‘The baby will have the right beginning’: Infant caregiver and health worker views on point-of-care HIV birth testing across 10 sites in Zimbabwe

doi:10.21203/rs.3.rs-1594505/v1

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Research Article

‘The baby will have the right beginning’: Infant caregiver and health worker views on point-of-care HIV birth testing across 10 sites in Zimbabwe

https://doi.org/10.21203/rs.3.rs-1594505/v1

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Background

The survival of HIV-infected infants depends on early identification and initiation on effective treatment. HIV-exposed infants are tested at 6 weeks of age; however, testing for HIV sooner (e.g., shortly after birth) can identify in utero infection, which is associated with rapid progression. Infant early diagnostic virologic tests often have long turnaround times, reducing the utility of early testing. Point-of-care (POC) testing allows neonates born in health facilities to get results prior to discharge.

Methods

Beginning in 2018, Zimbabwe offered standard HIV testing at birth to high-risk HIV-exposed infants; as part of a pilot program, at 10 selected hospitals, POC birth testing (BT) was offered to every HIV-exposed infant. To understand the views of infant caregivers and health workers regarding POC BT, 48 interviews were held: 23 with infant caregivers and 25 with health workers, including 6 nurses-in-charge. Participants were purposively sampled across the participating sites. Interviews were held in English, Shona, or Ndebele, and transcribed in English. Line-by-line coding was carried out, and content analysis and constant comparison were used to identify key themes for each respondent type.

Results

Findings were organized under four themes: challenges with BT, acceptability of BT, benefits of BT, and recommendations for BT programs. Overall, BT was well accepted by caregivers and health workers because it encouraged mothers to better care for their uninfected newborns or initiate treatment more rapidly for infected infants. While the benefits were well understood, mothers felt there were some challenges, namely that they should be informed in advance about testing procedures and tested in a more private setting. Caregivers and HCWs also recommended improving awareness of BT, both among health care workers and in the community in general, as well as ensuring that facilities are well-stocked with supplies and can deliver results in a timely way before scaling up programs.

Conclusions

Caregivers and health workers strongly support implementation and expansion of birth testing programs due to the benefits for newborns. The challenges noted should be taken as planning guidance, rather than reasons to delay or discontinue birth testing programs.

Birth testing

HIV/AIDS

point of care

postnatal care

qualitative

interviews

Zimbabwe

Many HIV-exposed newborns are not tested for HIV or are tested too late to receive timely clinical intervention; long turnaround times for virologic tests compound the issue.
Point-of-care HIV testing has been shown to greatly reduce turnaround time for infant HIV diagnostic tests at 6-8 weeks of age; point-of-care HIV testing for newborns offers the possibility of rapid testing and result return, often prior to hospital discharge after birth.
There have been very few studies of birth testing, even fewer on point-of-care birth testing, and almost none on the use of point-of-care birth tests in routine settings across districts. Pilot studies have suggested high uptake, effectiveness, and acceptability.

Point-of-care birth testing was well accepted by caregivers and health workers in a routine setting in Zimbabwe because it encouraged mothers to better care for their uninfected newborns or initiate treatment more rapidly for infected infants.
Some noted challenges were a maternal desire to be informed in advance about testing procedures and tested in a more private setting, as well as ensuring that facilities are well-stocked with supplies and community awareness is high.
Caregivers and health workers strongly support implementation and expansion of birth testing programs due to the benefits for newborns. The challenges noted should be taken as planning guidance, rather than reasons to delay or discontinue birth testing programs.

Prevention of mother-to-child HIV transmission has greatly reduced the number of children born with HIV, but in 2020, there were still 150,000 cases of perinatal transmission globally; despite greater availability of pediatric treatments, 37% of HIV-exposed infants are not tested in the first two months of life (¹). Mortality for untreated infants is high, with almost 50% succumbing to the disease before age two, with the highest risk occurring around 10 weeks of age (²). Innovations in testing technologies and improved service delivery are urgently needed to address this gap.

Early infant diagnosis at age 6-8 weeks is recommended by the World Health Organization (WHO) and has been scaled up many countries (³). Where 6-week testing programs are strong, the WHO more recently recommended considering the addition of birth testing (BT) to the existing testing algorithm (⁴). Because disease progression can be rapid among untreated infants, especially preterm or low birth weight infants, identifying infections immediately after birth and initiating a treatment regimen can greatly improve survival for the most at-risk infants (⁵).

Due to the need for virologic testing and lengthy laboratory processing procedures for infant blood samples, the turnaround times for conventional BT can be slow, reducing the clinical effectiveness of testing. Nonetheless, successful BT pilots and programs have been introduced in many countries in Southern Africa, including Eswatini, Malawi, Mozambique, South Africa, Zambia, and other countries (^6-7), although studies in each recorded challenges and delays, with some specifically noting the need for rapid on-site tests (^8,9,10,11). The introduction of point-of-care (POC) testing, which allows for on-site processing of blood tests, instead of sending samples to reference laboratories, provides the possibility to offer BT and receive results within hours or days, rather than weeks or months. Previous studies have shown that POC is feasible at birth (^12,13); offering birth testing with POC with rapid availability of test results allows most caregivers to know the result before discharge after delivery. Infants who are identified as HIV-positive can be enrolled in the HIV program per protocol and initiated on treatment as soon as possible.

Previous studies have shown that POC testing at age 6-8 weeks can reduce median turnaround time from sample collection to results from 55 to 0 days (¹⁴). Building on the existing POC early infant diagnosis program in Zimbabwe, the Ministry of Health and Child Care worked with the Elizabeth Glaser Pediatric AIDS Foundation, with funding from Unitaid, to offer HIV testing at birth to every HIV-exposed infant born at or presenting to 10 hospitals throughout the country (¹⁵). Studies around the time of data collection found an HIV prevalence among adults to range between 10-18% (¹⁶); despite the high coverage of ART among pregnant women (92%), the prevalence of maternal-to-child transmission is still relatively high (8%) (¹⁷). National data from Zimbabwe suggest that the proportion of HIV-exposed infants receiving a 6-8 week HIV test was 56% (¹⁸).

Implementation of BT and the use of POC tests requires both health care workers and infant caregivers to find such testing acceptable (¹⁹). Previous studies in Kenya and Eswatini found POC BT to be highly acceptable to infant caregivers, as the reduction in waiting time for test results greatly reduced anxiety and fear, although many families noted feeling concern about infant pain or fragility. POC BT was also found to be acceptable to health workers, although they also expressed concerns about capacity, workload, sustainability, and post-test engagement of patients in care (^20,21). Following the introduction of POC BT in Zimbabwe, we carried out a qualitative study on the acceptability of POC BT among health workers and infant caregivers. This is one of the first studies to assess POC BT in a routine setting. This study was aimed at understanding the views of infant caregivers and health care workers on POC birth testing in Zimbabwe, with the goal of understanding the acceptability, feasibility, and necessary inputs for a successful POC birth testing program. It was part of a larger study of POC birth testing which also included quantitative data collection in the same 10 sites (14).

Study hospitals (n=10) were selected based on high volumes of births to HIV-infected women, and co-located maternities with an existing POC testing platform on site. Every infant born at or presenting with 72 hours of birth to one of the 10 hospitals was eligible for testing and qualitative participants were selected from the pool of infant caregivers who were offered such a test, as well as health care workers in the same hospitals who were involved with BT. Recruitment for qualitative interviews took place over approximately a one-month period at each site, until the minimum number of interviewees was met. The number and type of qualitative respondents was purposively chosen to include a range of stakeholders, namely health care workers and infant caregivers, with potentially divergent experiences or views. Interviews were conducted by research assistants that were trained in study protocol procedures, conducting qualitative interviews, and human subject ethics. Participants were given $5 to cover travel costs; health care workers were given $4 and a snack as a token of appreciation for their time.

Participants were approached to participate and consented by study staff and invited to participate regardless of their acceptance of testing or receipt of test result. Participants were informed that participation was fully voluntary and asked to provide written informed consent before beginning interviews. Interviews were held in private locations within the hospital facilities. Interviews were guided by pre-developed and pre-tested semi-structured field guides, and were held in English, Shona, or Ndebele, by multi-lingual study staff, depending on comfort and capacity of the interviewee. Interviews lasted between 40 min and 1.5 hours and were audio recorded with permission of participants. Audio recordings were transcribed verbatim by multi-lingual research assistants familiar with the project. Inadvertent disclosure of names or other potentially-identifying information by respondents was redacted during transcription. Shona and Ndebele transcripts were translated into English. Study team members reviewed a selection of transcripts to ensure quality.

Data were uploaded into and analyzed using MaxQDA software version 12.0. General codes developed a priori based on previous knowledge of the topic and study objectives were used in the preliminary analysis of transcripts after reading each for familiarity. More detailed codes were developed during the analysis process, as nuance emerged, and further themes were identified from the data. Thematic analysis and constant comparison methods were utilized to identify and categorize each theme, according to the type of respondent (²²). Themes and subthemes were organized and finalized, and illustrative quotes were selected for each.

A total of 48 interviews were conducted with participants. Twenty-three in-depth interviews (IDIs) were conducted with caregivers and 25 IDIs were conducted with health care workers (HCWs), including 6 who were nurses-in-charge. The caregivers were all mothers, aged 21 to 40 years; for most, the infant being tested was not their first birth. Of the HCWs, most were nurse midwives with 1 to 10 years of experience in their current maternity and/or postnatal unit. Almost all HCWs reported being trained in both early infant diagnosis (EID) and POC EID. Findings were organized under four themes: challenges with BT, acceptability of BT, benefits of BT, and recommendations for BT programs.

Acceptability of Birth Testing

All caregivers appreciated the availability of BT, valuing the ability to go home knowing the child’s status rather than waiting for a prolonged period to receive test results, generally at least six weeks. For infants who received a positive diagnosis, caregivers appreciated being able to get the child on appropriate treatment early based on the HIV birth status.

“I’m just happy that they tested the baby and gave me the results there and there I didn’t have to wait for three months, so I’m very happy with that.” (caregiver)

Many HCWs felt that BT POC testing was more convenient than standard dried blood spot (DBS) testing, with quicker results, but several highlighted that the convenience was only possible with enabling factors such as sufficient staff, training, and the availability of birth testing resources.

“The [BT] program was readily accepted because when it was introduced … it came with less burden than DBS because DBS is strenuous plus it has long turn around …” (HCW)

Caregivers generally trusted the infant test result, and most did not plan to get a confirmatory test elsewhere, but stated they would wait to have the child tested again at 6 weeks as instructed. This was especially true for caregivers of infants who tested HIV-negative. As one HCW highlighted, if the infant tests positive, caregivers may raise questions about the test’s accuracy more so than if the baby tests negative.

“I’m going to wait for my six weeks visit [to test the baby again], for now I will just give my baby the [prophylactic] medication then they will repeat the test at six weeks as told.” (caregiver)

“They (mothers) do accept [the test results], … but then that’s when questions are like: ‘my child has become positive; isn’t the baby having my antibodies?’ otherwise when the baby is negative there are no questions, but if positive they will ask …” (HCW)

Benefits of birth testing

Caregivers explained that during birth testing they were provided information on how to care for the infant according to the received result, and with this knowledge, it encouraged them to properly care for their child.

“I was happy with that (birth testing) because they will have intervened early by protecting it so that it does not show that the baby has been diagnosed with HIV or not, because they had explained that if the baby is HIV positive and give it the required medication then the baby will be as healthy as other babies you will not notice any difference. As a parent I will be knowing how to protect the baby, what type of food I should give the baby and giving medication on time.” (caregiver)

Both caregivers and HCWs highlighted that when caregivers know their infant was HIV-negative at birth, it can motivate the caregiver to try to keep the infant HIV-negative by closely following care instructions including medication administration, returning for appointments, and proper feeding.

“We had a challenge: we said exclusive breastfeeding so the mother was not sure whether the baby will test negative or positive so some were just doing mixed feeding but ever since we started POC birth testing the mothers will be eager to know what to do which will make their babies negative and they will be having that zeal so that their babies remain negative...” (HCW)

Most caregivers and HCWs said one of the main benefits of birth testing is the ability to initiate an HIV-positive infant on treatment early, rather than waiting until the usual early infant diagnostic test was performed at age 4–6 weeks.

“If the baby is supposed to be on medication, we may do so early instead of waiting for 6 weeks. It may be too late to wait for 6 weeks, and the child would have been affected so much.” (caregiver)

Challenges with birth testing

Many caregivers and HCWs discussed challenges with information about birth testing being provided to caregivers too late. Several mothers noted that they would have preferred to learn about birth testing in advance, such as during ANC visits, rather than at delivery.

“…what we knew way back was that a child gets tested at 6 months so when you are told a new thing now at first you are a bit puzzled because you don’t know the effects because it’s like an immediate thing which has just come so your mind spins and you don’t know how to accept it and you don’t know what to do…” (caregiver)

Both caregivers and HCWs stated that some women may need and/or want to first discuss testing the child with their husband or partner. Some respondents described situations where the partner was not available at the time of delivery as a reason that the newborn was not tested at birth.

“There are some people who still have to get consent from the partner … it becomes a challenge now because the husband might not be available at the time you want to do the test and the mother would tell you I cannot do this without the father’s consent.” (HCW)

“…if you are married and if you are in a relationship whereby you communicate before you do anything, you inform each other like are you ok with it…it [birth] testing is one of those things.” (caregiver)

A few respondents commented that women may not be in a mental state to care for an HIV-positive newborn right after delivery, including needing to be ready to take home antiretroviral treatment (ART) medication at discharge. Both caregivers and HCWs noted this as a possible disincentive to accept birth testing, but caregivers generally thought it was not enough of a reason to not test.

“When she [a mother] gives birth to a baby who test positive, …she has to go home with drugs for the baby. It becomes difficult for her to adjust when the baby has tested positive, instead of us giving her time to think over it and come back. … People are not getting time to decide when the baby is positive, they are given medication for the baby, no time to think about it, to decide whether to give the baby [the medications] or not. I think that’s one of the challenges the mother won’t be prepared psychologically.” (HCW)

Several caregivers were appreciative that the testing was done in a private location away from other patients, and many respondents commented on the importance of privacy. For one caregiver the fact that the testing was not conducted in a private location, prevented her from asking all her questions as she wanted to maintain privacy.

“… I was happy that it was done privately right. Where we were, no one knew where I was going. …” (caregiver)

“I couldn’t ask [all my questions] because there was no time and I wanted to maintain privacy since we were in the ward.” (caregiver)

While most women said testing the newborn and receiving the results took less than two hours, HCWs raised concerns that some women may not be willing to wait the additional time it takes for testing for a variety of reasons, such as transportation schedules or impatient family members waiting for the mother.

“They [mothers] are willing, but to wait for 1 hour waiting for results they won’t be comfortable…they will wait because they don’t have a choice, but you will see that they are not happy waiting.” (HCW)

HCWs also explained that the wait time for results could be over an hour if there were stock outs of necessary supplies, a backlog of other samples, or other challenges with the POC machine. HCWs felt these delays might hinder caregivers’ confidence in the program or affect receipt of the child’s result if the caregiver could not wait and was unable to return to the facility.

“There is a challenge at times there will [be] 3 or 4 kids who will need birth [testing] and older kids 6 weeks who will need testing so the machine will be one. People will take time waiting to be tested so some end up going away.” (HCW)

While most HCWs were not concerned about testing a newborn, a few were worried that a newborn was too young to be tested. Among the HCWs who expressed concerns, most felt that knowing the newborn’s status was more advantageous and outweighed any concerns about the infant’s age and fragility. A couple of caregivers noted that it was difficult to see their child pricked and hear them cry, but for these caregivers knowing the newborn status right away was more important than the momentary discomfort.

“There are none [risks] except I was hurt a bit when they pricked the baby and it cried when they were taking blood - but there was nothing bad about it though.” (caregiver)

Recommendations for Birth Testing Programs

Participants gave recommendations for health system, facility, and community levels. Several HCWs suggested including birth testing information as part of health education during ANC visits to help women plan for any additional time to wait for test results, process information, and ask questions, as well as allow caregivers to discuss testing the child with their partners prior to delivery. One HCW suggested providing women with written information materials they could take home.

“I think [information should be given] through health education of the mothers during the ANC because they really need to know what is going to happen.” (HCW)

“The partner can be involved when they come with their partners for the routine ANC visits and we talk to them we allow them to ask questions and by the time they deliver maybe the partner would actually agree because they have information.” (HCW)

At the individual facility level, both caregivers and HCWs stressed that birth testing needs to be discussed in a private location, not in open wards; however, HCWs stated that their facilities may need additional private spaces for counseling, testing, and providing results.

“Our infrastructure remains a challenge…because when you want to do birth testing soon after delivery you cannot do it because our set up is very poor, there will be other patients in the same room…and we cannot divulge anything. …” (nurse-in-charge)

In addition, HCWs recommended that all facility staff, in particular nurse midwives and other maternal/postnatal department staff, should be educated about birth testing so that any staff member can identify and inform caregivers about birth testing.

“… we also need to conduct teachings, workshops, tutorials so that every health worker knows that there is birth testing so that even if a client comes and asks I have heard about this, any health workers in that facility must be able to explain and give information to that client.” (HCW)

HCWs were unified in their recommendations to ensure that BT programs maintain a consistent and adequate supply of birth testing materials, and most notably cartridges, to ensure that all newborns can be tested and tested in a timely manner.

“The people who are providing the cartridges should be aware of the number of babies that are born every month, maybe an average at this hospital, so that maybe they give enough resources to cater for all of them.” (HCW)

To avoid backlogs and reduce wait times, HCWs suggested providing facilities with more than one POC machine and/or providing POC machines to smaller facilities.

“…we sometimes have too many specimens to do at one [time], those that need testing at birth and the other ones being tested at six weeks all to be done with one machine, … it becomes a very big burden such that you don’t finish running the specimens in single a day and some people will be waiting and they will be complaining you are taking too long to produce the results. ….” (nurse-in-charge)

Several HCWs also suggested educating the general community about birth testing to increase caregivers’ awareness and acceptance of birth testing.

“I think there should be community talks, like health education, health workers going to community impacting knowledge about the benefits of birth testing …” (HCW)

Overall, caregivers and HCWs strongly recommended continuing and expanding birth testing programs due to the related benefits, such as early initiation. They noted the challenges as program aspects to be considered, not a reason to delay or discontinue testing programs.

Infant caregivers and health workers were overwhelmingly accepting of POC BT, even as concerns about the program were noted. Infant caregivers noted ongoing structural challenges with health systems, such as the lack of private space in hospitals in which to discuss tests and results, and noted the need for introducing the topic of birth testing both to a wider audience in the community, and at appointments prior to delivery. Caregivers also worried about the age and fragility of newborns to have a blood draw; however, no respondents believed this outweighed the need and benefit of having the test. Further, most infant caregivers were grateful to receive test results sooner in order to act sooner to prevent transmission in the postpartum period or initiate treatment as soon as possible.

Health workers equally saw a benefit of being able to provide test results quickly, especially as they previously had challenges contacting patients after discharge. Health workers agreed with the need to raise awareness about BT generally in the community, but also noted the need to ensure consistent supplies of equipment (namely, cartridges) before scaling up programs, in order to ensure that every patient offered a test was actually able to receive one and get results in the promised timely way. Considering the benefits, infant caregivers and health workers, including in-charge nurses, were in favor of continuing, expanding, and promoting POC BT.

Findings from this study suggest that, while scaling up POC BT programs, attention should be paid to the health system aspects that are necessary for its success: specifically, ensuring private areas for patient testing and discussion, ensuring sufficient numbers of trained staff to run tests, and strengthening forecasting and supply chain systems for testing equipment. As much as possible, health care workers should include discussions about BT in antenatal care visits and allowing infant caregivers time (both antenatally and postnatally) to ask questions about the test and be reassured about its safety and minimal pain and invasiveness.

In other studies, BT has been found to be generally acceptable among caregivers and HCWs (^23,24). Similar to this study, other studies have found parental concern about pricking newborns (23^,24), but in general BT was considered to be in the best interest of the child and the benefits seen to outweigh the concerns. Similar to this study, a study in Kenya reported that BT can improve newborn care and reduce parental anxiety (²⁵). However, the same study also found concerns that a HIV-positive result at birth would impact parent-infant bonding and negatively impact care (25).

Compared to conventional birth testing, POC BT offers a unique opportunity to ensure that infants are tested and lab results returned more quickly. A pilot study in Eswatini that provided intensive support to return results managed a median turnaround time of 13 days, but a recent study from Zambia which evaluated a conventional BT pilot, and which may represent a more typical experience, reported a median turnaround time of 53 days (11). Thus, even with intensive support to conventional systems, POC is likely to significantly improve turnaround times in most settings.

One of the main challenges, regardless of testing method, is ensuring that infants who test HIV-positive are linked to care in order to begin treatment. The conventional testing study in Zambia found that only a third of infants diagnosed with HIV were linked to care (11), but a BT study in Eswatini found 84% of infants testing positive were initiated on treatment (12). A qualitative study on birth testing in Lesotho found that treatment acceptance did not appear to be different between mothers learning their child was infected at birth versus other time points (24), and it is likely that linkage to care depends more on availability of treatment services or clinics and interoperability of medical record systems than parental acceptance.

One of the initial concerns raised with BT was whether parents would return in the 6-8 week window period for the follow-up test as recommended. Quantitative data from the same study as presented here found a 46% return for subsequent testing within 8 weeks after an initial POC negative birth test (²⁶). The conventional testing study in Eswatini found that return rates for the follow-up appointment dropped from 78% to 74% after the introduction of BT (23), but the POC birth testing study in Eswatini found a 91% return rate for infants at 6-8 weeks who tested negative at birth (12). A POC birth testing study in Kenya also found that 92% returned at the six-week follow-up period (²⁷). Thus, it appears feasible to encourage and achieve high levels of follow up testing for those testing negative at birth. Qualitative research may be helpful to identify the barriers still outstanding for those who did not return for follow up testing.

On the health system side, this study identified the challenge of adequate staff and supplies, which has been reported elsewhere in the literature (25). Challenges with stockouts, broken machines, expensive cartridges, and electrical blackouts remain persistent barriers to sustainable implementation. A study in Kenya comparing piloting POC machines against conventional lab-based processing found higher rates of missed testing opportunities, largely due to machine/stock outs and invalid results (27).

This study provides important insight into the experiences with POC BT but has some limitations. As this was not a longitudinal or comparative study, each participant only had the experience of POC BT, unless they had other children who were tested, most likely receiving conventional testing at 6 weeks, and possibly at different clinics under different circumstances. As it is possible to have a conventional BT or a 6-week POC test, the experiences of POC and BT together may be conflated. Although efforts were made to include a selection of participants from across multiple regions in the country, the selected facilities were only hospital level, and patients at other types of medical facilities (where the program might expand to) may be different. Lastly, because acceptance of BT was so high, we were unable to interview caregivers who refused testing, and this minority of caregivers may have differing views than the caregivers who accepted testing.

Because BT is so new, and POC BT even newer, this study provides important information about its acceptability among various stakeholders. Unlike previous pilot studies, this study included 10 hospitals in a wide range of regions, providing further confidence in the near-universality of acceptability.

As POC BT is introduced in a country or region, the specific needs of the infant caregivers and health care workers should be taken into consideration, as there may be differences in the experiences and concerns across countries. Future research should also seek to understand the views of the general community on HIV and birth testing and to identify the best strategies for raising community awareness. Programs will need to implement strategies to improve linkage to care for infected infants as well as follow-up for subsequent testing for infants initially testing negative (²⁸), as well as ensure consistent availability of supplies. As POC BT becomes available in lower-volume clinics and health facilities, further implementation research will be needed about how to ensure its optimal use and effectiveness.

POC BT not only improves timeliness and clinical outcomes, but it overwhelmingly acceptable to infant caregivers and health care workers. Caregiver concerns did not deter from testing, and more rapid results allowed for more immediate health-promoting actions. Most had positive experiences and wanted to share knowledge about the ability of the test with their communities. HCWs note the need to strengthen supply chains in order that those seeking care receive it. The use of POC BT should be scaled up wherever possible, to reach the most at-risk infants, and improve health and survival.

AIDS Acquired Immunodeficiency Syndrome; ARV Antiretrovirals; BT Birth Testing; DBS Dried Blood Spot; EID Early Infant Diagnosis; HCW Health Care Worker; HIV Human Immunodeficiency Virus; IDI In-depth interview; POC Point of Care; WHO World Health Organization

Ethics approval and consent to participate

All methods were performed in accordance with the relevant guidelines and regulations. This study was approved by the Advarra (formerly Chesapeake) IRB in the US, the Medical Research Council of Zimbabwe (MRCZ – study number MRCZ/A/2343), and the Research Council of Zimbabwe (RCZ). Participation was entirely voluntary. Written informed consent was obtained from all study participants and or their legal guardians before participating in interviews.

Consent for publication

Not applicable.

Availability of data and materials

Tools are available upon reasonable request from the corresponding author. Data contain potentially identifiable information and cannot be shared outside of the study team; however summarized reports can be shared on request.

Competing interests

The authors declare no conflicts of interest.

Funding

The study was funded by Unitaid, Geneva, Switzerland. The funding body was not involved in the study design, data analysis, or writing the manuscript.

Authors' contributions

ES and JC conceptualized the project. HWM and AC oversaw data collection, with the support of ES, LK, A Mahomva, and A Mushavi. LK and ES analysed data. ES drafted the manuscript. All authors reviewed, edited, and approved the final manuscript.

Acknowledgements

Thank you to the study participants, especially recently-delivered women and health care workers, who took time to share their experiences with us. Thanks to other contributors to the project including data collectors, coordinators, and translators. Thanks to Lynne Mofenson for review of the final manuscript.

Patient and Public Involvement statement

The development of the research question and outcome measures were informed by previous research on patient priorities, experiences, and preferences. The direct outcome of the research is to assess patient preferences and acceptability of a new technology by asking patients (in the case of children: their families) and health care workers directly. However, patients were not involved in the design, recruitment, or conduct of the study. Findings will be shared with the Ministry of Health, who can share results with health facilities and patient populations. Participants are included in the acknowledgments.

UNICEF. HIV-AIDS data July 2021. URL: https://data.unicef.org/resources/dataset/hiv-aids-statistical-tables
Newell ML, Coovadia H, Cortina-Borja M, et al. Ghent International AIDS Society (IAS) Working Group on HIV Infection in Women and Children. Mortality of infected and uninfected infants born to HIV-infected mothers in Africa: a pooled analysis. Lancet. 2004;364(9441):1236-43.
World Health Organization. WHO recommendations on the diagnosis of HIV infection in infants and children. World Health Organization, Geneva. 2010.
World Health Organization. Consolidated guidelines on HIV prevention, testing, treatment, service delivery and monitoring: Recommendations for a public health approach (July 2021). World Health Organization, Geneva. 2021. URL: https://www.who.int/publications/i/item/9789240031593
Cotton MF, Holgate S, Nelson A, et al. The last and first frontier emerging challenges for HIV treatment and prevention in the first week of life with emphasis on premature and low birth weight infant. J Int AIDS Soc. 2015;18 (Suppl 6):20271
Moucheraud C, Chasweka D, Nyirenda D, et al. Simple screening tool may help identify high-risk children for targeted HIV testing in Malawian inpatient wards. JAIDS. 2018;79(3):352-357..
Ibrahim M, Maswabi K, Ajibola G, et al. Targeted HIV testing at birth supported by low and predictable mother-to-child transmission risk. J Int AIDS Soc. 2018;21(50):e25111.
Nelson A, Maritz J, Giddy J, et al. HIV testing and antiretroviral therapy initiation at birth: views from a primary care setting in Khayelitsha. S Afr J HIV Med. 2015;16(1):376.
Bisschoff C, Coulon J, Isaacs Z, et al. HIV testing at birth: Are we getting it right? S Afr J HIV Med. 2019;20(1):951.
Smith S, Govender K, Moodley P, et al. Impact of Shifts to Birth Testing on Early Infant Diagnosis Program Outcomes in KwaZulu-Natal, South Africa. Pediatr Infect Dis J. 2019;38(7):e138-e142.
Sutcliffe CG, Mutanga JN, Moyo N, et al. Acceptability and feasibility of testing for HIV infection at birth and linkage to care in rural and urban Zambia: a cross-sectional study. BMC Infect Dis. 2020;20(1):227.
Khumalo P, Sacks E, Chouraya C, et al. The cascade of care from routine point-of-care HIV testing at birth: results from an 18-month pilot program in Eswatini. J Acquir Immune Defic Syndr. 2020;84 Suppl 1 (1):S22-S27.
Meggi B, Vojnov L, Mabunda N, et al. Performance of point-of-care birth HIV testing in primary health care clinics: An observational cohort study. PLoS One. 2018;13(6):e0198344.
Bianchi F, Cohn J, Sacks E, et al. 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):e373-3381.
Mafaune, HW, Sacks E, Chadambuka A et al. Effectiveness of maternal transmission risk stratification in identification of infants for HIV birth testing: lessons from Zimbabwe. J Acquir Immune Defic Syndr. 2020;84 Suppl 1 (1):S28-S33.
ZIMPHIA: Zimbabwe Summary Sheet. ZIMPHIA-2020-Summary-Sheet-FINAL.pdf (usembassy.gov). Accessed 17 March 2022.
UNICEF. Zimbabwe Fact Sheet on HIV/AIDS. HIV/Aids | UNICEF Zimbabwe, Accessed 17 March 2022.
Early Infant Diagnosis. Aidsinfo.org. Accessed November 2, 2020.
Katirayi L, Ochuka B, Mafaune H, et al. "We need it the same day so that the mother goes home happy”: Qualitative study of caregivers and community members’ perspectives towards the use of point of care early infant diagnosis. J Acquir Immune Defic Syndr. 2020;84 Suppl 1 (1):S49-S55.
Wexler C, Maloba M, Brown M, et al. 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.
Sacks E, Khumalo P, Tsabedze B, et al. "The right time is just after birth": acceptability of point-of-care birth testing in Eswatini: qualitative results from infant caregivers, health care workers, and policymakers. BMC Pediatr. 2020 Jul 15;20(1):347.
Pope C, Mays N. Qualitative Research in Health Care. Wiley and Sons, 2006.
Teasdale CA, Tsiouris F, Mafukidze A, et al. Birth testing for infant HIV diagnosis in Eswatini: implementation experience and uptake among women living with HIV in Manzini Region. Pediatr Infect Dis J. 2020;39 (9):e325-e241.
Gill MM, Mofenson LM, Phalatse M, et al. Piloting very early infant diagnosis of HIV in Lesotho: Acceptability and feasibility among mothers, health workers and laboratory personnel. PLOS ONE. 2018;13(2): e0190874.
Wexler C, Kamau Y, Muchoki E, et al. (2021). Implementing at-birth, point-of-care HIV testing in Kenya: a qualitative study using the Consolidated Framework for Implementation Research. Implementation Sci Commun. 2021; 2(1), 89.
Aitcheson N, Sacks E, Nyamundaya T, et al. The cascade of care for early infant diagnosis in Zimbabwe: Point of Care HIV testing at birth and 6-8 weeks [Poster Presentation]. 13th ANNUAL CHOP PEDIATRIC GLOBAL HEALTH CONFERENCE - Making Up for Lost Time: Addressing Children’s Needs Post-Pandemic, Philadelphia, PA, United States. 2021, October 29-30.
Finocchario-Kessler S, Wexler C, Brown M, et al.. Piloting the feasibility and preliminary impact of adding birth HIV polymerase chain reaction testing to the early infant diagnosis guidelines in Kenya. Pediatric Infect Dis J. 2021;40(8), 741–745.
Jean-Philippe P, Spiegel H, Gnanashanmugam D, et al. HIV birth testing and linkage to care for HIV-infected infants. AIDS. 2017;31(13):1797-1807.

No competing interests reported.

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‘The baby will have the right beginning’: Infant caregiver and health worker views on point-of-care HIV birth testing across 10 sites in Zimbabwe

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Abstract

Background

Methods

Results

Conclusions

What Is Known About The Subject

What This Study Adds

Background

Methods

Findings

Acceptability of Birth Testing

Benefits of birth testing

Challenges with birth testing

Recommendations for Birth Testing Programs

Discussion

Conclusions

List Of Abbreviations

Declarations

References

Additional Declarations

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Version 1