This study has demonstrated that nurse based PoC HEID is feasible in resource constrained health care systems as a means to ensure timely test results and interventions for HIV exposed infants. From the main study, we demonstrated that nurses at different levels of the health care system, are capable of performing PoC testing reliably [9]. In this study, we were able to demonstrate a good overall impression and acceptability of PoC EID testing using Gene-Xpert among nurses based in primary health-care facilities. Both findings are similar to studies done in similar settings that assessed the performance and acceptability of PoC EID testing at nurse based primary health care clinics which showed it was both accurate, feasible and acceptable to have nurses perform PoC EID [12,13,14].

It was evident that, all laboratory staff found the two days training was adequate for meeting their skills performing tests. However, six (6/24) of the nurses found the training time not enough especially those from primary health facilities. All but two nurses from primary health facilities felt confident after the training. This may be explained by the numbers of nurses from primary health facilities that suggested more time to be provided for training and more samples to be run for training purposes. However, in the overall impression, almost all the nurses and all laboratory personnel agreed that this platform was easy to learn. Despite the perceptions of inadequacy of the training at the start, several on-job trainings and support were being provided continuously to increase the nurses’ experience and confidence in running the tests.

While all laboratory staff used the Xpert user manual, only two nurses from secondary health facility did use the manual. Those nurses from primary health facility were even less likely to use the manual for reference. Though reasons for not using the manual were not assessed, some challenges such as language barrier may have contributed to this. The manual was in English language, which is not as comfortable as Swahili especially in lower level facilities. The manual did however use simple, easy to understand wording rather than technical terms making it easy for those who reported to have used it often. This highlights the consideration for language translation in development of manuals and job-aides especially in settings as these.

All of the HCWs agreed that HIV-1 Qual PoC testing should be generally used in clinical health care facilities. This was similarly demonstrated in a study done in South Africa, where acceptability of PoC testing was high among nurses at the facilities [15]. Half (11/24) of the nurses did however point out that HIV-1 Qual PoC would add a burden to their routine workload. This was despite the compensation they received for every participant that was attended. In programmatic settings, adopting nurse based PoC testing, would require designating this duty to nurses who are less occupied with other activities at the clinic as well as prioritizing testing at the clinic for high risk mother-infant pairs that require immediate decisions on ART initiation and or enhanced prophylaxis.

Due to the unreliable power supply in most rural and semi urban settings, operationalization of PoC platforms would require a sustainable back up such as solar power as a means to ensure continued testing even in the event of power outages. This operational feature is important in resource constrained settings and PoC platforms with the ability to store charge or use a backup power supply have shown to function well even at community levels [16].

Our study was limited by the small sample size of health care workers involved in the assessment due to the design of the primary study that involved only a number of HCWs in the selected facilities. Also, since the Xpert HIV-1 qual assay was still an investigational assay not yet prequalified by the WHO, test results were not used for medical decision making but rather based on the conversational platforms (Taqman) at the centralized laboratory [17]. Thus, we were unable to assess the impact of Xpert HIV-1 qual on immediate treatment initiation, or infant’s health outcomes. This study operational feasibility assessment was done in clinical trial settings rather than programmatic settings, however, the results highlight on the possible opportunity of involving nurses in performance of PoC EID testing platforms.

In conclusion, nurses at primary health facilities demonstrated very good perception and experiences of using Xpert HIV-1 qual platform for EID testing. With appropriate training, targeted task distribution at the clinics, continual supportive supervision and power back up mechanisms, it is possible to have efficient nurse based PoC EID testing. This decentralization of tests will ensure effective implementation of birth testing, timely availability of results and initiation of follow up with prompt clinical decisions for prophylaxis and treatment [11, 13]. Nurse based PoC tests are not meant to replace the conventional testing that is currently available, but rather supplement it, especially in the most remote areas where, due to structural challenges, are more likely to have longer TATs for HEID results.