Rapid diagnostic tests (RDTs) can improve fever management in sub-Saharan Africa, but their impact depends on more than test performance, according to a mixed-studies systematic review published in Nature Communications.
The review analyzed 48 publications from 33 countries, including 37 primary studies and 11 systematic reviews, examining factors that influence the adoption and long-term use of RDTs for conditions such as malaria, HIV, tuberculosis, COVID-19, dengue, typhoid, and other causes of febrile illness.
Across the studies, researchers identified 436 implementation factors – 321 barriers and 115 facilitators – which were grouped into 35 themes. Most were related to the diagnostic technology itself, healthcare organizations, and the clinicians and health workers using the tests.
Several barriers appeared consistently across diseases and settings. These included stockouts of test kits and reagents, poor integration of testing into clinical workflows, insufficient training, increased workload for healthcare workers, and lack of confidence in test results when they conflicted with clinical judgment.
The review also highlighted challenges associated with single-disease testing programs. Malaria RDTs, for example, have reduced presumptive treatment, but a negative result often leaves clinicians with limited diagnostic options. In settings where additional tests are unavailable, this uncertainty can contribute to inappropriate antibiotic prescribing or continued reliance on clinical suspicion alone.
Factors that supported RDT uptake included simple test design, rapid turnaround times, regular training and supervision, reliable supply chains, and integration of testing into routine patient pathways. Adoption was often higher when tests were performed early in the patient journey, allowing results to inform clinical decisions during the consultation.
The review found that organizational factors were particularly important. Frequent stockouts, equipment maintenance problems, unreliable electricity supplies, and unclear responsibility for testing could all limit sustained use. For instrument-based platforms such as GeneXpert, infrastructure and maintenance requirements remained important considerations.
The findings suggest that successful diagnostic implementation requires attention to workflow, training, infrastructure, supply management, and clinical integration, in addition to analytical performance. The authors also identified a lack of evidence on how RDT programs are sustained after initial rollout, noting that most studies focused on adoption rather than long-term use.
The researchers conclude that future fever-management strategies may benefit from more integrated diagnostic approaches that address multiple potential causes of fever rather than relying on single-disease testing alone.
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