A mixed methods study on the barriers and facilitators of implementing HIV re-testing guidelines on pregnant women at a referral hospital in Kenya

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However, the barriers and facilitators in the implementation of HIV re-testing guidelines among pregnant women in Kenya are not well understood. The aim of the present study was to evaluate the barriers and facilitators of HIV testing guidelines among pregnant women at the Pumwani Maternity Hospital. Methods This was a mixed methods study. Qualitative data on the barriers and facilitators of HIV re-testing among pregnant women was collected by interviewing key informants (healthcare workers). Quantitative data was collected from pregnant women who had been recruited into the study. Women with an initial HIV negative result at the antenatal clinic (ANC) were recruited at the labor/postnatal ward and at six weeks postnatal review. Quantitative data was analyzed using descriptive statistics while qualitative data was audio recorded, transcribed, and themes were identified. Results There were 242 women who participated in the interview 97 of whom were followed up at 6 weeks via a telephone interview. There were 170 women interviewed at labor ward. The retesting rate was 116 (69.5%). Majority of the women 114 (67.5%) lacked awareness on the need for HIV retesting. Of the 97 women followed up at 6 weeks postpartum, 72 (75%) were retested for HIV. Of the 15 HCWs who were interviewed, 14 (93.3%) had received HTS training. There was varied knowledge on repeat testing guidelines for HIV and the team relied on mentor mothers and prevention of mother to child transmission (PMTCT) nurses to implement the guideline. Conclusion These findings suggest that there were more missed opportunities for HIV re-testing at the labor ward relative to re-testing. There is a need to improve HIV screening at the labor ward to minimize lost opportunities for HIV screening. Mother-to child-transmission HIV testing Pumwani maternity hospital HIV re-testing Figures Figure 1 Figure 2 Figure 3 Figure 4 Background HIV/AIDS is a significant global health challenge, particularly affecting resource-limited settings and vulnerable populations [ 1 – 6 ]. Despite substantial progress in prevention of mother-to-child transmission (PMTCT) programs, vertical transmission of HIV continues to pose a substantial risk [ 7 , 8 ]. According to the World Health Organization (WHO), an estimated 1.5 million (1.2–2.1 million) children (0–14 years old) worldwide were living with HIV in 2022, with the majority acquiring the infection through mother-to-child transmission (MTCT) [ 9 – 11 ]. Early diagnosis and prompt initiation of antiretroviral therapy (ART) are critical to reducing MTCT rates and improving maternal and child health outcomes [ 12 – 14 ]. HIV prevalence in Kenya remains a significant public health concern, with an estimated 1.4 million people living with HIV in 2022 [ 15 ]. The country has made strides in scaling up PMTCT interventions, guided by national guidelines developed by the Ministry of Health and the National AIDS Control Council [ 16 ]. These guidelines recommend routine HIV testing at various stages of pregnancy and postpartum to ensure timely diagnosis and intervention [ 16 ]. Despite these efforts, challenges such as missed opportunities for retesting during labor and postpartum periods persist, potentially compromising the effectiveness of PMTCT programs. Pumwani Maternity Hospital (PMH), located in Nairobi, Kenya, is a referral maternity hospital which provides maternal and child health services, including comprehensive PMTCT services [ 17 ]. PMH serves a diverse population with varying socioeconomic backgrounds, contributing to its significance in addressing maternal and child health disparities in the region. The hospital follows national guidelines for HIV testing and PMTCT, aiming to achieve high rates of HIV testing uptake and adherence to treatment protocols among pregnant women and postpartum mothers. Despite the implementation of guidelines advocating for HIV retesting during labor and postpartum, there is a paucity of data regarding the actual adherence to these guidelines among healthcare providers at PMH. Moreover, the missed opportunities for HIV retesting during labor and postpartum periods among women attending the hospital are not known. Understanding the missed opportunities for HIV retesting during labor and postpartum and the knowledge, attitudes, and practices of healthcare workers (HCWs) towards HIV retesting guidelines is crucial for identifying barriers and facilitators to guideline implementation and designing targeted interventions to improve the uptake of HIV retesting and ultimately reduce MTCT rates. The aim of the present study was to determine the proportion of missed opportunities for HIV retesting during labor and postpartum periods among women attending PMH and to explore healthcare workers' knowledge, attitudes, and practices regarding HIV retesting guidelines at PMH. Methods Ethics statement Authorization to conduct the study was obtained from the Kenyatta Hospital Ethics Research /Committee. REF: KNH-ERC/A/449. The authors confirm that all methods were carried out in accordance with relevant guidelines and regulations. Study design and setting This was a mixed methods study that used qualitative (key informant interview guide) and quantitative (survey questionnaire) techniques. The study was conducted at the Antenatal Clinic, labor/postnatal ward and Maternal and Child health clinic at Pumwani Maternity Hospital. PMH is an Obstetric and Referral hospital specialized for delivery of expectant mothers in Nairobi, and adjacent districts. It is the l argest referral Maternity Hospital in East Africa. It has 2 theatres, 350 Obstetric beds, and 150 baby cots. Normal deliveries conducted per day are 50–100, and Caesarean Sections are 10–15 per day. The staff consists of 27 doctors (20 medical officers,4 specialist obstetricians/gynaecologist,3 pediatricians) 10 clinical officers, 123 nurses (40 in maternity theatre,57 in labor ward and 26 in newborn unit) and 100 community health volunteers. In antenatal clinic, 60 mothers are seen daily. Other services offered within the facility include ART, HIV counseling, family planning services, child welfare services and adolescent health care. Study population An exit interview was administered to consecutive mothers in labor/postnatal wards and those attending routine 6 weeks immunization clinic after obtaining informed consent. Due to inconveniences made by the Covid 19 pandemic, there were very low numbers of mothers attending 6 weeks Mother and Child Health (MCH) clinics at the facility. A decision was made to conduct a follow up interview for those interviewed at labor. Heath workers included doctors, clinical officers, nurses and counselors at ANC clinic, labor ward and MCH. They were purposively selected for in-depth interviews over the telephone as face-to-face interviews would pose a risk of exposure to Covid 19 infection. Study period and outcomes The study was conducted over three months (July 2020 and September 2020). The study aimed to achieve the following outcomes: a). Estimate of proportion of cases of missed opportunities for repeat HIV test for during labor/delivery and 6 weeks immunization clinic (Missed opportunity was defined as proportion of women who (were not tested) do not know their current HIV status after labor/delivery and after 6 weeks maternal and child health clinic (MCH) attendance). b). Level of knowledge of HCWs workers on HTS in pregnancy and postpartum, their attitudes on the national guidelines and their practices which involved offering the test. Inclusion and exclusion criteria Inclusion criteria Mothers who had delivered in the prior twenty-four to seventy-two hours and mothers attending 6 weeks immunization clinic who in both instances had a negative result during first ANC visit. Mothers who consented to a telephone interview conducted for the 6 weeks postnatal follow up. Health care workers (Doctors, clinical officers, nurses and counselors) stationed at Antenatal Care Clinic, labor/postnatal ward and Maternal and Child health clinic who worked in the facility. Exclusion criteria Known HIV positive pregnant women (documented) and mothers or health care workers who did not provide informed. Sample size determination Fischer’s formula was applied to deduce the sample size calculation for mothers. n = z 2 p (1-p) d 2 n = sample size z = standard normal deviate of desired level of confidence (1.96) p = Proportion in target population with specific characteristics (68% of mothers get retested at ANC) M Lollah study in Kisumu County, d = desired study precision (0.05). From this formula, n was found to be 335. A ratio of 1:1 was used for mothers in labor/postnatal ward and those at the MCH clinic. Purposive sampling was used for health care workers, 15 participants were included, and some were key informants in managerial and administrative positions. Study procedure The principal investigator (PI) trained 2 research assistants on the outline of HIV testing guidelines in labor/delivery and postpartum period as in the National guidelines by NASCOP 2016 and MOH 2018. A preliminary visit to the study location was conducted to introduce the research assistants to the clinical staff prior to commencement of the study. Knowledge and attitude of healthcare workers Sensitization regarding the study was conducted to administrative staff then individually to those who agreed to participate in the study. Following verbal consent, HCW were interviewed over the telephone, using standard pretested questionnaire to determine knowledge on HTS. The questionnaire collected data as in (Appendix 4b). The data included a. Age, level of education and job type, b. training (if any) received on HIV testing in pregnancy and postpartum period, c. awareness of core principles, protocol and time taken for testing. Data collection, management and analysis Survey forms were coded, entered and managed in the Microsoft Access database. The information was exported to SPSS version 23.0 for analysis of statistics. Descriptive statistics were used to give a description of the study population (both HCWs and post-natal mothers). Rates of HIV test uptake were computed as proportions with 95% confidence intervals. Data from key informant interviews was coded according to emerging themes and subthemes using thematic analysis approach. It was then presented as frequency tables of codes and direct quotes from the participants. Audio recordings from in-depth interviews were transcribed. The emergent themes were identified, noted down using excel and presented in tabular form using thematic analysis approach. Results Quantitative data Sociodemographic features of the study participants Table 1 shows the demographic characteristics of the participants of this study. Table 1 Sociodemographic features of the study participants Variable Frequency (%) Age (Years) 24 and below 25–34 35 and above 89 (36.8) 131 (54.1) 22 (9.1) Education level None Primary Secondary Tertiary 1 (0.4) 57 (23.6) 111 (45.9) 73 (30.2) Marital status Married Single Separated/divorced Widowed 195 (80.6) 42 (17.4) 4 (1.7) 1 (0.4) Occupation None Self-employed Employed 138 (57.3) 59 (24.5) 44 (18.3) Type of delivery SVD CS 140 (57.9) 102 (42.2) Planned pregnancy Yes No 143 (59.1) 99 (40.9) SVD : Spontaneous Vaginal Delivery, CS : Caesarean Section Two hundred and forty-two women participated in this study. 131 (54.1%) were between 25 and 34 years of age, married (195: 80.6%), had at least a secondary level of education (111; 45.9%), were unemployed (138: 57.3%), reported having planned pregnancies (143: 59.1%), and delivered through spontaneous vaginal delivery (140: 57.9%). Table 1 . HIV retesting at labor ward One hundred and sixty-seven women at the labor ward of the Pumwani maternity hospital were interviewed. One hundred and sixteen women (69.5%) were retested for HIV, of which 43 (37.1%) were aware while 73(62.9%) were not aware of the need for HIV retesting. Figure 2 . Most women 121 (73.3%) reported that they knew the HIV status of their partners’. Among the women who were not tested at the labor ward, 45 (88.2%) reported that they had not been approached by a healthcare worker regarding testing, while 6 (11.8%) did not give consent. All 51 women who were not tested at the labor ward expressed an interest in having the test done during the interview. Factors associated with HIV retesting at the labor ward of Pumwani maternity hospital The crude association model showed an association between women who reported awareness of retesting for HIV in labor ward (OR 2.4(1.1, 5.31) p = 0.028) and having the test done. Women who were aware that a HIV repeat test was supposed to be done at the labor ward were twice as likely to have the test done than women who were not aware that the test was supposed to be done at the labor ward. Table 2 . Table 2 Factors associated with HIV testing at the labor ward of Pumwani Maternity Hospital Characteristic Test done (%) n = 116 Test not done (%) n = 51 COR (95%CI) p value AOR (95%CI) p value Age 25–34 24 and below 35 and above 61 (52.6) 49 (42.2) 6 (5.2) 28 (54.9) 17 (33.3) 6 (11.8) 1 (Reference) 1.32 (0.6, 2.6) 0.46 (0.1, 1.5) 0.440 0.210 1 (Reference) 1.64 (0.7, 3.6) 0.38 (0.1, 1.6) 0.222 0.192 Marital status Married Single Other 95 (81.9) 19 (16.4) 2 (1.7) 42 (8.3) 7 (13.7) 2 (4) 1 (Reference) 1.2 (0.4, 3.1) 0.44 (0.1, 3.3) 0.704 0.422 1 (Reference) 1.08 (0.3, 3.2) 0.55 (0.1, 4.7) 0.887 0.591 Education level Primary Secondary and above 38 (32.8) 78 (62.7) 12 (23.5) 39 (76.5) 1 (Reference) 0.63 (0.3, 1.3) 0.232 1 (Reference) 0.58 (0.2, 1.3) 0.206 Awareness of need for re-testing for HIV No Yes 73 (62.9) 43 (37.1) 41 (80.4) 10 (19.6) 1 (Reference) 2.4 (1.1, 5.3) 0.028 1 (Reference) 2.02 (0.8, 4.6) 0.093 Awareness of partner HIV status Yes No 30 (26.5) 83 (73.5) 14 (28) 36 (72) 1 (Reference) 1.08 (0.1, 2.3) 0.847 1 (Reference) 0.9 (0.3, 2.1) 0.801 Planned pregnancy No Yes 46 (39.7) 70 (60.3) 22 (43.1) 29(56.9) 1 (Reference) 1.15 (0.5, 2.2) 0.673 1 (Reference) 1.1 (0.5, 2.5) 0.724 Type of delivery SVD CS 61 (52.6) 55 (47.4) 32 (62.7) 19 (37.3) 1 (Reference) 1.51 (0.7, 2.9) 0.225 1(Reference) 1.62 (0.6, 6.1) 0.210 HIV retesting at 6 weeks postpartum. A total of 170 women were interviewed at 6 weeks postpartum to get information on HIV retesting. Among them 122 (71.8%) reported to have done a repeat HIV test. Only 68 (40%) of the women were aware of a repeat HIV test at 6 weeks postpartum. Among the ones not tested, 47 (27.6%) women reported not to have been approached by a healthcare worker while only 1 did not give consent. Thirty-two (78%) women not tested for HIV expressed interest in having a HIV test done during the interview. Figure 3 Association between awareness of patients towards HIV retesting and whether the women retested after 6 weeks Table 3 shows the association between awareness of patients towards HIV retesting and whether the women retested Table 3 Association between awareness of patients towards HIV retesting and whether the women retested after 6 weeks HIV test done Awareness No Yes COR No 40(83.3%) 62(50.8%) 1 (Reference) Yes 8 (16.7%) 60 (49.2%) 4.8 (2.1, 11.2) There was a significant association between awareness of women towards testing and retesting for HIV 6 weeks postpartum. Moreover, women who were aware about retesting 6 weeks post-partum were 4.8 times more likely to have the test done that women who were not aware. Qualitative data In-depth interviews Table 4 shows the sociodemographic characteristics of the key informants at the Pumwani maternity hospital. Table 4 Sociodemographic characteristics of the key informants at the Pumwani maternity hospital during the study period Characteristics Frequency Percentage Age (Years) 50 4 26.7 31–40 8 53.3 41–50 2 13.3 Gender Female 13 86.7 Male 2 13.3 Job type Healthcare provider 14 93.3 Managerial 1 6.7 Education level Bachelor’s degree 5 33.3 Certificate 3 20.0 Diploma 5 33.3 Master’s or higher 2 13.3 HTS training No 1 6.7 Yes 14 93.3 Years of HTS training 2009 2 14.3 2012–2018 5 35.5 2019 3 21.4 2020 4 28.6 HTS: HIV testing services Fifteen healthcare workers (clinicians, nurses, and counselors) within the maternity unit at Pumwani Hospital were interviewed. This included those in administrative and those providing direct care to patients. All interviews were conducted virtually either through zoom or WhatsApp and were recorded then transcribed verbatim. Two independent coders developed a code book based on three transcripts each, which were later merged at consensus coding. Themes were then arrived at through an iterative process of content analysis using both deductive and inductive processes. Among the 15 interviewees, 13 (86.7%) were female and slightly more than half 8 (53.3%) were between 31–40 years old. Regarding the level of education, 5 of the interviewees (33.3%) had attained a bachelor’s degree or higher and 14 (93.3%) had received HIV testing services (HTS) training. Time since HTS training varied with only 4 (28.6%) receiving training within the current year and 3 (21.4%) receiving training in the past year. Table 4 . Tabl5 5 contains information from the interviewees regarding the core principles of HTS. Table 5 Information from interviewees on the core principles of HIV testing services (HTS) Core principles of HTS Frequency Percentage Test all, no opt out, if positive immediately start on treatment 1 6.7 Consent, confidentiality, counseling, correct results, connection/linkage to care 11 73.3 Consent, confidentiality, correct results 3 20.0 Total 15 100.0 Most interviewees 11 (73.3%) described the core principles of HIV testing services (HTS) to be consent, confidentiality, counseling, correct results and linkage to care. Table 5 . Table 6 shows the information from interviewees on the protocol for HIV testing services. Table 6 Information from interviewees on protocol for HIV testing services (HTS) Protocol for HTS Frequency Percentage Pretest counseling, HIV test, Posttest counseling, assess other conditions, referral and linkage to care 11 73.3 Pretest counseling, HIV test, Posttest counseling 1 6.7 Pretest counseling, HIV test and Posttest counseling with risk reduction plan 3 20.0 Total 15 100.0 Eleven (73.3%) of the interviewees described the HTS Protocol as -Pretest counseling, HIV test, Posttest counseling, assess other conditions, referral and linkage to care. Table 6 . Table 7 shows the information from interviewees regarding the approximate testing time. Table 7 Information from interviewees regarding the approximate total testing time Approximate total testing time Frequency Percentage 10 1 6.7 15 4 26.7 20 3 20.0 30 6 40.0 45 1 6.7 Total 15 100.0 Most interviewees reported that the approximate total testing time was mostly 30 minutes Themes identified from the qualitative data Varied knowledge on repeat testing guidelines among interviewees Some of the health care workers were quite familiar with the guidelines while others were not quite sure what was stipulated for repeat HIV testing among women in labor or during delivery and thereafter.. “What I know is any mother who comes in who is in labor, despite the last time they were tested they still need to be offered counseling and testing. But if they come in the advanced stage of labor, you can wait for the mother to deliver then you do the testing. Still at six weeks they still offer when they go for the post-natal check, just in case of missed opportunities.” Participant 12 “We do not have much information or in communication with the patients on this, the only thing we can do is to call the PMTCT nurse to come and do it, but I think every nurse who is working at the labor ward, we need to have this information.” ( Participant 3) Standard hospital procedures are supportive of retesting guidelines The interviewees noted that it was within hospital procedures to only admit mothers who had been retested into the postnatal wards as well as only discharge those who had been retested. These procedures were targeted at enhancing implementation of the guidelines. “Even the postnatal nurses do not receive (the mother) if that second counseling and testing is not done, it is must together with the ANC profile.” ( Participant10) “To me I think they (guidelines) are doing a good job and because we have the mentor mothers and the PMTCT nurses doing the job, so chances of missed opportunities for testing are very low. “( Participant 11 ) “So, during admission if you see a mother who has not been tested, we inform the PMTCT department, so they follow up on that or maybe if you find a mother who already has been admitted in the ward, and you find out the patient has not been tested you still notify the PMTCT team then they do it as soon as possible.” (Participant 5 ) Challenges in implementing the HIV re-testing guidelines “On challenges maybe due to burnout the nurses may not have good time to assess the risks among HIV positive mothers or even those who are HIV negative. So sometimes there is a lot of workload and at 6 weeks we miss on retesting because of workload.” Participant 6 “We tend to actually miss out the mothers when bring their babies at six weeks, unfortunately place like Pumwani we are sometimes a bit busy, okay the workload is high and the counselors are few, so you realized that sometimes we are unable to test all the mothers, however much we are actually trying to pull up our socks.” Participant 4 “ And then the patient’s attitude, you know you cannot force someone, I must plead, and that is a barrier still. And then you find, from my scenario I find patients who antenatal were HIV positive, but some of them rub out the results from the antenatal clinic or they know they are positive but maybe wherever they started their antenatal clinic they request someone to write they are negative.” Participant 12 There is need for regular updates or training on the HIV retesting guidelines “I think for me that I would say is that most of us having no good knowledge, we can't say we are proud of the knowledge we have about HIV and everything concerning it. So, training should be there every now and then, and you know with this HIV things, like the time I was in labor ward I think some things changed.” Participant 14 “So, if everyone else is trained because most of the time you find that the project staff is trained alone, and the other staff are not. If everyone in the facility is aware of these guidelines that could make our work easier.” Participant 7 Discussion The present study was a mixed methods study on the barriers and facilitators in implementing HIV re-testing guidelines on pregnant women at a referral hospital in Kenya. The study findings indicate that the HIV re-testing rate at the labor ward of Pumwani Maternity Hospital was 69.5%, while at 6 weeks postpartum, the retesting rate was slightly higher at 71.8%. Awareness of the need for re-testing was a significant determinant, with women who were aware of the guidelines being approximately 2.4 times more likely to be retested in the labor ward and 4.8 times more likely to be retested at 6 weeks postpartum. This suggests that awareness is a critical factor in increasing HIV re-testing rates, as corroborated by studies showing that patient education and counseling are essential for promoting adherence to HIV re-testing protocols [ 18 , 19 ]. The relatively high re-testing rate at 6 weeks compared to labor ward testing highlights potential gaps in guideline implementation at the labor ward. These findings align with the literature, which notes that healthcare settings often face barriers to implementing HIV re-testing guidelines during labor due to the urgency of care and high workload [ 20 – 22 ]. The reliance on prevention of mother-to-child transmission (PMTCT) nurses and mentor mothers, as identified in the study, underscores the need for task-sharing and adequate staffing to support re-testing during critical periods. Additionally, the results showed that 93.3% of healthcare workers (HCWs) at Pumwani Maternity Hospital had received HIV testing services (HTS) training, yet there were inconsistencies in knowledge and adherence to re-testing guidelines. This discrepancy between training and practice suggests potential gaps in training content, as well as systemic issues such as high staff turnover and lack of refresher training[ 20 – 24 ]. The qualitative findings revealed several barriers to guideline implementation, including high workload, staff shortages, and patient attitudes toward re-testing. These factors are consistent with previous research showing that structural constraints and patient perceptions significantly influence the uptake of HIV testing services [ 25 – 30 ]. Moreover, the study found that most women (67.5%) lacked awareness of the need for HIV re-testing during labor. This aligns with findings from other studies, where poor patient awareness was identified as a primary barrier to HIV re-testing uptake [ 31 , 32 ]. In response to this issue, strategies such as targeted health education campaigns and community engagement have been recommended to improve patient knowledge and promote re-testing adherence[ 33 – 35 ]. In terms of facilitators, the study highlighted those institutional procedures, such as mandatory retesting before discharge, supported guideline adherence. This finding is supported by recent literature, which emphasizes that strong institutional policies and supervision are key enablers of HIV re-testing uptake [ 26 , 36 , 37 ]. However, the study's reliance on PMTCT nurses for guideline implementation may indicate a dependence on vertical programs, which can be unsustainable in the long run. Recent research advocates integrating HIV services into routine maternal healthcare to ensure sustainability and reduce dependence on specific cadres of healthcare workers[ 38 , 39 ]. This integration approach has shown promise in several settings by improving continuity of care and reducing the likelihood of missed re-testing opportunities [ 40 , 41 ]. Limitations The study was subject to several limitations. Firstly, Pumwani Maternity hospital has extensive mentoring and support by the county and NGOs with PMTCT programmes that other facilities may not have. Secondly the study was carried out over three months, and this might not factor in the seasonal variability. Lastly, we couldn’t verify information given via telephone interviews, especially HIV retests at week 6. Conclusion And Recommendations The high retesting rate at 6 weeks postpartum, compared to labor ward retesting, suggests that structural factors and patient awareness play a crucial role in determining re-testing adherence. To improve implementation, strategies should focus on enhancing patient education, strengthening institutional protocols, and ensuring regular training and support for HCWs to bridge the gap between training and practice. Future research should evaluate the long-term impact of these strategies to sustain high re-testing rates and minimize missed opportunities for intervention. Declarations Conflicts of interest/Competing interests: The authors declare no conflict of interest Informed Consent Statement : Participants’ consent was given as per Section 25–32 of the World Medical Association’s Declaration of Helsinki – Ethical Principles for Medical Research Involving Human Subjects [ 42 ]. Authorization to conduct the study was obtained from the Kenyatta Hospital Ethics Research /Committee. REF: KNH-ERC/A/449. The authors confirm that all methods were carried out in accordance with relevant guidelines and regulations. Funding: The author(s) received no financial support for the research, authorship, and or publication of this article. Author Contribution Conceptualization, JN and DW; methodology, JN, DW, and AM, ; software, JN; validation, DW, RK, AM; formal analysis, JN; investigation, JN, DW, RK, AM; resources, JN, DW, RK, AM; data curation, DW; writing—original draft preparation, JN, DW, RK, AM; writing—review and editing, JN; visualization, JN; supervision, DW, RK, AM; project administration, JN. All authors have read and agreed to the published version of the manuscript. Acknowledgement The authors would like to thank Mrs. Hellen Moraa Okinyi, Ms. Rose Njogu, Pumwani Maternity Hospital staff and all participants who contributed to the success of this research. Data availability: The datasets associated with this manuscript are available from the corresponding author upon reasonable request. Code availability: Not applicable References LeVasseur MT, Goldstein ND, Welles SL. 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Peltzer K, Prado G, Horigian V, Weiss S, Cook R, Sifunda S, Jones D. Prevention of mother-to-child transmission (PMTCT) implementation in rural community health centres in Mpumalanga province, South Africa. J Psychol Afr. 2016;26:415–8. Jones DL, Peltzer KF, Sifunda S, Weiss SM, Setswe G, Ramlagan S, Maduna MG. PMTCT implementation in rural community health centres in Mpumalanga province, South Africa. 2015. Kawonga M, Blaauw D, Fonn S. The influence of health system organizational structure and culture on integration of health services: the example of HIV service monitoring in South Africa. Health Policy Plan. 2016;31:1270–80. Wringe A, Moshabela M, Nyamukapa C, Bukenya D, Ondenge K, Ddaaki W, Wamoyi J, Seeley J, Church Kathryn, Zaba B, Hosegood V, Bonnington O, Skovdal M, Renju J. HIV testing experiences and their implications for patient engagement with HIV care and treatment on the eve of ‘test and treat’: findings from a multicountry qualitative study. Sex Transm Infect. 2017;93 Suppl 3. Chimoyi L, Tshuma N, Muloongo K, Setswe G, Sarfo B, Nyasulu PS. HIV-related knowledge, perceptions, attitudes, and utilisation of HIV counselling and testing: a venue-based intercept commuter population survey in the inner city of Johannesburg, South Africa. Glob Health Action. 2015;8:26950. Ryan S, Hahn E, Rao A, Mwinnyaa G, Black J, Maharaj R, Mvandaba N, Nyanisa Y, Quinn TC, Hansoti B. The impact of HIV knowledge and attitudes on HIV testing acceptance among patients in an emergency department in the Eastern Cape, South Africa. BMC Public Health. 2020;20:1–10. Geelhoed D, Lafort Y, Chissale É, Candrinho B, Degomme O. Integrated maternal and child health services in Mozambique: structural health system limitations overshadow its effect on follow-up of HIV-exposed infants. BMC Health Serv Res. 2013;13:1–8. Ebrahim NB, Atteraya MS. Understanding structural determinants of HIV testing in a resource-limited setting: the case of Ethiopian women. Soc Inq J Soc Sci Res. 2020;2:216–33. Drake AL, Thomson KA, Quinn C, Owiredu MN, Nuwagira IB, Chitembo L, Essajee S, Baggaley R, Johnson CC. Retest and treat: a review of national HIV retesting guidelines to inform elimination of mother-to‐child HIV transmission (EMTCT) efforts. Afr J Reprod Gynaecol Endosc. 2019;22. Orinda JO, Ayodo G, Ondeng’e K, Ochung A, Onguru D. Factors influencing repeat HIV testing among mothers in perinatal clinics of rural and urban settings in Kisumu County, Kenya. Afr J Health Sci. 2023;36:234–43. Desai M. Facilitators and barriers to active recall for HIV and STI testing of MSM at high risk of HIV infection in genito-urinary medicine clinics. 2015. Bourne C, Zablotska I, Williamson A, Calmette Y, Guy R. Promotion and uptake of a new online partner notification and retesting reminder service for gay men. Sex Health. 2012;9:360–7. Alexander J, Bambury E, Mendoza A, Reynolds J, Veronneau R, Dean E. Health education strategies used by physical therapists to promote behaviour change in people with lifestyle-related conditions: A systematic review. Hong Kong Physiother J. 2012;30:57–75. Napierala Mavedzenge S, Baggaley R, Corbett EL. A review of self-testing for HIV: research and policy priorities in a new era of HIV prevention. Clin Infect Dis. 2013;57:126–38. Yapa HM, Dhlomo-Mphatswe W, Moshabela M, De Neve J-W, Herbst C, Jiamsakul A, Petoumenos K, Post FA, Pillay D, Barnighausen T, Wyke S. A continuous quality improvement intervention to improve antenatal HIV care testing in rural South Africa: evaluation of implementation in a real-world setting. Int J Heal policy Manag. 2022;11:610. Haskins L, Chiliza J, Barker P, Connolly C, Phakathi S, Feeley A, Horwood C. Evaluation of the effectiveness of a quality improvement intervention to support integration of maternal, child and HIV care in primary health care facilities in South Africa. BMC Public Health. 2020;20:1–12. Bulstra CA, Hontelez JAC, Otto M, Stepanova A, Lamontagne E, Yakusik A, El-Sadr WM, Apollo T, Rabkin M, UNAIDS Expert Group on Integration, Atun R, Barnighausen T. Integrating HIV services and other health services: a systematic review and meta-analysis. PLoS Med. 2021;18:e1003836. Winestone LE, Bukusi EA, Cohen CR, Kwaro D, Schmidt NC, Turan JM. Acceptability and feasibility of integration of HIV care services into antenatal clinics in rural Kenya: a qualitative provider interview study. Glob Public Health. 2012;7:149–63. Mutabazi JC, Zarowsky C, Trottier H. The impact of programs for prevention of mother-to-child transmission of HIV on health care services and systems in sub-Saharan Africa-A review. Public Health Rev. 2017;38:1–27. WMA Declaration of Helsinki – Ethical Principles for Medical Research Involving Human Subjects – WMA – The World Medical Association. https://www.wma.net/policies-post/wma-declaration-of-helsinki-ethical-principles-for-medical-research-involving-human-subjects/ . Accessed 7 Aug 2024. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5413119","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":384226464,"identity":"d55e5054-b7dc-4dd2-b830-396cd7e07b17","order_by":0,"name":"Justina Njuki","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA1ElEQVRIiWNgGAWjYBACxgY2MF3fDyITCkjQwjizAaTFgCh7oFo2HABRxGhhnpGW+LjgVx2z8fnViR8eGDDI84sdIOCwGWmHjWf2HWYzu/F2swTQYYYzZycQ0pLeJs3bc4DH7MbZDSAtCQa3CWtp/83bUydhPOPs5h9Eakk7xszzg9nAgL93G5G29DxLluZtOJwgcYN3m0WCgQRhvxi2pxl+5vlTl8Dff3bzzR8VNvL80oS0NICsagMSEmCVEviVg4A8mPwDxPwHCKseBaNgFIyCkQkAKMFF5vvTDNEAAAAASUVORK5CYII=","orcid":"","institution":"University of Nairobi","correspondingAuthor":true,"prefix":"","firstName":"Justina","middleName":"","lastName":"Njuki","suffix":""},{"id":384226468,"identity":"b1ce172c-4607-4229-a790-7686407fa971","order_by":1,"name":"Dalton Wamalwa","email":"","orcid":"","institution":"University of Nairobi","correspondingAuthor":false,"prefix":"","firstName":"Dalton","middleName":"","lastName":"Wamalwa","suffix":""},{"id":384226469,"identity":"3ad27872-8fa2-4500-9cae-63df15912fd5","order_by":2,"name":"Rashmi Kumar","email":"","orcid":"","institution":"University of Nairobi","correspondingAuthor":false,"prefix":"","firstName":"Rashmi","middleName":"","lastName":"Kumar","suffix":""},{"id":384226470,"identity":"32205a92-4ca9-47d2-96cb-60234ac4e13c","order_by":3,"name":"Anne-Marie Macharia","email":"","orcid":"","institution":"University of Nairobi","correspondingAuthor":false,"prefix":"","firstName":"Anne-Marie","middleName":"","lastName":"Macharia","suffix":""}],"badges":[],"createdAt":"2024-11-08 02:53:21","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5413119/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5413119/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":71890180,"identity":"fbd00c09-d872-42f4-8f3a-34f1d383783c","added_by":"auto","created_at":"2024-12-19 12:55:18","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":45858,"visible":true,"origin":"","legend":"\u003cp\u003eOverview of the procedure used to recruit study participants at Pumwani maternity hospital during the study period\u003c/p\u003e","description":"","filename":"Picture1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5413119/v1/ffa7dd06ad501c0f3f804f02.jpg"},{"id":71890184,"identity":"79352aa6-cdcc-4b00-82c5-d57e1f4169f5","added_by":"auto","created_at":"2024-12-19 12:55:22","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":79361,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of the number of women at the labor ward of Pumwani Maternity hospital who were HIV retested during the study period relative to those who were not.\u003c/p\u003e","description":"","filename":"Picture3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5413119/v1/4099b82cede7511791d48ee1.jpg"},{"id":71890187,"identity":"7e1674e9-2483-40e8-bb12-e331c61f1d45","added_by":"auto","created_at":"2024-12-19 12:55:25","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":79361,"visible":true,"origin":"","legend":"\u003cp\u003eData on HIV testing of women followed up for 6 weeks post-partum\u003c/p\u003e","description":"","filename":"Picture4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5413119/v1/67ef2ba018b464f1230ae4f5.jpg"},{"id":71890182,"identity":"c904ce5d-2396-46e2-bf06-aebdc14b4a6f","added_by":"auto","created_at":"2024-12-19 12:55:21","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":81023,"visible":true,"origin":"","legend":"\u003cp\u003eHIV retesting in labour\u003c/p\u003e","description":"","filename":"Picture5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5413119/v1/a6468654f17603240d3cc046.jpg"},{"id":79334191,"identity":"ef2b8a99-39ee-494b-85c3-8d408e9c51fa","added_by":"auto","created_at":"2025-03-27 07:24:12","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1699327,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5413119/v1/8f8f46ab-de10-42db-b8d1-2ed13a866882.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"A mixed methods study on the barriers and facilitators of implementing HIV re-testing guidelines on pregnant women at a referral hospital in Kenya","fulltext":[{"header":"Background","content":"\u003cp\u003eHIV/AIDS is a significant global health challenge, particularly affecting resource-limited settings and vulnerable populations [\u003cspan additionalcitationids=\"CR2 CR3 CR4 CR5\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Despite substantial progress in prevention of mother-to-child transmission (PMTCT) programs, vertical transmission of HIV continues to pose a substantial risk [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. According to the World Health Organization (WHO), an estimated 1.5\u0026nbsp;million (1.2\u0026ndash;2.1\u0026nbsp;million) children (0\u0026ndash;14 years old) worldwide were living with HIV in 2022, with the majority acquiring the infection through mother-to-child transmission (MTCT) [\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Early diagnosis and prompt initiation of antiretroviral therapy (ART) are critical to reducing MTCT rates and improving maternal and child health outcomes [\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHIV prevalence in Kenya remains a significant public health concern, with an estimated 1.4\u0026nbsp;million people living with HIV in 2022 [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The country has made strides in scaling up PMTCT interventions, guided by national guidelines developed by the Ministry of Health and the National AIDS Control Council [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. These guidelines recommend routine HIV testing at various stages of pregnancy and postpartum to ensure timely diagnosis and intervention [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Despite these efforts, challenges such as missed opportunities for retesting during labor and postpartum periods persist, potentially compromising the effectiveness of PMTCT programs.\u003c/p\u003e \u003cp\u003ePumwani Maternity Hospital (PMH), located in Nairobi, Kenya, is a referral maternity hospital which provides maternal and child health services, including comprehensive PMTCT services [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. PMH serves a diverse population with varying socioeconomic backgrounds, contributing to its significance in addressing maternal and child health disparities in the region. The hospital follows national guidelines for HIV testing and PMTCT, aiming to achieve high rates of HIV testing uptake and adherence to treatment protocols among pregnant women and postpartum mothers.\u003c/p\u003e \u003cp\u003e Despite the implementation of guidelines advocating for HIV retesting during labor and postpartum, there is a paucity of data regarding the actual adherence to these guidelines among healthcare providers at PMH. Moreover, the missed opportunities for HIV retesting during labor and postpartum periods among women attending the hospital are not known. Understanding the missed opportunities for HIV retesting during labor and postpartum and the knowledge, attitudes, and practices of healthcare workers (HCWs) towards HIV retesting guidelines is crucial for identifying barriers and facilitators to guideline implementation and designing targeted interventions to improve the uptake of HIV retesting and ultimately reduce MTCT rates. The aim of the present study was to determine the proportion of missed opportunities for HIV retesting during labor and postpartum periods among women attending PMH and to explore healthcare workers' knowledge, attitudes, and practices regarding HIV retesting guidelines at PMH.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eEthics statement\u003c/h2\u003e \u003cp\u003eAuthorization to conduct the study was obtained from the Kenyatta Hospital Ethics Research /Committee. \u003cb\u003eREF: KNH-ERC/A/449.\u003c/b\u003e The authors confirm that all methods were carried out in accordance with relevant guidelines and regulations.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy design and setting\u003c/h3\u003e\n\u003cp\u003eThis was a mixed methods study that used qualitative (key informant interview guide) and quantitative (survey questionnaire) techniques. The study was conducted at the Antenatal Clinic, labor/postnatal ward and Maternal and Child health clinic at Pumwani Maternity Hospital. PMH is an Obstetric and Referral hospital specialized for delivery of expectant mothers in Nairobi, and adjacent districts. It is the \u003cb\u003el\u003c/b\u003eargest referral Maternity Hospital in East Africa. It has 2 theatres, 350 Obstetric beds, and 150 baby cots. Normal deliveries conducted per day are 50\u0026ndash;100, and Caesarean Sections are 10\u0026ndash;15 per day. The staff consists of 27 doctors (20 medical officers,4 specialist obstetricians/gynaecologist,3 pediatricians) 10 clinical officers, 123 nurses (40 in maternity theatre,57 in labor ward and 26 in newborn unit) and 100 community health volunteers. In antenatal clinic, 60 mothers are seen daily. Other services offered within the facility include ART, HIV counseling, family planning services, child welfare services and adolescent health care.\u003c/p\u003e\n\u003ch3\u003eStudy population\u003c/h3\u003e\n\u003cp\u003eAn exit interview was administered to consecutive mothers in labor/postnatal wards and those attending routine 6 weeks immunization clinic after obtaining informed consent. Due to inconveniences made by the Covid 19 pandemic, there were very low numbers of mothers attending 6 weeks Mother and Child Health (MCH) clinics at the facility. A decision was made to conduct a follow up interview for those interviewed at labor. Heath workers included doctors, clinical officers, nurses and counselors at ANC clinic, labor ward and MCH. They were purposively selected for in-depth interviews over the telephone as face-to-face interviews would pose a risk of exposure to Covid 19 infection.\u003c/p\u003e\n\u003ch3\u003eStudy period and outcomes\u003c/h3\u003e\n\u003cp\u003eThe study was conducted over three months (July 2020 and September 2020). The study aimed to achieve the following outcomes: a). Estimate of proportion of cases of missed opportunities for repeat HIV test for during labor/delivery and 6 weeks immunization clinic (Missed opportunity was defined as proportion of women who (were not tested) do not know their current HIV status after labor/delivery and after 6 weeks maternal and child health clinic (MCH) attendance). b). Level of knowledge of HCWs workers on HTS in pregnancy and postpartum, their attitudes on the national guidelines and their practices which involved offering the test.\u003c/p\u003e\n\u003ch3\u003eInclusion and exclusion criteria\u003c/h3\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eInclusion criteria\u003c/h2\u003e \u003cp\u003eMothers who had delivered in the prior twenty-four to seventy-two hours and mothers attending 6 weeks immunization clinic who in both instances had a negative result during first ANC visit. Mothers who consented to a telephone interview conducted for the 6 weeks postnatal follow up. Health care workers (Doctors, clinical officers, nurses and counselors) stationed at Antenatal Care Clinic, labor/postnatal ward and Maternal and Child health clinic who worked in the facility.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eExclusion criteria\u003c/h3\u003e\n\u003cp\u003eKnown HIV positive pregnant women (documented) and mothers or health care workers who did not provide informed.\u003c/p\u003e\n\u003ch3\u003eSample size determination\u003c/h3\u003e\n\u003cp\u003eFischer\u0026rsquo;s formula was applied to deduce the sample size calculation for mothers.\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003ez\u003c/span\u003e\u003csup\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e2\u003c/span\u003e\u003c/sup\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003ep (1-p)\u003c/span\u003e\u003c/p\u003e \u003cp\u003ed\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;sample size\u003c/p\u003e \u003cp\u003ez\u0026thinsp;=\u0026thinsp;standard normal deviate of desired level of confidence (1.96)\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;Proportion in target population with specific characteristics (68% of mothers get retested at ANC) M Lollah study in Kisumu County, d\u0026thinsp;=\u0026thinsp;desired study precision (0.05). From this formula, n was found to be 335. A ratio of 1:1 was used for mothers in labor/postnatal ward and those at the MCH clinic. Purposive sampling was used for health care workers, 15 participants were included, and some were key informants in managerial and administrative positions.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eStudy procedure\u003c/h2\u003e \u003cp\u003e The principal investigator (PI) trained 2 research assistants on the outline of HIV testing guidelines in labor/delivery and postpartum period as in the National guidelines by NASCOP 2016 and MOH 2018. A preliminary visit to the study location was conducted to introduce the research assistants to the clinical staff prior to commencement of the study.\u003c/p\u003e \u003cp\u003e\u003cimg 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\"\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eKnowledge and attitude of healthcare workers\u003c/h2\u003e \u003cp\u003e Sensitization regarding the study was conducted to administrative staff then individually to those who agreed to participate in the study. Following verbal consent, HCW were interviewed over the telephone, using standard pretested questionnaire to determine knowledge on HTS. The questionnaire collected data as in (Appendix 4b). The data included a. Age, level of education and job type, b. training (if any) received on HIV testing in pregnancy and postpartum period, c. awareness of core principles, protocol and time taken for testing.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eData collection, management and analysis\u003c/h2\u003e \u003cp\u003eSurvey forms were coded, entered and managed in the Microsoft Access database. The information was exported to SPSS version 23.0 for analysis of statistics. Descriptive statistics were used to give a description of the study population (both HCWs and post-natal mothers). Rates of HIV test uptake were computed as proportions with 95% confidence intervals. Data from key informant interviews was coded according to emerging themes and subthemes using thematic analysis approach. It was then presented as frequency tables of codes and direct quotes from the participants. Audio recordings from in-depth interviews were transcribed. The emergent themes were identified, noted down using excel and presented in tabular form using thematic analysis approach.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\n \u003ch2\u003eQuantitative data\u003c/h2\u003e\n \u003cdiv id=\"Sec16\" class=\"Section3\"\u003e\n \u003ch2\u003eSociodemographic features of the study participants\u003c/h2\u003e\n \u003cp\u003eTable \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e shows the demographic characteristics of the participants of this study.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eSociodemographic features of the study participants\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFrequency (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAge (Years)\u003c/p\u003e\n \u003cp\u003e24 and below\u003c/p\u003e\n \u003cp\u003e25\u0026ndash;34\u003c/p\u003e\n \u003cp\u003e35 and above\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e89 (36.8)\u003c/p\u003e\n \u003cp\u003e131 (54.1)\u003c/p\u003e\n \u003cp\u003e22 (9.1)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eEducation level\u003c/p\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003cp\u003ePrimary\u003c/p\u003e\n \u003cp\u003eSecondary\u003c/p\u003e\n \u003cp\u003eTertiary\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1 (0.4)\u003c/p\u003e\n \u003cp\u003e57 (23.6)\u003c/p\u003e\n \u003cp\u003e111 (45.9)\u003c/p\u003e\n \u003cp\u003e73 (30.2)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMarital status\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003cp\u003eSeparated/divorced\u003c/p\u003e\n \u003cp\u003eWidowed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e195 (80.6)\u003c/p\u003e\n \u003cp\u003e42 (17.4)\u003c/p\u003e\n \u003cp\u003e4 (1.7)\u003c/p\u003e\n \u003cp\u003e1 (0.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eOccupation\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003cp\u003eSelf-employed\u003c/p\u003e\n \u003cp\u003eEmployed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e138 (57.3)\u003c/p\u003e\n \u003cp\u003e59 (24.5)\u003c/p\u003e\n \u003cp\u003e44 (18.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eType of delivery\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eSVD\u003c/p\u003e\n \u003cp\u003eCS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e140 (57.9)\u003c/p\u003e\n \u003cp\u003e102 (42.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePlanned pregnancy\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e143 (59.1)\u003c/p\u003e\n \u003cp\u003e99 (40.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\u003cstrong\u003eSVD\u003c/strong\u003e: Spontaneous Vaginal Delivery, \u003cstrong\u003eCS\u003c/strong\u003e: Caesarean Section\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003eTwo hundred and forty-two women participated in this study. 131 (54.1%) were between 25 and 34 years of age, married (195: 80.6%), had at least a secondary level of education (111; 45.9%), were unemployed (138: 57.3%), reported having planned pregnancies (143: 59.1%), and delivered through spontaneous vaginal delivery (140: 57.9%). Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\n \u003ch2\u003eHIV retesting at labor ward\u003c/h2\u003e\n \u003cp\u003eOne hundred and sixty-seven women at the labor ward of the Pumwani maternity hospital were interviewed. One hundred and sixteen women (69.5%) were retested for HIV, of which 43 (37.1%) were aware while 73(62.9%) were not aware of the need for HIV retesting. Figure \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e. Most women 121 (73.3%) reported that they knew the HIV status of their partners\u0026rsquo;.\u003c/p\u003e\n \u003cp\u003eAmong the women who were not tested at the labor ward, 45 (88.2%) reported that they had not been approached by a healthcare worker regarding testing, while 6 (11.8%) did not give consent. All 51 women who were not tested at the labor ward expressed an interest in having the test done during the interview.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\n \u003ch2\u003eFactors associated with HIV retesting at the labor ward of Pumwani maternity hospital\u003c/h2\u003e\n \u003cp\u003eThe crude association model showed an association between women who reported awareness of retesting for HIV in labor ward (OR 2.4(1.1, 5.31) p\u0026thinsp;=\u0026thinsp;0.028) and having the test done. Women who were aware that a HIV repeat test was supposed to be done at the labor ward were twice as likely to have the test done than women who were not aware that the test was supposed to be done at the labor ward. Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eFactors associated with HIV testing at the labor ward of Pumwani Maternity Hospital\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" style=\"width: 32.9162%;\"\u003e\n \u003cp\u003eCharacteristic\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" style=\"width: 12.2653%;\"\u003e\n \u003cp\u003eTest done (%)\u003c/p\u003e\n \u003cp\u003en\u0026thinsp;=\u0026thinsp;116\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" style=\"width: 15.6445%;\"\u003e\n \u003cp\u003eTest not done (%)\u003c/p\u003e\n \u003cp\u003en\u0026thinsp;=\u0026thinsp;51\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" style=\"width: 12.8912%;\"\u003e\n \u003cp\u003eCOR (95%CI)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" style=\"width: 6.6333%;\"\u003e\n \u003cp\u003ep value\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" style=\"width: 13.0163%;\"\u003e\n \u003cp\u003eAOR (95%CI)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ep value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 32.9162%;\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003cp\u003e25\u0026ndash;34\u003c/p\u003e\n \u003cp\u003e24 and below\u003c/p\u003e\n \u003cp\u003e35 and above\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 12.2653%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e61 (52.6)\u003c/p\u003e\n \u003cp\u003e49 (42.2)\u003c/p\u003e\n \u003cp\u003e6 (5.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 15.6445%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e28 (54.9)\u003c/p\u003e\n \u003cp\u003e17 (33.3)\u003c/p\u003e\n \u003cp\u003e6 (11.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 12.8912%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1 (Reference)\u003c/p\u003e\n \u003cp\u003e1.32 (0.6, 2.6)\u003c/p\u003e\n \u003cp\u003e0.46 (0.1, 1.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 6.6333%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e0.440\u003c/p\u003e\n \u003cp\u003e0.210\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 13.0163%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1 (Reference)\u003c/p\u003e\n \u003cp\u003e1.64 (0.7, 3.6)\u003c/p\u003e\n \u003cp\u003e0.38 (0.1, 1.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e0.222\u003c/p\u003e\n \u003cp\u003e0.192\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 32.9162%;\"\u003e\n \u003cp\u003eMarital status\u003c/p\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 12.2653%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e95 (81.9)\u003c/p\u003e\n \u003cp\u003e19 (16.4)\u003c/p\u003e\n \u003cp\u003e2 (1.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 15.6445%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e42 (8.3)\u003c/p\u003e\n \u003cp\u003e7 (13.7)\u003c/p\u003e\n \u003cp\u003e2 (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 12.8912%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1 (Reference)\u003c/p\u003e\n \u003cp\u003e1.2 (0.4, 3.1)\u003c/p\u003e\n \u003cp\u003e0.44 (0.1, 3.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 6.6333%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e0.704\u003c/p\u003e\n \u003cp\u003e0.422\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 13.0163%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1 (Reference)\u003c/p\u003e\n \u003cp\u003e1.08 (0.3, 3.2)\u003c/p\u003e\n \u003cp\u003e0.55 (0.1, 4.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e0.887\u003c/p\u003e\n \u003cp\u003e0.591\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 32.9162%;\"\u003e\n \u003cp\u003eEducation level\u003c/p\u003e\n \u003cp\u003ePrimary\u003c/p\u003e\n \u003cp\u003eSecondary and above\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 12.2653%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e38 (32.8)\u003c/p\u003e\n \u003cp\u003e78 (62.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 15.6445%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e12 (23.5)\u003c/p\u003e\n \u003cp\u003e39 (76.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 12.8912%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1 (Reference)\u003c/p\u003e\n \u003cp\u003e0.63 (0.3, 1.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 6.6333%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e0.232\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 13.0163%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1 (Reference)\u003c/p\u003e\n \u003cp\u003e0.58 (0.2, 1.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e0.206\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 32.9162%;\"\u003e\n \u003cp\u003eAwareness of need for re-testing for HIV\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 12.2653%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e73 (62.9)\u003c/p\u003e\n \u003cp\u003e43 (37.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 15.6445%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e41 (80.4)\u003c/p\u003e\n \u003cp\u003e10 (19.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 12.8912%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1 (Reference)\u003c/p\u003e\n \u003cp\u003e2.4 (1.1, 5.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 6.6333%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e0.028\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 13.0163%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1 (Reference)\u003c/p\u003e\n \u003cp\u003e2.02 (0.8, 4.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e0.093\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 32.9162%;\"\u003e\n \u003cp\u003eAwareness of partner HIV status\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 12.2653%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e30 (26.5)\u003c/p\u003e\n \u003cp\u003e83 (73.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 15.6445%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e14 (28)\u003c/p\u003e\n \u003cp\u003e36 (72)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 12.8912%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1 (Reference)\u003c/p\u003e\n \u003cp\u003e1.08 (0.1, 2.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 6.6333%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e0.847\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 13.0163%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1 (Reference)\u003c/p\u003e\n \u003cp\u003e0.9 (0.3, 2.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e0.801\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 32.9162%;\"\u003e\n \u003cp\u003ePlanned pregnancy\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 12.2653%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e46 (39.7)\u003c/p\u003e\n \u003cp\u003e70 (60.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 15.6445%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e22 (43.1)\u003c/p\u003e\n \u003cp\u003e29(56.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 12.8912%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1 (Reference)\u003c/p\u003e\n \u003cp\u003e1.15 (0.5, 2.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 6.6333%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e0.673\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 13.0163%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1 (Reference)\u003c/p\u003e\n \u003cp\u003e1.1 (0.5, 2.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e0.724\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 32.9162%;\"\u003e\n \u003cp\u003eType of delivery\u003c/p\u003e\n \u003cp\u003eSVD\u003c/p\u003e\n \u003cp\u003eCS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 12.2653%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e61 (52.6)\u003c/p\u003e\n \u003cp\u003e55 (47.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 15.6445%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e32 (62.7)\u003c/p\u003e\n \u003cp\u003e19 (37.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 12.8912%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1 (Reference)\u003c/p\u003e\n \u003cp\u003e1.51 (0.7, 2.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 6.6333%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e0.225\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 13.0163%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1(Reference)\u003c/p\u003e\n \u003cp\u003e1.62 (0.6, 6.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e0.210\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u003cstrong\u003eHIV retesting at 6 weeks postpartum.\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eA total of 170 women were interviewed at 6 weeks postpartum to get information on HIV retesting. Among them 122 (71.8%) reported to have done a repeat HIV test. Only 68 (40%) of the women were aware of a repeat HIV test at 6 weeks postpartum. Among the ones not tested, 47 (27.6%) women reported not to have been approached by a healthcare worker while only 1 did not give consent. Thirty-two (78%) women not tested for HIV expressed interest in having a HIV test done during the interview. Figure \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eAssociation between awareness of patients towards HIV retesting and whether the women retested after 6 weeks\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eTable \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e shows the association between awareness of patients towards HIV retesting and whether the women retested\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eAssociation between awareness of patients towards HIV retesting and whether the women retested after 6 weeks\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eHIV test done\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAwareness\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCOR\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e40(83.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e62(50.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (Reference)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e8 (16.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e60 (49.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.8 (2.1, 11.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003eThere was a significant association between awareness of women towards testing and retesting for HIV 6 weeks postpartum. Moreover, women who were aware about retesting 6 weeks post-partum were 4.8 times more likely to have the test done that women who were not aware.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\n \u003ch2\u003eQualitative data\u003c/h2\u003e\n \u003cdiv id=\"Sec20\" class=\"Section3\"\u003e\n \u003ch2\u003eIn-depth interviews\u003c/h2\u003e\n \u003cp\u003eTable \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e shows the sociodemographic characteristics of the key informants at the Pumwani maternity hospital.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab4\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eSociodemographic characteristics of the key informants at the Pumwani maternity hospital during the study period\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eCharacteristics\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFrequency\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePercentage\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"4\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003cp\u003e(Years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026gt;\u0026thinsp;50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e26.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e31\u0026ndash;40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e53.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e41\u0026ndash;50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e13.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e86.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e13.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eJob type\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHealthcare provider\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e93.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eManagerial\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"4\"\u003e\n \u003cp\u003eEducation level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBachelor\u0026rsquo;s degree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e33.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCertificate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e20.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDiploma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e33.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMaster\u0026rsquo;s or higher\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e13.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eHTS training\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e93.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"4\"\u003e\n \u003cp\u003eYears of HTS training\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2009\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e14.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2012\u0026ndash;2018\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e35.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2019\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e21.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2020\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e28.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003eHTS: HIV testing services\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003eFifteen healthcare workers (clinicians, nurses, and counselors) within the maternity unit at Pumwani Hospital were interviewed. This included those in administrative and those providing direct care to patients. All interviews were conducted virtually either through zoom or WhatsApp and were recorded then transcribed verbatim. Two independent coders developed a code book based on three transcripts each, which were later merged at consensus coding. Themes were then arrived at through an iterative process of content analysis using both deductive and inductive processes. Among the 15 interviewees, 13 (86.7%) were female and slightly more than half 8 (53.3%) were between 31\u0026ndash;40 years old. Regarding the level of education, 5 of the interviewees (33.3%) had attained a bachelor\u0026rsquo;s degree or higher and 14 (93.3%) had received HIV testing services (HTS) training. Time since HTS training varied with only 4 (28.6%) receiving training within the current year and 3 (21.4%) receiving training in the past year. Table \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e\n \u003cp\u003eTabl5 5 contains information from the interviewees regarding the core principles of HTS.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab5\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eInformation from interviewees on the core principles of HIV testing services (HTS)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCore principles of HTS\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFrequency\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePercentage\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTest all, no opt out, if positive immediately start on treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eConsent, confidentiality, counseling, correct results, connection/linkage to care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e73.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eConsent, confidentiality, correct results\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e20.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e100.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003eMost interviewees 11 (73.3%) described the core principles of HIV testing services (HTS) to be consent, confidentiality, counseling, correct results and linkage to care. Table \u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e.\u003c/p\u003e\n \u003cp\u003eTable \u003cspan class=\"InternalRef\"\u003e6\u003c/span\u003e shows the information from interviewees on the protocol for HIV testing services.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab6\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eInformation from interviewees on protocol for HIV testing services (HTS)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eProtocol for HTS\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFrequency\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePercentage\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePretest counseling, HIV test, Posttest counseling, assess other conditions, referral and linkage to care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e73.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePretest counseling, HIV test, Posttest counseling\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePretest counseling, HIV test and Posttest counseling with risk reduction plan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e20.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e100.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003eEleven (73.3%) of the interviewees described the \u003cstrong\u003eHTS Protocol as\u003c/strong\u003e -Pretest counseling, HIV test, Posttest counseling, assess other conditions, referral and linkage to care. Table \u003cspan class=\"InternalRef\"\u003e6\u003c/span\u003e.\u003c/p\u003e\n \u003cp\u003eTable \u003cspan class=\"InternalRef\"\u003e7\u003c/span\u003e shows the information from interviewees regarding the approximate testing time.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab7\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 7\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eInformation from interviewees regarding the approximate total testing time\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eApproximate total testing time\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFrequency\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePercentage\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e26.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e20.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e40.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e100.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003eMost interviewees reported that the approximate total testing time was mostly 30 minutes\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\n \u003ch2\u003eThemes identified from the qualitative data\u003c/h2\u003e\n \u003cdiv id=\"Sec22\" class=\"Section3\"\u003e\n \u003ch2\u003eVaried knowledge on repeat testing guidelines among interviewees\u003c/h2\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;Some of the health care workers were quite familiar with the guidelines while others were not quite sure what was stipulated for repeat HIV testing among women in labor or during delivery and thereafter..\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;What I know is any mother who comes in who is in labor, despite the last time they were tested they still need to be offered counseling and testing. But if they come in the advanced stage of labor, you can wait for the mother to deliver then you do the testing. Still at six weeks they still offer when they go for the post-natal check, just in case of missed opportunities.\u0026rdquo;\u003c/em\u003e \u003cstrong\u003eParticipant 12\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;We do not have much information or in communication with the patients on this, the only thing we can do is to call the PMTCT nurse to come and do it, but I think every nurse who is working at the labor ward, we need to have this information.\u0026rdquo; (\u003c/em\u003e \u003cstrong\u003eParticipant 3)\u003c/strong\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e\n \u003ch2\u003eStandard hospital procedures are supportive of retesting guidelines\u003c/h2\u003e\n \u003cp\u003e\u003cem\u003eThe interviewees noted that it was within hospital procedures to only admit mothers who had been retested into the postnatal wards as well as only discharge those who had been retested. These procedures were targeted at enhancing implementation of the guidelines.\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Even the postnatal nurses do not receive (the mother) if that second counseling and testing is not done, it is must together with the ANC profile.\u0026rdquo; (\u003c/em\u003e \u003cstrong\u003eParticipant10)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u0026ldquo;To me I think they (guidelines) are doing a good job and because we have the mentor mothers and the PMTCT nurses doing the job, so chances of missed opportunities for testing are very low. \u0026ldquo;(\u003c/em\u003e\u003cstrong\u003eParticipant 11\u003c/strong\u003e\u003cem\u003e)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;So, during admission if you see a mother who has not been tested, we inform the PMTCT department, so they follow up on that or maybe if you find a mother who already has been admitted in the ward, and you find out the patient has not been tested you still notify the PMTCT team then they do it as soon as possible.\u0026rdquo;\u003c/em\u003e \u003cstrong\u003e(Participant 5\u003c/strong\u003e\u003cem\u003e)\u003c/em\u003e\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec24\" class=\"Section2\"\u003e\n \u003ch2\u003eChallenges in implementing the HIV re-testing guidelines\u003c/h2\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;On challenges maybe due to burnout the nurses may not have good time to assess the risks among HIV positive mothers or even those who are HIV negative. So sometimes there is a lot of workload and at 6 weeks we miss on retesting because of workload.\u0026rdquo;\u003c/em\u003e \u003cstrong\u003eParticipant 6\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;We tend to actually miss out the mothers when bring their babies at six weeks, unfortunately place like Pumwani we are sometimes a bit busy, okay the workload is high and the counselors are few, so you realized that sometimes we are unable to test all the mothers, however much we are actually trying to pull up our socks.\u0026rdquo;\u003c/em\u003e \u003cstrong\u003eParticipant 4\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026ldquo;\u003c/strong\u003e \u003cem\u003eAnd then the patient\u0026rsquo;s attitude, you know you cannot force someone, I must plead, and that is a barrier still. And then you find, from my scenario I find patients who antenatal were HIV positive, but some of them rub out the results from the antenatal clinic or they know they are positive but maybe wherever they started their antenatal clinic they request someone to write they are negative.\u0026rdquo;\u003c/em\u003e \u003cstrong\u003eParticipant 12\u003c/strong\u003e\u003c/p\u003e\n \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e\n \u003ch2\u003eThere is need for regular updates or training on the HIV retesting guidelines\u003c/h2\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I think for me that I would say is that most of us having no good knowledge, we can\u0026apos;t say we are proud of the knowledge we have about HIV and everything concerning it. So, training should be there every now and then, and you know with this HIV things, like the time I was in labor ward I think some things changed.\u0026rdquo;\u003c/em\u003e \u003cstrong\u003eParticipant 14\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;So, if everyone else is trained because most of the time you find that the project staff is trained alone, and the other staff are not. If everyone in the facility is aware of these guidelines that could make our work easier.\u0026rdquo;\u003c/em\u003e\u003cstrong\u003eParticipant 7\u003c/strong\u003e\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003e The present study was a mixed methods study on the barriers and facilitators in implementing HIV re-testing guidelines on pregnant women at a referral hospital in Kenya. The study findings indicate that the HIV re-testing rate at the labor ward of Pumwani Maternity Hospital was 69.5%, while at 6 weeks postpartum, the retesting rate was slightly higher at 71.8%. Awareness of the need for re-testing was a significant determinant, with women who were aware of the guidelines being approximately 2.4 times more likely to be retested in the labor ward and 4.8 times more likely to be retested at 6 weeks postpartum. This suggests that awareness is a critical factor in increasing HIV re-testing rates, as corroborated by studies showing that patient education and counseling are essential for promoting adherence to HIV re-testing protocols [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e The relatively high re-testing rate at 6 weeks compared to labor ward testing highlights potential gaps in guideline implementation at the labor ward. These findings align with the literature, which notes that healthcare settings often face barriers to implementing HIV re-testing guidelines during labor due to the urgency of care and high workload [\u003cspan additionalcitationids=\"CR21\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The reliance on prevention of mother-to-child transmission (PMTCT) nurses and mentor mothers, as identified in the study, underscores the need for task-sharing and adequate staffing to support re-testing during critical periods.\u003c/p\u003e \u003cp\u003e Additionally, the results showed that 93.3% of healthcare workers (HCWs) at Pumwani Maternity Hospital had received HIV testing services (HTS) training, yet there were inconsistencies in knowledge and adherence to re-testing guidelines. This discrepancy between training and practice suggests potential gaps in training content, as well as systemic issues such as high staff turnover and lack of refresher training[\u003cspan additionalcitationids=\"CR21 CR22 CR23\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. The qualitative findings revealed several barriers to guideline implementation, including high workload, staff shortages, and patient attitudes toward re-testing. These factors are consistent with previous research showing that structural constraints and patient perceptions significantly influence the uptake of HIV testing services [\u003cspan additionalcitationids=\"CR26 CR27 CR28 CR29\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Moreover, the study found that most women (67.5%) lacked awareness of the need for HIV re-testing during labor. This aligns with findings from other studies, where poor patient awareness was identified as a primary barrier to HIV re-testing uptake [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. In response to this issue, strategies such as targeted health education campaigns and community engagement have been recommended to improve patient knowledge and promote re-testing adherence[\u003cspan additionalcitationids=\"CR34\" citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. In terms of facilitators, the study highlighted those institutional procedures, such as mandatory retesting before discharge, supported guideline adherence. This finding is supported by recent literature, which emphasizes that strong institutional policies and supervision are key enablers of HIV re-testing uptake [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e However, the study's reliance on PMTCT nurses for guideline implementation may indicate a dependence on vertical programs, which can be unsustainable in the long run. Recent research advocates integrating HIV services into routine maternal healthcare to ensure sustainability and reduce dependence on specific cadres of healthcare workers[\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. This integration approach has shown promise in several settings by improving continuity of care and reducing the likelihood of missed re-testing opportunities [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec27\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThe study was subject to several limitations. Firstly, Pumwani Maternity hospital has extensive mentoring and support by the county and NGOs with PMTCT programmes that other facilities may not have. Secondly the study was carried out over three months, and this might not factor in the seasonal variability. Lastly, we couldn\u0026rsquo;t verify information given via telephone interviews, especially HIV retests at week 6.\u003c/p\u003e \u003c/div\u003e "},{"header":"Conclusion And Recommendations","content":"\u003cdiv id=\"Sec28\" class=\"Section2\"\u003e \u003cp\u003eThe high retesting rate at 6 weeks postpartum, compared to labor ward retesting, suggests that structural factors and patient awareness play a crucial role in determining re-testing adherence. To improve implementation, strategies should focus on enhancing patient education, strengthening institutional protocols, and ensuring regular training and support for HCWs to bridge the gap between training and practice. Future research should evaluate the long-term impact of these strategies to sustain high re-testing rates and minimize missed opportunities for intervention.\u003c/p\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eConflicts of interest/Competing interests:\u003c/h2\u003e \u003cp\u003eThe authors declare no conflict of interest\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eInformed Consent\u003c/h2\u003e \u003cp\u003e\u003cb\u003eStatement\u003c/b\u003e: Participants\u0026rsquo; consent was given as per Section 25\u0026ndash;32 of the World Medical Association\u0026rsquo;s Declaration of Helsinki \u0026ndash; Ethical Principles for Medical Research Involving Human Subjects [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. Authorization to conduct the study was obtained from the Kenyatta Hospital Ethics Research /Committee. \u003cb\u003eREF: KNH-ERC/A/449.\u003c/b\u003e The authors confirm that all methods were carried out in accordance with relevant guidelines and regulations.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e \u003cp\u003eThe author(s) received no financial support for the research, authorship, and or publication of this article.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eConceptualization, JN and DW; methodology, JN, DW, and AM, ; software, JN; validation, DW, RK, AM; formal analysis, JN; investigation, JN, DW, RK, AM; resources, JN, DW, RK, AM; data curation, DW; writing\u0026mdash;original draft preparation, JN, DW, RK, AM; writing\u0026mdash;review and editing, JN; visualization, JN; supervision, DW, RK, AM; project administration, JN. All authors have read and agreed to the published version of the manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003e The authors would like to thank Mrs. Hellen Moraa Okinyi, Ms. Rose Njogu, Pumwani Maternity Hospital staff and all participants who contributed to the success of this research.\u003c/p\u003e\u003ch2\u003eData availability:\u003c/h2\u003e \u003cp\u003eThe datasets associated with this manuscript are available from the corresponding author upon reasonable request.\u003c/p\u003e\u003ch2\u003eCode availability:\u003c/h2\u003e \u003cp\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLeVasseur MT, Goldstein ND, Welles SL. A public health perspective on HIV/AIDS in Africa: Victories and unmet challenges. Pathophysiology. 2014;21:237\u0026ndash;56.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCahill S, Valad\u0026eacute;z R. 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Evaluation of the effectiveness of a quality improvement intervention to support integration of maternal, child and HIV care in primary health care facilities in South Africa. BMC Public Health. 2020;20:1\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBulstra CA, Hontelez JAC, Otto M, Stepanova A, Lamontagne E, Yakusik A, El-Sadr WM, Apollo T, Rabkin M, UNAIDS Expert Group on Integration, Atun R, Barnighausen T. Integrating HIV services and other health services: a systematic review and meta-analysis. PLoS Med. 2021;18:e1003836.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWinestone LE, Bukusi EA, Cohen CR, Kwaro D, Schmidt NC, Turan JM. Acceptability and feasibility of integration of HIV care services into antenatal clinics in rural Kenya: a qualitative provider interview study. Glob Public Health. 2012;7:149\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMutabazi JC, Zarowsky C, Trottier H. The impact of programs for prevention of mother-to-child transmission of HIV on health care services and systems in sub-Saharan Africa-A review. Public Health Rev. 2017;38:1\u0026ndash;27.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWMA Declaration of Helsinki \u0026ndash; Ethical Principles for Medical Research Involving Human Subjects \u0026ndash; WMA \u0026ndash; The World Medical Association. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.wma.net/policies-post/wma-declaration-of-helsinki-ethical-principles-for-medical-research-involving-human-subjects/\u003c/span\u003e\u003cspan address=\"https://www.wma.net/policies-post/wma-declaration-of-helsinki-ethical-principles-for-medical-research-involving-human-subjects/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 7 Aug 2024.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Mother-to child-transmission, HIV testing, Pumwani maternity hospital, HIV re-testing","lastPublishedDoi":"10.21203/rs.3.rs-5413119/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5413119/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003e The Ministry of Health-Kenya developed guidelines on HIV testing for pregnant women at different points in time as a mitigative measure against mother-to child-transmission (MTCT) of HIV. However, the barriers and facilitators in the implementation of HIV re-testing guidelines among pregnant women in Kenya are not well understood. The aim of the present study was to evaluate the barriers and facilitators of HIV testing guidelines among pregnant women at the Pumwani Maternity Hospital.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis was a mixed methods study. Qualitative data on the barriers and facilitators of HIV re-testing among pregnant women was collected by interviewing key informants (healthcare workers). Quantitative data was collected from pregnant women who had been recruited into the study. Women with an initial HIV negative result at the antenatal clinic (ANC) were recruited at the labor/postnatal ward and at six weeks postnatal review. Quantitative data was analyzed using descriptive statistics while qualitative data was audio recorded, transcribed, and themes were identified.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThere were 242 women who participated in the interview 97 of whom were followed up at 6 weeks via a telephone interview. There were 170 women interviewed at labor ward. The retesting rate was 116 (69.5%). Majority of the women 114 (67.5%) lacked awareness on the need for HIV retesting. Of the 97 women followed up at 6 weeks postpartum, 72 (75%) were retested for HIV. Of the 15 HCWs who were interviewed, 14 (93.3%) had received HTS training. There was varied knowledge on repeat testing guidelines for HIV and the team relied on mentor mothers and prevention of mother to child transmission (PMTCT) nurses to implement the guideline.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThese findings suggest that there were more missed opportunities for HIV re-testing at the labor ward relative to re-testing. There is a need to improve HIV screening at the labor ward to minimize lost opportunities for HIV screening.\u003c/p\u003e","manuscriptTitle":"A mixed methods study on the barriers and facilitators of implementing HIV re-testing guidelines on pregnant women at a referral hospital in Kenya","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-19 12:55:12","doi":"10.21203/rs.3.rs-5413119/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"17bc6780-f968-47de-a05d-75c8ed65e107","owner":[],"postedDate":"December 19th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-03-27T07:23:39+00:00","versionOfRecord":[],"versionCreatedAt":"2024-12-19 12:55:12","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5413119","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5413119","identity":"rs-5413119","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}