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Delivery of index-linked HIV testing for children: learnings from a qualitative process evaluation of the B-GAP study
Stefanie Dringus1, Katherine Davis2, Victoria Simms3,4
1Public Health, Environments and Society Department, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK. stefanie.dringus@gmail.com.
Insights
Index-linked HIV testing for children in Zimbabwe identified undiagnosed cases but faced challenges. Adapting strategies to local clinic attendance and household structures is crucial for effective implementation and scale-up.
Area of Science:
- Public Health
- Pediatric Infectious Diseases
- Implementation Science
Background:
- Index-linked HIV testing offers a strategy to identify children with undiagnosed HIV.
- The Bridging the Gap in HIV Testing and Care for Children in Zimbabwe (B-GAP) study evaluated this approach in children aged 2-18 years.
- A process evaluation explored considerations for programmatic delivery and scale-up.
Purpose of the Study:
- To evaluate the implementation of index-linked HIV testing for children in Zimbabwe.
- To identify barriers and facilitators to the strategy's programmatic delivery and scale-up.
Main Methods:
- A qualitative process evaluation using implementation documentation.
- Analysis of field team logs, meeting minutes, incident reports, and group chats.
- Thematic analysis to inform intervention scale-up.
Main Results:
- Reduced clinic attendance due to community-based care and proxy treatment collection.
- Challenges with household structures and high community mobility.
- Instances of 'soft refusal,' stigma, and unfamiliarity with testing methods.
- Difficulties in facility-based testing and stockouts/staffing shortages.
Conclusions:
- Attrition occurred along the index-linked HIV testing cascade for children.
- Programmatic adaptations are needed to address clinic attendance and household structures.
- Tailoring index-linked HIV testing to specific subpopulations and contexts is essential for effectiveness.
Background:
Index-linked HIV testing for children, whereby HIV testing is offered to children of individuals living with HIV, has the potential to identify children living with undiagnosed HIV. The "Bridging the Gap in HIV Testing and Care for Children in Zimbabwe" (B-GAP) study implemented and evaluated the provision of index-linked HIV testing for children aged 2-18 years in Zimbabwe. We conducted a process evaluation to understand the considerations for programmatic delivery and scale-up of this strategy.
Methods:
We used implementation documentation to explore experiences of the field teams and project manager who delivered the index-linked testing program, and to describe barriers and facilitators to index-linked testing from their perspectives. Qualitative data were drawn from weekly logs maintained by the field teams, monthly project meeting minutes, the project coordinator's incident reports and WhatsApp group chats between the study team and the coordinator. Data from each of the sources was analysed thematically and synthesised to inform the scale-up of this intervention.
Results:
Five main themes were identified related to the implementation of the intervention: (1) there was reduced clinic attendance of potentially eligible indexes due to community-based differentiated HIV care delivery and collection of HIV treatment by proxy individuals; (2) some indexes reported that they did not live in the same household as their children, reflecting the high levels of community mobility; (3) there were also thought to be some instances of 'soft refusal'; (4) further, delivery of HIV testing was limited by difficulties faced by indexes in attending health facilities with their children for clinic-based testing, stigma around community-based testing, and the lack of familiarity of indexes with caregiver provided oral HIV testing; (5) and finally, test kit stockouts and inadequate staffing also constrained delivery of index-linked HIV testing.
Conclusions:
There was attrition along the index-linked HIV testing cascade of children. While challenges remain at all levels of implementation, programmatic adaptations of index-linked HIV testing approaches to suit patterns of clinic attendance and household structures may strengthen implementation of this strategy. Our findings highlight the need to tailor index-linked HIV testing to subpopulations and contexts to maximise its effectiveness.
