Abstract
BackgroundIn 2005, Rwanda drafted a national TB/HIV policy and began scaling-up collaborative TB/HIV activities. Prior to the scale-up, we evaluated existing TB/HIV practices, possible barriers to policy and programmatic implementation, and patient treatment outcomes. We then used our evaluation data as a baseline for evaluating the national scale-up of collaborative TB/HIV activities from 2005 through 2009.MethodsOur baseline evaluation included a cross-sectional evaluation of 23/161 TB clinics. We conducted structured interviews with patients and clinic staff and reviewed TB registers and patient records to assess HIV testing practices, provision of HIV care and treatment for people with TB that tested positive for HIV, and patients' TB treatment outcomes. Following our baseline evaluation, we used nationally representative TB/HIV surveillance data to monitor the scale-up of collaborative TB/HIV activitiesResultsOf 207 patients interviewed, 76% were offered HIV testing, 99% accepted, and 49% reported positive test results. Of 40 staff interviewed, 68% reported offering HIV testing to >50% of patients. From 2005-2009, scaled-up TB/HIV activities resulted in increased HIV testing of patients with TB (69% to 97%) and provision of cotrimoxazole (15% to 92%) and antiretroviral therapy (13% to 49%) for patients with TB disease and HIV infection (TB/HIV). The risk of death among patients with TB/HIV relative to patients with TB not infected with HIV declined from 2005 (RR = 6.1, 95%CI 2.6, 14.0) to 2007 (RR = 1.8, 95%CI 1.68, 1.94).ConclusionsOur baseline evaluation highlighted that staff and patients were receptive to HIV testing. However, expanded access to testing, care, and treatment was needed based on the proportion of patients with TB having unknown HIV status and the high rate of HIV infection and poorer TB treatment outcomes for patients with TB/HIV. Following our evaluation, scale-up of TB/HIV services resulted in almost all patients with TB knowing their HIV status. Scale-up also resulted in dramatic increases in the uptake of lifesaving HIV care and treatment coinciding with a decline in the risk of death among patients with TB/HIV.
Highlights
In 2005, Rwanda drafted a national TB disease and HIV infection (TB/HIV) policy and began scaling-up collaborative TB/HIV activities
Baseline Evaluation All geographic regions of the country were represented by the sample of 23 TB clinics and the geographic distribution of the sample approximated the distribution of clinics nationally (Table 1)
On-site HIV testing and antiretroviral therapy (ART) services were available at 74% and 65% of the health facilities in our sample compared to 70% and 41% of facilities nationally
Summary
In 2005, Rwanda drafted a national TB/HIV policy and began scaling-up collaborative TB/HIV activities. We used our evaluation data as a baseline for evaluating the national scale-up of collaborative TB/HIV activities from 2005 through 2009. Up to 50% of patients with both TB disease and HIV infection die during TB treatment with most deaths occurring within 2 months of being diagnosed with TB [2,3,4,5,6]. In 2004, the World Health Organization (WHO) issued policy guidance on collaborative TB/HIV activities to reduce the and counseling (PITC). For the majority of patients with TB/HIV, ART included efavirenz-based regimens initiated after completing the two month intensive phase of anti-TB treatment
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