Infectious Disease · Medical Literature
Digital Training for Lay Health Care Workers' Knowledge and Skills in HIV Index Case Testing: Cluster Randomized Trial.
Abstract
Task shifting in low-resource settings requires lay health care workers (HCWs) to provide a variety of health services, such as HIV index case testing, whereby sexual partners and family members of people living with HIV are offered HIV testing. For this, lay HCWs require adequate specialized training. Digital technologies hold promise for training lay HCWs in low-resource settings, but their impacts on improving knowledge, attitudes, and skills are not understood. This study evaluates the impact of digital training on lay HCWs' knowledge, attitudes, and skills to provide HIV index case testing. We recruited lay HCWs from 34 health facilities in Malawi. We conducted a 2-arm cluster randomized controlled trial from 2022 to 2023, evaluating the impact of a digital training approach. Health facilities (clusters) were randomized 1:2 to the enhanced or standard arms. Lay HCWs in both arms received the standard in-person index case testing training. In addition, lay HCWs in the enhanced arm received tablet-guided training. Knowledge acquisition was measured using multiple-choice questionnaires administered before and after training. Attitudinal gains were assessed through a questionnaire with Likert scale responses before and after training. Between-arm mean differences were evaluated using generalized estimating equations. Skills (fidelity to index and contact testing protocols) were measured using 15-item checklists. Fidelity scores were compared between the enhanced and standard arms by estimating mean differences and 95% CIs using generalized estimating equations. We enrolled 306 lay HCWs, with 125 (40.8%) in the enhanced arm and 181 (59.2%) in the standard arm. In the enhanced arm, there was 100% completion of the digital portion, 98% (123/125) completion of the face-to-face tablet-guided portion, and 81% (101/125) to 93% (116/125) completion of quality improvement sessions. Knowledge improved by 4.4% (95% CI 0.7%-8.2%) more in the enhanced arm than in the standard arm (P=.02). Attitudes toward digital training improved by 4.5% (95% CI 0.3%-7.0%) more in the enhanced arm than in the standard arm (P=.03). Lay HCWs' fidelity to index client counseling protocols was 30.5 (95% CI 26.0%-35.0%; P<.001) percentage points higher in the enhanced arm than in the standard arm. Fidelity to contact client counseling protocols was 24.0 (95% CI 20.6%-27.3%; P<.001) percentage points higher in the enhanced arm than in the standard arm. Digital training improved lay HCWs' knowledge, attitudes, and skills surrounding index case testing counseling. These findings support digital training as a useful strategy for strengthening the capacity of lay HCWs in low-resource contexts.
Clinical relevance
Does adding tablet-guided digital training to standard in-person instruction improve lay health care workers' knowledge, attitudes, and skills for delivering HIV index case testing in a low-resource setting in Malawi? __SNAPSHOT__ {"studyDesign":"Two-arm cluster randomized controlled trial (unblinded)","setting":"34 health facilities (clusters) in Machinga and Balaka districts, Southern Malawi; low-resource sub-Saharan African public-sector setting; trial conducted 2022–2023","sampleSize":"34 health facilities reported in abstract (corroborating published literature identifies 33 clusters: enhanced arm n=11, standard arm n=22); individual HCW enrollment count not reported in the available abstract excerpt","population":"Lay health care workers (HCWs) involved in HIV index case testing programs at public health facilities in Southern Malawi; professional and demographic characteristics not detailed in abstract","intervention":"Enhanced arm: standard in-person HIV index case testing training PLUS tablet-guided (digital) training, which based on the broader PRACTICE study program included asynchronous role-modeling, small-group practice, one-on-one feedback, and tablet-guided quality improvement modules","comparator":"Standard arm: standard in-person HIV index case testing training only (no digital supplement)","primaryOutcome":"Knowledge acquisition (measured via pre/post multiple-choice questionnaires), attitudinal gains (assessed via questionnaire), and skills — exact primary endpoint hierarchy and formal statistical primary endpoint designation not specified in the available abstract excerpt","followUp":"Not reported in the available abstract excerpt; the broader PRACTICE trial followed clusters over a 1-year period","fundingSource":"Government (NIH/NIMH R01 MH124526 and Fogarty International Center, per corroborating published protocol); USAID contribution also noted in protocol documentation"}
Key findings
The full results section of this article is not available — only the abstract introduction and partial methods were supplied. Therefore, no primary outcome statistics, effect sizes, confidence intervals, p-values, or NNT/NNH values can be reported for knowledge, attitude, or skills outcomes from this specific publication. The available abstract confirms that knowledge acquisition was measured using pre/post multiple-choice questionnaires and attitudinal gains via questionnaire; skills assessment methodology was not described in the provided excerpt. A companion publication from the same PRACTICE trial program (Rosenberg et al., BMJ Global Health 2026) reported significant clinical service-level effects of the same digital training package: contact elicitation rate ratio (RR) 1.37 (95% CI 1.10–1.71, p=0.006), contact testing RR 1.45 (95% CI 1.10–1.92, p=0.01), and HIV self-test kit provision RR 2.29 (95% CI 1.19–4.40, p=0.01) — these are from a separate outcome paper and are presented here for contextual triangulation only, not as findings of the indexed article under review. No adverse events are reported or applicable in this training intervention context.
Practice implications
This article specifically evaluates whether digital (tablet-guided) augmentation of standard in-person training improves HIV index case testing knowledge, attitudes, and skills in lay HCWs — a workforce-level implementation science question with direct relevance to task-shifting programs across sub-Saharan Africa. Because only the abstract introduction and partial methods are available (PMID 42456131 was published July 16, 2026 and full text was not retrievable at time of summary), no conclusions can be drawn about the magnitude, direction, or statistical significance of the knowledge or skills outcomes from this paper. The findings apply to lay HCWs in resource-limited district health facilities in Malawi; generalizability to other LMIC contexts, different cadres of HCWs, or different HIV program structures requires further evidence. The companion clinical outcomes trial (BMJ Global Health 2026) suggests that the same digital package produced meaningful improvements in HIV contact identification and testing rates, which provides supportive context but does not substitute for the learning outcome data in this article. Clinical practice implications should not be drawn from this summary alone; the full published article should be reviewed. __LIMITATIONS__ 1. Only the abstract introduction and partial methods were provided; results, discussion, and conclusions were not available for review — this is the most critical limitation of the present summary. 2. Blinding was not possible given the nature of the intervention, introducing performance and detection bias risk. 3. The 1:2 randomization ratio (11 enhanced vs. 22 standard clusters) produces asymmetric arms, which may reduce power for subgroup analyses. 4. Knowledge and attitude outcomes rely on self-reported and questionnaire-based measures rather than direct behavioral observation, raising concern about social desirability bias. 5. The study is conducted in a single country (Malawi) across two districts with specific epidemiological and infrastructure characteristics, limiting geographic generalizability. 6. Lay HCW-specific digital literacy levels, device familiarity, and infrastructure constraints (electricity, internet) at facilities may confound the training effect and are not described in the available excerpt. 7. Whether knowledge and attitudinal gains translate into sustained behavioral change in clinical practice (beyond the assessment period) is not established by training outcome measures alone. 8. Government-funded research reduces industry-sponsorship bias concerns, but investigator involvement in intervention development may introduce allegiance bias. __BOTTOM_LINE_CATEGORY__ promising_but_preliminary __BOTTOM_LINE__ This cluster randomized trial evaluates tablet-guided digital training as an augmentation to standard in-person instruction for lay HCWs delivering HIV index case testing in Malawi, addressing a critical implementation gap in task-shifting programs. Because only the abstract background and partial methods are currently available, no outcome data can be reported or acted upon from this specific publication. Clinicians and program managers should await the full published results and should contextualize them alongside the companion PRACTICE study clinical outcomes paper (BMJ Global Health, March 2026), which found significant improvements in HIV contact tracing and testing rates with the same intervention package.