Table 1 Approaches to the critical processes of setting up the Early Infant Diagnosis (EID) program in Tanzania, outcomes observed and challenges encountered

Community preparation:

-Engaged communities before services were introduced.

-Targeted influential community leaders for community advocacy.

-Utilized community gatherings for mass communication.

-Created anticipation for the services.

-Community members encouraged to access services.

-Quickly informed many community members.

-Community members expected same-day test results and not to have to return for results at a later visit.

Health facility selection:

-Selected sites with existing PMTCT* programs and maternal child health clinics.

-There was a ready need for EID** services which then easily integrated.

-Some PMTCT programs were not functioning optimally in providing HIV testing and counseling and PMTCT antiretroviral regimens.

-Infant follow-up was not a consistent component of all PMTCT programs.

Health facility preparation:

-Sensitized all health facility staff to refer possible HIV-exposed infants for EID services.

-Identified space where EID services would be offered.

-Worked with health facility staff to create and implement a detailed practical plan on how services would be offered.

-Implemented a system for transporting samples from the site to the laboratory and results delivery back to the site.

-Children were referred from many service delivery points.

-Streamlined registration and follow-up of HIV-exposed infants.

-Streamlined delivery of services.

-Established sample transportation and results delivery systems.

-Health workers had multiple competing responsibilities.

-Maintaining efficiency of the sample transportation and results delivery system.

Capacity building:

-Conducted didactic training complemented with on-site mentorship.

-Empowered health workers and allowed them to develop confidence to implement services.

-Ensured supervision in the early phases of implementation.

-Linked didactic training to implementation.

-Transfer of trained personnel to other departments, facilities or regions. Request for financial incentives by health workers.

Laboratory establishment:

-Renovated an existing zonal laboratory that served multiple sites within the catchment area.

-Trained laboratory staff at a laboratory with established PCR facilities.

-Provided expert mentorship and on-going regular supervision at the laboratory.

-Conducted quality assurance assessments according to standard procedures.

-Minimized start-up costs.

-Laboratory staff gained a practical view of how systems work.

-Ensured continuity of quality PCR services.

-Ensuring continuous supply of materials and supplies for DNA PCR testing.

-Lab personnel had competing responsibilities.

Defining the HIV testing algorithm:

-Done at national level with involvement of key stakeholders including the Ministry of Health and donors.

-Promoted national and stakeholder acceptance of the testing algorithm.

-Reaching agreement on an algorithm that was both cost-effective but clinically relevant.

Registration and follow-up HIV-exposed infants and data collection:

-Created specific tools for recording data related to HIV-exposed infants and PCR testing.

-Developed standard operating procedures for the new clinical services.

-Registered HIV-exposed infants prior to availability of EID services were available.

-Provided comprehensive follow-up care (e.g. giving cotrimoxazole).

-Due to limited resources, preferentially followed-up infants that tested DNA PCR positive through appointment cards, phone calls and home visits.

-Monitoring and evaluation systems were readily available for the national roll-out.

-Ensured HIV-exposed infants were being identified, registered and provided with necessary services.

-Ensured that those at the greatest risk of mortality (HIV-infected infants) were referred to the HIV care and treatment clinic.

-Health services poorly equipped to retain infants for longitudinal follow-up.

-High rate of loss to follow-up to obtain for DNA PCR results.

-Some mothers stopped breastfeeding after first negative PCR result.

-High rate of loss to follow-up to obtain final infection status after breast feeding cessation.