TABLE 2.

Identified Barriers to Implementing Xpert TB Testing in Studies in Low- and Middle-Income Countries

Barriers	India	Mongolia	Mozambique	Nepal	Nigeria	Pakistan	Swaziland	Uganda	Vietnam
Patient-level factors
Distance to testing sites²⁹^,³³^,³⁵	X			X		X
Cost of testing in private health clinics³⁵						X
Human resources
Inadequate/inconsistent staff training on testing processes/guidelines, and/or limited awareness of availability²⁶^,²⁸^–³⁰^,³²^,³⁴^,³⁵	X	X	X		X	X		X	X
Low self-efficacy and confidence that Xpert improves outcomes¹⁵								X
Workload capacity in laboratories¹⁵^,³⁰		X						X
High staff turnover¹⁵^,³¹^,³²					X			X	X
Initial struggle with English software (since rectified)²⁶			X
Material resources
Inadequate power supply¹⁵^,²⁶^,²⁷^,³¹^,³³^,³⁵			X	X	X	X	X	X
Poorly equipped labs (e.g., limited space for patient assessment; no ventilation, workbench, air conditioning, and/or refrigerator)¹⁵^,²⁶^,³⁴			X		X			X
Inappropriate storage of cartridges³¹					X
Service implementation
Geographically dispersed TB laboratories³⁵						X
Transportation of sputum samples (e.g., inconsistent/delays in availability of deliveries; improper packaging/temperature control during transport)¹⁵^,³²^,³⁴^,³⁵					X	X		X	X
Inability to track/follow up with patients testing positive¹⁵								X
Determining an appropriate testing algorithm²⁶			X
Failure to identify eligible cases for screening³⁰^,³²		X							X
Limitations to accessing updated and clear standard operating procedures/internal audits²⁷^,³²							X		X
Poor quality samples collected²⁷^,²⁹^,³⁰^,³²	X	X					X		X
Service coordination
Supply chain for procurement of cartridges, reagents, and/or medicines resulting in lack of supplies¹⁵^,²⁶^,³⁰^,³²^–³⁵		X	X	X	X	X		X	X
Lack of referral pathways/communication between staff and health centers (e.g., referral pathways and transfer of results)²⁷^–³⁰^,³²^–³⁵	X	X		X	X	X	X	X	X
Insufficient oversight from national body/remote monitoring¹⁵^,²⁶			X						X
Delays in notification of results¹⁵^,²⁶^,²⁸^–³⁰^,³⁴	X	X	X		X			X
Limited ability to track positive cases and confirm treatment²⁶^,²⁸^,³⁵			X			X		X
Technical operations
Xpert maintenance (e.g., frequency of maintenance not always implemented as required; poor understanding of routine maintenance in dusty, non-temperature-controlled labs)²⁶^–²⁸^,³¹^,³³^,³⁵			X	X	X	X	X	X
Failure of calibration and required replacement²⁶			X
Lack of timely replacement of damaged modules³³				X
Module malfunction²⁸^,³¹					X			X
Limited internet connectivity²⁶^,³¹			X		X
Local repair options limited³⁰		X