Open Access Open Badges Research article

The failure of routine rapid HIV testing: a case study of improving low sensitivity in the field

Benjamin J Wolpaw1*, Catherine Mathews12, Mickey Chopra3, Diana Hardie4, Virginia de Azevedo5, Karen Jennings5 and Mark N Lurie6

Author affiliations

1 Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa

2 School of Public Health and Family Medicine, University of Public Health, Cape Town, South Africa

3 School of Public Health, University of the Western Cape, Bellville, South Africa

4 National Health Laboratory Service and Division of Virology, University of Cape Town, Cape Town, South Africa

5 Cape Town City Health Department, City of Cape Town, Cape Town, South Africa

6 Department of Community Health, Brown University Medical School, Providence, USA

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Citation and License

BMC Health Services Research 2010, 10:73  doi:10.1186/1472-6963-10-73

Published: 22 March 2010



The rapid HIV antibody test is the diagnostic tool of choice in low and middle-income countries. Previous evidence suggests that rapid HIV diagnostic tests may underperform in the field, failing to detect a substantial number of infections. A research study inadvertently discovered that a clinic rapid HIV testing process was failing to detect cases of established (high antibody titer) infection, exhibiting an estimated 68.7% sensitivity (95% CI [41.3%-89.0%]) over the course of the first three weeks of observation. The setting is a public service clinic that provides STI diagnosis and treatment in an impoverished, peri-urban community outside of Cape Town, South Africa.


The researchers and local health administrators collaborated to investigate the cause of the poor test performance and make necessary corrections. The clinic changed the brand of rapid test being used and later introduced quality improvement measures. Observations were made of the clinic staff as they administered rapid HIV tests to real patients. Estimated testing sensitivity was calculated as the number of rapid HIV test positive individuals detected by the clinic divided by this number plus the number of PCR positive, highly reactive 3rd generation ELISA patients identified among those who were rapid test negative at the clinic.


In the period of five months after the clinic made the switch of rapid HIV tests, estimated sensitivity improved to 93.5% (95% CI [86.5%-97.6%]), during which time observations of counselors administering tests at the clinic found poor adherence to the recommended testing protocol. Quality improvement measures were implemented and estimated sensitivity rose to 95.1% (95% CI [83.5%-99.4%]) during the final two months of full observation.


Poor testing procedure in the field can lead to exceedingly low levels of rapid HIV test sensitivity, making it imperative that stringent quality control measures are implemented where they do not already exist. Certain brands of rapid-testing kits may perform better than others when faced with sub-optimal use.