title: Point-of-care screening for syphilis and HIV in the borderlands: challenges in implementation in the Brazilian Amazon.
abstract: BACKGROUND
  Point-of-care (POC) screening for HIV and syphilis using rapid testing was implemented in indigenous communities in the triple-border area of the Brazilian Amazon. We describe the context of the early introduction of POC screening, explore hindering and enabling factors for POC implementation, and recommend strategies for feasible, viable, and sustainable syphilis and HIV screening interventions.
  
  
  METHODS
  This was a qualitative study based on grounded theory methodology. Data were collected using in-depth interviews, semi-structured questionnaires, and field observations and were analysed using the framework approach. Qualitative information was complemented by quantitative data for descriptive purposes.
  
  
  RESULTS
  An overall high score for vulnerability to acquiring HIV and syphilis was observed among the indigenous communities. Health professionals reported satisfactory rapid testing acceptance, although concerns were raised about the pain of the fingerprick. Counselling-related challenges included ensuring the accuracy of translations, collaborating with translators and communicating positive test results. Over 3 months, 86.7% of the syphilis-positive individuals began treatment, and all of them notified their partners. Accessibility, measured as travel time via the local transportation network, was a barrier to health care access. A lack of gasoline for boats and other transportation was also a hindering factor at all levels of implementation.
  
  
  CONCLUSIONS
  The recommendations address the preparation phase at the coordination level as well as at the training level. Tools such as strengths, weaknesses, opportunities, and threats (SWOT) analyses; checklists; context-adapted protocols; and fact sheets are very simple methods to facilitate implementation. The findings of this study are important because they may inform the implementation of new health technologies in low-resource national disease control programmes in remote communities.
authors.affiliation: Swiss Tropical and Public Health Institute, University of Basel, Basel, Switzerland. carole.zenruffinen@gmail.com.
authors.forename: Carole Zen
authors.initials: CZ
authors.lastname: Ruffinen
authors.affiliation: Fundação de Medicina Tropical Doutor Heitor Vieira Dourado (FMT-HVD), Avenida Pedro Teixeira 25, CEP: 69040-000, Manaus, Amazonas State, Brazil. xellsabido@gmail.com.|TransLab. Department of Medical Sciences, Faculty of Medicine, Universitat de Girona, Catalunya, Spain. xellsabido@gmail.com.
authors.forename: Meritxell
authors.initials: M
authors.lastname: Sabidó
authors.affiliation: Departamento de Saúde Coletiva, Universidade de Brasília, Brasília, Brazil. ximenapam@gmail.com.
authors.forename: Ximena Pamela
authors.initials: XP
authors.lastname: Díaz-Bermúdez
authors.affiliation: Fundação de Medicina Tropical Doutor Heitor Vieira Dourado (FMT-HVD), Avenida Pedro Teixeira 25, CEP: 69040-000, Manaus, Amazonas State, Brazil. marcuslacerda.br@gmail.com.
authors.forename: Marcus
authors.initials: M
authors.lastname: Lacerda
authors.affiliation: Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK. David.Mabey@lshtm.ac.uk.
authors.forename: David
authors.initials: D
authors.lastname: Mabey
authors.affiliation: Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK. Rosanna.Peeling@lshtm.ac.uk.
authors.forename: Rosanna W
authors.initials: RW
authors.lastname: Peeling
authors.affiliation: Departamento de DST/Aids, Fundação Alfredo da Mata, Manaus, Amazonas State, Brazil. adelebenz@gmail.com.|Departamento de IST, Aids e Hepatites Virais, Secretaria de Vigilância em Saúde, Ministério da Saúde, Brasília, Brazil. adelebenz@gmail.com.
authors.forename: Adele Schwartz
authors.initials: AS
authors.lastname: Benzaken
mesh_terms: D001938:Brazil; D003376:Counseling; D005260:Female; D066296:Grounded Theory; D015658:HIV Infections / Q000175:diagnosis* / Q000208:ethnology; D006282:Health Personnel; D006297:Health Services Accessibility; D006303:Health Services, Indigenous; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D008403:Mass Screening; D000067716:Point-of-Care Testing; D044382:Population Groups; D011247:Pregnancy; D011251:Pregnancy Complications, Infectious / Q000175:diagnosis / Q000208:ethnology; D036301:Qualitative Research; D012747:Sexual Partners; D011795:Surveys and Questionnaires; D013587:Syphilis / Q000175:diagnosis* / Q000208:ethnology