Implementation bottlenecks of near point of care HIV viral load monitoring for children and young people in Tanzania: A Qualitative Study

BACKGROUND: Near point-of-care (n)POC Human Immunodeficiency Virus (HIV) viral load (VL) monitoring, consisting of VL testing in laboratories close to HIV treatment facilities, improves turnaround time from sampling to result. Other benefits of using nPOC monitoring are reduced laboratory workload, and limited loss of results, all leading to improved clinic retention and treatment adherence. However, the specific implementation bottlenecks are still unclear. This study aims to investigate the bottlenecks in the implementation of nPOC HIV VL monitoring among children and young people (ages 0-24 years) living with HIV, as experienced by healthcare workers (HCWs) in Tanzania. METHODS: We conducted observations in clinics and in-depth interviews with HCWs from January 2023 to January 2024 at Tanzanian intervention sites within the East Africa Point-of-Care Viral Load Monitoring (EAPOC-VL) study. The EAPOC-VL study was conducted in four countries in East Africa (Tanzania, Kenya, Rwanda, Uganda). It was a cluster-randomised controlled trial, in which participants were tested at three time points (months 0, 6, and 12). We purposively selected 25 HCWs involved in implementing nPOC at the intervention sites for in-depth interviews. We interviewed HCWs at baseline (month 0) and after the initiation of nPOC HIV VL monitoring (months 1 and 6). We conducted deductive thematic framework analysis using the Measurement Instrument for Determinants of Innovations (MIDI), to which an inductive approach was added to identify facilitators and barriers across intervention, provider, organisational, social and political contexts. We used NVivo 12 to organise the data. RESULTS: A total of 75 interviews were conducted among 43 HCWs across 3 time points: 33 at baseline (T0), 25 at month 1 (T1; 19 participants from T0 and 6 new participants) and 17 at month 6 follow up (T2;6 participants from T1, 7 returning participants from T0 and 4 new participants). Observations and interviews showed that nPOC HIV VL testing improved result turnaround time and enabled same-day counselling, which motivated both HCWs and clients. This data showed that knowledge, confidence, and adherence to procedures after training. Near POC, HIV VL was supported by compatibility with existing practices, strong teamwork, and management commitment. However, challenges included clients waiting at the clinic for over two hours to receive their results, the scarcity of resources, such as rooms and electricity, and staff shortages. Finally, delays were observed when samples had to be transported to nearby laboratories. CONCLUSION: Near POC HIV VL monitoring shortens turnaround times and enables immediate counselling. To maximise these benefits, there is a need to prioritise investment in staff training, infrastructure, improving sample handling/turnaround time and guideline alignment. Developing these areas will enhance service delivery and allow for improved outcomes among children and young people living with HIV.