Abstract
BackgroundMany 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.MethodsWe 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.ResultsChallenges with Xpert implementation occurred at every step of the diagnostic evaluation process, leading to low overall uptake of testing. Of 2192 patients eligible for TB testing, only 574 (26%) who initiated testing were referred for Xpert testing. Of those, 54 (9.4%) were Xpert confirmed positive just under half initiated treatment within 14 days (n = 25, 46%). Gaps in required infrastructure at 23 community health centers to support the hub-and-spoke system included lack of refrigeration (n = 14, 61%) 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, twice, or three times a week at 10 (43%), nine (39%) and four (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 two health centers. Of the 15 Xpert testing sites, five (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%.ConclusionsAlthough 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.
Highlights
Many high burden countries are scaling-up GeneXpert® MTB/RIF (Xpert) testing for tuberculosis (TB) using a hub-and-spoke model
Of the 23 community health centers, only 2 (9%) had access to and sufficient airtime to use mobile phones to communicate with testing facilities or patients
Results for patients referred from each health center were printed from the Xpert machine when the corresponding boda rider came to the Xpert site in order to verify that the specific results provided matched the identifiers for all of the samples that were delivered
Summary
Many high burden countries are scaling-up GeneXpert® MTB/RIF (Xpert) testing for tuberculosis (TB) using a hub-and-spoke model. Because of the substantial cost and infrastructure requirements of 4-module Xpert deployment, many high burden countries have adopted a “hub-and-spoke” model for scale-up In this model, four module Xpert devices are placed at higher-level health facilities with adequate infrastructure requirements including security, stable power supply (hubs), each of which receive sputum samples from several lower level health facilities (spokes). Four module Xpert devices are placed at higher-level health facilities with adequate infrastructure requirements including security, stable power supply (hubs), each of which receive sputum samples from several lower level health facilities (spokes) The goal of these hub-and-spoke units is to expand coverage of Xpert testing services using existing devices and infrastructure, thereby increasing access to rapid and more sensitive diagnostic testing for patients who present to lower level health facilities
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