We identified three temporal discrepancies in labelling, reading, and recording rapid HIV test results, which may contribute to diagnostic misclassification errors.
High frequency testing affects correct labelling
While the standard operating procedures for the rapid HIV test kits used in Zimbabwe do not stipulate any limits to how many tests a single person can administer at a time, prescriptions around the different steps involved (see Table 1) put a natural limit to how many tests a person can handle at the same time. Indeed, one participant mentioned that during a training on test kits it was emphasized that testing multiple clients at the same time is problematic, simply because it may lead to a mix-up.
What we were taught when we did our training was that we should deal with one client at a time and issue them their results rather than testing many people at a time. In such a case you can give someone a wrong test result. Karen, age 45, Avuma District Hospital.
Reflecting this, and when asked about their testing practices, participants often provided desirable accounts, explaining how they test one client at a time, so that they can carefully label the test-kits:
I will be dealing with one patient at a time so when they come for testing, I deal with them and everything about their results; and the moment that I put their blood sample on the test kit, I then mark it with a number hence making the results correct so that when another patient comes in you will know that you have allocated this number to this person. Mark, age 50, Dunba Mission Hospital.
However, when our observations and conversations turned towards their work conditions, it became clear that testing one or a few clients at a time was a luxury few could afford. One tester, Cecilia, reported that in her clinic they administered one test at a time, but she recognized the impact of workload on misclassification errors in testing facilities with high volumes of clients:
We administer one test at a time […] we write down their names for us to tell which result belongs to each of them. I think that for those centers that have high volumes of clients, there is that chance to give a wrong test result if the strips are not properly labelled. I think the misclassification errors are made when issuing the results. Cecilia, age 38, Imchiliz Clinic.
The demand for rapid HIV testing, coupled with limited resources, contributed to high frequency testing, or testing of multiple people at once (batch testing). This was observed in many of the participating clinics. When asked to further elaborate on the impact of high client volumes, Karen and Mary explain how they, as HIV testers, often feel compelled to speed up the testing process (often to reduce waiting time), and acknowledge that this increase in frequency and pace may lead to improper labelling practices:
When you have tested a lot of people and you want to make your things [the testing process] come out quickly […] one may label wrongly, right. You may give someone a wrong test result. Karen, age 45, Avuma District Hospital.
Yah, it can occur maybe due to pressure. If the tester is not efficient enough to write down names or to put some symbols on the test kits to show which test belongs to each person, maybe he will end up giving the wrong result. Mary, age 35, Angrushi Clinic.
The workload associated with high frequency or batch testing is further compounded by repeat testing when obtaining discordant results. As discussed further in Skovdal et al. (2020) the rapid HIV test strategy in Zimbabwe stipulates that if the first test is positive, a different and second test needs to be run. If they produce discordant results, the two tests should be repeated. If the test results remain discordant, a third “tie-breaker” is to be run.
Yes, the workload may become too much since there will be many patients but especially when we experience a lot of discordant results plus that requires a lot of time of which you won’t be having such an amount of time to do everything perfectly. The patients will be standing outside in a long queue so for you to have such time to do all that, and you are the only tester with the different test kits revealing a different set of results. Mark, age 50, Dunba Mission Hospital.
Obtaining discordant results can be detrimental to the temporal flow of other activities, with repeat testing consuming additional time. The work environment spares little time to deal with discordant results. In these situations, Mark points to how HIV testers may not do everything perfectly, falling short of the precision assumed by the rapid HIV testing scripts.
The above accounts highlight recognition of a clash between two tempi: the desired and scripted tempo of rapid HIV test-kits, which assumes a balanced relationship between frequency and tempo, and the fast-paced tempo experienced at clinic-level, defined by high client volumes, repeat testing, and low staffing resources. This discrepancy may, as Karen, Mary and Mark suggest, result in diagnostic misclassifications.
Mistiming affects the reading of test results
The scripted rapid HIV test practice stipulates that once a test-kit has been accurately labelled, an appropriate blood sample, in sufficient quantities, must be collected (see Table 1). This is done through a finger prick. The blood sample must then be added onto the test device, followed by a buffer mixture. As soon as the buffer mixture has been added, a waiting time ensues. This is the time required for the test-kits to produce a valid result. Confusingly, the different test-kits used in Zimbabwe have different scripted timings, or valid results intervals (VRIs). For one test-kit, the waiting time is 5–15 min, and the HIV tester is given strict instructions not to read results after 15 min. Two test-kits require a 15-min wait, yet for one of them the waiting time can be extended up to 60 min:
Wait a minimum of 15 min (up to 60 min) after buffer is added and read results. Test kit 1 standard operating procedures.
Read the test results 15 min after the addition of the Running Buffer. In some cases, a test line may appear in less than 15 min, however, 15 min are needed to report a non-reactive result. Read results in a well-lit area. Do not read results after 20 min. Test kit 2 standard operating procedure.
For both Test kits 1 and 2, the waiting times are 15 min, yet the VRIs differ significantly between the two tests. For Test kit 1, HIV testers have 45 min to read the test results. In contrast, for Test kit 2 testers only have five minutes. In the previous section we outlined the regularity of batch testing, yet none of our participants alluded to the fact that batch testing with Test kit 2—given the short window to read results—is in practice impossible to do. Although understanding of the required VRI may be lacking, there was general awareness about the need to wait 15 min before reading the results, as illustrated by Agnes:
If you do not give it enough time, the kit might give a negative result before it produces a positive result. You would have read the results too early before the positive line is produced. You’ll give the client a wrong result. Agnes, age 36, Lutu Mission Hospital.
This recognition and caution were however often undermined by work pressures, either a result from high workloads, related to high frequency testing, or general interruptions. Through our observations we noted that although the testers did often look at their watch when they had applied the buffer fluid (so at the start of the VRI), they did not typically set a timer to notify them of the end of the VRI. We also observed constant distractions during the wait time, phone calls, colleagues knocking on the door, and clients popping in, making it difficult for testers to stick to the VRI, even if they were timed and only did one test at a time. These everyday issues were further exacerbated by different ‘crisis moments’, such as the long queues noted by Mark above, or stress induced by clients who expressed impatience:
Also, sometimes the clients can hustle you up. They won’t be patient enough so you will be pushed to give the results maybe earlier than the required time. Mary, age 35, Angrushi Clinic.
In our observations we witnessed multiple incidents of impatient clients who directly confronted HIV testers to vent their frustrations. In Kuvubam Polyclinic, one incident provides insight into why HIV testers may want to speed up the testing process:
Mbuya carried out the test on him. It was a very tense session because he was showing signs of being violent and he was extremely agitated. Even the neighbour pointed out that since morning he had become very short tempered and annoyed very easily. When Mbuya pricked him, he almost slapped her. Luckily the neighbour was there to restrain him. The client was extremely annoyed, and it was written all over his face. Participant observation, Kuvubam Polyclinic, 26.04.2018.
These accounts and observations highlight circumstances that may result in premature readings of test-kits. They indicate a different form of tempi clash. The tempo at which the test results are produced is determined by the timing specifications of the given test device. These timing specifications, relating to the VRIs, are considered stable and objective times that must be followed. The rapid HIV testing script therefore assumes that HIV testers synchronize and pace their activities of testing to fit with the objective timing criteria inscribed in the rapid HIV testing technology. However, as the examples by Rose and Mary indicate, this synchronization is not always possible, either because of high frequency testing or the influence of impatient clients. The latter example adds a dimension to the tempi clash, as HIV testers must juggle and synchronise not only the objective timing criteria of the test-kits, but also the subjectivity of time as experienced by clients who are anxiously waiting for their results. As Adam [19] argues, times of stress may be perceived to go faster than they do in reality. Likewise, when one is struck with boredom, it feels like time slows down. The quote by Mary points to this subjectivity of time, suggesting that HIV testers may be ‘pushed’ into reading test results prematurely, increasing the chances of mistiming the reading of test results.
Recording is time-consuming, but prioritized, affecting sequential steps
Recording requires that the HIV testers write down the test results and client information in multiple books and registers. This recording was considered an important but strenuous and time-consuming process:
Recording is time-consuming. It is very time-consuming. To avoid leaving out one of those books [where test results are registered] you should have a sequence that you follow after testing a client i.e., [first noting results in] the pre-ART register, attendance register, dispensing register, pharmacy register and then allocate a green book. Cecilia, age 38, Imchiliz Clinic.
Cecilia’s list of various registers demonstrates why recording is considered a time-consuming activity, taking up much of the HIV testers’ time. Despite the time-consuming character of the work, recording was still regarded as an essential part of the rapid HIV testing script:
There is no other way out; we must record the details because they are important to us as a facility, so they have to be recorded at all times. It does not matter what the workload is like, recording must be done at all times. Tino, age 28, Lindase Mission Hospital.
The recording of test results was thus said to be done in meticulous detail. Only a few participants could give examples of HIV test results not being adequately recorded in the required registers:
We might see that there is a client who tested positive, and we ask whether she refused to be on ART because her details won’t be recorded in the other register. We will realize that it was a mistake. If there is anything that can be corrected, we will correct it so that the information recorded in all the books will be the same. Cecilia, age 38, Imchiliz Clinic.
Recording test results is a prioritized step of the HIV testing script. However, the time-consuming nature of this prioritized step, coupled with high frequency testing, may have contributed to a de-prioritization of other steps in the finite timeframe of “rapid” HIV testing, such as reading test results before they are ready or by omitting counselling, as explained by Alice:
If there are many clients to attend to, sometimes you don’t have enough time to counsel people. […] If there are many people, it means that the level of counselling may become poor because you will be having a lot of clients. Alice, age 41, Ango District Hospital.
Also our observations documented instances of counselling being omitted due to workloads and time pressures. To maintain the momentum achieved by testing multiple people at once, an HIV tester at Lutu Mission Hospital was observed to provide counselling to multiple clients at once, in a single session. These findings suggest that following some aspects of the script (e.g., recording) comes at a cost to the time available for other steps in the testing process.