From Policy to Practice: A Process Evaluation of Implementing Opt-Out HIV Testing in Antenatal Clinics Across Ghana

Abstract

In 2008, Ghana adopted the WHO/UNAIDS guideline for 'opt-out' HIV testing in antenatal clinics (ANCs). Although initial concerns were expressed about healthcare providers’ (HCPs’) ability to adhere to the intervention’s delivery, mainstream research has predominantly emphasised effectiveness questions to report variable testing uptake. This process evaluation aims to uncover the contextual factors that moderate adherence to the intervention in 12 of Ghana’s antenatal clinics (ANCs). We employed Carroll's (2007) modified framework of implementation fidelity to investigate factors that moderated the implementation of the provider-initiated opt-out HIV testing policy. Moderating factors explored were complexity, context, facilitating strategies, and participant responsiveness. We conducted 28 individual interviews and 11 focus group discussions, together with unstructured non-participant observations of the ANC environment and HIV testing activities. Key informants included 4 national-level officers, 4 regional-level officers, and 12 ANC managers. HCP interviews explored the complexity and facilitation of the HIV testing process and experiences with the opt-out intervention. Pregnant women's interviews explored their experiences with the opt-out intervention. The data was analysed using the constructs of Carroll’s implementation framework. We found weak antenatal clinic infrastructure, the complex nature of the opt-out intervention, a lack of facilitation, varied participant responses and power imbalance as moderators of the opt-out intervention implementation. These moderating factors collectively hinder the adoption of a right-based approach to HIV testing.