In this mixed methods study, most of the contextual barriers were interlinked and cross-cutting among CFIR domains, with the majority emerging from the inner setting. Major implementation barriers in the inner setting include unavailable communication systems and information gap as well as inadequate resources to support expansion of POCT to other screening sites. Merging and integration of the qualitative and quantitative findings, showed evidence of impact of barriers as expressed in qualitative themes and the coverage expressed as proportions in the surveyed ART clients.
Most respondents reported poor AHD screening coordination among implementers due to communication challenges owing to the absence of ground telephone system and other social platforms for communicating and sharing relevant AHD updates. Communication system barriers existing between healthcare providers and their clients have also been documented elsewhere [24]. Thus, the use of social mobile platforms (SMPs) with instant messaging applications such as WhatsApp is highly recommended. In Ghana, WhatsApp platforms successfully facilitated networking and communication among healthcare workers which offered collaborative opportunities for TB screening and case detection [15]. SMPs provide a fast and affordable means of information sharing between healthcare providers in the management of clients [20, 21, 22].
Some respondents also suggested quarterly cross departmental meetings to facilitate information sharing of AHD updates among implementers. AHD services could also be integrated into ART and TB programmes which are well established and sufficiently supported by MoH PEPFAR implementing partners. Integration of related health programs reduces duplication of services, is cost-effective, and as well as efficient [23, 24].
Facility work flow and distance were also identified as potential barriers as they led to long AHD screening pathways for clients. Similar findings were also reported in a study conducted in the Eastern Africa where overcrowding, long waiting times and lack of resources emerged as prominent barriers [30]. In our study, we noted long client waiting time primarily due to the fact that testing was conducted only in a medical laboratory which also performed other testing services for in-patients and out-patients. Most respondents wished the Point of Care Testing (POCT) for AHD diagnostic services were stationed at ART clinic where the majority of new ART clients report for care. This was underlined as a solution to the problem of long waiting time and loss to follow-up due to congestion at the main laboratory.
However, financial and diagnostic resources are required for the establishment of a functional compartment for AHD services at ART clinic. A recent study at a tertiary healthcare facility in Malawi estimated a capital investment cost of establishing and equipping an advanced HIV disease room for diagnostic tests to be U$10,708 [12]. This amount is affordable for MoH with the support from the U.S. President’s Emergency Plan for AIDs Relief (PEPFAR) which has recently focused on decreasing mortality among PLWH by addressing advanced HIV Disease and its associated opportunistic infections [31].
As a means to increase access to knowledge and information about AHD screening, formal AHD trainings are highly recommended. In our study, stakeholders alluded that healthcare providers with less knowledge of the intervention lacked confidence and self-efficacy when conducting AHD screening in various screening points within the hospital. This led to low screening coverage as many eligible clients were missed out. Such findings corresponds with programme evaluation reports which highlights inadequately trained providers as a stumbling block to a successful implementation of the HIV programmes [27, 28, 29, 30]. Limited trained personnel is a common challenge in the delivery of AHD screening and diagnostic services [14]. Therefore, improving knowledge and information through both formal and informal training is therefore paramount [36]. There is also urgent need for hospital implementation leads to make use of learning platforms such as morning handover reporting and weekly ground ward rounds which we found not to be adequately utilized by nurses and clinicians.
Our investigation also revealed that posters for AHD screening were not available in all screening points. Nursing and clinical staff with less knowledge of the intervention had no access to such reference material. This widened the knowledge and information gap and partly contributed to non-compliance of AHD screening guidelines. Posters with information about eligibility criteria and testing algorithm could be a significant step towards improving adherence to guidelines by health care providers. One advantage of using posters is that they are readily available, hence provides instant knowledge and awareness of the intervention [37].
Most trained healthcare workers perceive the AHD screening package of care to have more clinical benefits to their clients. This is a facilitator of the AHD screening as health providers are motivated by positive clinical outcomes of the intervention. Many scientific papers have reported various benefits of the WHO AHD management package of care which includes improvement in diagnosis and management of opportunistic conditions, leading to improvement of quality of life for PLWH who would otherwise die to HIV related complications [2, 9, 30, 34, 35].
Supervision also tops as strong facilitators of implementation of interventional programmes in HIV/TB [40]. Similar findings emerged in our study in which external networks and partnerships with other health organizations significantly contributed to efficient delivery of the AHD screening services through capacity building. With MoH led mentorship and supervision programmes, major implementation gaps were identified and quickly addressed. Besides, Lighthouse organization technical team was very key in supporting AHD package through facilitation of AHD trainings, review meetings and involvement in reporting monthly data for evaluation.
A successful implementation of an intervention also require presence of experienced focal leaders to oversee the implementation process [41]. Our study site had two focal persons: one with a laboratory background coordinating HIV Testing Services (HTS), while the other one with a clinical background, coordinated ART services. Their extensive knowledge of the AHD management package of care, and high level of commitment, facilitated the implementation of this complex intervention. Globally, there is a tremendous need for well-trained leaders in both healthcare and advocacy, especially in countries with high HIV prevalence and limited human resource capacity [38, 39]. This enables smooth implementation of interventional programmes aiming at reducing the burden of HIV infections and mortality.
Study limitations
We acknowledge that the study wasn’t done on large scale, involving multiple health facilities implementing the WHO recommended AHD package of care due to time and financial constraints.
We also wished we could have interviewed clients who underwent AHD screening services to better understand their experiences. One of the strength of this study is that we employed mixed methods, of which qualitative and quantitative data triangulation improved validity of the findings.