IntroductionFewer than 50% of people with tuberculosis receive a molecular WHO-recommended rapid diagnostic test (mWRD). We performed a mixed-methods systematic review to categorise barriers and enablers that affect mWRD use and impact and evaluate mWRD implementation strategies. Parts of this review informed the WHO standard: Universal Access to Tuberculosis Diagnostics.MethodsWe searched multiple databases without language restrictions until 29 July 2022. We included studies that used qualitative, quantitative or mixed methods study designs. Four reviewers independently screened studies and extracted data. We categorised studies as thick or thin depending on whether authors analysed findings beyond a descriptive list of barriers or enablers and demonstrated insights into participants' perspectives. We appraised study quality by adapting the Standards for Reporting Implementation Studies statement. We synthesised data using a thematic approach and used GRADE-CERQual to assess confidence in the findings.ResultsWe identified 54 high-thickness studies from 18 countries, including public and private healthcare settings. Implementation strategies included engaging patients, training and supporting clinicians, building infrastructure and interactive assistance. Examples included remote outreach programmes, community testing, longitudinal clinician engagement, auxiliary workers, multicomponent strategies, performance feedback, improving health information management to strengthen care linkage and diagnostic network improvement. We had high or moderate confidence in our findings.ConclusionInnovative and contextually relevant implementation strategies are needed for tuberculosis programmes to realise the benefits of improved accuracy and diagnostic expediency that mWRDs offer. Multicomponent strategies that centre equity and longitudinal health worker training across the diagnostic cascade must be prioritised.