Feasibility, challenges, and solutions for implementing targeted universal tuberculosis testing: perceptions of healthcare professionals in South Africa

Tuberculosis (TB) remains a leading cause of mortality, particularly among people with HIV (PWH). In South Africa, the targeted universal TB testing (TUTT) strategy was introduced to shift from symptom-based to symptom-agnostic screening to improve early case detection in PWH. However, limited research has explored provider perceptions of the TUTT strategy. We explored healthcare professionals’ perceptions of the introduction, feasibility, challenges, and potential solutions for implementing TUTT. We conducted a qualitative study using in-depth interviews with 11 purposively selected healthcare professionals (nurses, program managers, and doctors) involved in integrated TB/HIV care in KwaZulu-Natal Province, South Africa. Interviews were audio-recorded, transcribed, and analysed through inductive thematic analysis. Four thematic categories with eight overarching themes were identified. TUTT introduction was characterised by largely informal communication, which contributed to variable understanding, while structured dissemination and mentorship supported clearer uptake. TUTT feasibility was shaped by facility capacity, with adequate staffing, diagnostic resources, and workflow organisation enabling smoother integration, whereas under-resourced facilities struggled. Implementation challenges included sputum collection difficulties, especially among asymptomatic PWH, staff shortages, heavy workloads, and fragmented TB/HIV data systems. Proposed solutions centred on expanding access through alternative triage tools such as mobile digital chest X-rays, point-of-care tests, community-based testing, and strengthening provider training, role clarity, and patient education. TUTT is perceived as a valuable strategy to improve TB detection in PWH, but its success hinges on addressing operational, infrastructural, and patient engagement barriers. Strengthening resources, integrating data systems, and adopting locally tailored, patient-centred approaches are essential to bridge the gap between policy and practice, thereby optimizing TUTT.