Abstract
Background
Many high burden countries are scaling-up GeneXpert® MTB/RIF (Xpert) testing for tuberculosis (TB) using a hub-and-spoke model. However, the effect of scale up on reducing TB has been limited. We sought to characterize variation in implementation of referral-based Xpert TB testing across Uganda, and to identify health system factors that may enhance or prevent high-quality implementation of Xpert testing services.
Methods
We conducted a cross-sectional study triangulating quantitative and qualitative data sources at 23 community health centers linked to one of 15 Xpert testing sites between November 2016 and May 2017 to assess health systems infrastructure for hub-and-spoke Xpert testing. Data sources included a standardized site assessment survey, routine TB notification data, and field notes from site visits.
Results
Challenges with Xpert implementation occurred at every step of the diagnostic evaluation process, leading to low overall uptake of testing. Of 2,241 patients eligible for TB testing, only 580 (26%) were referred for Xpert testing. Of those, 57 (9.6%) were Xpert confirmed positive just over half initiated treatment within 14 days (n=33, 58%). Gaps in required infrastructure at 23 community health centers to support the hub-and-spoke system included lack of refrigeration (n=14, X%) for sputum testing and lack of telephone/mobile communication (n=21, 91%). Motorcycle riders responsible for transporting sputum to Xpert sites operated variable with trips once a week, 2x/week or 3x/week at 10 (43%), 9 (39%) and 4 (17%) health centers, respectively. Staff recorded Xpert results in the TB laboratory register at only one health center and called patients with positive results at only 2 health centers. Of the 15 Xpert testing sites, 5 (33%) had at least one non-functioning module. The median number of tests per day was 3.57 (IQR 2.06-4.54), and 10 (67%) sites had error/invalid rates >5%.
Conclusions
Although Xpert devices are now widely distributed throughout Uganda, health system factors across the continuum from test referral to results reporting and treatment initiation preclude effective implementation of Xpert testing for patients presenting to peripheral health centers. Support for scale up of innovative technologies should include support for communication, coordination and health systems integration.
Provider-Initiated HIV Testing and Counseling: Increased Uptake in Two Public Community Health Centers in South Africa and Implications for Scale-Up
