cl2 at cell efficiencies < 5 MWh per tonne and with repeated harvesting of iron combined with technoeconomic analysis of pathways to cost competitive iron production. Lastly, we share ongoing scale-up efforts including recent data from a 100 cm2 bifacial cell. The process is unique in that the co-production of NaOH can lead to a net-negative emissions pathways for metals production.

From PERFORM to PERFORM2Scale: lessons from scaling-up a health management strengthening intervention to support Universal Health Coverage in three African countries.

Strengthening management and leadership competencies among district and local health managers has emerged as a common approach for health systems strengthening and to achieve Universal Health Coverage (UHC). While the literature is rich with localized examples of initiatives that aim to strengthen the capacity of district or local health managers, particularly in sub-Saharan Africa, considerably less attention is paid to the science of 'how' to scale-up these initiatives. The aim of this paper is thus to examine the 'process' of scaling-up a management strengthening intervention (MSI) and identify new knowledge and key lessons learned that can be used to inform the scale-up process of other complex health interventions, in support of UHC. Qualitative methods were used to identify lessons learned from scaling-up the MSI in Ghana, Malawi and Uganda. We conducted 14 interviews with district health management team (DHMT) members, three scale-up assessments with 20 scale-up stakeholders, and three reflection discussions with 11 research team members. We also kept records of activities throughout MSI and scale-up implementation. Data were recorded, transcribed and analysed against the Theory of Change to identify both scale-up outcomes and the factors affecting these outcomes. The MSI was ultimately scaled-up across 27 districts. Repeated MSI cycles over time were found to foster greater feelings of autonomy among DHMTs to address longstanding local problems, a more innovative use of existing resources without relying on additional funding and improved teamwork. The use of 'resource teams' and the emergence of MSI 'champions' were instrumental in supporting scale-up efforts. Challenges to the sustainability of the MSI include limited government buy-in and lack of sustained financial investment.

Three strategies to revive teetering clean hydrogen dreams

A global effort is underway to realize long-held visions of a diversified clean hydrogen (H2) economy. In the United States, the Department of Energy has selected seven clean H2 hub proposals into which it plans to invest $7 billion, along with another $1 billion to stimulate demand for the molecules. Coupled with generous production subsidies, these moves are intended to support early-movers to prove business models, initiate the build-out of distribution infrastructure, and catalyze further scale-up efforts. Major public support programs are also underway in Europe, Asia, the Middle East, North Africa, and Australia. Despite this unprecedented level of public funding, there is a growing risk that follow-on commercial adoption could be mostly limited to substitution in existing uses, new entrants will struggle to gain traction, and private capital will remain on the sidelines for emerging applications. Drawing on insights from senior stakeholders from across the clean H2 value chain and investment community, we explain why the long-term prospects for most clean H2 use-cases remain moribund, and show how public support can address the underlying “system-level” gaps that must also be overcome to truly unlock large-scale growth. In particular, there is an opportunity and need for public support to help resolve three underlying issues: (i) clarifying fit with the broader clean energy ecosystem; (ii) bridging “chicken-and-egg” barriers; and (iii) harnessing incumbency without being captured by it.

Optimizing Solar Panel Systems using Machine Learning and Ant Colony Optimization

In this study, the optimization of solar panel systems is investigated using machine learning algorithms and Ant Colony optimization. The performance of ML models, such as Artificial Neural Network, Support Vector Machine, Decision Tree, and Random Forest, is assessed relying on precision, recall, F1 score, and accuracy. Furthermore, the ANN model is combined with ACO for additional optimization. The results of the experimentation indicate that the ANN model demonstrates the best performance with the following scores: 97.86% precision, 96.50% recall, 97.20% F1 score, and 98.00% accuracy. In addition, when ACO is applied, the ANN model focuses its capabilities to predict the pressure hitting on the panel as follows: 98.50% precision, 97.80% recall, 98.15% F1 score, and 98.80%. The given outcomes also reflect the application of confusion matrices to show the classification of each model, and the results indicate that the most effective way to predict the parameters of the solar panel and optimize the system is presented by the combination of ANN and ACO. In such a way, the importance of using machine learning approaches and optimization techniques to optimize the energy generation efficiency in renewable energy systems is indicated. In the future, extensive research should be performed to assess experiments on large-scale solar panel systems using the proposed approaches and algorithms to scale-up sustainability efforts and minimize the environmental impact.

Training experienced mental health practitioners to deliver foundational trauma education: The core curriculum on childhood trauma.

The majority of U.S. mental health practitioners receive little to no foundational trauma education, and instead rely on in-service or continuing education to fill this deficit. Consequently, it is essential to have experienced mental health practitioners capable of delivering trauma education. Since 2009; experienced mental health practitioners have been trained to use the Core Curriculum on Childhood Trauma (CCCT) to deliver trauma education to other mental health practitioners. Despite prior evidence that the CCCT increases the trauma skills of trainees, to date no evaluation has been conducted on developing facilitators' skills, a crucial element in ensuring effective education. Longitudinal, multiinstrument data were collected from 85 CCCT facilitators trained between October 2016-January 2020; along with learning outcome data from 1646 mental health practitioners trained by those facilitators through March 2021. High facilitator skill levels were seen across all instruments, including statistically significant change between preand posttraining measures for 7 core facilitator skills (effect sizes: .90 to 2.25). The data also identified challenges in facilitator development and retention. CCCT facilitator training effectively imparts skills needed to increase workforce trauma capacity; however, modifications to the facilitator development model are needed to maximize impact of scale-up efforts. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Detection of High-Risk Human Papillomavirus Genotypes Among HIV-Infected Women in Four States in Nigeria.

Introduction The World Health Organization states that almost all cervical cancer cases are linked to infection with high-risk human papillomavirusestransmitted through sexual contact. Implementing effective surveillance and preventive measures would enable the prevention of most cervical cancer cases, especially in HIV-infected women. Every year, about 12,000 women in Nigeria are diagnosed, with almost 8,000 deaths. HPV cervical cancer testing capacity is low in Nigeria. Testing scale-up and sensitization efforts across health facilities, including cervical tissue sample collection, are needed to reduce the cases of cervical cancer. This study aimed to assess the genotype-specific prevalence of clinically relevant high-risk HPV among women living with HIV in Nigeria. Methods A descriptive, cross-sectional study was conducted among adult HIV-infected women attending health facilities in four Nigerian states. From August to October 2022, cervical tissue was collected into PCR cell media, transported to the Nigerian Institute of Medical Research, and assayed for HPV presence and genotype using the Cobas 6800 System (Roche Diagnostics). Statistical analysis was conducted with Stata 2. Results A total of 4423 cervical swab samples were tested. The ages of women ranged from 18 to 72 years (mean 36.61±8.61). In our study, we found that 16.3% of participants tested positive for HPV. Among the high-risk HPV genotypes detected, HPV16 was present in 1.44% of participants, HPV18 in 1.29%, and other high-risk HPV (OHR-HPV) in 11.35%. Additionally, co-infections were observed, with 0.98% of participants testing positive for both HPV16 and OHR-HPV, 1.12% for HPV18 and OHR-HPV, and 0.12% for HPV16, HPV18, and OHR-HPV concurrently. However, 7.4% of the total results were deemed invalid. Conclusion OHR-HPV is prevalent among HIV-infected women across the north and west geopolitical zones of Nigeria. Policies and interventions geared towards curtailing the incidence of cervical cancer are fervently solicited.

A feasibility study of external implementation support provided across two states in the U.S.

Background External implementation support (EIS) can aid implementation and scale-up efforts, but less has been reported about the experience of those receiving EIS, such as the feasibility and usability of participating in the support process. Method From November 2016 to April 2022, data were collected from the support participants across 13 regions in North Carolina and South Carolina implementing the Triple P system of interventions and the regional support team members who provided EIS to these partners. The experience of participating in EIS was assessed using measures of acceptability, appropriateness, accessibility, quality of delivery, feasibility, likelihood and actual use of support materials received, degree of collaboration, and frequency of contact. Mann–Whitney U tests or Kruskal–Wallis tests were conducted to explore differences in these measures across a variety of regional characteristics and contexts. Results Support participants generally found EIS to be accessible, acceptable, appropriate, feasible, and delivered with high quality across different states, regions, and over the course of the support relationship. Support was generally provided 1–2 times per month and collaboration between regional support teams and regional Triple P partners was rated highly significant differences between support participant experiences were generally limited to ratings of support accessibility, engagement with data collection processes, and number of monthly contacts. Conclusions This pattern of findings suggests that EIS as provided by regional support teams is feasible for support participants across a diversity of contexts. Additional research on EIS would help refine the field and illuminate promising practices and mechanisms of change to accelerate successful and sustainable implementation.

A nanofluidic exchanger for harvesting saline gradient energy.

The energy of saline gradients is a very promising source of non-intermittent renewable energy, the exploitation of which is hampered by the lack of viable technology. The most investigated harvesting methods rely on selective transport of ions or water molecules through semi-permeable or ion-selective membranes, which demonstrate limited power densities of the order of a few W m-2. While in the last decade, single nanofluidic objects such as nanopores of nanotubes have opened up very promising prospects with power density capabilities in the order of kW or even MW m-2, scale-up efforts face serious issues, as concentration polarization phenomena result in a massive loss of performance. We propose here a concept of a nanofluidic exchanger for power generation from saline gradients, focused on designing a nanoscale flow able to harvest the power at the output of the nanopores. We study analytically and numerically a simple exchanger made of a selective nanoslit fed by a nanofluidic assembly. One specific feature of such an exchanger relies on the non-linear ion fluxes through the nanoslit analytically expressed from the integration of the Poisson-Nernst-Planck equations. Such an elemental brick could be massively parallelized in stackable electricity-generating layers using standard technologies of the semi-conductor industry. We demonstrate here a scheme for rationalizing the choice of the exchanger parameters, taking into account the transport properties at all scales. The full numerical resolution of the three-dimensional device shows that net power densities of 300 W m-2 and more can be achieved.

Risk Minimization in Scale-Up of Biomass and Waste Carbon Upgrading Processes.

Improving the odds and pace of successful biomass and waste carbon utilization technology scale-up is crucial to decarbonizing key industries such as aviation and materials within timelines required to meet global climate goals. In this perspective, we review deficiencies commonly encountered during scale-up to show that many nascent technology developers place too much focus on simply demonstrating that technologies work in progressively larger units ("profit") without expending enough up-front research effort to identify and derisk roadblocks to commercialization (collecting "information") to inform the design of these units. We combine this conclusion with economic and timeline data collected from technology scale-up and piloting operations at the National Renewable Energy Laboratory (NREL) to motivate a more scientific, risk-minimized approach to biomass and waste carbon upgrading scale-up. Our proposed approach emphasizes maximizing information collection in the smallest, most agile, and least expensive experimental setups possible, emulating the mentality embraced by R&D across the petrochemical industry. Key points are supported by examples of successful and unsuccessful scale-up efforts undertaken at NREL and elsewhere. We close by showing that the U.S. national laboratory system is uniquely well equipped to serve as a hub to facilitate effective scale-up of promising biomass and waste carbon upgrading technologies.

Aligning public health and public safety: Probation as a touchpoint to identify and link patients with opioid use disorder to opioid agonist treatment.

People in criminal justice settings (CJS) have high rates of opioid use disorder (OUD) and HIV. Probation is part of the CJS and congregates many individuals with high rates of mental health and substance use disorders relative to the general population; nevertheless, probation remains a major improvement to incarceration. As a steppingstone to full decarceration efforts, community supervision settings like probation can be leveraged as "touchpoints" to identify and link people with OUD (and other co-morbid conditions) to treatment and reduce criminal activity. To determine the feasibility of a modified screening, brief intervention and referral to treatment (SBIRT) strategy to link probationers to opioid agonist therapies (OAT) in the newly created probation system in Ukraine, we conducted a single-arm SBIRT intervention in eight probation centers in four Ukrainian administrative regions. For those screening positive for OUD, interest in OAT was assessed before and after a brief intervention. Those interested in OAT were referred to community OAT services. Participants with OUD also underwent HIV testing. Of the 1,298 consecutive individuals screened, 208 (16.0%) met criteria for opioid dependence. Of these, 122 (58.7%) enrolled in brief intervention, of which 54 (44.3%) had HIV and 14 (25.9%) of these were newly diagnosed. After the brief intervention, interest in starting OAT increased significantly from a median of 7.0 to 8.0 (P = <0.001) using a 10-point scale. Thirty (N = 30; 24.6%) of the enrolled participants initiated OAT and 21 of these (70%) were retained in treatment for 6 months. The prevalence of OUD (and HIV) is high among people in probation in Ukraine. SBIRT can identify a large number of people eligible for OAT, many of whom were willing to initiate and remain on OAT. Integrating SBIRT into probation can potentially assist with OAT scale-up and help address HIV prevention efforts.

A clustered randomized control trial to assess feasibility, acceptability, and impact of implementing the birth companion intervention package in Ethiopia, Kenya, and Nigeria: study protocol

BackgroundA birth companion is a simple and low-cost intervention that can improve both maternal and newborn health outcomes. The evidence that birth companionship improves labor outcomes and experiences of care has been available for many years. Global and national policies exist in support of birth companions. Many countries including Ethiopia, Kenya, and Nigeria have not yet incorporated birth companions into routine practice in health facilities. This paper presents the protocol for a trial that aims to assess if a package of interventions that addresses known barriers can increase the coverage of birth companions.MethodsThis two parallel arm cluster randomized controlled trial will evaluate the impact of a targeted intervention package on scale-up of birth companionship at public sector health facilities in Ethiopia (five study sites encompassing 12 facilities), Kenya (two sites encompassing 12 facilities in Murang’a and 12 facilities in Machakos counties), and Nigeria (two sites encompassing 12 facilities in Kano and 12 facilities in Nasarawa states). Baseline and endline assessments at each site will include 744 women who have recently given birth in the quantitative component. We will interview a maximum of 16 birth companions, 48 health care providers, and eight unit managers quarterly for the qualitative component in each country.DiscussionAmple evidence supports the contribution of birth companions to positive health outcomes for mothers and newborns. However, limited data are available on effective strategies to improve birth companion coverage and inform scale-up efforts. This trial tests a birth companion intervention package in diverse clinical settings and cultures to identify possible barriers and considerations to increasing uptake of birth companions. Findings from this study may provide valuable evidence for scaling up birth companionship in similar settings.Trial registrationTrial is registered with ClinicalTrials.gov with identifier: NCT05565196, first posted 04/10/ 2022.

From trials to communities: implementation and scale-up of health behaviour interventions

BackgroundTo maximise their potential benefits to communities, effective health behaviour interventions need to be implemented, ideally ‘at scale’, and are often adapted as part of this. To inform future implementation and scale-up efforts, this study broadly sought to understand (i) how often health behaviour interventions are implemented in communities, (ii) the adaptations that occur; (iii) how frequency it occurred ‘at scale’; and (iv) factors associated with ‘scale-up’.MethodsA cross-sectional survey was conducted of corresponding authors of trials (randomised or non-randomised) assessing the effects of preventive health behaviour interventions. Included studies of relevant Cochrane reviews served as a sampling frame. Participants were asked to report on the implementation and scale-up (defined as investment in large scale delivery by a (non)government organisation) of their intervention in the community following trial completion, adaptations made, and any research dissemination strategies employed. Information was extracted from published reports of the trial including assessments of effectiveness and risk of bias.ResultsAuthors of 104 trials completed the survey. Almost half of the interventions were implemented following trial completion (taking on average 19 months), and 54% of those were adapted prior to doing so. The most common adaptations were adding intervention components, and adapting the intervention to fit within the local service setting. Scale-up occurred in 33% of all interventions. There were no significant associations between research trial characteristics such as intervention effectiveness, risk of bias, setting, involvement of end-user, and incidence of scale-up. However the number of research dissemination strategies was positively associated to the odds of an intervention being scaled-up (OR = 1.50; 95% CI: 1.19, 1.88; p < 0.001).ConclusionsAdaptation of implemented trials is often undertaken. Most health behaviour interventions are not implemented or scaled-up following trial completion. The use of a greater number of dissemination strategies may increase the likelihood of scaled up.

Scale-up and techno-economic analysis of microbial electrolysis cells for hydrogen production from wastewater

Microbial electrolysis cells (MECs) have demonstrated high-rate H2 production while concurrently treating wastewater, but the transition in scale from laboratory research to systems that can be practically applied has encountered challenges. It has been more than a decade since the first pilot-scale MEC was reported, and in recent years, many attempts have been made to overcome the barriers and move the technology to the market. This study provided a detailed analysis of MEC scale-up efforts and summarized the key factors that should be considered to further develop the technology. We compared the major scale-up configurations and systematically evaluated their performance from both technical and economic perspectives. We characterized how system scale-up impacts the key performance metrics such as volumetric current density and H2 production rate, and we proposed methods to evaluate and optimize system design and fabrication. In addition, preliminary techno-economic analysis indicates that MECs can be profitable in many different market scenarios with or without subsidies. We also provide perspectives on future development needed to transition MEC technology to the marketplace.

Implementation of continuous-wave Doppler ultrasound to detect the high-risk foetus in the low-risk mother: lessons from South Africa

IntroductionDetecting the risk of stillbirth during pregnancy remains a challenge. Continuous-wave Doppler ultrasound (CWDU) can be used to screen for placental insufficiency, which is a major cause of stillbirths in low-risk pregnant women. This paper describes the adaptation and implementation of screening with CWDU and shares critical lessons for further rollout. Screening of 7088 low-risk pregnant women with Umbiflow™ (a CWDU device) was conducted in 19 antenatal care clinics at nine study sites in South Africa. Each site comprised a catchment area with a regional referral hospital and primary healthcare antenatal clinics. Women with suspected placental insufficiency as detected by CWDU were referred for follow-up at the hospital. A 35–43% reduction in stillbirths was recorded.MethodsThe authors followed an iterative reflection process using the field and meeting notes to arrive at an interpretation of the important lessons for future implementation of new devices in resource-constrained settings.ResultsKey features of the implementation of CWDU screening in pregnancy combined with high-risk follow-up are described according to a six-stage change framework: create awareness; commit to implement; prepare to implement; implement; integrate into routine practice; and sustain practice. Differences and similarities in implementation between the different study sites are explored. Important lessons include stakeholder involvement and communication and identifying what would be needed to integrate screening with CWDU into routine antenatal care. A flexible implementation model with four components is proposed for the further rollout of CWDU screening.ConclusionsThis study demonstrated that the integration of CWDU screening into routine antenatal care, combined with standard treatment protocols at a higher-level referral hospital, can be achieved with the necessary resources and available maternal and neonatal facilities. Lessons from this study could contribute to future scale-up efforts and help to inform decisions on improving antenatal care and pregnancy outcomes in low- and middle-income countries.

Cost-effectiveness of a direct to beneficiary mobile communication programme in improving reproductive and child health outcomes in India

IntroductionKilkari is the largest maternal messaging programme of its kind globally. Between its initiation in 2012 in Bihar and its transition to the government in 2019, Kilkari was scaled to...

Implementation of an early childhood mental health consultation pilot in Virginia: Critical tensions and implications for scale-up

Early childhood mental health consultation (ECMHC) is a targeted prevention service that aims to build the capacity of early care and education (ECE) professionals and foster supportive environments that promote children’s social–emotional competence and improve mental health and well-being. A key challenge to delivering ECMHC at scale is navigating complex multi-level factors to maximize successful implementation and program benefits at scale. The current study describes the implementation tensions arising during the first year of a pilot ECMHC program conducted in partnership across multiple agencies and a state’s department of education. In the 2021–2022 pilot year, ECMHC was offered as a free service to ECE programs in one large region of Virginia, with the goal of examining feasibility to scale statewide in future years. Consultation was implemented in 45 preschool classrooms across 30 programs. Implementation data were collected using consultation logs and participant surveys, and 20 participants (educators, families, program directors) participated in focus groups. Three implementation tensions are highlighted in this paper: (1) ideal plans versus reality of a new ECMHC roll-out; (2) how to support ECE professionals’ practice as it relates to children’s behavior, without contributing to a deficit view that children need to be “fixed;” and (3) systemic factors in the early childhood field that undermine the implementation and effectiveness of ECMHC. For each tension, we provide context from the larger literature on ECMHC, describe relevant decision points from Virginia’s pilot ECMHC program, and present implementation data to illustrate these tensions in practice. We conclude with reflections on lessons learned that have implications for other ECMHC and SEL intervention scale-up efforts.

How to scale-up: a comparative case study of scaling up a district health management strengthening intervention in Ghana, Malawi and Uganda

BackgroundThe need to scale up public health interventions in low- and middle-income countries to ensure equitable and sustainable impact is widely acknowledged. However, there has been little understanding of how projects have sought to address the importance of scale-up in the design and implementation of their initiatives. This paper aims to gain insight into the facilitators of the scale-up of a district-level health management strengthening intervention in Ghana, Malawi and Uganda.MethodsThe study took a comparative case study approach with two rounds of data collection (2019 and 2021) in which a combination of different qualitative methods was applied. Interviews and group discussions took place with district, regional and national stakeholders who were involved in the implementation and scale-up of the intervention.ResultsA shared vision among the different stakeholders about how to institutionalize the intervention into the existing system facilitated scale-up. The importance of champions was also identified, as they influence buy-in from key decision makers, and when decision makers are convinced, political and financial support for scale-up can increase. In two countries, a specific window of opportunity facilitated scale-up. Taking a flexible approach towards scale-up, allowing adaptations of the intervention and the scale-up strategy to the context, was also identified as a facilitator. The context of decentralization and the politics and power relations between stakeholders involved also influenced scale-up.ConclusionsDespite the identification of the facilitators of the scale-up, full integration of the intervention into the health system has proven challenging in all countries. Approaching scale-up from a systems change perspective could be useful in future scale-up efforts, as it focuses on sustainable systems change at scale (e.g. improving district health management) by testing a combination of interventions that could contribute to the envisaged change, rather than horizontally scaling up and trying to embed one particular intervention in the system.

How pregnant women living with HIV and their male partners manage men's HIV self-testing: qualitative analysis of an HIVST secondary distribution process in Kampala, Uganda.

Increased HIV testing by men in sub-Saharan Africa is key to meeting UNAIDS 2025 testing targets. Secondary distribution of HIV self-testing (HIVST) kits by pregnant women attending antenatal care to male partners has been shown to increase testing among African men. A detailed understanding of how women and male partners manage the distribution and use of HIVST and subsequent linkage to clinic-based follow-up can inform implementation and scale-up efforts. We use qualitative data from the Obumu Study, a randomized trial of secondary distribution of HIVST by pregnant women living with HIV to male partners in Kampala, Uganda, to unpack the HIVST delivery process. The protocol included a clinic visit by male partners to confirm HIVST results. Individual interviews eliciting data on experiences of delivering and using HIVST and of subsequent linkage to clinic-based testing were conducted with a purposefully selected sample of 45 women and 45 male partner Obumu Study participants from November 2018 to March 2021. Interview data from 59 participants (29 women and 30 men) in the HIVST arm were analysed through coding and category construction. Women living with HIV were apprehensive about delivering HIVST to their partners, especially if they had not disclosed their HIV status. They invested effort in developing strategies for introducing HIVST. Male partners described a range of responses to receiving the self-testing kit, especially fear of a positive test result. Women reported leading the self-testing process, often conducting the test themselves. Most women confidently interpreted HIVST results. However, they tended to defer to healthcare workers rather than report positive results directly to partners. Women told their partners the testing process required a clinic follow-up visit, often without explaining the visit's purpose. Many partners delayed the visit as a result. Women again responded by strategizing to persuade their partners to link to follow-up care. Secondary distribution of HIVST by pregnant women living with HIV to male partners can be challenging, especially when women have not disclosed their HIV status. Additional support may alleviate the burden; outreach to male partners may facilitate linkage to confirmatory testing and HIV care or prevention.