Discussion
confusion, anxiety, virologic failure, RLS, HIV drug resistance
By qualitatively exploring perceived attitudes towards, facilitators to, and barriers to current DRM testing approaches in Kenya among patients, providers, and policymakers, our study provides key insights on how to leverage existing DRM testing procedures for more optimal scale-up in RLS. The perceived potential for DRM testing to significantly impact patient health outcomes, i.e., resulting in an ART regimen change, was supported by all, from patients to policymakers. Improving provider confidence and comfort with ordering and interpreting DRM testing results via regular trainings and implementing a simpler, decentralized DRM testing ordering process are clear next steps in improving DRM testing scale-up in Kenya and related settings.Globally, HIV drug resistance is a substantial threat to the success of ART and the elimination of HIV [DRM testing was perceived as fundamental to the clinical decision-making process for patients with virologic failure, by allowing providers to infer past ARV drug exposures when missing from records or not disclosed by patients, and to develop a plan for optimal ART regimens moving forward. For example, a study conducted in South Africa, reported that genotypic resistance testing informed clinical decision-making, causing providers to select a second-line regiment different to what would have been originally selected by the provider [While the DRM testing results were viewed as informative clinical tools, bureaucratic regulations were repeatedly emphasized as obstacles to optimal patient care, slowing down the DRM testing process and complicating DRM testing procedures. Our patients highlighted that the lack of timely receipt of results, a well-reported challenge for DRM testing, increased patient anxiety over delayed results and perceived worsening of patient health during the wait [In addition to bureaucratic regulations, the overall lack of provider and patient knowledge of the DRM testing process was another reported challenge. Specifically, the confusion among providers of when and how to order and interpret tests, as well as the lack of confidence in their recommendations to change ART regimens, remained a barrier to DRM testing use, delaying patient care and preventing patients in need of DRM testing from undergoing it—barriers that have also been reported elsewhere [Other challenges to DRM testing implementation in RLS include high capital expenditures and test costs, limited laboratory infrastructure, lack of skilled staff, and issues surrounding specimen collection, handling, tracking, and transport to centralized laboratories—findings that have been reported elsewhere [While our qualitative study sheds light on how impactful DRM testing might be for optimal HIV treatment decisions and current challenges in operationalizing DRM testing in Kenya, it also has several limitations. We were unable to obtain meaningful interviews from our young adolescent participants (ages 13–14 years), so we were unable to include the perspectives that may be unique to this population. We also did not sample providers based on years of experience; hence, our analysis does not establish connections between years of experience and comfort in use of DRM testing. Furthermore, the transcript coding and initial analysis was not led by Kenya-based team members, so our analytic framework may lack the necessary context to adequately interpret interviews and make appropriate conclusions. While the Seattle-based coding and analysis team met on several occasions with the Kenya-based team, a coding and analysis effort entirely led by Kenya-based team members could have possibly resulted in different conclusions or different emphases on certain findings. Additionally, our investigation was conducted during the COVID-19 pandemic, which made it difficult to conduct in-person interviews due to limitations in travel, especially with national-level stakeholders, which may have potentially influenced the responses we elicited, though we still captured body language via video calls in Zoom. Though our patient and provider sampling was limited to the facilities where the parent studies took place in Kisumu, Kenya, the themes we presented are applicable to other clinics in Kenya and likely other RLS. Notwithstanding these limitations, our work presents some of the most detailed findings to date with implications for DRM testing scale-up in RLS.