International Center for AIDS Care and Treatment Programs

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TB/HIV collaborative activities as part of the
package of care in Rwanda
Greet Vandebriel, MD, MPH Kenneth Turinawe, MD,
MPH Oct. 1st,2007 ICAP Annual Meeting, Nairobi
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ICAP-Rwanda TB/HIV Objectives

• Provide support to the MOH in improving linkages
  between HIV and TB programs and services
• Support the MOH (PNILT - TRAC / districts -
  sites) to coordinate planning, implementation and
  monitoring of national integrated TB and HIV
  services

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TB/HIV Policy

• PNILT-TRAC stakeholders workshop
• Representation from TB/HIV programs, governmental
  institutions, partners and international experts
• Objective discuss TB/HIV integration, make
  decisions and recommendations for a policy
• Results
• Policy developed, approved by
• MOH on Oct. 03, 2005
• and disseminated
• National TB/HIV working group
• established and regular
• meetings held

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Revision of Guidelines and Tools

• TB and HIV technical manual revised to include
  TB/HIV chapter
• TB training modules developed to include TB/HIV
  sessions
• TB and HIV recording and reporting tools revised
  to include information on TB/HIV
• System for ME of TB screening, developed and
  implemented
• IEC materials developed and distributed

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TB/HIV Model Centers
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One Stop Services for TB Patients with HIV
through the TB service

• HIV Counseling, Testing and CT
• HIV CT (PIT)
• Enrollment into care ( or shift HIV file to TB
  service)
• Venopucture for CD4 count
• Medical consultation, prescription of CTX, ART
• Distribution of CTX and ART (shift pharmacy
  tools, follow up of ART and CTX stock cards)
• AT the end of TB treatment the patient is refered
  and accompanied to the ART clinic for further
  follow up
• Home visits

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Intensified TB Case Finding in PLWH

• ART Clinic
• TB screening
• Transfer/Acompany confirmed TB cases to TB Clinic
  
• Community Based Testing
• Home visits to screen Association members and
  families for TB by PE

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TB/HIV Model Centers training centers
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From Model Centers to other ICAP Supported Centers

• One stop service is feasible
• Rolled out to 10 ICAP supported DH
• Needs assessment of training
• Theoretical training in TB and HIV care and
  treatment
• Practical training for nurses and visits for MD
  to Model Centers organized from April-July, 2007

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TB/HIV Site support
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TB/HIV Site Support

• Specific TB/HIV integration grid checklist
  developed by ICAP/PNILT
• ICAP TB/HIV team visits ICAP supported facilities
  regularly , jointly with DHT and PNILT
• Participation in MDT meeting
• TB/HIV Monitoring and evaluation

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to Sites Nationwide

• TB/HIV national WG adopted ICAP model for TB/HIV
  Integration as national model
• Harmonization of the approach
• Visits for Clinical Partners (USG, GF) to Model
  centers
• Theoretical Training of TB nurses
• Practical Training at Model centers and other
  ICAP sites
• Joint follow up by PNILT, TRAC, Partners

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HIV Counseling, Testing, Care and Treatment in
TB Patients at ICAP Supported Sites
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TB screening in Newly Enrolled Patients at ICAP
Supported Sites
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Challenges

• MOH PNILT TRAC
• Communication and collaboration between 2
  traditionally vertical programs
• Difference in approach to site support
• Harmonization of ME issues between MOH and ICAP
  (URS)
• Sites
• Space (counseling room), cross training, work
  load, rotation of staff
• Effective referrals between TB and HIV programs
  in facilities with TB service but without ART
  clinic
• Accurate recording and reporting of TB/HIV data
  (TB screening)
• Diagnostic follow up for TB suspects,
• Establishing adequate human resources to
  supervise and monitor program outcomes
• infection control

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Rwandan recipe for success

• Government commitment to integrating TB and HIV
  programs and services.
• Strong TB program and motivated team to support
  continuous TB/HIV training and supervision at
  decentralized district and facility level
• TB/HIV focal persons within PNILT-TRAC
• Establishment of 2 model centers and recrutement
  of TB/HIV focal point persons to design,
  implement and assess innovative strategies for
  TB/HIV integration
• Integration feasible with addition of minor
  resources in the existing system (reorganization
  crucial)
• Collaboration with other teams in ICAP to meet
  TB/HIV targets (care coordination, clinicians,
  ME among others)

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Way Forward

• Continue supporting MOH in TB/HIV integration
• Reinforce participation in the national TB/HIV
  working group to harmonize implementation
  strategies among partners
• Reinforce scaling up of one-stop services for TB
  patients with HIV at sites nationwide
• Continue site support (supportive supervision,
  mentoring, quality assessment (SOCs)
• Continue organization of practical/training
  visits of paterner organisations to ICAP
  supported sites
• Target All sites will have implemented one stop
  service by the end of 2008

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Acknowledgements
Supported by PEPFAR

• PNILT Dr Michel Gasana
• Mr Gaspard Kabanda
• TRAC Dr Anita Assimwe
• Dr Jules Mugabo
• Columbia University Prof. Wafaa El-Sadr
• Dr Jessica Justman
• Dr Simon Tsiouris
• Dr Ruben Sahabo
• ICAP-Rw
• CDC Dr Aliou Ayaba
• Dr Alyssa Finlay
• Gisenyi, Kicukiro teams