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Table 3 Themes and supporting quotes from interviews

From: “It was difficult to offer same day results”: evaluation of community-based point-of-care testing for sexually transmitted infections among youth using the GeneXpert platform in Zimbabwe

Themes

Quote

Limitations of the diagnostic device

Analytic capacity

-“That was never a success because at first, we had a machine that could run 2 samples then we got another which could run 4 samples and because there was a lot of samples to be done and other competing activities it was difficult to offer same day results.”

-“We collect samples let’s say 35 as an example, each sample takes about an hour to run and then we have 35 samples like how many hours do we have in a day of operating at the field? So it will mean that on a daily basis you will be able to run maybe 15 samples meaning that today’s samples won’t all be run there are some which are going to be left out. Then the next day it means we are going to start with the ones remaining from yesterday because there are expiration dates to these things. So you will find out that it was very impossible to give clients their results on daily basis, it was just impossible because of the turnaround time and all”

-“So the following day you would start with yesterday’s remainder and you had the load for that day and sometimes it would even flow over to the third day which means that it needed 3 days to maintain the time and running those tests for clients so that the samples wouldn’t expire as well.”

-“Then the other thing is that we were getting more samples than what we had initially anticipated, we had more samples than what the machine could handle. Initially we had planned that a person would collect the sample, the test is run, and they get the results the same day, but we were getting more samples than machines. Also, the test takes about 90 min. We ended up having a backlog of samples and people were not able to get their samples on the same day. CHIEDZA operates from Monday to Thursday then on a Friday it’s a debrief day, so we decided to run the samples on a Friday. We leave the office early and go to the community early to start doing the running of the samples. Also, before going to the field everyday someone got to the office early and started running the samples before actually going to the field. Then later on towards the end of the study we got another bigger machine and it helped to reduce the pressure.”

-“I think if we can get a bigger machine that can run more cartridges at the same time it will be better. When we started we had a machine that ran two then they brought another one that could run four samples which was better. A bigger machine will help to ensure that we have a smaller backlog.”

Analytical errors

-“But then the thing about that machine is that it is very sensitive to a lot of things because you will find out that you would have placed a sample in there to run only to realize after 45 min that there is an error maybe a bubble entered the sample, or the machine overheated or for whatever reason it will jam on you or give you an error after having been confident that I have done a proper thing yet there is a problem. But with time what I noticed is that we were able to use it but during the first days we didn’t do things properly but with experience and time we were able to use it properly”

-“Yes, so you will just be managing the booths and the machine and that meant that it was one person doing two jobs and that may bring out errors but then we ended up doing that trying to make up for that”

-“I think the process of moving from the test tube to the cartridge, so that there are no bubbles and the correct measurement, at times you will be in a rush to do more samples and you end up missing the correct measurement and having bubbles.”

-“There was a faulty cable which did not work properly. We ended up losing some samples because of that. At first, we did not know what the problem was we later discovered it was the faulty cable. The service providers of course some were confident with the machine whilst others were not so confident but all of them were trained. We had errors here and there especially at the start when we were starting because of the faulty cable but with time it got better.”

Challenges with implementation in a community setting

Unstable electrical supply

-“And when there is an electricity issues you need to have a backup generator on standby.”

-“The main problem was the electricity load shedding. When the battery had small power and there was no electricity it resulted in a backlog of sample testing.”

-“The other thing when we started, we had power cuts which created challenges. Eventually we got a generator but we did not have the technical know-how of how the machine responded to sudden change of power supply from Zesa to generator and if we switched the running samples automatically gave error messages and this gave us pressure in terms of backlog of specimen since we had to rerun all over again.”

-“The GeneXpert machines are very sensitive to electricity changes, so if there is a power cut or a small shift in power supply it just aborts the running process and it means that you to start afresh and you could lose your cartridges. All this has financial implications. In Bulawayo they did not have many electrical issues in their sites, they had back up power batteries which then enabled them to have more testing time in case there were some power cuts.”

-“We also had the problem of electricity when it goes and comes back that sudden change means you have to start the samples all over again.”

Non-controlled conditions

-“At [site name], there is no shelter it is just an open space affected by weather elements and I do not think that is ok.”

-“It was ok except for the [site name] site during the rainy season, those tents are porous and it affected our operations on such days are seriously affected.”

-“We had to monitor the temperature of the cartridges, samples and the machine. At some point we bought a thermometer, and we had a temperature log. There were concerns about the temperatures going up in the office during the day.”

Inadequate space

-“The fifth booth was for the machine; it was also the same booth that the nurses used for checking out and treating STIs so when they were busy inside you had to wait for them. So, the space was very limited.”

-“The space was not enough, we had a tent where we put all equipment and that is the tent we used for the running of samples, at times the urine will spill, and you have to disinfect the area but there is congestion all over.”

-“It helps to do our testing in a private setup. Because we were using the nurse’s lab to do these tests of which if a person wants to come and change a specimen, they then disturb a nurse who will be working on the lab so an extra tent will be good.”

Challenges associated with moving machine between sites

-“The other challenge is setting up the machine and folding everything back after use every day.”

-“And also, the running around with the samples, imagine with the urine and also storage of the urine samples that was another challenge and also considering that we had one car for the staff, for the luggage, for the tents and those machines are delicate and so that was another challenge when we were the ones doing it; and especially moving with the gadgets to and from I think it reduces the lifespan of the machine itself.”

-“If we had a place where they are just placed let’s say we would run the samples and then tomorrow we would bring another set of samples and they would be taken to a place where they are being run specifically there and before the end of day, I think that would have been a better option to have a central place where the tests are all being run. It’s a bit risky travelling with the machine and we actually gave the machine a nickname it’s called Precious and after some travelling, we would ask like is Precious sitting very well? Is Precious safe? Because it was our precious gadget you know.”

-“There is a difference because in the lab you do not move the machine frequently once its set it stays in that position for a long time, so you do not expect any hardware or connection errors. I guess when you are moving the machine around connected to batteries, when the batteries lose power, and you want to switch to electricity you are bound to lose that run.”

Provider buy-in

Training

-“The training we got was enough for me because the machine is straightforward, and it does not need a lot of work … I think everything was covered during the training.”

-“No, it was very simple because we received some training before we started running the machine. Any complications, I asked the nurses for assistance.”

-“I would say the training was 50% adequate because it was a one-day training, of course it was a practical training but the fact that it was just one day I could not grasp all the concepts at once.”

-“As much as all the staff members were trained on using the machine some of them did not have the lab background and it was difficult for them to adhere to the correct procedures of handling specimen. It came down to us the nurses doing all the specimen with the help of (name), so she was ok with lab things. The other staff members just helped with handling specimen, all this gave us pressure because we had to do all the work and chase the targets in booths as well.”

Increased workload and impact on other services

-“The queues were moving slow because you had to wait for one client and finish with them to avoid a mix-up of samples. If a client took the container and took a long time to bring a sample back, you had to wait for them until they got back. In the meantime, the queues would be growing longer.”

-“Roles for everyone changed … We were now laboratory scientists/ community health workers / youth worker/ lab scientists. Remember our role was to collect samples in the booth like we were the point of collection by asking clients to give us their samples. But tomorrow again you will be collecting samples depending on whether you are in the booth at that time running the laboratory at the same time. So we would run our own tests, and we would also collect; the roster was there already notifying us who is on the duty.”

-“You would find out that if you didn’t manage to finish running the tests if it’s your duty, you would have to go to the office on Friday if it’s your duty and even on weekends if you don’t manage to finish again. On Saturdays I remember we had a duty roster, and everyone was aware of their own Saturday to come to work so our roles definitely changed and the workload increased too.”

-“Remember CHIEDZA is too much multi-faceted, you are a construction worker in the morning you are supposed to pitch the tents and they are very heavy; you work in the afternoon and when it’s knock off time you unpitch those tents again. And then let’s say you were the one on duty of collecting urine samples and running them, and the GeneXpert machine has set time for switching on and off and then you have to record the results. You cannot expect someone else to come and record the results for you, so you record on the tablets and input on the forms so definitely our roles changed and workload increased”

-“Yes we can say we had more work to do yes because almost everyone would be in the booth of course and we would exchange after maybe 4 h then we change the other team to go into the booth as well. But then we needed to allocate at least one person to be running the GeneXpert machine during the day and that meant that we would one or two people less for the day in the booths.”

-“[In the Harare lab] There was more workload to do. It required that we work over the weekends to cover more ground, for example I could have 4 runs for Harare and maybe 2 or 3 more runs for Bulawayo and each run is about 90 min and we did not have a lot of machines. So, it really meant trying to create more time and it ended up in a situation where we had a backlog.”

-“Number 1, we need someone who will be responsible for the testing part like the running of samples because having one person taken out of the team manning that machine would mean that we are one man down and we are incapacitated. So at least if we know that we have a team member who is solely responsible for the running of the tests then it will be fine. Whether they have finished running the tests or not it will be entirely up to them to know how to run them as per their order it will be much easier because as a community health worker I will know that I am responsible only for collecting the samples and giving them to that person that would be great you know having that feeling that there is someone there who is manning the booth for samples only.”

Providers not offering a same day testing service

-“So, what we did was to inform all the clients to come back the following week to get their results whether positive or negative. We separated the positive results from the negative ones because we were most interested in the positive cases. If they did not come the following week, we then phoned them about their results and advised them to come back with their partners.”

-“No, I don’t recall any who did that, specifically for me I did not give results same day.”

-“So we would like; run the test this week and then you get your results next week through text messages telling the clients that their results are ready.”

-“No we did not, because we explained to them that we could only give results after a day or two.”

-“Almost everyone would just come back because the machine takes 90 min so you can’t ask a client to be waiting for such a long time at the site so because of the backlog we would end up running samples that were collected on Monday maybe on Wednesday after about 7 maybe after about more than 48 h so you then need to call the clients to come and get their results or send text messages to just say we are notifying you that your results are out, can you come and present yourself at our site for result collection.”

Clients

Clients’ competing priorities

-“I think for them it will not be a priority, some just do the test just because it is being offered and when you call them to come and get the results, they are just not bothered about coming to get them.”

-“Uhm, when using the GCCT screening machines I think the challenge is on follow-up of those clients to come and get their results because some of them just come to get tested and they don’t come back for their results.”

-“Most of them were saying that they are busy they need to rush somewhere though I realised that they do not want their results same day because of fear.”

-“When the results came out positive it became a big challenge because most clients put up fake contact details and so we could not contact them. You call that number it does not go through, because it was my duty to do contact tracing, you try again the following day, but the number will still not go through. Then we had to go back to their houses to look for them, it was really hard.”

-“Most of them were saying they cannot wait for 90 min they will rather go home and come back the following week.”

-“I think it will be difficult for youths to do that because already for them to wait for 20 min for HIV test results is a challenge, even waiting for 5 min they do not want these young people are always in a hurry. I do not see how they will sit around and wait for 90 min, maybe one or two will wait but the rest will not. A better option could be that they go back home then they come back to get the results after an hour or so.”

-“Then there were clients who came early morning, and they want their results at the same time. When you explained to them the 90 min waiting period, they did not want to understand that.”

-“No, they did not wait for their results, most of them did not want to wait for their results, those who came very early in the morning we told them to come for their results before 5 pm on that day. The rest came the following week or waited for the following week to collect their results.”

-“Only one or two boys who had come early and whilst their samples were running, they were playing pool in the social area.

-Yes, we had some but only like if they tell you that I will be going to school especially the University students who would tell you that next week I will be going back to school and then you will be like it’s okay you can still come back after two months. We would also try to run their tests first and then wait for the results that’s if they are willing to wait for 2 h and that would also depend on what time they would come.”

-“The test takes 90 min, and it is a long time for anyone to wait. A person spends 30 min in the booth and then they have to wait for 60 min for their results, a lot of people did not want to wait, and they did not wait.”