title: Implementation of repeat HIV testing during pregnancy in Kenya: a qualitative study.
abstract: Repeat HIV testing in late pregnancy has the potential to decrease rates of mother-to-child transmission of HIV by identifying mothers who seroconvert after having tested negative for HIV in early pregnancy. Despite being national policy in Kenya, the available data suggest that implementation rates are low.
  
  
  
  We conducted 20 in-depth semi-structured interviews with healthcare providers and managers to explore barriers and enablers to implementation of repeat HIV testing guidelines for pregnant women. Participants were from the Nyanza region of Kenya and were purposively selected to provide variation in socio-demographics and job characteristics. Interview transcripts were coded and analyzed in Dedoose software using a thematic analysis approach. Four themes were identified a priori using Ferlie and Shortell's Framework for Change and additional themes were allowed to emerge from the data.
  
  
  
  Participants identified barriers and enablers at the client, provider, facility, and health system levels. Key barriers at the client level from the perspective of providers included late initial presentation to antenatal care and low proportions of women completing the recommended four antenatal visits. Barriers to offering repeat HIV testing for providers included heavy workloads, time limitations, and failing to remember to check for retest eligibility. At the facility level, inconsistent volume of clients and lack of space required for confidential HIV retesting were cited as barriers. Finally, at the health system level, there were challenges relating to the HIV test kit supply chain and the design of nationally standardized antenatal patient registers. Enablers to improving the implementation of repeat HIV testing included client dissemination of the benefits of antenatal care through word-of-mouth, provider cooperation and task shifting, and it was suggested that use of an electronic health record system could provide automatic reminders for retest eligibility.
  
  
  
  This study highlights some important barriers to improving HIV retesting rates among pregnant women who attend antenatal clinics in the Nyanza region of Kenya at the client, provider, facility, and health system levels. To successfully implement Kenya's national repeat HIV testing guidelines during pregnancy, it is essential that these barriers be addressed and enablers capitalized on through a multi-faceted intervention program.
authors.affiliation: Department of Health Care Organization and Policy, University of Alabama at Birmingham School of Public Health, Birmingham, USA. rogersaj@uab.edu.
authors.forename: Anna Joy
authors.identifier: 0000-0002-9907-8806
authors.initials: AJ
authors.lastname: Rogers
authors.affiliation: Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya.
authors.forename: Elly
authors.initials: E
authors.lastname: Weke
authors.affiliation: Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya.
authors.forename: Zachary
authors.initials: Z
authors.lastname: Kwena
authors.affiliation: Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya.
authors.forename: Elizabeth A
authors.initials: EA
authors.lastname: Bukusi
authors.affiliation: Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya.
authors.forename: Patrick
authors.initials: P
authors.lastname: Oyaro
authors.affiliation: Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco California, USA.
authors.forename: Craig R
authors.initials: CR
authors.lastname: Cohen
authors.affiliation: Department of Health Care Organization and Policy, University of Alabama at Birmingham School of Public Health, Birmingham, USA.
authors.forename: Janet M
authors.initials: JM
authors.lastname: Turan
mesh_terms: D000288:Administrative Personnel; D000328:Adult; D001291:Attitude of Health Personnel; D005160:Facility Design and Construction; D005260:Female; D015658:HIV Infections / Q000175:diagnosis* / Q000635:transmission*; D006282:Health Personnel; D006297:Health Services Accessibility; D006801:Humans; D018445:Infectious Disease Transmission, Vertical / Q000517:prevention & control*; D007407:Interviews as Topic; D007630:Kenya; D008297:Male; D008423:Maternal Age; D010342:Patient Acceptance of Health Care; D011247:Pregnancy; D011263:Pregnancy Trimester, Third; D011295:Prenatal Care; D036301:Qualitative Research; D011933:Reagent Kits, Diagnostic / Q000600:supply & distribution; D013997:Time Factors; D014186:Transportation; D000078329:Workforce; D016526:Workload
chemical_list: D011933:Reagent Kits, Diagnostic
keywords: Guideline implementation; HIV counseling and testing; Kenya; PMTCT; Pregnancy