Table 2 Theme and quotes for the perceived impacts and areas of improvement for POC VL testing scale-up

Perceived positive impacts of POC VL testing intervention.

Rapid return of results or turnaround improves caretaking and facilitated timely interventions.

Enabled caregivers to reflect on their caregiving plan for their children.

“The positive thing [of POC VL testing] is that; for example, if you take my child’s viral load and give me the results after 3 days, it will make me start thinking where I might have gone wrong so that I can improve it. And by the time I will be returning for the next visit, I will know if it is high or low. It really helps because I will do something different early enough to improve it.” (39 years old, female, caregiver)

Allowed providers to make timely decisions regarding patient’s treatment plan.

“What is evident is that the turnaround time is reduced significantly; so, decisions can be made instantly…if this is made available then we can make a decision in a good time.” (Medical superintendent)

Decentralized POC VL testing reduces cost of test and can be used to support hard-to-reach areas.

Cost reduction by eliminating the need for transportation services.

“It being point-of-care means you don’t have to worry about carrying the sample from point A to point B getting a vehicle, courier services and other things…So that again becomes another beautiful thing and so it impacts on cost somehow.” (Technical advisor)

Accessible in hard-to-reach areas.

“So, the introduction of point-of-care was agreed upon in the technical working group that let’s use it for the far to reach areas. In our country, there are far or hard-to-reach areas where there are delays on transportation take many hours.” (Lab director)

Increased testing frequency improves VL monitoring of children and pregnant/postpartum women.

Early detection of viral failure for children.

“Because there is this norm of caregivers being changed; a child is taken to a grandmother, a child is taken to the sister or the auntie so you get adherence issue especially swallowing of antiretrovirals. So, it is better if we do it [VL testing] within three months, you can identify whether this child is failing or not.” (Nursing officer)

Ensure viral suppression for expectant mothers to prevent MTCT.

“I think on a personal level like I said, it’s [three-month testing] something that even I would desire. It’s just that the national algorithm is what limits us. But it’s something to be desired when you are looking at a child or a woman, you know, pregnancy is time-bound and you want to make sure this mother is suppressed by the time they are giving birth to actually reduce the chance of transmission.” (Technical advisor)

Perceived challenges with POC VL testing intervention.

Acceptability of POC VL testing in the healthcare sector.

Discrepancies between POC and centralized VL testing raise credibility concerns among patients.

“Although, the viral load test results have been varying for instance, the viral load test here at the study will differ from the viral load test result from the clinic. So, you end up asking yourself if the tests are different. So, it raises a lot of questions.” (39 years old, female, caregiver)

Providers hope for validation and verifications of POC VL testing.

“Now, the question of quality comes in and you know quality of testing. And you see now, from where I stand, when the question of quality comes in then you want to lean on to what you feel has been validated or what the national program or what the donor is advocating.” (Technical advisor)

Absence of supply chain to support POC diagnostics.

Lack of established supply chain to purchase reagents for the POC testing machines.

“The machine is…like right now, for example the point-of-care EID [early infant diagnosis] machine at another facility, it is not functional because it was brought under partner that their contract ended, nobody has ever bothered to buy the reagents, so the country says they do not have those cartridges in store, we have to buy them I don’t know from where and everybody feels that it is expensive, so it doesn’t help us much.” (Lab manager)

Capacity limitations.

Patient flow increase caused by reduction of testing turnaround time may increase workload for staff.

“Turnaround time[of POC VL testing] has reduced so the number of patients to be tested at a given time goes up. The testing intervals is reduced, so many patients are seen at a short time; which means the staff have more workload, isn’t it? So, the staff has to cover more work.” (Medical superintendent)

Leverage POC testing technology for other infectious diseases testing could be met by challenges with prioritization.

“We anticipate that since we are rolling out the multi-disease testing for VL and TB, they are also supposed to be layered on to support COVID testing in our respective counties. Yet when we reach there under multi-disease testing, there might be issues to deal with prioritization that might end up impacting the VL testing on the same equipment.” (Lab specialist)

Integration of POC VL testing into the current testing guidelines.

The presence of multiple testing guidance led to confusion among providers during their clinical decision-making process.

“Because you see like right now the guidance that has been loudly spoken of is the guidance [annual or six-month testing] we’ve received from CDC, who is our primary donor that; follow the national testing platform. So now again that brings conflicts because…from what the national test results may be done less frequently than what you are seeing in the [Opt4Kids and Opt4Mamas] patient, they are three different stories then it brings a little bit of confusion…In my opinion if those things could have been sorted out and that process of integration was more seem less, then there will be have no issue, there will be no negative aspect of POC because we want POC. We want that [three-months] frequency.” (Technical advisor)

Anxiety towards blood draws discouraged patients from VL testing.

Children fear the painful sensation brought by blood draws.

“That blood, when the syringe enters the veins, that is the thing I don’t like. It’s really hurting a lot.” (14 years old, male, child participant)

Frequent blood drawing cause anxiety among patients.

“Some won’t come and you know pricking a client every month won’t sound so good to them. Some fear it; yes of course and some tend to think that we are collecting their blood for some other reasons… I don’t know to them what they always think but they are ever complaining that we are collecting their blood every now and then. We have to give reasons why we are doing so and we always don’t have a reason.” (Nursing officer)

Suggested areas of improvement for VL testing scale-up.

Expansion of the POC VL testing scheme.

Policymakers hope for continual and expanded access to POC VL testing.

"I only strongly want to recommend the rolling out of opt [Opt4Kids and Opt4Mamas] to all our health facilities…so that everyone benefits from this and they appreciate the timely ART interventions" (County-level public health authority)

Optimizing clinical management, workload, and utilization of POC diagnostics.

Implementing a robust health information system can drastically improve clinical management and reduce workload.

“It’s [VL results communication] more or less, it’s running up on a paper-based system. Now, the ideal is that all the patient data is on electronic format…then the patient can actually be seen back by the clinician on the same day using a system which is available on the EMR [electronic medical records] and then the national program can also be able to get data actively within such a system…They[providers] also have so much on their hands. Especially if you have a data system that have duplicity in nature. The same data have to be entered at multiple points, then the users of the data who enters the data at times doesn’t see the value of putting in that data. So, we have a lot of data losses across of the cascade there. So, I think one of the main things is to ensure that a system is established and I think we are actually trying to support that. A system is established to avoid duplicity of data entry at various points." (Lab director)

Conducting local validation and quality checks for POC VL testing to build confidence among providers and other policymakers.

“Then what are the quality issues, this is my key problem, what are the quality issues because I really want to believe that before I bring the point-of-care machine, let us run the quality checks and validation so that we can compare the results.” (Lab manager)

Capacity building and partnership development for sustainable VL testing system.

Integrating POC VL testing guidelines with the current national recommendation through collaborative partnership between key stakeholders.

“Collaborating with the current implementing partner so that we harmonize the recommendations because after we get the recommendations, we have again share with the implementing partner on the ground and then we have to wait again for their views… So, if we harmonize that from our top management, it can be good and we can always deliver the services timely to the clients.” (Nursing officer)

Hiring more staff and buying machines to increase the capacity for POC VL testing.

“We need to equip the labs with POC machines and having sufficient staff to support the process.” (HIV advisor)

Envisioning the ideal testing experience.

Three-month testing is the ideal frequency as it allows early detection and intervention for high VL patients.

“And after every three months, we can help those people who are failing to make a decision as fast as possible…One year [testing interval] is a long time. There are people who can be suppressed today and when you tell them your VL is suppressed and you are taking your drugs well, after that he goes and relaxes. So, by the end of one year, you might find that this patient has a lot of VL.” (Clinic manager)

Patients find the amount of blood draw acceptable after receiving education from providers and healthcare staff.

“That quantity is okay… We were told that when a small amount is taken, no results can be obtained and so they must work with a certain quantity to get the required result…If you don’t know anything, you should ask. In the past, we had concerns but it was explained to us and now we know.” (36 years old, female, caregiver)

Performing POC VL testing in the laboratory is preferred; testing at lab can minimize contamination and improve clinical flow.

“Lab is okay because you wouldn’t have to mess up within because everything is arranged well; the syringes and everything else but a room like this, when you want to take the sample then someone knocks at the door. At the lab, people knows that they have to wait to be called in. and those who are associated with the patient knows that he/she has gone to the lab and they wouldn’t disturb."(39 years old, female, caregiver)

Two hundred Shillings or less is the ideal cost for a POC VL test.

“I would be willing to pay because it concerns my child’s health. If it is compulsory to pay, you have to pay because it helps you to know your child’s health progress…I think 100 shillings, 200 shillings or less would be okay. Above 100 shillings would be an extra burden.” (56 years old, female, caregiver)

Ensuring confidentiality when delivering VL results.

“I think it’s important you first ask me where I am because you could be giving me the results and yet I’m in a place where I’m not able to talk to you freely.” (37 years old, female, caregiver)

Preferred method of delivering result is through calls or SMS. State the exact quantity of VL when delivering results.

“I would love if the results will be communicated just like the way they text us or they call us… For a person who is interested, at least they should tell send us the text and tell us the amount of virus according to the viral load results how they came.” (39 years old, female, caregiver)