Table 1.

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

Process	Approach	Outcomes observed	Challenges encountered
Community preparation:	-Engaged communities before services were introduced. -Targeted influential community leaders for community advocacy. -Utilized community gatherings for mass communication.	-Created anticipation for the services. -Community members encouraged to access services. -Quickly informed many community members.	-Community members expected same-day test results and not to have to return for results at a later visit.
Health facility selection:	-Selected sites with existing PMTCT* programs and maternal child health clinics.	-There was a ready need for EID** services which then easily integrated.	-Some PMTCT programs were not functioning optimally in providing HIV testing and counseling and PMTCT antiretroviral regimens. -Infant follow-up was not a consistent component of all PMTCT programs.
Health facility preparation:	-Sensitized all health facility staff to refer possible HIV-exposed infants for EID services. -Identified space where EID services would be offered. -Worked with health facility staff to create and implement a detailed practical plan on how services would be offered. -Implemented a system for transporting samples from the site to the laboratory and results delivery back to the site.	-Children were referred from many service delivery points. -Streamlined registration and follow-up of HIV-exposed infants. -Streamlined delivery of services. -Established sample transportation and results delivery systems.	-Health workers had multiple competing responsibilities. -Maintaining efficiency of the sample transportation and results delivery system.
Capacity building:	-Conducted didactic training complemented with on-site mentorship.	-Empowered health workers and allowed them to develop confidence to implement services. -Ensured supervision in the early phases of implementation. -Linked didactic training to implementation.	-Transfer of trained personnel to other departments, facilities or regions. Request for financial incentives by health workers.
Laboratory establishment:	-Renovated an existing zonal laboratory that served multiple sites within the catchment area. -Trained laboratory staff at a laboratory with established PCR facilities. -Provided expert mentorship and on-going regular supervision at the laboratory. -Conducted quality assurance assessments according to standard procedures.	-Minimized start-up costs. -Laboratory staff gained a practical view of how systems work. -Ensured continuity of quality PCR services.	-Ensuring continuous supply of materials and supplies for DNA PCR testing. -Lab personnel had competing responsibilities.
Defining the HIV testing algorithm:	-Done at national level with involvement of key stakeholders including the Ministry of Health and donors.	-Promoted national and stakeholder acceptance of the testing algorithm.	-Reaching agreement on an algorithm that was both cost-effective but clinically relevant.
Registration and follow-up HIV-exposed infants and data collection:	-Created specific tools for recording data related to HIV-exposed infants and PCR testing. -Developed standard operating procedures for the new clinical services. -Registered HIV-exposed infants prior to availability of EID services were available. -Provided comprehensive follow-up care (e.g. giving cotrimoxazole). -Due to limited resources, preferentially followed-up infants that tested DNA PCR positive through appointment cards, phone calls and home visits.	-Monitoring and evaluation systems were readily available for the national roll-out. -Ensured HIV-exposed infants were being identified, registered and provided with necessary services. -Ensured that those at the greatest risk of mortality (HIV-infected infants) were referred to the HIV care and treatment clinic.	-Health services poorly equipped to retain infants for longitudinal follow-up. -High rate of loss to follow-up to obtain for DNA PCR results. -Some mothers stopped breastfeeding after first negative PCR result. -High rate of loss to follow-up to obtain final infection status after breast feeding cessation.

*PMTCT = Prevention of Mother to Child HIV Transmission; **EID = Early Infant Diagnosis