Uncertainties, work conditions and testing biases: Potential pathways to misdiagnosis in point-of-care rapid HIV testing in Zimbabwe.

Morten Skovdal,Rufurwokuda Maswera,Constance Nyamukapa,Nadine Beckmann,Simon Gregson

doi:10.1371/journal.pone.0237239

Abstract

Disconcerting levels of misdiagnosis are common in point-of-care rapid HIV testing programmes in sub-Saharan Africa. To investigate potential pathways to misdiagnosis, we interviewed 28 HIV testers in Zimbabwe and conducted weeklong observations at four testing facilities. Approaching adherence to national HIV testing algorithms as a social and scripted practice, dependent on the integration of certain competences, materials and meanings, our thematic analysis revealed three underlying causes of misdiagnosis: One, a lack of confidence in using certain test-kits, coupled with changes in testing algorithms and inadequate training, fed uncertainties with some testing practices. Two, difficult work conditions, including high workloads and resource-depleted facilities, compounded these uncertainties, and meant testers got distracted or resorted to testing short-cuts. Three, power struggles between HIV testers, and specific client-tester encounters created social interactions that challenged the testing process. We conclude that these contexts contribute to deviances from official and recommended testing procedures, as well as testing and interpretation biases, which may explain cases of misdiagnoses. We caution against user-error explanations to misdiagnosis in the absence of a broader recognition of how broader structural determinants affect HIV testing practices.

Highlights

Extraordinary gains have been made in the scale-up of HIV testing and treatment in sub-Saharan Africa, contributing to significant reductions in AIDS-related deaths [1]
Whilst our study supports previous research highlighting that a lack of continuous, ongoing proficiency training can diminish the authenticity of point-of-care test results [24, 25], we provide additional insight by unpacking perceptions of causes and consequences of the uncertainties that arise from inexperience and changes in the script
We have found that uncertainties, difficult work conditions, and certain social interactions contribute to testing and interpretation biases, as well as deviances from the official testing procedures, which may offer some explanation to high levels of misdiagnosis

Summary

Introduction

Extraordinary gains have been made in the scale-up of HIV testing and treatment in sub-Saharan Africa, contributing to significant reductions in AIDS-related deaths [1]. There is growing evidence that large numbers of people in sub-Saharan Africa may receive incorrect information about their HIV status due to diagnostic or misclassification errors in HIV rapid testing programs [2,3,4,5]. Pathways to misdiagnosis in point-of-care rapid HIV testing qualitative data contain potentially identifying or sensitive information, and because we do not have consent from the participants to share their transcripts with the wider public. Under these conditions, the Medical Research Council of Zimbabwe have imposed restrictions on the public sharing of data.

Methods

Results

Discussion

Conclusion