Key Stakeholders’ Perspectives on Implementation and Scale up of HIV Self-Testing in Rwanda

Introduction: The World Health Organisation recommends HIV self-testing as an alternative testing method to help reach underserved populations, such as men in sub-Saharan Africa. Successful implementation and scale-up of HIV self-testing (HIVST) in Rwanda relies heavily on relevant stakeholders’ involvement. We sought to explore HIVST key stakeholders’ perceptions of the implementation and scale-up of HIVST in Rwanda. Method: We conducted in-depth interviews with personnel involved in HIV response projects in Rwanda between September and November 2019. We purposively sampled and interviewed 13 national-level key stakeholders from the Ministry of Health, Rwanda Biomedical Center, non-governmental organizations and HIV clinics at tertiary health facilities in Kigali. We used a thematic approach to analysis with a coding framework guided by Consolidated Framework for Implementation Research (intervention characteristics, inner setting, outer setting, characteristics of individuals involved in the implementation and the implementation process). Results: Key stakeholders perceived HIVST as a potentially effective initiative, which can be used in order to ensure that there is an improvement in uptake of testing services, especially for underserved populations in Rwanda. The following challenges for implementation and scale-up of HIVST were revealed: lack of awareness of the kits, high cost of the self-test kits, and concerns on results interpretation. Key stakeholders identified the following as prerequisites to the successful implementation and scale-up of HIVST in Rwanda; creation of awareness, training those involved in the implementation process, regulation of the selling of the self-test kits, reduction of the costs of acquiring the self-test kits through the provision of subsidies, and ensuring consistent availability of the self-test kits. Conclusions: Key stakeholders expressed confidence in HIVST’s ability to improve the uptake of HIV testing services. However, they reported challenges, which need to be addressed to ensure successful implementation and scale-up of the HIVST. There is a need for further research incorporating lower level stakeholders to fully understand HIVST implementation and scale-up challenges and strategies to inform policy.

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A systematic review of qualitative evidence on factors enabling and deterring uptake of HIV self-testing in Africa

BMC Public Health ◽

10.1186/s12889-019-7685-1 ◽

2019 ◽

Vol 19 (1) ◽

Cited By ~ 13

Author(s):

Bernard Njau ◽

Christopher Covin ◽

Esther Lisasi ◽

Damian Damian ◽

Declare Mushi ◽

...

Keyword(s):

Systematic Review ◽

Hiv Testing ◽

Linkage To Care ◽

Ease Of Use ◽

Sub Saharan Africa ◽

Care Providers ◽

African Countries ◽

Qualitative Evidence ◽

Self Testing ◽

Self Test

Abstract Background More than 40% of adults in Sub-Saharan Africa are unaware of their HIV status. HIV self-testing (HIVST) is a novel approach with a potential to increase uptake of HIV testing and linkage to care for people who test HIV positive. We explored HIV stakeholder’s perceptions about factors that enable or deter the uptake of HIV self-testing and experiences of self-testing of adult users in Africa. Methods This systematic review of qualitative evidence included articles on qualitative studies published or made available between January 1998 to February 2018 on perspectives of key stakeholders, including HIV policymakers, HIV experts, health care providers, and adult men and women (18 years and above) about factors that enable or deter the uptake of HIV self-testing and experiences of self-testing among adult users. We searched CINAHL, MEDLINE in Pubmed, EMBASE, AJOL, PsycINFO, Social Science Citation Index (SSCI), and Web of Science for articles in English on HIVST with qualitative data from different African countries. Results In total, 258 papers were retrieved, and only nine (9) studies conducted in 5 African countries were eligible and included in this synthesis. Perceived facilitators of the uptake of HIVST were autonomy and self-empowerment, privacy, confidentiality, convenience, opportunity to test, including couples HIV testing, and ease of use. The perceived barriers included the cost of buying self-test kits, perceived unreliability of test results, low literacy, fear and anxiety of a positive test result, and potential psychological and social harms. HIV stakeholder’s concerns about HIVST included human right issues, lack of linkage to care, lack of face-to-face counseling, lack of regulatory and quality assurance systems, and quality of self-test kits. Actual HIVST users expressed preference of oral-fluid self-testing because of ease of use, and that it is less invasive and painless compared to finger-stick/whole blood-based HIV tests. Lack of clear instructions on how to use self-test kits, and existing different products of HIVST increases rates of user errors. Conclusions Overcoming factors that may deter HIV testing, and HIVST, in particular, is complex and challenging, but it has important implications for HIV stakeholders, HIVST users, and public health in general. Research is warranted to explore the actual practices related to HIVST among different populations in Africa.

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At-home HIV self-testing during COVID: implementing the GetaKit project in Ottawa

Can J Public Health ◽

10.17269/s41997-021-00505-8 ◽

2021 ◽

Author(s):

Patrick O’Byrne ◽

Alexandra Musten ◽

Lauren Orser ◽

Gauri Inamdar ◽

Marie-Odile Grayson ◽

...

Keyword(s):

Hiv Testing ◽

Scale Up ◽

Vaccine Trial ◽

Hiv Treatment ◽

Baseline Survey ◽

Healthcare Settings ◽

Self Testing ◽

Self Test ◽

The University ◽

Hiv Negative

Abstract Setting In March 2020, COVID-19 shuttered access to many healthcare settings offering HIV testing and there is no licensed HIV self-test in Canada. Intervention A team of nurses at the University of Ottawa and Ottawa Public Health and staff from the Ontario HIV Treatment Network (OHTN) obtained Health Canada’s Special Access approval on April 23, 2020 to distribute bioLytical’s INSTI HIV self-test in Ottawa; we received REB approval on May 15, 2020. As of July 20, 2020, eligible participants (≥18 years old, HIV-negative, not on PrEP, not in an HIV vaccine trial, living in Ottawa, no bleeding disorders) could register via www.GetaKit.ca to order kits. Outcomes In the first 6 weeks, 637 persons completed our eligibility screener; 43.3% (n = 276) were eligible. Of eligible participants, 203 completed a baseline survey and 182 ordered a test. These 203 participants were an average of 31 years old, 72.3% were white, 60.4% were cis-male, and 55% self-identified as gay. Seventy-one percent (n = 144) belonged to a priority group for HIV testing. We have results for 70.9% (n = 129/182) of participants who ordered a kit: none were positive, 104 were negative, 22 were invalid, and 2 “preferred not to say”; 1 participant reported an unreadiness to test. Implications Our results show that HIV self-testing is a pandemic-friendly strategy to help ensure access to sexual health services among persons who are good candidates for HIV testing. It is unsurprising that no one tested positive for HIV thus far, given the 0.08% positivity rate for HIV testing in Ottawa. As such, we advocate for scale-up of HIV self-testing in Canada.

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Landscape analysis – assessing countries' readiness to scale up nutrition actions in the WHO African region

African Journal of Food, Agriculture, Nutrition and Development ◽

10.18697/ajfand.52.who-2 ◽

2012 ◽

Vol 12 (52) ◽

pp. 6260-6273

Author(s):

U Trübswasser ◽

◽

C Nishida ◽

K Engesveen ◽

F Coulibaly-Zerbo ◽

...

Keyword(s):

Child Nutrition ◽

Scale Up ◽

Landscape Analysis ◽

Sub Saharan Africa ◽

World Health ◽

Surveillance Systems ◽

African Region ◽

Human Resource Capacity ◽

World Health Assembly Resolution ◽

Sub Saharan

The purpose of this paper is to describe the use of the Landscape Analysis to assess strengths and weaknesses in combating malnutrition in Sub-Saharan Africa. The Landscape Analysis is an inter-agency initiative to assess gaps and constraints and to identify opportunities for effective nutrition actions in order to accelerate intersectoral action for improving nutrition. In-depth Country Assessments to evaluate countries' "readiness" to scale up nutrition action have been conducted since 2008 in Sub-Saharan Africa. "Readiness" was assessed in terms of the commitment and capacity of each country and the focus was high stunting burden countries. The main focus was countries with heavy burden of undernutrition. From 2008 to September 2011, a total of 14 countries had undertaken the Landscape Analysis Country Assessment. Nine of them were in Africa: Burkina Faso, Comoros, Cote d’Ivoire, Ethiopia, Ghana, Madagascar, Mali, Mozambique, and South Africa. Three additional countries (Guinea, Namibia and Tanzania) were also planning to complete the Landscape Analysis Country Assessment in early 2012. From the findings in the nine countries, the following recommendations have been made: • Existing nutrition architectures and coordination mechanisms should be strengthened and better utilized; • Nutrition needs to be mainstreamed and integrated in relevant sector policies; • Advocacy at high levels is needed to highlight the importance of the lifecourse perspective, focusing particularly on nutrition interventions from preconception until the first two years of life; • National nutrition policies need to be translated into programmatic actions; • Human resource capacity for public health nutrition needs to be built with high quality in-service trainings in the short-term and long-term strategies to provide pre-service trainings; • Community-based outreach should be strengthened by using existing channels; • National nutrition surveillance systems need to be strengthened to ensure adequate use of data for monitoring, evaluation, and planning purposes. As part of the implementation of the 2010 World Health Assembly resolution on Infant and Young Child Nutrition (WHA 63.23) WHO has proposed a process to help countries in developing scale-up plans, which incorporates the Landscape Analysis Country Assessment as a tool to help countries in undertaking the initial context mapping. The countries that have already undertaken an in-depth Country Assessment, such as the Landscape Analysis Country Assessment, are ready to move forward in implementing the next steps in developing scaling-up plans to accelerate action in nutrition. At the same time, WHO will support additional countries that have expressed interest in conducting the Country Assessment.

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An Unsupervised Smart App–Optimized HIV Self-Testing Program in Montreal, Canada: Cross-Sectional Study (Preprint)

10.2196/preprints.10258 ◽

2018 ◽

Author(s):

Nitika Pant Pai ◽

Megan Smallwood ◽

Laurence Desjardins ◽

Alexandre Goyette ◽

Krisztian G Birkas ◽

...

Keyword(s):

Rapid Test ◽

Health Impact ◽

Completion Rate ◽

World Health ◽

Health Clinic ◽

Testing Strategy ◽

Cross Sectional ◽

Self Testing ◽

Hiv Test ◽

Self Test

BACKGROUND Although HIV self-testing strategies have been recommended by the World Health Organization, HIV self-tests are not yet approved in Canada. Currently approved HIV self-tests offer toll-free lines that are insufficient for initiating expedited linkages to counseling and care, accurate interpretation, and support during HIV self-testing. We developed an innovative, multilingual software app called HIVSmart! to plug these gaps. OBJECTIVE This study aimed to test our app-optimized oral HIV self-testing strategy for feasibility in men who have sex with men (MSM) who presented to test at a large sexual health clinic (Clinique Médicale L’Actuel) in Montreal. METHODS Between July 2016 and February 2017, we offered a strategy consisting of the OraQuick In-Home HIV Test (an investigational device) and a tablet installed with the HIVSmart! app to study participants, who presented at a private office in the clinic, mimicking an unsupervised home environment. We evaluated the strategy for its feasibility, acceptability, and preference. Using the HIVSmart! app, participants were guided through the self-testing process. We determined feasibility with a metric defined as the completion rate, which consisted of the following 3 steps: (1) self-test conduct; (2) self-test interpretation; and (3) linkages to care. Participants independently performed, interpreted, recorded their self-test and result, engaged in pre- and posttest counseling, and sought linkages to care. Laboratory tests (p24, Western Blot, and RNA), as per country algorithms, were expedited, and linkages based on the rapid test status were arranged. RESULTS Mean age of the 451 participants enrolled was 34 (range, 18-73) years. Of all participants, 97.1% (438/451) completed and submitted the survey through the HIVSmart! app. In total, 84.7% (371/438) of the participants were well educated (beyond high school) and 52.5% (230/438) had been tested within the past 6 months. Of the 451, 11.5% (52/451) were on pre-exposure prophylaxis. Feasibility (completion rate), an average proportion of the 3 steps, was computed to be 96.6% (419/451). The acceptability of the strategy was high at 98.5% (451/458). A majority of the participants (448/451, 99.3%) were found to be self-tested and lab-confirmed negative and were counseled after self- and rapid tests. In total, 0.7% (3/451) of the participants who self-tested positive and were lab-confirmed positive were linked to a physician within the same day. Furthermore, 98.8% (417/422) of the participants found the app to be useful and 94.0% (424/451) were willing to recommend it to a friend or partner. CONCLUSIONS The HIVSmart! app-optimized strategy was feasible, accepted, and preferred by an educated, urban MSM population of Montreal. With the app, participants were able to perform, interpret, store results, and get rapidly linked to care. The HIVSmart!-optimized, self-testing strategy could be adapted and contextualized to many at-risk populations within Canada and worldwide, thereby maximizing its public health impact.

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Achieving Sustainability and Scale-Up of Mobile Health Noncommunicable Disease Interventions in Sub-Saharan Africa: Views of Policy Makers in Ghana (Preprint)

10.2196/preprints.11497 ◽

2018 ◽

Author(s):

Daniel Opoku ◽

Reinhard Busse ◽

Wilm Quentin

Keyword(s):

Mobile Health ◽

Scale Up ◽

Noncommunicable Disease ◽

Sub Saharan Africa ◽

Successful Implementation ◽

Policy Makers ◽

Context Factors ◽

Number Of Patients ◽

Sub Saharan

BACKGROUND A growing body of evidence shows that mobile health (mHealth) interventions may improve treatment and care for the rapidly rising number of patients with noncommunicable diseases (NCDs) in sub-Saharan Africa (SSA). A recent realist review developed a framework highlighting the influence of context factors, including predisposing characteristics, needs, and enabling resources (PNE), for the long-term success of mHealth interventions. The views of policy makers will ultimately determine implementation and scale-up of mHealth interventions in SSA. However, their views about necessary conditions for sustainability and scale-up remain unexplored. OBJECTIVE This study aimed to understand the views of policy makers in Ghana with regard to the most important factors for successful implementation, sustainability, and scale-up of mHealth NCD interventions. METHODS Members of the technical working group responsible for Ghana’s national NCD policy were interviewed about their knowledge of and attitude toward mHealth and about the most important factors contributing to long-term intervention success. Using qualitative methods and applying a qualitative content analysis approach, answers were categorized according to the PNE framework. RESULTS A total of 19 policy makers were contacted and 13 were interviewed. Interviewees had long-standing work experience of an average of 26 years and were actively involved in health policy making in Ghana. They were well-informed about the potential of mHealth, and they strongly supported mHealth expansion in the country. Guided by the PNE framework’s categories, the policy makers ascertained which critical factors would support the successful implementation of mHealth interventions in Ghana. The policy makers mentioned many factors described in the literature as important for mHealth implementation, sustainability, and scale-up, but they focused more on enabling resources than on predisposing characteristics and need. Furthermore, they mentioned several factors that have been rather unexplored in the literature. CONCLUSIONS The study shows that the PNE framework is useful to guide policy makers toward a more systematic assessment of context factors that support intervention implementation, sustainability, and scale-up. Furthermore, the framework was refined by adding additional factors. Policy makers may benefit from using the PNE framework at the various stages of mHealth implementation. Researchers may (and should) use the framework when investigating reasons for success (or failure) of interventions.

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Introducing bedaquiline: experiences from the Challenge TB Project

The International Journal of Tuberculosis and Lung Disease ◽

10.5588/ijtld.19.0790 ◽

2020 ◽

Vol 24 (10) ◽

pp. 1046-1053

Author(s):

C. G. Edwards ◽

D. F. Wares ◽

G. Dravniece ◽

A. Gebhard ◽

E. Tiemersma ◽

...

Keyword(s):

Scale Up ◽

World Health ◽

Initial Time ◽

Successful Implementation ◽

Global Public Health ◽

Serious Adverse Events ◽

Health Crisis ◽

Time Investment ◽

Drug Regulatory Agencies ◽

Health Organization

BACKGROUND: Drug-resistant tuberculosis (DR-TB) remains a global public health crisis. In 2013, the World Health Organization recommended the introduction of bedaquiline (BDQ) for eligible DR-TB patients.METHODS: We conducted a retrospective review and analyses of project reports from 2016 to mid-2019 on the processes, activities implemented, available results on enrolment and interim treatment outcomes, across the 23 Challenge TB (CTB) supported countries.RESULTS: Initial introduction of BDQ-containing regimens in the 23 CTB-supported countries took on average 2 years, with subsequent nation-wide scale-up achieved in Ethiopia and Kyrgyzstan within a short time period. Successful implementation required critical interventions including advocacy, revision of policies and guidelines, capacity building of health care workers, and strengthening of laboratory networks. The number of countries providing BDQ increased from 9 to 23; 9398 patients were enrolled on bedaquiline containing regimens; 71% were culture-negative after 6 months of treatment; and the number of countries reporting serious adverse events increased (from 5 to 18). Major challenges included limited in-country coordination with drug regulatory agencies, unrealistic quantification and drug ordering, weak laboratory networks and reporting systems for drug safety.CONCLUSION: BDQ introduction required a systematic and programmatic approach. The initial time investment helped achieve initial introduction and scale-up of coverage, ownership and sustainability by National TB Programmes.

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Venues and methods to improve professional men’s access to HIV self-testing and linkage to HIV prevention or treatment: a qualitative study

BMC Health Services Research ◽

10.1186/s12913-021-07259-6 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Patience A. Muwanguzi ◽

Esther M. Nasuuna ◽

Florence Namimbi ◽

Charles Peter Osingada ◽

Tom Denis Ngabirano

Keyword(s):

Qualitative Study ◽

Hiv Testing ◽

Underserved Populations ◽

Linkage To Care ◽

Sub Saharan Africa ◽

Hiv Care ◽

Eligibility Criteria ◽

Prevention Services ◽

Self Testing ◽

Engaging Men

Abstract Background HIV testing among men in sub-Saharan Africa is sub-optimal. Despite several strategies to improve access to underserved populations, evidence regarding engaging men in professional and formal occupations in HIV testing is limited. This study explored employed professional men’s preferences for uptake of HIV self-testing, and linkage to HIV care, or prevention services. Methods This was an explorative-descriptive qualitative study where a sample of 33 men from six Ugandan urban centres. Participants were purposively selected guided by the International Standard Classification of Occupations to participate in in-depth interviews. The data were collected using an interview guide and the sample size was determined by data saturation. Eligibility criteria included fulltime formal employment for over a year at that organization. The data were analyzed manually using thematic content analysis. Results Three categories emerged: uptake of HIV self-tests, process of HIV self-testing and linkage to post-test services. The different modes of distribution of HIV self-test kits included secondary distribution, self-tests at typically male dominated spaces, delivery to workplaces and technology-based delivery. The process of HIV self-testing may be optimized by providing collection bins, and mHealth or mobile phone applications. Linkage to further care or prevention services may be enhanced using medical insurance providers, giving incentives and tele counselling. Conclusion We recommend utilization of several channels for the uptake of HIV self-tests. These include distribution of test kits both to offices and men’s leisure and recreation ‘hot spots’, Additionally, female partners, peers and established men’s group including social media groups can play a role in improving the uptake of HIV self-testing. Mobile phones and digital technology can be applied in innovative ways for the return of test results and to strengthen linkage to care or prevention services. Partnership with medical insurers may be critical in engaging men in professional employment in HIV services.

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1275. Will an App-Optimized HIV Self-testing Strategy Work for South Africans? Results From a Large Cohort Study

Open Forum Infectious Diseases ◽

10.1093/ofid/ofy210.1108 ◽

2018 ◽

Vol 5 (suppl_1) ◽

pp. S388-S388

Author(s):

Nitika Pant Pai ◽

Ali Esmail ◽

Gayatri Marathe ◽

Suzette Oelofse ◽

Marietjie Pretorius ◽

...

Keyword(s):

Cohort Study ◽

Odds Ratio ◽

Scale Up ◽

Global Scale ◽

Testing Strategy ◽

Monthly Income ◽

South Africans ◽

Self Testing ◽

Large Cohort Study ◽

Self Test

Abstract Background HIV self-testing (HIVST) offers a potential for expanded test access; challenges remain in operationalizing rapid personalized linkages and referrals to care. We investigated if an app-optimized personalized HIVST strategy improved referrals, detected new infections and expedited linkages to care and treatment. Methods In an ongoing cohort study (n = 2,000) based in South Africa, from November 2016 to January 2018, to participants presenting to self-test at community township based clinics, we offered a choice of the following strategies: (a) unsupervised HIVST; (b) supervised HIVST. We also observed participants opting for conventional HIV testing (ConvHT) in geographically separated clinics. We observed outcomes (i.e., linkage initiation, referrals, disease detection) and compared it between the two (HIVST vs. ConvHT) for the same duration. Results Of 2,000 participants, 1,000 participants were on HIVST, 599 (59.9%) chose unsupervised HIVST, 401 (40.1%) on supervised HIVST; compared with 1,000 participants on ConvHT. Participants in HIVST vs. ConvHT were comparable young (mean age 27.7 [SD = 9.0] vs. 29.5 [SD = 8.4]); female (64.0% vs. 74.7%); poor monthly income <3,000 RAND ($253 USD) (79.9% vs. 76.4%). With HIV ST (vs. ConvHT), many more referrals (17.4% [15.1–19.9] vs. 2.6% [1.7–3.8]; RR 6.69 [95% CI: 4.47–10.01]), and many new infections (86 (8.6% (6.9–10.5)) vs. 57 (5.7% (4.3–7.3)); Odds Ratio 1.55 [95% CI 1.1–2.2]) were noted. Break up: 45 infections in supervised HIVST 45 (52.3%); 41 infections in unsupervised HIVST (47.6%)]. Preference for HIVST was at 91.6%. With an app-optimized HIVST strategy, linkages to care were operationalized within a day in all participants (99.7% (HIVST) vs. 99.2% (ConvHT); RR 1.005 [95% CI: 0.99–1.01]); 99.8% supervised HIVST, 99.7% unsupervised HIVST. Conclusion Our app-optimized HIVST strategy successfully increased test referrals, detected new infections, and operationalized linkages within a day. This innovative, patient preferred strategy holds promise for a global scale up in digitally literate populations worldwide. Disclosures All authors: No reported disclosures.

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Scaling up interventions for depression in sub-Saharan Africa: lessons from Zimbabwe

Global Mental Health ◽

10.1017/gmh.2016.8 ◽

2016 ◽

Vol 3 ◽

Cited By ~ 15

Author(s):

D. Chibanda ◽

R. Verhey ◽

E. Munetsi ◽

S. Rusakaniko ◽

F. Cowan ◽

...

Keyword(s):

Health Workers ◽

Core Competencies ◽

Scale Up ◽

Health Care Facilities ◽

Sub Saharan Africa ◽

District Health ◽

Key Stakeholders ◽

Extensive Consultation ◽

Sub Saharan ◽

Hiv Programs

BackgroundThere is a dearth of information on how to scale-up evidence-based psychological interventions, particularly within the context of existing HIV programs. This paper describes a strategy for the scale-up of an intervention delivered by lay health workers (LHWs) to 60 primary health care facilities in Zimbabwe.MethodsA mixed methods approach was utilized as follows: (1) needs assessment using a semi-structured questionnaire to obtain information from nurses (n = 48) and focus group discussions with District Health Promoters (n = 12) to identify key priority areas; (2) skills assessment to identify core competencies and current gaps of LHWs (n = 300) employed in the 60 clinics; (3) consultation workshops (n = 2) with key stakeholders to determine referral pathways; and (4) in-depth interviews and consultations to determine funding mechanisms for the scale-up.ResultsFive cross-cutting issues were identified as critical and needing to be addressed for a successful scale-up. These included: the lack of training in mental health, unavailability of psychiatric drugs, depleted clinical staff levels, unavailability of time for counseling, and poor and unreliable referral systems for people suffering with depression. Consensus was reached by stakeholders on supervision and support structure to address the cross-cutting issues described above and funding was successfully secured for the scale-up.ConclusionKey requirements for success included early buy-in from key stakeholders, extensive consultation at each point of the scale-up journey, financial support both locally and externally, and a coherent sustainability plan endorsed by both government and private sectors.

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Rolling out Xpert MTB/RIF® for tuberculosis detection in HIV-positive populations: An opportunity for systems strengthening

African Journal of Laboratory Medicine ◽

10.4102/ajlm.v6i2.460 ◽

2017 ◽

Vol 6 (2) ◽

Cited By ~ 6

Author(s):

Ishani Pathmanathan ◽

Anand Date ◽

William L. Coggin ◽

John Nkengasong ◽

Amy S. Piatek ◽

...

Keyword(s):

Scale Up ◽

World Health ◽

People Living With Hiv ◽

Successful Implementation ◽

High Expectations ◽

Resource Limited ◽

Health Organization ◽

Living With Hiv ◽

And Control ◽

Monitoring Treatment

Background: To eliminate preventable deaths, disease and suffering due to tuberculosis ,improved diagnostic capacity is critical. The Cepheid Xpert MTB/RIF® assay is recommended by the World Health Organization as the initial diagnostic test for people with suspected HIV associatedtuberculosis. However, despite high expectations, its scale-up in real-world settings has faced challenges, often due to the systems that support it.Opportunities for System Strengthening: In this commentary, we discuss needs and opportunities for systems strengthening to support widespread scale-up of Xpert MTB/RIF as they relate to each step within the tuberculosis diagnostic cascade, from finding presumptive patients, to collecting, transporting and testing sputum specimens, to reporting and receiving results, to initiating and monitoring treatment and, ultimately, to ensuring successful and timely treatment and cure. Investments in evidence-based interventions at each step along the cascade and within the system as a whole will augment not only the utility of Xpert MTB/RIF, but also the successful implementation of future diagnostic tests.Conclusion: Xpert MTB/RIF will only improve patient outcomes if optimally implemented within the context of strong tuberculosis programmes and systems. Roll-out of this technology to people living with HIV and others in resource-limited settings offers the opportunity to leverage current tuberculosis and HIV laboratory, diagnostic and programmatic investments, while also addressing challenges and strengthening coordination between laboratory systems, laboratory-programme interfaces, and tuberculosis-HIV programme interfaces. If successful, the benefits of this tool could extend beyond progress toward global End TB Strategy goals, to improve system-wide capacity for global disease detection and control.

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