“Testing Can Be Done Anywhere”: A Qualitative Assessment of Targeted Community-Based Point-of-Care Early Infant Diagnosis of HIV in Lusaka, Zambia

Community-based point-of-care testing is an acceptable, appropriate, and feasible strategy for improving access to HIV diagnostic services for high-risk HIV-exposed infants. Key Findings Our novel community-based point-of-care (POC) early infant diagnosis (EID) testing model was introduced into the national prevention of mother-to-child transmission/EID program and leveraged infrastructure from contemporaneous index testing and back-to-care programs. The POC model was perceived as lowering some structural barriers to accessing EID testing and may help reach high-risk mother-infant pairs who may have challenges otherwise accessing HIV testing in traditional health care settings. Because the service is closer to home, privacy must be ensured to address concerns about disclosing HIV status to community members and neighbors. Key Implications Implementation of the community POC EID testing model by lay health care providers using the m-PIMA HIV-1/2 Detect platform may help overcome structural barriers to EID access, increase coverage of EID services for HIV-exposed infants at high risk of HIV acquisition, and reinforce other ongoing HIV case-finding activities in the community. Routine education about the community-based POC EID model at strategic service delivery points within health facilities and communities may help address questions and potential misconceptions about the model, as well as increase overall community knowledge about EID services, particularly those offered in the community. ABSTRACT Introduction: Delayed HIV diagnosis in HIV-exposed infants (HEIs) results in missed opportunities for early antiretroviral therapy (ART), causing significant morbidity and mortality. Early infant diagnosis (EID) depends on the availability of accessible and reliable testing services. We explored the acceptability, appropriateness, and feasibility of deploying a targeted community-based point-of-care (POC) EID testing model (i.e., “community POC model”) to reach high-risk mother-infant pairs (MIPs) in Lusaka, Zambia. Methods: We conducted in-depth interviews with a purposive sample of health care workers, study staff, and caregivers in high-risk MIPs at 6 health facilities included in a larger implementation research study evaluating the community POC model. We defined “high-risk MIPs” as mothers who did not receive antenatal testing or an attended delivery or infants who missed EID testing milestones. Interviews were audio-recorded, translated, and transcribed verbatim in English. Content and thematic analysis were done using NVivo 10 software. Results: Health care workers (n=20) and study staff (n=12) who implemented the community POC model noted that the portability and on-screen prompts of the POC platform made it mobile and easy to use, but maintenance and supply chain management were key to field operations. Respondents also felt that the community POC model reached more infants who had never had EID testing, allowing them to find infants with HIV infection and immediately initiate them on ART. Caregivers (n=22) found the community POC model acceptable, provided that privacy could be ensured because the service was convenient and delivered close to home. Conclusion: We demonstrate the acceptability, appropriateness, and feasibility of implementing the community POC model in Zambia, while identifying potential challenges related to client privacy and platform field operations. The community POC model may represent a promising strategy to further facilitate active HIV case finding and linkage to ART for children with undiagnosed HIV infection in the community.