Understanding how digital training enhances healthcare worker perceptions of HIV index case testing: a qualitative explanatory analysis.

Background: HIV index case testing involves offering HIV testing services to the sexual partners and children of people living with HIV. In Malawi, index case testing implementation has been suboptimal due to inadequately trained health care workers (HCW). In a cluster-randomized trial, we tested the impact of a digital training approach (Enhanced strategy) to improve HCW capacity to conduct HIV index case testing services. We conducted a qualitative explanatory analysis to understand the impacts of the training on health workers' perceptions of delivering the intervention. Methods: In a cluster randomized trial, 33 clusters (health facilities) were randomized 1:2 to the Enhanced and Standard arms. HCWs in both arms received brief centralized in-person training on index case testing. HCWs in the Enhanced arm also received decentralized digital training through 20 synchronous and asynchronous sessions, which provided knowledge on protocols and principles of index case testing, modelled counseling scenarios, practice counseling, and individual feedback. We conducted 26 in-depth interviews with HCWs from 14 clusters (n = 6 Enhanced, n = 8 Standard) in the weeks after the Enhanced training. Interviews focused on HCW perceptions of their work. Interview transcripts in the weeks after training were analyzed thematically using an inductive approach. We compared responses of HCWs from Enhanced and Standard arms. Results: Overall, HCW in the Enhanced arm perceived greater ease counseling clients after the training. This was attributed to five facilitators:1) HCWs perceived the checklists as helping them operationalize ICT, 2) Video vignettes facilitated new counseling skills, 3) HCWs expressed greater comfort and confidence handling a range of clients, 4) HCWs perceived their counselling skills were more impactful, and 5) HCWs expressed greater confidence identifying and solving facility-level challenges. HCWs from the Standard arm requested additional tools, and referred to more experienced providers, reflecting less confidence in index case testing implementation. Conclusions: Digital training was viewed as a mechanism for enhancing knowledge, counselling skills, and comfort and confidence to address facility-level challenges. Digital training with video vignettes, and checklists to guide practice and feedback sessions are key strategies for HCWs capacity-building in low-resource settings. Trial Registration Number: NCT05343390.